February 20, 2014 at 3:19 pm ET
TMC Brief Presented by America’s Health Insurance Plans: Biden Says Obamacare Enrollment May Miss Mark, Acute Care Hospital Prices Flat in January
Today’s Washington Read:
Joe Biden: Obamacare Enrollment May Miss Mark
from Politico by Associated Press
Vice President Joe Biden said Wednesday that it would be a good start for the federal health care law if 5 million to 6 million people sign up by the end of March, an acknowledgement that enrollments might fall significantly short of the Obama administration’s unofficial goal of 7 million. Biden, who was attending a private fundraiser in Minneapolis, made a brief unannounced stop at a coffee shop and visited with a handful of women who have signed up for coverage. Open enrollment under the federal law ends on March 31, after which people without insurance are subject to federal tax penalties. We didn’t want this to start off as shaky as it did,” he said. “But it’s complicated.” In its original projection, the administration said 7 million Americans would have to be signed up by the end of March for the insurance pool at the heart of the law to function properly. Biden acknowledged that “we may not get to 7 million, but if we get to 5 or 6 million that’s a hell of a start.”
Today’s Business Strategy Read:
Acute Care Hospital Prices Flat in January
from Modern Healthcare by Melanie Evans
Acute-care hospital prices as measured by the Producer Price Index were nearly flat in January, federal data show. Hospital prices increased 0.1% last month, according to preliminary figures, compared with 0.7% during the same month a year ago. The Producer Price Index is the broader of two inflation measures released by the Bureau of Labor Statistics. It gauges the change in reimbursement paid to hospitals. The Consumer Price Index, an alternative measure of inflation that generally looks at retail price inflation, tracks changes in commercial insurance reimbursement. Figures for the Consumer Price Index are expected to be releasedThursday. During the 12 months that ended in January, acute-care hospital prices increased 1%, the preliminary figure shows, compared with an increase of 2.9% the prior year.
Today’s Chart Review:
Employer Health Care Survey
from Aon Hewitt
Mark Your Calendars (All Times Eastern):
Thursday: Quarterly earnings: Actavis, Allscripts,
Thursday: MACPAC meeting @
Thursday: Chamber of Commerce event on healthcare and trasportation @2:45pm
Thursday: Families USA call on state Medicaid enrollment @12pm
Friday: Quarterly earnings: Acceleron Pharmaceutical
Friday: Institute for Defense and Government Advancement event on military behavioral health @9am
Friday-Sunday: National Governors Association Winter Meeting
NEWS ARTICLES
1-4: General
5-7: Payers
8-12: Providers
13-17: Pharma/Biotech/Device
18-20: Health IT
OPINIONS, EDITORIALS, PERSPECTIVES
21, 22: Wall Street Journal
23: Forbes
24: National Journal
25: Health Affairs
RESEARCH REPORTS, ISSUE BRIEFS, CASE STUDIES
26: North Star Opinions Research
27: SANS Institute
28: Urban Institute
29, 30, 31: New England Journal of Medicine
NEWS ARTICLES
General
1) Joe Biden: Obamacare Enrollment May Miss Mark
from Politico by Associated Press
Vice President Joe Biden said Wednesday that it would be a good start for the federal health care law if 5 million to 6 million people sign up by the end of March, an acknowledgement that enrollments might fall significantly short of the Obama administration’s unofficial goal of 7 million. Biden, who was attending a private fundraiser in Minneapolis, made a brief unannounced stop at a coffee shop and visited with a handful of women who have signed up for coverage. Open enrollment under the federal law ends on March 31, after which people without insurance are subject to federal tax penalties. We didn’t want this to start off as shaky as it did,” he said. “But it’s complicated.” In its original projection, the administration said 7 million Americans would have to be signed up by the end of March for the insurance pool at the heart of the law to function properly. Biden acknowledged that “we may not get to 7 million, but if we get to 5 or 6 million that’s a hell of a start.”
