Archive for: May 2013

Medicaid Expansion Could Provide 1.3 Million Veterans with the Care America Owes Them

May 30, 2013, 2:16 PM, Posted by Brent Thompson

military soldier soluting

This past weekend, many of us enjoyed a great Memorial Day holiday filled with family, fun, and backyard barbecues.

Others, such as National Journal's Major Garrett visited somber war memorials. In his “All Powers” column, Garrett writes poignantly and passionately about our combat veterans—reflections inspired by a visit to the Vietnam Veterans Memorial wall in Washington.

In How We Could Do More For Our Vets, Garrett writes about the health struggles of his cousin, a Vietnam vet, and the level of care that our nation owes to a generation of Iraq and Afghanistan war veterans.

Garrett’s thought-provoking piece is worth your time.

As I read his column, I was reminded how surprised I was earlier this spring when I read an RWJF/Urban Institute report on the prospects for covering 1.3 million uninsured veterans and their families under the Affordable Care Act (ACA).

Wait just a second, I thought. All the brave men and women who put their lives on the line for our country have access to the health care they need through the Department of Veterans Affairs (VA), right?

Wrong.

According to Urban’s Jennifer Haley and Genevieve Kenney, “priority is based on service-related disabilities, income, and other factors. Many low-income veterans eligible for VA care may not live close to VA facilities or may not know that VA care is available. Most spouses of veterans do not qualify for VA care, and many also do not qualify for Medicaid under the current requirements, which vary by state.”

But there is good news. The ACA’s Medicaid expansion means a “substantial increase in Medicaid eligibility for uninsured veterans,” according to the authors. In other words, 1.3 million vets could be in a position to secure public health insurance beginning in 2014.

Unfortunately, less than half of these uninsured vets will actually receive coverage because they live in states that are likely to reject Medicaid expansion. Wow.

It might be too much to ask Americans to add policy articles to their summer reading stack, but I urge you to spend a few minutes with Garrett's piece and the RWJF/Urban Institute report.

And when you do, think about what America’s veterans deserve from our nation.

Brent Thompson is a communications officer working with RWJF's Coverage team.

To End Readmissions, Look to a Wired Community

May 30, 2013, 1:14 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

What does it take to keep the sick and elderly from spinning through the revolving doors of the nation’s hospitals? Answer: A village.

Although avoiding unnecessary hospital readmissions is typically framed as an issue for hospitals, it’s more accurately seen as an issue for entire communities. One in five Medicare beneficiaries now end up back in the hospital within 30 days of discharge, at an estimated cost of more than $17 billion annually. It will take local health care communities working together to keep more of those patients at home, or at the very least, in a less acute care site.

A recent report from the Robert Wood Johnson Foundation, The Revolving Door: A Report on US Hospital Readmissions, profiles cases that make the point.

  • Eric was discharged from the hospital after being treated for chronic obstructive pulmonary disease, yet he didn’t fully understand how to use his inhaler and continued to smoke. He soon ended up back in the hospital. Whose responsibility was it to make sure that the cycle didn’t repeat itself? As it happened, his health plan eventually flagged him as at risk for readmission and he received regular follow-up care, such as smoking cessation classes, and having to answer five questions a day from his care team so they could monitor his breathing. 
  • Barbara, who has type 2 diabetes, was hospitalized with her blood sugar out of control, and then discharged without understanding how to administer her insulin properly or maintain an appropriate diet. Like Eric, she was one of the 50 percent of newly discharged Medicare patients who don’t see a primary care clinician or specialist within two weeks of leaving the hospital. Whose job was it to get her that appointment? It took a trip back to the hospital before she met with a dietitian and learned how to administer and adjust her insulin.

To crack down on avoidable readmissions, Medicare began penalizing hospitals last year if patients with three conditions—pneumonia, congestive heart failure, and heart attack—were readmitted within 30 days at rates above certain thresholds. At least two other federally sponsored efforts, the Partnership for Patients and the Community-Based Care Transition Program have also worked over the past several years to reduce avoidable readmission rates. A third, the Beacon Community Cooperative Agreement program, is now shedding a bright light on how communities can best use information technology in the process.

