The Users' Guide to the Health Reform Galaxy

Moving the Needle on Kids' Enrollment in Public Insurance Programs

Today’s post comes to us from Catherine Hess, Senior Program Director at the National Academy for State Health Policy (NASHP) and Program Director, Maximizing Enrollment for Kids.

Too often, when trying to address problems in our society, we look for a silver bullet – one solution. To the casual observer, last year’s passage of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) might seem like a silver bullet for the problem of uninsured children. Unfortunately, while public insurance programs like the Children’s Health Insurance Program (CHIP) and Medicaid theoretically extend coverage to a wide swath of the uninsured, many who are eligible are not enrolled in these programs.

But we know from research and over a decade of experience with CHIP that there is no silver bullet. There are multiple key strategies, and to be effective, they need to be tailored to different state and local circumstances.

To that end, the National Academy for State Health Policy (NASHP) collaborated with the Robert Wood Johnson Foundation (RWJF) to launch Maximizing Enrollment for Kids, a four-year, $15 million national program that helps states tailor and adopt key strategies to improve enrollment. Our ultimate goal is to “move the needle” to cover many more uninsured children, and we are documenting and sharing what works as we go along. 

We received applications from over half the states for this program, a positive sign of their interest. Eight states demonstrating commitment and vision to maximizing enrollment of eligible, uninsured children were selected: Alabama, Illinois, Louisiana, Massachusetts, New York, Utah, Virginia and Wisconsin.

If this program is successful – and so far, so good – these states will increase the efficiency of their systems. But another simple but particularly remarkable point is that as they improve systems, these states will spend more on covering additional children. Think about that. Even in a nasty budget climate, states want these programs to function at their top potential. This is highly encouraging.

Rx for Primary Care

Sheldon D. Horowitz, M.D., a special advisor to the president of the American Board of Medical Specialties and principal investigator of the Improving Performance in Practice (IPIP) initiative, writes about an effort to give small physician practices the tools they need to improve quality.

Today is National Doctors Day, a day set aside to thank physicians for all they do in applying modern medical science and technology to the special calling of preventing and treating people’s injuries and illnesses. It seems appropriate, then, to recognize a program devoted to helping doctors in primary-care practices do that more effectively.

The program, called Improving Performance in Practice (IPIP), provides practices with tools, support, coaching and a collaborative learning environment in which they can assess their performance and engage systematically in quality-improvement activities using their own practice data. Doctors can also compare their data to others in their cohort groups as benchmarks.

As everyone involved in quality improvement knows, translating the latest and best medical techniques and protocols into practice is easier said than done. That’s especially true for the small offices where 60 percent of U.S. physicians work. Compared to big hospitals and integrated group practices, they typically have fewer resources available for quality-improvement efforts. IPIP fills the resource gap for small practices in seven states by giving them process-improvement kits based on the Chronic Care Model and providing quality-improvement coaches, typically registered nurses, to guide practices through the steps involved in taking full advantage of the program’s resources.

To enroll, practices choose a focus area—asthma or diabetes in most cases—and commit to using a registry or electronic medical records to manage their patient populations, if they don’t already. Then they begin providing monthly data on a set of quality measures covering care processes and outcomes.

Such measurement and reporting are essential. As one Colorado doctor told IPIP staff, “Until I saw my data, I thought I was providing excellent care. Now I see we have a lot of work to do.”

Among other things, coaches help practices improve their division of labor and work flow by relentlessly asking the question: “Is this physician work or non-physician work?” If a doctor isn’t needed for a particular task—say, administering an annual sensory exam to diabetics to test for nerve damage—then someone else in the office should take care of it so doctors can focus on the things that only they can do. These work-flow improvements help practices get more done—and also improve job satisfaction. “I was considering leaving the profession,” Dr. Tracy Hofeditz of Lakewood, Colo., told IPIP staff. “But now I have rediscovered the joy of practicing medicine.”

One key benefit of participating in the program is that it helps practices comply with ABMS Maintenance of Certification®, professional recognition for quality and pay-for-performance programs.

Patients, meanwhile, get more effective care. For example, in the 16-month period between June 2008 and October 2009, Pennsylvania IPIP practices saw a 15-percentage-point increase in the share of diabetes patients with blood pressure of 140/90 or less—an important threshold level to stay below.