2) CBO Chief Poses Test for White House
from Wall Street Journal by Damian Paletta
The biggest challenges to the Obama administration’s economic policy in the past month have come not from Republicans but from Douglas Elmendorf, a bookish former economics staffer in the Clinton White House who now runs the Congressional Budget Office. From his perch at the nonpartisan agency that advises Congress, Mr. Elmendorf has chipped away at two pillars of President Barack Obama’s economic policy: the Affordable Care Act and the push to raise the minimum wage. The budget office calculated earlier this month that the health law would lead some people to leave their jobs or ratchet back their work hours, and it said this week that raising the federal minimum wage to $10.10 an hour from $7.25 could lead 500,000 people to lose their jobs. Both reports were nuanced and included complex and layered projections that Mr. Elmendorf emphasized may or may not materialize. But because the CBO has a reputation as an impartial umpire in a town full of spinmasters, the White House moved quickly to try to frame or discredit the agency’s conclusions.
3) Obamacare Rewrites of Health Law Rile Republicans
from Bloomberg by Mike Dorning
President Barack Obama’s repeated postponement of deadlines in the rollout of his health-care overhaul has sparked accusations from Republicans that he’s straying into dangerous territory by rewriting the law. He’s not the first president to follow his own timetable instead of the one passed by Congress. From pollution controls and maritime safety rules to financial regulations, delaying enforcement of new laws has become common for presidencies, including those of Ronald Reagan, Bill Clinton and George W. Bush, even in the face of statutory requirements and frequent outcries. Deadlines set in laws are “aspirational dates,” said Ross Baker, a political science professor at Rutgers University. “From a strict rule-of-law perspective, it’s not good,” Baker said. “There ought to be precision, finality.” Still, he said, occasional delays in enforcement of complex legal changes “build a certain amount of flexibility into the system.”
4) U.S. Stock-Index Futures Fall on China Manufacturing Data
from Bloomberg by Namitha Jagadeesh
U.S. stock-index futures fell, indicating the Standard & Poor’s 500 Index will decline for a second day, as a report showed Chinese manufacturing shrank. Futures on the S&P 500 expiring in March lost 0.3 percent to 1,819.7 at 7:28 a.m. in New York. The gauge had slumped as much as 5.8 percent since reaching a record onJan. 15 as investor concern about Federal Reserve tapering fueled a rout in emerging markets. It subsequently rose 5 percent from a Feb. 3 low through yesterday’s close. Dow Jones Industrial Average contracts lost 40 points, or 0.3 percent, to 15,976 today.
Payers
5) California Exchange Adds 828,000 to Obamacare, Airs More Latino Ads
from LA Times by Chad Terhune
California’s insurance exchange said more than 828,000 people have signed up for Obamacare coverage ahead of a March enrollment deadline. With six weeks left for open enrollment, the Covered California exchange also unveiled new TV ads Wednesday aimed at reaching uninsured Latinos. The state exchange said it saw an uptick in Latino enrollment during January after a slow start in the fall. The state said 28% of enrollees last month identified themselves as Latino, compared to 18% for October through December. Latinos represent more than half of the state’s uninsured population, and many of them qualify for federal premium subsidies under the healthcare law. Covered California said it will spend $8.2 million through March on Spanish-language advertising, up 73% from what it spent in the fourth quarter. The state is also hiring more bilingual call-center employees and looking to host more enrollment events at Latino supermarkets in Southern California. For the first time, California officials said how many enrollees actually paid their first month’s premium. The state said about 80% of people who picked a health plan for Jan. 1 paid in time for coverage to take effect.
6) Most Employers Will Keep Offering Workers Health Insurance: Survey
from Modern Healthcare by Paul Demko
The vast majority of employers will continue to offer workers health insurance coverage in the coming years, but many will alter the way they deliver those benefits, according to a new survey by Aon Hewitt. Of the 1,230 companies surveyed, employing more than 10 million workers, 95% indicated that they expect to continue offering employees health insurance coverage during the next three to five years. But a third of those companies stated that they expect to use a private exchange in the future to allow employees to pick a health plan that fits their needs. That would be a significant spike from the 5% that said they do so now. Altogether, roughly 70% of companies surveyed indicated that they expect to provide a benefits package that gives workers some choice in what type of plan they enroll in, compared with 45% that said they currently require employees to select coverage.
