Feb 18, 2014, 10:32 AM, Posted by
The Academy Awards are just a few short weeks away, much as is the end of this year’s open enrollment period for the health insurance exchanges. We health policy geeks who also love movies can now give out our own award—for the film that most closely resembles the rollout of the marketplaces under the Affordable Care Act.
As far as I’m concerned, there’s only one real candidate: “Gravity,” the science-fiction space drama directed by Mexican-born Alfonso Cuaron and starring the actors Sandra Bullock and George Clooney.
The film wins because its big themes are the same ones reflected in the experience of the exchanges: the omnipresence of Murphy’s Law and human perseverance overcoming calamity. What’s more, gravity—the real star of “Gravity”—is a universal force that can’t be overcome (and is one of the few scientific aspects of the movie that the critics agree the filmmakers got right). Is it too much to see a parallel to the Affordable Care Act’s coverage expansion, which is inching forward despite the formidable odds stacked against it?
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Jan 27, 2014, 6:28 PM, Posted by
RWJF recently convened a panel of distinguished guests for a Google+ Hangout to examine targeted interventions that could help America’s youngest children live healthier, happier, and safer lives. Here's an archived version of the Hangout.
"It is easier to build strong children than to repair broken men," wrote Frederick Douglass, the 19th century African-American social reformer, writer and orator. A century and a half later, to improve the health of Americans, it's essential to start with kids.
That’s a preeminent conclusion of the new report of the RWJF Commission to Build a Healthier America called Time to Act: Investing in the Health of Our Children and Communities. The report focuses on ways to influence the upstream determinants of Americans' generally poor health, including low levels of education and incomes, unsafe environments, and non-nutritious food. Of the panel's three top recommendations, the first is distinctly child-centric: "Invest in the foundations of lifelong physical and mental well-being of our youngest children." Were he alive today, Douglass would surely agree.
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Jan 16, 2014, 5:23 PM, Posted by
“Past performance is no guarantee of future results,” goes the boilerplate warning on financial investments. The caution is worth keeping in mind in the wake of a recently published study that found that expanding Oregon’s Medicaid program in 2008 led to a 41 percent increase in emergency department (ED) use by many of those newly covered by the program.
The study, by an esteemed group of researchers (some of whom are affiliated with the National Bureau of Economic Research) is the latest to emerge from the Oregon Health Insurance Experiment. This series has focused on the effects of 2008-2009 policy changes that led thousands of previously uninsured Oregonians to enroll in Medicaid. The latest study found that costly visits to the ED rose across the board over a two-year period, including for relatively simple conditions, such as headaches, that could easily have been treated in primary care settings.
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Dec 9, 2013, 4:33 PM, Posted by
- Transparency is an idea whose time has come—in large part because U.S. consumers are feeling so much pain from higher health costs. Health economists have long noted that U.S. health care prices are out of whack and that hospital chargemasters are nonsensical. Recent media coverage of these phenomena has captured widespread attention, perhaps because consumers are being hit so hard in the pocketbook. Since 2000, rising prices of hospital charges, professional services, drugs, devices and administrative costs, are responsible for 91 percent of the increases in health spending. Meanwhile, consumers’ out-of-pocket spending on health care, estimated at $329 billion this year, is projected to rise to $411 billion in 2020—a 25 percent increase. Almost three in five workers in small firms, and one in three workers in larger firms, are in a health plan with a deductible of at least $1,000 for single coverage, and in 2012, nearly one of five U.S. adults was contacted by a collection agency over unpaid medical bills.
It’s well established that much of this money is being spent on health care of questionable value. With so much of their money—and their well-being—now at stake, “People are going to impose transparency on the health care industry,” predicted Leah Binder, a conference participant who heads the Leapfrog Group.
- Consumers and patients deserve to know far more about the costs and quality of care, but unless the two are linked, the public may continue with its longstanding delusion that the more expensive the care, the better the quality. Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, noted that this widespread consumer misapprehension constitutes a “perverse incentive” for providers to continue to raise prices. Meanwhile, evidence of poor quality abounds. Martin Makary, a Johns Hopkins University physician and author of Unaccountable: What Hospitals Won’t Tell You And How Transparency Can Revolutionize Health Care, reminded the conference that preventable adverse events in hospitals are now the nation’s third leading cause of death annually. Many highly esteemed medical centers that end up routinely on “best hospital” lists don’t make the Joint Commission’s tally of top performers on basic quality and safety measures.