That kind of success helps explain why IPIP, which began as a small pilot program in Fall 2006, has quickly grown to serve more than 350 practices with 1,400 doctors and 350,000 asthma and diabetes patients from Colorado to North Carolina.

For more about IPIP, which is sponsored in part by the Robert Wood Johnson Foundation and convened by the American Board of Medical Specialties, download a copy of its recently released program brief.

Health Reformer’s Lexicon: Individual Mandate

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Individual mandate

Similar to the way that auto insurance is required for all drivers, the individual mandate is a provision that requires all Americans to carry health insurance.

Why It Matters: Supporters of the concept believe that the mandate will lead more people to obtain health insurance and push the U.S. closer to universal coverage.

As Laura Meckler of The Wall Street Journal explains,

The thrust is to get everyone into the health-insurance pool so that healthy people, who are cheap to cover, help balance out the sick, who are expensive.

Opponents believe the mandate is unconstitutional and claim that it encroaches on individuals’ personal rights. Others fear that individuals may not be able to afford it.

Roots: The concept originally surfaced in the early 1990s. It was included in the Health Equity and Access Reform Today Act of 1993.

In 2006, Massachusetts introduced an individual mandate that penalizes people who do not have coverage. As a result, the state now has the lowest rate of uninsured residents in the nation – at 2.7 percent, and an increase in the number of people covered under employee-sponsored insurance, but is currently struggling to rein in the overall cost of health care.

Where the Term Appears: The individual mandate appears in the health care bill, which was signed by President Obama earlier this week. According to the language in the bill, the mandate will:

Require U.S. citizens and legal residents to have qualifying health coverage.

Individuals without coverage will be subject to pay a tax penalty that will be phased-in over four years starting in 2014. Certain qualifying individuals will be considered exempt from having to pay these fees.

Exemptions will be granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, if the lowest cost plan option exceeds 8% of an individual’s income, and if the individual has income below 100% of the poverty level.

Although similar, the reconciliation act presents a slightly different tax penalty structure.

Previous Lexicon entries include:
- Accountable Care Organization
- Meaningful Use
- Patient Centered Medical Home

Reactions

Yesterday, I was picking up my children from their afterschool program, and two of the teachers who run the program pulled me aside and said:  “Uh, do you have a few minutes?  We were wondering if you could tell us about health reform—like what, exactly, was in that bill that just passed, and how it will affect us.”

I was astonished.  These teachers know where I work (you have to include that info on the enrollment forms for the program) but I had no idea they knew anything about the Robert Wood Johnson Foundation or, for that matter, what my job is here.  (Which recently changed.)   But getting past my astonishment about the questions, I was also struck by how straightforward and simple their desire was:  they wanted to know more about the health reform legislation.  And, they wanted to know if their lives would change.  In today's 24/7 media spin cycle, you’d have to be deaf, dumb, and blind to not be aware that something was going on related to America’s health care, in the last 14 months, but clearly, so much of what happened with respect to the health reform debate was challenging for the ordinary citizen to understand, especially in terms of what was at stake, for different people.   

I don’t think I have an opinion on whether it’s a good or a bad thing that the bill became law without greater understanding from people like these teachers about what was actually in the bill, even though there are many who would argue one side or another of that question.  First of all, I’ve seen enough policy sausage-making to know that no matter how much you try to get people to understand what’s at stake, and no matter how much you invite comment and input from different perspectives, you’re still gonna get accused of leaving people out.  And it seems reasonable to assume that there was no intentional, diabolical plan to leave people like these teachers out of the debate; it’s more that that health care reform is, by its very nature,  a highly complex topic, and as far as I can tell, many efforts were made to engage different groups, but America’s collective attention span for understanding this issue was a limited commodity, crowded by earthquakes and Tiger Woods. 

A major step forward for better health and health care

When the Robert Wood Johnson Foundation opened its doors as a national philanthropy almost 40 years ago, it appeared that health reform was right around the corner. It looks like history will record 2010 as the year our nation finally turned the corner towards providing coverage for millions more Americans, fixing our broken health care system, and helping us all live healthier lives.