The Beacon program was part of 2009 federal legislation aimed at boosting adoption of electronic health records (EHRs) and other health information technology. Seventeen communities won three-year grants totaling  $250 million to use EHRs, and exchange of digital information among health care providers, to improve health and health care. Three of the communities—Cincinnati, Detroit and Western New York—are closely linked to the RWJF’s Aligning Forces for Quality efforts in those same communities.  

One tool that Beacon has tested is electronic alerts that originate in a hospital’s information system when patients undergo a change in status—for example, when they are admitted to the hospital, discharged, or transferred to another facility such as a nursing home. If the community has a health information exchange system, the message is processed and turned into an ADT alert, then sent to a primary care doctor or care manager. These professionals can then step in to smooth the transition and make certain that chronically ill patients get the attention they need.

Use of ADT alerts has been shown to deter unnecessary visits to the emergency room and initial as well as repeat hospitalizations. But communities must do a lot of hard work, together, to put them in place. They have to forge agreements with technology vendors, adopt data use agreements among providers, and undertake measures to protect patients’ privacy.  What’s more, primary care physicians usually have to adapt the way they practice medicine, becoming far more proactive rather than reactive.

Fortunately, even as the Beacon program draws to a close in September, the 17 communities have banded together as the “Beacon Nation” to share the lessons they’ve learned with others. The group recently released the first of eight learning guides, this one to help communities improve care transitions using the ADT alerts. (Full disclosure: Along with my foundation colleague Michael Painter, I serve as one of 14 unpaid members of an advisory committee to the Beacon Nation group.)

Following the steps in the learning guide isn’t simple, but the take-home message is, says Farzad Mostashari, head of the Office of the National Coordinator of Health Information Technology, which oversees the Beacon program. “What the guide teaches us is that it’s not all about the technology,” he says. “Incorporating the technology with the people [in the community]—that’s the lesson.”

In other words, welcome to today’s high-tech health care villages—where lots of dedicated people and communities are coming together to achieve the Triple Aim.

Rebuilding Health Communities After Disaster

May 28, 2013, 4:30 PM, Posted by Risa Lavizzo-Mourey

Risa Lavizzo-Mourey RWJF President and CEO Risa Lavizzo-Mourey, MD

It is a testament to the American spirit that less than a day after a tornado brought a 20-mile-wide swath of death and destruction to Moore, OK, public officials and residents unequivocally pledged to rebuild the community. “We will rebuild and we will regain our strength,” Gov. Mary Fallin told a news conference after viewing the devastation. Similar assertions were made after Hurricane Sandy wiped out entire neighborhoods on the New York and New Jersey coasts eight months ago, and will surely be made again and again after future natural disasters.

I applaud the can-do determination. But I also suggest that we take a minute and think, not just about rebuilding, but creating something better. Why not rebuild communities where health and wellness is a top priority?

That's according to RWJF President and CEO Risa Lavizzo-Mourey, MD, in her latest post on the professional social networking site LinkedIn. Dr. Lavizzo-Mourey is one of about 300 LinkedIn Influencers writing for the site.

Dr. Lavizzo-Mourey writes:

Imagine rebuilding neighborhoods that make healthy living an easy and fun choice, that offer more places to safely walk or bike, more open spaces where families can exercise and play, and more restaurants that offer healthy choices and provide nutritional information on their menus.

To learn how New Orleans successfully rebuilt a healthier environment after Hurricane Katrina read the rest of the LinkedIn post here

Avoid SNAP Judgments

May 22, 2013, 11:41 AM, Posted by Culture of Health Blog Team

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Almost 48 million Americans receive benefits from the Supplemental Nutrition Assistance Program—SNAP, for short. This federal entitlement program helps low-income Americans purchase food for their families, and it encourages healthy eating habits.