7) Akansas’ Private Option Medicaid Alternative Bill Fails Again
from Modern Healthcare by Virgil Dickson
The Arkansas House failed for the second consecutive day to approve legislation to fund the state’s compromise private-option alternative to Medicaid expansion, even as other Republican-controlled states consider similar approaches. Arkansas House Speaker Davy Carter, a Republican, vowed that the House will keep voting on the measure until it passes. The legislative session ends March 1. There is no limit on how many times the bill can be voted on, said Matt DeCample, a spokesman for Gov. Mike Beebe, a Democrat. The private-option plan allowed the state to buy private insurance for Arkansans with incomes of up to 138% of the federal poverty level, using federal Medicaid money. An appropriations bill that would have funded the option for another year needed 75 votes to pass the 100-member house, but only received 68 Wednesday, two fewer than what the bill got Tuesday.
Providers
8) Uninsured Trauma Patients May Get Better Hospital Care
from USA Today by Kim Painter
Lacking health insurance usually means getting worse health care, but that may not be true when it comes to a traumatic injury, a new study suggests. The study, published Wednesday in JAMA Surgery, found that uninsured patients with severe injuries – the kind commonly associated with car crashes, serious falls and gunshots – were significantly more likely than insured patients to be transferred out of hospitals not specializing in trauma care. It’s most likely that those patients made their way to trauma centers, hospitals set up to handle such cases and proved to save more lives, researchers say. “This is one scenario where the uninsured may not be worse off,” says lead author M. Kit Delgado, a specialist in emergency medicine at the University of Pennsylvania.
9) Partners’ South Shore Bid Would Raise Costs, Not Quality, Panel Says
from Modern Healthcare by Melanie Evans
Partners HealthCare System’s proposed acquisition of South Shore Hospital and a physician group would raise costs and do little for the quality of healthcare, the Massachusetts Health Policy Commission concluded in its first transaction review under the state’s 2012 healthcare cost-control law. The deal would drive up health spending by as much as $26 million a year based on cost projections for the state’s three largest commercial insurers, the report said (PDF). There was not enough proof that quality—already high for both organizations—would improve, the commission concluded. The panel, created under a law that seeks to hold state spending in line with or below Massachusetts’ economic growth, said it would refer the transaction to the state attorney general.
10) Groups Call For Safe Reduction of C-Sections
from USA Today by Liz Szabo
In a bid to reduce rates of cesarean sections that have climbed more than 60% in the past 15 years, two major medical societies issued guidelines today that urge women and doctors to have more patience during labor, allowing nature to take its course rather than rushing to surgery. The growing use of C-sections, accounting for one-third of all deliveries in the USA, has raised concerns on a number of fronts. Although the surgeries are performed out of caution for newborns, they sharply increase the risk of complications and death for women. The death rate is more than three times higher in mothers who undergo C-sections – 13 deaths per 100,000 women – than in those who deliver vaginally, according to the new report, issued by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine.
11) Acute Care Hospital Prices Flat in January
from Modern Healthcare by Melanie Evans
Acute-care hospital prices as measured by the Producer Price Index were nearly flat in January, federal data show. Hospital prices increased 0.1% last month, according to preliminary figures, compared with 0.7% during the same month a year ago. The Producer Price Index is the broader of two inflation measures released by the Bureau of Labor Statistics. It gauges the change in reimbursement paid to hospitals. The Consumer Price Index, an alternative measure of inflation that generally looks at retail price inflation, tracks changes in commercial insurance reimbursement. Figures for the Consumer Price Index are expected to be releasedThursday. During the 12 months that ended in January, acute-care hospital prices increased 1%, the preliminary figure shows, compared with an increase of 2.9% the prior year.
12) Duke CEO Dzau Named President of Institute of Medicine
from Modern Healthcare by John Frank
Duke University Health System President and CEO Dr. Victor Dzau was named president of the Institute of Medicine, succeeding the longtime president, Dr. Harvey Fineberg, the National Academy of Sciences announced Wednesday. Dzau, whose six-year term will begin July 1, has done research in the area of treatment for high blood pressure and congestive heart failure and pioneered the use of gene therapy for vascular disease, the institute said in announcing the selection. Dzau served on the IOM Council from 2008 through 2013, Fineberg said in a statement.