While the Foundation can’t and doesn’t advocate for legislation, we have been advocates of covering all Americans and improving the quality of our health care system from our very first day.  We are driven by our mission: to improve the health and health care of all Americans.  This is a mission that stands the test of time and has guided our efforts over the past four decades to: Cover the uninsured; Improve the quality, value, and equality of health care; Prevent disease and promote healthier lifestyles; and, strengthen public health, and at the same time address the root factors that influence our health so much. 

Today, major health reform legislation will become law.  No legislation is perfect, and I’m not going to get into the specifics of what the legislation does and doesn’t do.  What I can and will say is that this legislation marks a historic milestone on the road to better health and health care, meets the core coverage principles endorsed by the Foundation, and addresses many key areas on both sides of the health and health care equation.

But, just as covering the uninsured alone won’t solve what’s ailing the health care system, the legislation will only be one part of the story—a stop on the long journey we are all on together.  And the destination is not yet in our sights.  The high numbers of uninsured, the staggering rates of childhood obesity, the broken systems of health care and public health that still need re-building—these problems will not vanish with the President’s signature.  It’s a long journey with few rest breaks and plenty of road blocks yet to come.  But it is these achievements along the way that keep us going and get us one step closer to realizing the full promise of our philanthropy and our nation.

The Galaxy Welcomes the Wonk Review

 
Photo used under Creative Commons from j9sk9s

This month, we health care wonks and basketball fans each have our own version of March Madness. As the 2010 NCAA Men’s (and Women’s) Division 1 Basketball Tournament play begins this afternoon, policymakers are hurtling toward what may well be the last round of health care reform. (This week, we at the Foundation are also giving primetime spotlight attention to health insurance coverage issues, as part of our 8th annual Cover the Uninsured Week.)

Like the health reform debate, the NCAA basketball tournament is full of make-or-break, game-changing moments. In the nineties, we watched Chris Webber’s infamous time-out call that led to the end of Michigan’s “Fab Five”, and Christian Laettner’s “buzzer-beater” shot that led to Duke’s ultimate glory. Two years ago, it was “Mario’s Miracle” three-point shot in the last few seconds of regulation game time that led to Kansas’ big OT win against Memphis.

Today, I present you with the latest Health Wonk Review (HWR) – the March Madness edition. For those who may not know, the HWR is a bi-weekly collection of top scoring posts from the health policy world. So with a nod to the tourney’s artful, alliterative lingo – think “Final Four” and “Sweet Sixteen” – we review the health wonk game from the following angles: Players’ Pool, Fans’ Favorites, Referees’ Records, Coaches’ Corner, Commentators’ Color, and the League’s Landscape.

As this edition’s sideline reporter, here’s the highlights reel from the health reform blogosphere.

Players’ Pool
Each team roster is full of players with different styles of game. At the New Health Dialogue blog, Joanne Kenen writes about respecting each player’s perspective for palliative care treatment. 

John Goodman selects a few chronic disease management projects that might deserve the “Most Outstanding Player” award for their work over at his Health Policy Blog.  He takes a shot at RWJF in the elbow, but we're not calling a foul: hard elbows are a part of the game.

Fans’ Favorites
Joan Alker is cheering for team Medicaid in her latest post at the Say Ahh! Children’s Health Policy Blog. Alker notes that Medicaid provides both children and adults access to care, and suggests that increasing reimbursement rates would help us expand the system. 

As ultimate cheerleaders, we cross our fingers and hope that this will be the year our Cinderella team (or cause) rises to the top. This loyalty sometimes clouds our judgment (and perhaps our bracket choices). But over at Managed Care Matters, Joe Paduda asks fans to take a moment and step out of their fantasies, to consider the consequences of expanding coverage now while controlling costs later.

And while there is little doubt that EHRs were the crowd pleaser at this year’s Healthcare Information and Management Systems Society conference (aka HIMSS10), Peggy Salvatore at Healthcare Talent Transformation believes that fans need more guidance on the role of Health IT in future gameplay. 

Referees’ Records
While on the subject of EHRs, EHR Blogger Glen Laffel tells us that a new official, the FDA, wants a bid in the regulatory shuffle to ensure that systems are safe. Glen suggests that too much officiating can cause an upset, and argues that ONC should remain the head official to evaluate the safety and efficacy of EHRs.