Writing in the Huffington Post, RWJF Senior Vice President James S. Marks, MD, MPH, says SNAP's benefits to society are clear, in spite of arguments to the contrary. For every dollar spent on federal food aid, he says, benefits generate $1.72 in economic activity. Of course, SNAP principally helps families alleviate hunger, reap critical nutritional benefits, and combat the nationwide obesity epidemic.

Unfortunately, federal lawmakers are considering ways to take a bite out of SNAP. Two million people would lose food assistance, and more than 200,000 children would stop receiving free school meals under a version of the Farm Bill recently passed by the House Agriculture Committee, Marks asserts. A Senate bill would cut less, he adds, but the reduction in benefits and more stringent eligibility requirements would still be substantial, and damaging to the public's health.

"Fortunately, there is still an opportunity for Congress to chart a different course," Marks suggests. "As we strive for a full economic recovery and a healthier nation, supporting SNAP is both the right thing to do and the smart thing to do."

Read the blog post

Sorting Out the Meaning of Hospital Pricing Disparities

May 21, 2013, 12:57 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer: Toward a Healthier America

What does U.S. health care have in common with an exotic international bazaar? The prices at either one are almost never posted, whether for a heart bypass operation or an antique rug. And the final price will almost certainly have little to do with the seller’s opening bid.

The nature of the U.S. medical bazaar was laid out earlier this month when the Centers for Medicare and Medicaid Services (CMS) released the prices billed to Medicare by more than 3,300 hospitals for 100 of the most common conditions or procedures. Not only was there wide variation in what hospitals charged, but there was also considerable variation in what Medicare actually paid—even though  hospital payment rates have been set prospectively, based on nearly 800 so-called diagnosis related groups (DRGs) for 30 years.

View full post

Why Employers Should Take a Healthy Interest in Employee Wellness

May 16, 2013, 11:18 AM, Posted by Risa Lavizzo-Mourey

Risa Lavizzo-Mourey

Employers finance the largest share of the nation’s health care costs. If they want to hold down medical spending—and reap the other benefits associated with better employee health, such as reduced absenteeism—then investing in wellness is one of the smartest business decisions companies can make.

That's according to RWJF President and CEO Risa Lavizzo-Mourey, MD, in her inaugural post on the professional social networking site LinkedIn. Dr. Lavizzo-Mourey is one of about 300 LinkedIn Influencers.

Dr. Lavizzo-Mourey writes:

Cold, hard data on the success, or failure, of a wellness program, derived from credible and transparent measurements will not only increase staff morale and quantify the value of their personal investment, it will also generate a trove of information that can and should be used by employers to extract reduced insurance rates."

Susan Dentzer: Toward a Healthy America

May 9, 2013, 4:38 PM, Posted by Susan Dentzer

Susan Dentzer Susan Dentzer

Many of the nation’s health economists are reviewing recent history to figure out what factors, besides the weak economy, might have caused health spending to slow over the past few years.  That’s a useful exercise, of course, but it’s even more crucial that we be hyper alert to the rocky health spending ahead—particularly as millions of Americans prepare to gain health coverage under the Affordable Care Act.

Towards that end, the Robert Wood Johnson Foundation recently teamed with several other nonprofits to fund four major analyses on health costs. The resulting reports, listed below, offer strategies for achieving a sustainable rate of growth of health spending, up to a trillion dollars’ worth of federal savings over a decade, and major improvements in the care provided to Americans.

In an era characterized by a lack of national consensus on so many pressing issues, these reports have a surprising amount in common. Each calls for even greater acceleration of the move away from fee-for-service payments to health providers, and toward payments pegged to improved health outcomes.  Almost all the reports propose major changes in Medicare and Medicaid, as well as extending payment and reforms to the privately reimbursed segments of the health care system.

Four reports do not a national groundswell make, but they could do provide the rationale for federal legislation, regulations and private sector system transformation that could further constrain health spending while improving care.

Medicare. Most of the reports envision fixing aspects of the traditional Medicare and Medicare Advantage programs, while simultaneously engaging in far broader reforms.