Pharma/Biotech/Device
13) Bayer, Novartis, Others Eye Merck’s Consumer Health Unit
from Reuters by Olivia Oran, Soyoung Kim and Anjuli Davies
A handful of consumer and healthcare companies including Bayer AG and Novartis are exploring a deal for Merck & Co Inc’s consumer healthcare business, as they seek to gain scale in a fragmented industry, according to several people familiar with the matter. Reckitt Benckiser Group PLC and Procter & Gamble Co are also among the parties that have held discussions with Merck about buying the unit, best known for Coppertone sunscreen and Claritin allergy medicine, the sources said this week. The Merck business, which also includes Dr. Scholl’s foot care and other consumer products, could be worth $10 billion to $12 billion in a potential sale, the people said, asking not to be identified because the process is private.
14) Scientists Struggle to Replicate Stem-Cell Research Breakthrough
from Wall Street Journal by Gautam Naik and Alexander Martin
Scientists say they are struggling to replicate a new approach for creating stem cells, raising further questions about the breakthrough technique whose announcement garnered international attention. The experiments have come under increased scrutiny after Japan’s Riken research institute, where the work took place, opened an investigation last week into whether there were any irregularities in images used in two scientific papers describing the stem-cell technique using mouse cells. Human stem cells can turn into any type of body cell, potentially providing new treatments for numerous ailments, but existing ways to create them entail the risk of cancer or can raise ethical concerns because they involve embryos.
15) Cancer Immunotherapy Treatment Shows More Promise
from Wall Street Journal by Ron Winslow
A technique to genetically modify a patient’s own immune cells eradicated tumors in 14 of 16 patients with advanced leukemia—at least for a time—in a study that adds to growing enthusiasm for efforts to enlist the body’s immune system in the fight against cancer. The findings, from researchers at Memorial Sloan-Kettering Cancer Center, also add fuel to an emerging race to bring new so-called cancer immunotherapy treatments to the market. Juno Therapeutics Inc., a Seattle startup, is preparing to launch a mid-stage, or phase 2, study of the treatment based on the results of the new study. Novartis SA plans a phase 2 trial of a similar strategy developed at the University of Pennsylvania. The patients, all adults, were diagnosed with acute lymphoblastic leukemia, or ALL, an especially aggressive disease, and all had relapsed after standard therapy.
16) Lilly Lung Cancer Drug Improves Survival in Late-Stage Trial
from Reuters by Esha Dey
An experimental cancer drug developed by Eli Lilly and Co, touted by some to be the company’s next blockbuster, significantly improved survival rates in lung cancer patients, sending the company’s shares up 3 percent in early trading. Lilly needs new drugs to offset declining sales of its older drugs as they lose patent protection. Ramucirumab, designed to treat multiple cancers, has the potential to generate annual sales of $1.5 billion by 2020, according to some analysts. The drug has already been shown be successful in treating stomach cancer, and Lilly is waiting for approval from the U.S. Food and Drug Administration to market it for that disease.
17) Avastin Prolongs Survival in Advanced Cervical Cancer
from USA Today by Liz Szabo
The drug Avastin helps women with advanced cervical cancer live nearly four months longer, according to a new study that’s predicted to change the standard of care for the disease. Women who combined Avastin and chemotherapy lived a median of 17 months after diagnosis, while those who received chemo alone lived 13.3 months, according to a study of 452 women in the New England Journal of Medicine. Just two decades ago, women with advanced cervical cancer lived only eight or nine months, says lead author Krishnansu Tewari, a professor of gynecologic oncology at the University of California Irvine Medical Center. Giving patients more time is especially important, given that women in the study were relatively young, in their 40s and 50s, Tewari says.