Fred Lee at Health Care Hacks reports on a series of fouls (aka medical errors). Doctors who studied patients over the age of 65 found that patients who did not receive referrals were less likely to receive recommended follow up treatment. Unlike game refs, the researchers stray away from finger pointing to assign blame, and instead insist that doctors and patients play nice and work together as a team to produce better outcomes.

Health care leaders must be careful not to abuse home court privileges (an advantage the NCAA team prevents by not allowing teams the chance to play on their own turf). Roy Poses at Health Care Renewal reminds us about the dangers that conflicts of interest present in the health care arena by reviewing the details of a deal between a for-profit medical school and a NY-based hospital corporation.

And while game official Anthony Wright issues a technical foul to Anthem on its proposed rate hikes over on Health Access, referee Louise Norris at Colorado Health Insurance Insider finds Anthem at midcourt in insurance rates in Denver and calls for play to resume.

Coaches’ Corner
In the words of Rick Pitino, (the man who first introduced me to the world of college basketball in the nineties with his fast-breaking, full-court pressing Kentucky Wildcats,) “Excellence is the unlimited ability to improve the quality of what you have to offer.”

When assessing the quality of care provided in nursing care settings, the INQRI Blog coaches examined past plays and their results (aka processes and outcomes). They also reviewed patients’ feedback, noting the importance of including patients’ voices in improving care delivery models. *editor’s disclaimer: INQRI is a program supported by the Robert Wood Johnson Foundation

David Harlow over at the HealthBlawg thinks that educators need to go back to the books. According to the results of a recent study produced by the Lucian Leape Institute and the National Patient Safety Foundation, faculty need to spend more time in the classrooms consistently teaching students important “chalk talk” lessons about patient safety.

Commentators’ Color
And now it’s time to step into the play booth. Over at InsureBlog, Henry Stern provides us with a play-by-play summary of his recent interview with Rep. Joe Wilson. The Congressman discusses coverage mandates at the state-level, stimulus funds and the reconciliation process.

On the Disease Management Care Blog, Jaan Sidorov outlines his must-picks to implement pilot Accountable Care Organization models. According to Jaan, we need to select pilots that have physicians who have “a track record of exposure to the ‘systemness’” of disease management programs and patient-centered medical home settings, and thus experience with patient engagement and care management.

And Workers’ Comp Insider sportscaster Tom Lynch takes us from hoops to the world of baseball to recount former athlete and soon-to-be retired Sen. Jim Bunning’s latest actions at bat, with regard to COBRA benefits and the Sustainable Growth Rate.

Finally, we close out the commentary section with Sens. Tom Harkin and Mike Enzi, who weigh in with their thoughts on the Health Affairs Blog about the latest national and local efforts to battle obesity.

League’s Landscape
In the beginning, the NCAA men’s basketball tournament featured just eight teams. In today’s championship battle, we have 65, (plus constant chatter that the NCAA may add more teams to the mix). Similarly, as our health care market expands, we must continue to look at ways to restructure the system to ensure that we are providing high-quality, cost-efficient care.

When considering ways to rebuild the system, we must look to the individual teams (aka states), who often provide invaluable insight for national reformers. RWJF Senior Program Officer Brian C. Quinn and Lynn A. Blewett, director of the State Health Access Data Assistance Center, share findings on our blog from a recent report that highlights the growing challenges states face in meeting the needs of the middle class. As they write, “Just 66 percent now receive insurance through their employer, a drop of seven percentage points since 2000”. As part of our Cover the Uninsured Week, we aim to foster discussion to expand coverage across all states.

Austin Frakt from The Incidental Economist also examines local-level data, and gives us a detailed look at the history of the relationship between Medicare Advantage payments and traditional fee for service Medicare costs. He suggests that we restructure benchmark rates to control costs.

In another post on payment reform, Chris Langston at health AGEnda writes, when it comes to providing care, we can’t assume that “what IS, is what OUGHT to be.” If physicians are not currently providing recommended care, they will report less time spent on treatment, which will lead to lower Medicare reimbursement fees, and another reduction in the amount of care provided. 

As sports fans and health reform analysts, we’ve waited all season for the Big Dance. And now that we’ve made our predictions and selected our best picks, we sit back to watch the game unfold.