Conference speakers agreed that there’s a pronounced need to combat these trends by developing more and better quality measures—especially those capturing care outcomes, and in particular, the outcomes that are most important to patients. Providers’ scores on these measures should then be funneled to purchasers and the public. “When consumers can really start to see that this hospital is better than this other hospital, or this doctor is better than that doctor, they will start to move,” said Bill Kramer, executive director for national health Policy at the Pacific Business Group on Health.
Promising prototypes of the platforms that could communicate such information include winners of the RWJF Hospital Price Transparency Challenge—for example, Consumer Reports’ Hospital Adviser: Hip & Knee, which combines hospital quality rankings with Medicare cost data to help consumers pinpoint high value institutions where they could obtain surgery.
- Fostering greater transparency will be a long process, but there could be relatively quick “wins.” Many contracts between health insurers and providers contain “gag clauses” that bar both parties from disclosing claims data or prices paid for care. The clauses appear to serve both parties’ interests—helping to protect health plans’ proprietary interests in the provider networks they’ve established, and providers’ desire not to disclose how little they are willing to be paid. California has outlawed such clauses in health plan contracts, and many conference attendees agreed that other states should follow suit.
What’s more, a total of 16 states have set up mandatory or voluntary all-payer claims data bases (APCDs) to pool statewide data on diagnoses, procedures, care locations, and provider payments. Conference participants agreed that more states should enact mandatory APCD’s, or use the regulatory authority in state insurance laws to compel insurers to issue payment and pricing data, as was done in Rhode Island. More states could also follow the lead of Maine Quality Counts, the private, independent nonprofit organization that leads the RWJF-sponsored Aligning Forces for Quality coalition in the state, and which has aggregated health plan data for purchasers, consumers and providers to promote transparency on quality and cost.
- Transparency in the hands of consumers could be powerful—but in the hands of providers, even more so. Health care providers themselves often lack information about the quality and costs of their care. In particular, transparency can focus attention on the extreme amount of variation among providers in the care they provide. Glenn Steele, president and CEO of Geisinger Health System, described how Geisinger’s physicians came together to define “best practices” across a dozen hospital episodes of care, including heart bypasses, hip replacements, and gastric bypass surgery. As physicians in the system adhered to these guidelines, spending fell, by 20 percent because doctors narrowed the indications for which they agreed that the procedures were warranted, and 15 percent by reducing unnecessary variation.
- Transparency is a necessary but insufficient tool for health system transformation. Openness about price and quality alone is “not going to be enough” to achieve the goals of the Triple Aim, observed Steven Brill, whose Time magazine article in March 2013 gave renewed focus to the issue. Payment reforms and “culture change” that shift providers from a volume-based to-value-based approaches remain critical. What’s more, consumers need to have health insurance benefit designs beyond high-deductible health plans that encourage them to make wise choices, such as “value-based” benefits” that help nudge them toward cost-effective care delivered by low-cost, high quality providers. Others at the conference warned that regulators must stay attuned to unintended consequences of health system transformation, such as the consolidation of health care providers that could lead to attempts to jack up prices.
In the end, “We don’t win the game until the care gets better,” observed Jay Want, CEO of WantHealthcare. The nation also must ensure “that the transparency we seek will serve to change the way we think about health and wellness,” said RWJF president and CEO Risa Lavizzo-Mourey. “We need to use our skills, our imagination, our influence, and, yes, our hearts, to transform our nation into one that considers being healthy part of what it means to be an American.”
To that end, transparency about the choices we face as a nation on the costs and quality of health and health care can give our society a critical lens to look within.
Nov 26, 2013, 10:14 AM, Posted by
Watch our December 6, 2013, FirstFriday Google+ Hangout archive on transparency in health care.