Health IT
18) More Cyberattacks Target Healthcare Organizations
from Modern Healthcare by Rachel Landen
Healthcare organizations are increasingly under attack from cybercriminals seeking to gain access to patient data and to Internet-connected medical devices, according to a report released today. Devices and networks at 375 healthcare-related organizations were compromised between September 2012 and October 2013, according to the Health Care Cyberthreat Report, published by San Mateo, Calif.-based cybersecurity firm Norse Corp. and the SANS Institute, a security research institute in Bethesda, Md. That includes breaches that result in everything from the exposure of patient data to the potential exploitation of radiology imaging software, videoconferencing systems and mail servers. The majority of those targeted were healthcare providers, although health plans and pharmaceutical companies have also been attacked. And not all of the victims are even aware that their systems are under siege.
19) CMS: Full ICD-10 Testing Coming This Summer
from Medpage Today by David Pittman
Federal health officials will conduct end-to-end testing of ICD-10 billing code submissions with a limited number of providers this summer, the Centers for Medicare and Medicaid Services (CMS) announcedWednesday. “The small sample group of providers who participate in end-to-end testing will be selected to represent a broad cross-section of provider types, claims types, and submitter types,” the CMS announcement read. Details about such testing will come later, CMS said. CMS had previously said it wouldn’t do such testing for the bill-coding system which goes live Oct. 1, saying it was confident its current testing was sufficient.
20) Computer Woes Hit Banner Hospital System
from USA Today by Ken Alltucker of The Arizona Republic
Banner Health grappled with a widespread computer outage Wednesday as hospitals and doctors resorted to backup paper systems to provide care for patients. The Phoenix-based health system did not immediately know what triggered the computer troubles that started just before 10 a.m. PST. An official described the computer troubles as a rolling outage of computer systems at hospitals and other health care facilities in Phoenix, Colorado and Nevada. By late Wednesday, a spokesman said, technicians had identified the problem and were fixing it. They expect to investigate the root cause of the problem Thursday.
AHIP’s National Health Policy Conference: ACA and the Year Ahead, March 5-6 in Washington, D.C., will convene key Administration andstate officials, Members of Congress, and the foremost health care thought leaders and health insurance industry professionals to provide high-level insight, analysis and policy recommendations on health care issues and trends. Don’t miss this timely opportunity to engage andshare ideas with industry experts and vested stakeholders. Register today.
OPINIONS, EDITORIALS, PERSPECTIVES
Wall Street Journal
21) The Medicare Advantage Democrats
from Wall Street Journal by Editorial Board
Democrats in competitive races seem to have gotten hall passes to try to dissociate themselves from ObamaCare heading into the midterm elections, but the White House must be ruing some of the liberties their party comrades are taking with this new political independence. Witness the parade of Democrats pleading for more money for that great liberal anathema, Medicare Advantage. The Affordable Care Act was expressly designed to restrict this successful and increasingly popular George W. Bushprogram that now provides 28% of seniors with private insurance options. But some Democrats are suddenly discovering reservations about this now that the law and the Administration’s regulations are starting to restrict patient choice and harm beneficiaries. Nineteen Democrats joined 21 of their Senate Republican colleagues on a letter this week to Medicare administrator Marilyn Tavenner that raises “serious concerns” about the Advantage payment cuts for 2015 that the Administration is expected to announce Friday.
22) Democrats Change Their ObamaCare Strategy
from Wall Street Journal by Karl Rove
Just a few months ago Senate Majority Leader Harry Reid said ObamaCare “will be a net positive” for Democratic candidates in 2014. Former House Speaker Nancy Pelosi proclaimed “Democrats stand tall in support of the Affordable Care Act.” The party’s national chairwoman, Rep. Debbie Wasserman Schultz, predicted “Democratic candidates will be able to run on ObamaCare as an advantage” in the congressional midterms. That was then. Now Democrats are circulating a new strategy memo (obtained by Politico) advising candidates to distance themselves from the law. The new line is that it’s a waste of time to repeal ObamaCare, Democrats are committed “to fixing and improving the law,” and Republicans want to go back to the bad-old days.