Thanks for letting me call the shots for this edition of HWR. Don’t forget to tune-in on April 1 to the next edition over on the Health Technology News blog, as host Rich Elmore breaks down the latest health policy rebounds, slam dunks and results.

The economic squeeze on the American middle class

Brian C. Quinn a senior program officer at the Robert Wood Johnson Foundation and Lynn A. Blewett, Director of the State Health Access Data Assistance Center (SHADAC) write about Cover the Uninsured Week.

The inner researcher(s) in us don’t generally get excited about spending days working on national awareness campaigns. But for the last eight years, Cover the Uninsured Week has provided an exciting opportunity for RWJF and SHADAC to explore interesting trends in health insurance coverage. This year, with families across the country struggling through the second recession in the last decade, it seemed natural for us to look into how those economic downturns have affected health insurance coverage.

The resulting report – Barely Hanging On: Middle-Class and Uninsured –released today, chronicles coverage trends in all 50 states from 2000 to 2008.  The findings? The first decade of this century has been marked by declines in employer-sponsored insurance coverage, greater costs to employers and employees for individual and family health insurance policies and significant erosion in private coverage.   Coupled with this we find significant declines in median incomes across the US.  This raises increasing concerns for the affordability of coverage for the middle class and a continued increase in the numbers of uninsured in nearly every state.

One finding that hits home for millions of people: America’s middle-class is bearing the brunt of these trends. Middle-income earners – families making roughly $45,000 to $85,000 a year – became uninsured at a pace faster than those who made more money, as well as those with lower incomes. In total, 13 million middle-income earners were uninsured in 2008 – about 2.4 million more than in 2000.

As the cost of health insurance premiums rose by 56 percent for family coverage (adjusted for inflation), many employers stopped offering health insurance coverage, shifted the increase in costs to employees in terms of higher premiums or changed the criteria for employees’ eligibility. By 2008, more than one in five people who work in firms that offer health insurance weren’t eligible for the benefit. For those employers who still paid the bulk of their employees’ insurance premiums, rising costs have been passed on to workers, likely causing some workers to drop their work sponsored coverage. In all, 21 percent of employees who worked for firms that offered employer-sponsored insurance (ESI) in 2008 did not accept or “take up” the offer.  Among the middle class, just 66 percent now receive insurance through their employer, a drop of seven percentage points since 2000.  

ESI has long been the mainstay of health coverage for middle-class families, who typically do not qualify for government insurance programs. Among middle-income Americans, only about half of the decline in employer-sponsored coverage from 2000 to 2008 was offset by increased enrollment in government insurance programs. For people who earned less money, declines in ESI were even steeper, but those numbers were almost completely offset by increases in coverage through government insurance programs like Medicaid and SCHIP. The result is that it’s the middle class that is going without.

America’s middle class is being squeezed to the point that they are barely hanging on. Overall, the average cost an employee paid for a family insurance policy rose significantly by 81 percent from 2000 to 2008, while median household income fell significantly by 2.5 percent (adjusted for inflation). Clearly, hard-working families are at the brink.

We are concerned about the erosion of ESI and the continued growth in health care coverage costs.  In this economic crisis, we know that business owners can’t afford to shoulder more of the burden of health care costs.  Yet, at the same time, state are facing unprecedented budget shortfalls and are not able to meet the need of  laid-off workers and the members of the once-middle class who are now uninsured.   If nothing is done to stave off these trends, it could spell doom for our nation’s middle class, our health care system, and ultimately the future of our economic recovery.

During this 8th Cover the Uninsured Week, people across the nation will hold events and have discussions about what to do about this national crisis. We’ve certainly done our part to build awareness. Now it’s up to the people to take action.

America's uninsured: still matters.

I know this is going to make me sound old (truth hurts), but I can clearly remember the first Covering the Uninsured Week, eight years ago.  It was one of the very first issues I worked on at RWJF and one that I'd really like to see get solved in our lifetime. And, I think you can choose to either get really depressed about the fact that we haven't solved it yet, or, you can reflect on how long it really takes to change the thinking around a particular problem and to make that problem really matter to a broad swathe of people, but eventually, success starts to seem more possible.  The sun is shining today, so I choose the latter.

There's lots of chatter going on in the blogosphere about this year's CTUW, so I'll just point you to a few of those, beginning with one of the very first posts on this blog, from David Morse about last year's CTUW.  And then you can check out the Wall Street Journal blog and the New Health Dialogue about this year's CTUW, and our prospects for making the goal of covering all Americans a reality. 