Panic about high health insurance premiums. Fears about high-cost health-care providers being cut out of health plan networks. Worries that the health plans now available through health insurance exchanges won’t cover the care that patients need.
Welcome to the rollout of Obamacare....right?
Actually, with the exception of the new health insurance exchanges, all of the phenomena described above have a long history. Similar concerns were voiced loudly in the late 1980s and 1990s, when “managed care” in health insurance became a dominant force on the health care and health insurance landscape.
What’s amazing to people who lived through both of these eras—then and now—is how little has changed.
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Nov 4, 2013, 1:22 PM, Posted by
Amid the attention focused on technology flaws of the nation’s new health insurance exchanges, a happier story has received less attention: the relative ease with which many Americans newly eligible for an expanded Medicaid program are now enrolling in coverage in many states. There’s a lesson in this story for all of us—that governments at many levels can, and often do, get things right. But sometimes it takes years of effort, policy changes, big dollar investments, and improved know-how to make all the processes work.
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Oct 4, 2013, 4:37 PM, Posted by
When the starting gun went off this week for the nation’s health insurance exchanges, millions of Americans began shopping for coverage. For those running the exchanges, or marketplaces, it was the start of a marathon.
That’s the conclusion that emerged from a Health Reporters’ Roundtable that the foundation sponsored in Washington recently. As top officials overseeing three of the state-based exchanges told reporters, signing people up for health insurance is just one of their tasks. Over time, the officials plan to use the power of their exchanges to help drive broader changes to improve the quality and value of U.S. health care.
The foundation-funded State Health Reform Assistance Network is providing technical support to 11 states. Two of those states, Maryland and Rhode Island, were represented at the roundtable—the former by its exchange director, Christine Ferguson, and the latter by Maryland’s secretary of health and hygiene, Joshua Sharfstein, who chairs that state exchange’s board. A third state, California, isn’t receiving help from the network, but was represented by Peter Lee, the director of its exchange, Covered California.
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Aug 20, 2013, 4:32 PM, Posted by
In my last post, I wrote about what would best motivate physicians to transform health care: carrots, sticks or something else. The case for “something else” was made in a series of innovation sessions presented at a recent American Board of Internal Medicine (ABIM) Foundation forum. They focused on evolving health care delivery models aimed at increasing quality, decreasing cost and enhancing patient-centered care.
Readers of Daniel Pink’s book Drive will be familiar with his thesis about “Type I” human behavior: the kind that is less concerned with “the external rewards to which an activity leads and more with the inherent satisfaction of the activity itself.” Many innovations presented at the forum echoed that theme—augmenting the satisfaction that doctors get from focusing most of their attention on helping patients.
Engaging doctors: At the forum, Craig Sammit, the CEO of Wisconsin-based Dean Health noted that “extrinsic” motivators, such as showing doctors how their relative performance data stacked up against their peers, had substantial impact in spurring improvement. But he observed that the measures that were most effective in transforming the way care is delivered at Dean were those that helped make the organization “the best place for a physician to work.”
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Aug 14, 2013, 2:14 PM, Posted by
An old joke has it that the doctor’s pen is the costliest technology in medicine, since money typically flows where physicians’ prescriptions and other orders decide that it should go. As a result, influencing these decisions is key to achieving the Triple Aim of better health and health care at lower cost.
But what’s more likely to influence doctors: external factors, such as bonuses for improving the quality of care, or internal factors, such as appealing to their sense of altruism or satisfaction with their work? In other words, carrots, sticks, or something altogether different—what Daniel H. Pink, author of Drive, calls “our innate human need to direct our own lives, to learn and create new things, and to do better by ourselves and our world”?
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Jul 31, 2013, 9:54 AM, Posted by
Imagine the outrage if an investigation uncovered a decades-old scheme in which hundreds of billions of taxpayer dollars were siphoned off to pay for health care of little to no value. That finding would probably mean that millions of Americans subjected to this unnecessary care could have been harmed as a result.
Guess what? An investigation—actually a new report from the Institute of Medicine—just did "uncover" such a scheme. And much of the original detective work was done by researchers at Dartmouth, supported in part through grants from the Robert Wood Johnson Foundation.
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