Forbes
23) Obamacare, Plus Minimum Wage Hikes, Equals Higher Unemployment
from Forbes by Don Susswein
The Congressional Budget Office has generated huge controversy with its conclusion that the Affordable Care Act will tend to discourage work among lower wage workers. An even bigger controversy may be buried in their analysis of the effect on the demand for low-wage workers. According to the CBO, the new penalties on employers who fail to offer health benefits “will initially reduce employers’ demand for labor and thereby tend to lower employment.” That sounds like a clear warning of job losses to come. But note their cautious use of the term “initially.” What happens next? The CBO explains that generalized job loss is only a temporary problem. Why? Over time, employer demand will stop declining because employers will shift these new health care costs to workers in the form of reduced cash wages.
National Journal
24) The Obamacare Enrollment Crash Is Coming
from National Journal by Sam Baker
Obamacare’s enrollment numbers are surging—for now. After a disastrous launch, the law’s backers are breathing a sigh of relief as enrollees flock to its insurance exchanges. But the totals are built on a shaky foundation, and at some point soon, the exchange enrollment figures are going to fall, perhaps by more than 1 million people.Right now, the administration is counting the total number of people who have selected an insurance policy under the law, rather than the number of people who’ve paid for it. But at some point, likely this spring, the administration will be forced to disclose how many people are actually paying their premiums—a more accurate, yet undoubtedly lower count of who actually got insured under the Affordable Care Act. About 20 to 30 percent of people who selected a plan did not make their first payment, according to anecdotal estimates from individual insurance companies. Those numbers aren’t official or final, and could improve—but however they end up, that’s the real measure of Obamacare’s first-year success.
Health Affairs
25) Care Delivery And Coordination In The Accountable Care Environment
from Health Affairs by Susan Block, Vicki Jackson and Thomas Lee
As we enter the world of accountable care, palliative care programs bring tremendous assets to our health care system. Accountable care organizations (ACOs) seek to improve quality and reduce costs for a defined population of patients, and palliative care offers value on both the quality and cost sides of the equation. Partners Health System (PHS), where we currently practice (or recently practiced [TL]), and which encompasses Brigham and Women’s Hospital (BWH), Massachusetts General Hospital (MGH), and affiliated community hospitals, has had a strong and long-term commitment to palliative care. In preparation for the new ACO environment, leaders recognized the contribution palliative care can make to health care “value,” especially in the care of our sickest (and most expensive) patients, invested in enhancing and enlarging our hospital-based programs, and provided new resources to expand the reach of palliative care within the hospital, and, most importantly, in the outpatient setting and the community.
ACA’s Future: The Good, The Bad, and The Ugly. Avik Roy of the Manhattan Institute for Policy Research, and Jonathan Cohn of the NewRepublic, will discuss the politics and fiscal implications surrounding the ACA’s full implementation and certain future. You’ll find this andmore valuable sessions and engaging speakers at AHIP’s National Health Policy Conference: ACA and the Year Ahead, March 5-6 in Washington, D.C. Register today.
RESEARCH REPORTS, ISSUE BRIEFS, CASE STUDIES
North Star Opinion Research
26) HHS Prescription Drug Mandate Hands GOP a 2014 Issue
from North Star Opinion Research by Whit Ayers
A new report by respected former CBO economist Douglas Holtz-Eakin (released by the American Action Forum) shows that an obscure proposed Medicare regulation could offer surprising new ammunition for Republicans in this year’s mid-term elections. According to the report, the Department of Health and Human Services recently decreed that it will not allow most of the existing, low-premium plans in Medicare Part D to be offered again in 2015. That means millions of seniors will be forced out of these popular plans into new, higherpremium plans during “open enrollment” in October — right before the mid-term elections. Seniors are likely to have fewer choices, stingier benefits, and higher costs. This attempt to overhaul Medicare Part D offers big upsides to Republicans and big downsides for Democrats in 2014. Our polling shows that seniors are overwhelmingly satisfied with their current Part D drug benefit plans. They believe the plans cover the drugs they need, are convenient to use, and save them money.