Road Closed, Danger Ahead!

RWJF President and CEO Risa Lavizzo-Mourey writes on America's uninsured.  This post first appeared on The Huffington Post today.  

For decades, our health care system has been barreling down a dangerous road, plowing through stop signs and ignoring obvious warning signs – Higher Health Costs Approaching; 46 Million Uninsured Merging; Employer-Sponsored Coverage Closed Ahead.

Today, as part of the ninth annual Cover the Uninsured Week, the Robert Wood Johnson Foundation released a new report that warns of the dangers still ahead of us – and our health care system – if we don’t change direction. The analysis, conducted by researchers at the Urban Institute, shows that without significant reform to the current health care system the number of uninsured Americans could grow by 10 million people in just five years.  Spending on government health care programs for the poor will balloon, more than doubling by 2020. For employers who continue to offer health insurance benefits, an increasing amount of the costs would come out of workers’ pockets. At the same time, individuals and families would face higher out-of-pocket costs for premiums and health care services.

The report also finds that unless we change our health system so that it expands coverage to those who don’t have it, and makes coverage more affordable for those who do, middle-income families will be hardest hit. The uninsured rate for middle-class families earning roughly $40,000-$75,000 a year – could rise up to 28 percent.  That means one in four middle-income workers could be uninsured in 10 years. Uninsured rates will also rise among adults, age 45-64 and in 10 short years nearly a quarter of these middle aged adults could be uninsured.

This tells me, Warning: Danger Ahead. While we might not have an actual bright yellow sign signaling what comes next, we do have a map.  By examining the best available economic data, we can project what will happen to our health care system on its current trajectory—the number of uninsured Americans will continue to soar, and the increases in public and private spending will be dramatic and unsustainable.

For almost four decades, the Robert Wood Johnson Foundation has been making certain that the forces of health-system change remained fueled and driving forward. But the signs on this road are clear.  Unless action is taken to change the trajectory, our nation is on a collision course.

Health Reformer’s Lexicon: Patient-Centered Medical Home

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.

The term: Patient-centered medical home

The National Committee for Quality Assurance (NCQA) provides the following definition:

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients and their personal physicians, and, when appropriate, the patient’s family.

It is a model of care that aims to provide structured, proactive and coordinated care for patients rather than episodic treatments for illnesses.

In a medical home, the primary-care doctor operates as a “home base” for patients, overseeing all aspects of patients’ health; scheduling regular tests and check-ups by tracking health records electronically; advocating for patients with specialists; and, with nurses and other personnel, helping patients navigate the medical system so they don’t fall through the cracks or neglect to care for a chronic condition such as heart disease.

Why it matters: The medical-home model promotes coordinated care—especially for patients with chronic conditions. This in turn cuts costs while improving the quality of care.

Roots: Pediatricians were first to coin the term “medical home.” Concerned that the care of children, especially kids with chronic conditions, was not being coordinated effectively between specialists and the child’s pediatrician, the American Academy of Pediatrics advanced the concept of coordinating care through one doctor in 1967.

Thirty years later, in 2007, leading primary-care doctors’ organizations—the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association—listed requirements for a medical home in a formal statement.

Among these requirements is the idea that insurers recognize doctors’ additional work and the added value to patients for “work that falls outside of the face-to-face visit” and reward it with more compensation.

In the last few years, the American Medical Association has backed the medical-home concept; and by last year, 10 states had bills promoting medical homes.

Where the term appears: The president’s health reform proposal, like the Senate bill, sees the medical home more as an answer to shortages of primary-care doctors, nurses and others. It would spend money on training medical personnel in more efficient ways to deliver primary medical care, such as medical homes.

NCQA has established a recognition program to evaluate whether practices are operating as medical homes. Select health plans are using recognition standards like these to reward qualifying practices for improving health care quality.