For example, the National Commission report proposes jettisoning Medicare’s troubled physician payment formula, asserting that it “has not worked in practice and shows no prospect of ever working.”  The Bipartisan Policy Center proposes replacing the formula with episode-based or case-based payments tied to quality measures, again breaking the longstanding link to fee-for-service, while The Partnership for Sustainable Health Care report calls for gearing Medicare payments for new treatments to their effectiveness relative to other treatment options already available.

As for the people those programs cover, both the Bending the Curve and Bipartisan Policy Center reports propose a new benefit structure for the traditional Medicare program that would better protect patients from catastrophic costs while imposing a combined $500 deductible for hospital and physician services.  Higher income Medicare beneficiaries would pay higher premiums. And to encourage more appropriate use of care, there would be no more “first-dollar” coverage available in Medigap supplemental insurance – only coverage with a deductible of at least $250, and a limit on covering no more than half of an enrollee’s Medicare copayments or coinsurance.

New Care Systems. More important, the reports recommend that all of Medicare transition to a dramatically new system of care provision and payment.  The Bipartisan Policy Center uses the terminology “Medicare Networks; Bending the Curve calls it “Medicare Comprehensive Care,” and says it would build heavily on emerging accountable care organizations. Providers would be paid capitated rates for assigned patients, and would have to meet a set of quality and performance measures to receive full payment.  These payments would grow over time no faster than the overall economy.   Within five years, Medicare beneficiaries could be encouraged to join these organizations through incentives, such as reductions in Medicare premiums and copayments.

Tax and Antitrust. The reports also agree on a need to cap the federal tax exclusion for employer-provided health insurance.  Taxing individuals on any employer contributions to fund the most expensive health would both raise revenue and curb some of the inducement for greater consumption of health care. What’s more, the reports argue that federal antitrust enforcement should block hospital consolidations that simply give the institutions greater power to raise prices, but encourage such mergers if it results in integrated delivery systems that take on financial risk for delivering inferior quality or excessive costs.

Medical Liability. This favorite issue of physicians is also addressed, with several of the reports recommending major changes in medical liability that would sway doctors away from providing excessive care meant to prevent lawsuits.  One recommendation is for so-called “safe harbor” protections for clinicians who effectively practice recognized standards of care, and call for replacing tort claims with a new system that would directly compensate injured patients.

Of course, if effectuating any of these changes were easy, it would already have happened. Enacting any of these proposals will run up hard against defenders of the status quo. But change begins with a groundswell of agreement around what is possible and desirable.  These reports provide an important starting point for the next round of serious health care reforms.

About the Culture of Health Blog

May 9, 2013, 12:53 PM, Posted by Culture of Health Blog Team

Health and health care now occupy a well-deserved place of prominence in the national conversation. Prompted in part by the debate over health reform, we are now starting to examine and question virtually everything we know, or thought we knew, about our health care system—and our own roles and responsibilities as users of that system.

What we’re seeing is a marked shift away from blithe acquiescence to the status quo, and toward creating a "culture of health."

But what does that mean?

Risa Lavizzo-Mourey, MD, president and CEO of the Robert Wood Johnson Foundation, put it best in a recent lecture to medical professionals at the Johns Hopkins University School of Medicine:

“What we foresee is a vibrant American culture of health:

  • Where good health flourishes across geographic, demographic, and social sectors.
  • Where being healthy and staying healthy is an esteemed social value.
  • And everyone has access to affordable, quality health care.

“In this national culture of health…

  • Individuals, businesses, government, and organizations will foster healthy communities and lifestyles.
  • The economy will be less burdened by excessive and unwarranted health care spending.
  • Individuals will be proactive in making choices that lead to a healthy lifestyle.
  • And efficient and equitable health care will deliver optimal patient outcomes.

It will be a given that…

  • The health of the population guides public and private decision-making.
  • And, Americans will hold public leaders and policy-makers accountable for the community’s health.

At the Robert Wood Johnson Foundation, we are committed to this vision, and we are in it for the long haul. In this blog, we will regularly share our thoughts and ideas on how best to realize this vision, and we invite you to take part in the conversation.