SANS Institute
27) Health Care Cyberthreat Report
from SANS Institute by Barbara Filkins
Virtually all software, applications, systems and devices are now connected to the Internet. This is a reality that cybercriminals recognize and are actively exploiting. Some 94 percent of medical institutions said their organizations have been victims of a cyber attack, according to the Ponemon Institute. Now, with the push to digitize all health care records, the emergence of HealthCare .gov and an outpouring of electronic protected health information (ePHI) being exchanged online, even more attack surfaces are being exposed in the health care field. A SANS examination of cyberthreat intelligence provided by Norse supports these statistics and conclusions, revealing exploited medical devices, conferencing systems, web servers, printers and edge security technologies all sending out malicious traffic from medical organizations. Some of these devices and applications were openly exploitable (such as default admin passwords) for many months before the breached organization recognized or repaired the breach. The intelligence data that SANS examined for development of this report was specific to the health care sector and was collected between September 2012 and October 2013. The data analyzed was alarming. It not only confirmed how vulnerable the industry had become, it also revealed how far behind industry-related cybersecurity strategies and controls have fallen.
Urban Institute
28) The Inevitability of Disruption in Health Reform
from Urban Institute by Judy Feder
The recent furor over policy cancellations in the individual health insurance market demonstrates a long-standing challenge to the enactment, let alone the implementation, of effective health reform. Disruption of the 84 percent of Americans who have health insurance creates a powerful impediment to the extension of insurance to the 16 percent of Americans without it. But despite claims to the contrary, it is not possible to reform our health insurance arrangements without somehow disrupting existing arrangements. The ACA’s disruption, though, is remarkably modest—it is far less disruptive than other coverage expansion strategies, such as single-payer proposals on the left and market-based proposals on the right. And its disruption improves the pooling of risk that is essential to effective insurance. This brief clarifies the realities and political risks of disruption and places the ACA in context relative to other reform proposals.
New England Journal of Medicine
29) Post-Acute Care — The Next Frontier for Controlling Medicare Spending
from NEJM by Robert Mechanic
A striking conclusion from the Institute of Medicine’s recent report on geographic variation in Medicare spending is that post-acute care is the largest driver of overall variation. Medicare pays for post-acute care — short-term skilled nursing and therapy services for patients recovering from acute illness (typically after a hospitalization), provided by home health agencies, skilled nursing facilities (SNFs), inpatient rehabilitation hospitals, and long-term care hospitals. In 2012, Medicare spending for these services exceeded $62 billion. For patients who are hospitalized for exacerbations of chronic conditions such as congestive heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after a patient is discharged as it does for the initial hospital admission Medicare Acute and Post-Acute Care Payments for 30-Day Episodes That Began with a Hospitalization, 2008.). Post-acute care spending for surgical episodes is somewhat lower but still substantial. Medicare payments for post-acute care have grown faster than most other categories of spending.
30) The Hospital-Dependent Patient
from NEJM by David Reuben and Mary Tinetti
Approximately 20% of Medicare patients who have been hospitalized are readmitted within 30 days, with substantial implications for outcomes and costs of care. Many reasons have been identified, including poor transitions from the hospital setting, lack of medication reconciliation, inadequate access to medical services after discharge (e.g., timely postdischarge appointments with primary care physicians and specialists), and lack of accountability regarding which clinician is responsible after discharge. The problem has been conceptualized as a failure of the health care system to fulfill its responsibility to provide comprehensive, coordinated, and continuous care. Accordingly, the Centers for Medicare and Medicaid Services began to invoke penalties for readmissions of patients who have been discharged after hospitalizations for selected diagnoses. Hospitals and health systems are responding with innovations such as care coordinators, postdischarge pharmacists, care-transition coaches, and after-hours clinics. Although these efforts aimed at system-level problems do reduce the rate of preventable readmissions, there remains another more intractable cause of readmissions — hospital-dependent patients.
31) Post-Acute Care Reform — Beyond the ACA
from NEJM by Clay Ackerly and David Grabowski
Mrs. T. is an 88-year-old woman who lives alone, has a history of congestive heart failure and osteoarthritis, and has traditional fee-for-service Medicare coverage. One day, she was found lethargic and sent to the emergency department, where she was discovered to be in renal failure and was admitted to the hospital for fluids and monitoring. Her hospitalist concluded that she had accidentally overdosed on Lasix (furosemide). On hospital day 2, Mrs. T. was having difficulty ambulating, although her cognition and renal function had improved and she felt “back to her old self” and was eager to go home.