Previous Lexicon entries include:
- Sustainable Growth Rate
- Accountable Care Organization
- Meaningful Use

Creating a Positive Exchange

Enrique Martinez-Vidal, Director of the State Coverage Initiatives program, discusses the role of states in building and implementing health insurance exchanges:

I think we can all agree that watching the federal health reform efforts over the past couple of months has left us feeling like we are on a rollercoaster ride. Given our continued work with state officials, we know that despite the drama here in Washington, DC, the states must continue to focus on health care issues despite the historic recession that has caused dramatic deficits in almost every state. Over the past decade, we’ve documented the efforts of states to expand coverage to the uninsured, to reorganize and improve their insurance markets, and more recently, to undertake efforts to increase value in the health care system by redesigning the delivery system and exploring alternative payment incentives. Even this past year, despite fiscal constraints and uncertainty about potential federal reforms, a number of states made substantial strides in implementing reforms.

States have a wealth of experience with health reform efforts and, among the many lessons we’ve learned along the way, perhaps one of the most important is that the success of any reform is dependent on how well it is actually implemented.  As critical as good policy is to the inherent success of a reform, so too are the operational components. That’s where the reform rubber meets the road.

A perfect example and most relevant to us theses days is the concept of establishing state exchanges. We know that President Obama’s most recent proposal follows the Senate’s framework to have states play an important role in creating and overseeing health insurance exchanges. Moreover, whether or not federal reform occurs, we believe that states will be at the forefront of establishing exchanges. Some states are contemplating creating or already working towards implementing their own exchanges as a way to improve the functionality of the individual and small group markets. Likewise, individuals and employers are yearning for more comparative information about their insurance policy benefits and costs. While we already have the experience of Massachusetts’ and Utah’s initial work to look to, they took very different approaches. With more state experimentation in this arena, there will be various iterations along the policy continuum.

Because there still remain many questions regarding how to build an effective and sustainable exchange, we have begun the process of building an inventory of resources to support state work in this area. In late January, we hosted a meeting for state policymakers in partnership with officials from Massachusetts’ Commonwealth Health Insurance Connector Authority to learn from their experience thus far. Most recently, we released an issue brief Preparing for Health Reform: The Role of the Health Insurance Exchange, that raises many important issues that states must evaluate and consider before establishing an exchange. An exchange can do a lot – organize the insurance market, provide a central source of information, enable comparability of benefit designs, administer public subsidies, facilitate the purchase of insurance through standardized enrollment processes, and improve competition among carriers. And, at its very core, an exchange can seek to alter competition in the health insurance market from one based on avoiding risk to one based on price and quality. That is, if you build it correctly.

States policymakers need to develop a thorough understanding of both their uninsured and insured populations, the existing sources of public and private coverage, and the current structure of the commercial insurance market in their state. The roles and responsibilities of an exchange must be defined to determine the appropriate administrative and governance structure it should have. States may need to determine how premium subsidies (if there are subsidies) will be targeted and processed, how to be strategic with effective outreach and enrollment, as well as how to mitigate the potential for adverse selection where one participating carrier ends up with a disproportionate share of high-cost enrollees. In the final analysis, it is critical for a state to clearly understand the goals it is trying to achieve as it takes on the restructuring of its insurance markets.

So, if states build exchanges, will the people come?  While this question may only be answered over time, we believe that, for states, much will depend on assuring they are well-prepared by having laid the necessary groundwork for the development and implementation of these mechanisms that hold the promise of improving insurance markets.

And the drama goes on...

It’s not difficult to see parallels between theater and current health care reform debates, which are filled with a rotating cast of players who all vie for leading roles and their moment in the spotlight. In the latest edition of the Health Wonk Review, host Brad Wright compares the health care summit to a Kabuki theater production, an event he describes as full of “grandstanding and rhetoric–political posturing not substance.”

The review contains a post from our blog, written by Bob Berenson and Beth Docteur, about the substance comparative effectiveness research provides us to help identify health care improvements.

And as one act closes, another unfolds. I’m excited to announce that we will host the next edition of the Health Wonk Review. Check back on March 18 to see what health policy topics will make the list for the next big show.

Health Reformer’s Lexicon: Meaningful Use

The Health Reformer’s Lexicon is a regular feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit. 

The term: Meaningful use – assuring that health information technology (HIT) is used in a meaningful way to provide better patient care.

Congress earmarked billions of dollars to spur investment in “health information technology” (HIT) and electronic health records technology by health care providers, but money came with a string attached known as “meaningful use.” To qualify for these subsidies, doctors and hospitals must put the HIT they purchase to “meaningful use,” to improve the quality, efficiency, safety and coordination of care, and reduce disparities and engage patients and families in their care.

Why it matters: There is a lot of money at stake. Estimates are that between $14.1 billion and $27.3 billion in subsidies could flow to qualifying providers. These funds will help providers invest in HIT infrastructure. As results from the 21st  annual Healthcare Information and Management Systems Society leadership survey indicate,

Asked to identify their single IT priority during the next two years, 42 percent of respondents identified meeting meaningful use criteria.

But as we’ve noted previously on this blog, HIT in and of itself will not improve health care, it is how we implement and use it to engage with providers and patients that truly matters.

Roots: The Health-e Information Technology Act of 2008 was introduced as a bill “to promote the adoption and meaningful use of health information technology.” But the term “meaningful use” was put on the map by the American Recovery and Reinvestment Act of 2009, aka the “stimulus bill” under the bill’s Health Information Technology for Economic and Clinical Health Act provisions.

Where the term appears:  The usage that has mattered most of late came just two days before the end of 2009 when the Centers for Medicare & Medicare Services and the Office of the National Coordinator for Health Information Technology issued proposed rules that can be read here and here to define “meaningful use.” At 700 pages, at least one wag at Modern Healthcare deemed them "meaningful obtuse.“

CMS expects to finalize its meaningful use rule later this year.

New County Health Rankings Highlight Opportunities for Quality Improvement

Lisa Letourneau, executive director of Quality Counts, considers the implications of a new series of reports on county-by-county health variations.

No matter how healthy a community is, there is always room for improvement. For proof, just look at the County Health Rankings released recently by the Robert Wood Johnson Foundation and the University of Wisconsin’s Population Health Institute.

At first glance, the report on my home state of Maine in many ways confirms what health reformers have long understood: health follows wealth. With a few exceptions, the more affluent counties on the comparatively urbanized, southern coast of our state have better overall health profiles than the less-affluent counties in the densely wooded, rural parts of the state. For example, in Lincoln County, a coastal community in the mid-coast area, 9% of the population reports itself to be in “poor” or “fair” health. By comparison, that is a relatively low level and puts the county in the 90th percentile of results overall. But in Aroostook County, all the way at the rural north end of the state, the figure is 18%, twice the target level.

Health Reformer's Lexicon: Accountable Care Organization

The Health Reformer’s Lexicon is supposed to be a weekly feature that will examine key words, terms and phrases in health reform and explore their meaning and orbit.  But what can I say?  Snowstorms, and other developments, all can get in the way. 

The term: Accountable care organization (ACOs)

In a recent policy brief that examines the ACO concept, Urban Institute researchers Robert Berenson, M.D., and Kelly Devers, Ph.D., provide the following definition:

 A local health care organization and a related set of providers (at a minimum, primary care physicians, specialists, and hospitals) that can be held accountable for the cost and quality of care delivered to a defined population.

Why it matters: As Berenson and Devers note,
 
Proposing a new entity with the word “accountable” in its title begs the question of who is becoming more responsible for what, when it comes to delivering high-quality and efficient health care.

Policy makers are looking at ACOs as they search for ways to deliver well-coordinated care that produces positive outcomes while also slowing the rise in health care costs.

Roots: The term ACOs emerged publicly in a 2006 Health Affairs article where a footnote traces its etymology as follows:

The idea of using the term ‘accountable care organizations’ … grew out of an exchange between Elliott Fisher and Glenn Hackbarth at a Medicare Payment Advisory Commission meeting in November 2006.” (Fisher leads the Dartmouth Atlas Project, Hackbarth is the chair of MedPAC.)

Usage: The more fully refined ACO concept appeared nearly three years later, and a similar concept –“accountable care systems”– was explored in JAMA. 

But the references that may matter most at this point are the ones found in health reform legislation.

The Senate Finance Committee’s bill would:

Allow providers organized as accountable care organizations that voluntarily meet quality thresholds to share in the cost-savings they achieve for the Medicare program. To qualify as an ACO, organizations must agree to be accountable for the overall care of their Medicare beneficiaries, have adequate participation of primary care physicians and specialists, define processes to promote evidence-based medicine, report on quality and costs measure, and coordinate care.