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Last Build Date: Thu, 27 Oct 2016 21:06:15 +0000


ACA Round-Up: Dollar Thresholds For 2017; Information For Agents And Brokers

Thu, 27 Oct 2016 21:06:15 +0000

On October 27, the Internal Revenue Service released a number of inflation-adjusted thresholds for 2017. For calendar year 2017, the dollar individual responsibility penalty for failure to have minimum essential coverage or to claim an exemption from the requirement remains $695 per adult, and half this amount for children, up to a maximum of $6,085 per family. Taxpayers are alternatively subject to a penalty of 2.5 percent of their modified adjusted gross income above the filing limit up to the cost of a 60 percent actuarial value policy if that amount is greater than the dollar value penalty. When families file their taxes, if their advance premium tax credits exceed the premium tax credits that they were actually due, the caps on the amounts they must repay remain the same in 2017 as they were for 2016: $300 for unmarried individuals (other than surviving spouses or heads of households) with incomes under 200 percent of the federal poverty level (FPL); $750 for those with incomes 200 to 300 percent of the FPL; and $1,275 for those with incomes at least 300 percent but less than 400 percent of FPL. For all other taxpayers (including married individuals), the cap on repayment obligations remains $600 for those with incomes less than 200 percent of FPL, $1,500 for those with incomes between 200 and 300 percent of FPL; and $2,550 for those with incomes at least 300 percent but less than 400 percent of FPL. Individuals with incomes above 400 percent of FPL must repay all advance premium tax credits. For individuals to qualify for tax subsidies for health savings accounts (HSAs) for 2017 they must be enrolled in high-deductible health plans with deductibles of at least $2,250 but not more than $3,350, and out-of-pocket limits not exceeding $4,500. Family high-deductible health plans must have deductibles of at least $4,500 but not more than $6,750 with out-of-pocket limits not exceeding $8,250. Standardized plans will be available through the marketplaces that qualify for HSA eligibility. Information For Agents And Brokers On October 26, the Centers for Medicare and Medicaid Services released at its website (registration required) a 127 slide primer for the 2017 open enrollment period for agents and brokers participating in The slides cover ten topics: Agent/Broker registration reminders and tips, An overview of open enrollment, Annual redetermination and auto-re-enrollment updates, Helping consumers with Data Matching Issues (DMIs), New call center resources for agents/brokers, Marketplace call center tips, Working with navigators and other non-agent/broker assisters, An overview of pathways to assist consumers enrolling in coverage through the individual marketplace, A step-by-step review of the individual marketplace online application, and The Small Business Health Options Program (SHOP) marketplace highlights. The slides are not formal guidance and most of the information they contain has been released earlier. A number of topics, however, are described with particular clarity, including overviews of the 2017 open enrollment process and of the 2017 annual redetermination and auto-reenrollment process. There is a description of how will deal with people who received premium tax credits in 2014 and 2015 and failed to file or reconcile their taxes for those years. The slides include flow charts clearly contrasting the direct enrollment process—through which the applicant applies using a web-broker or insurer’s website that connects with—and the marketplace enrollment path, in which the entire enrollment process takes place on the website with agent or broker assistance. The slides also walk step by step through the process of applying for assistance online for a new enrollee and a returning enrollee showing each of the screens the applicant would see in the process. The slides describe a number of marketplace features new for 2017. Features of particular interest to brokers and agents include: Lists of agents and brokers who have c[...]

How Are Hospital-Based ACOs Addressing Community Health?

Thu, 27 Oct 2016 15:45:38 +0000

As Risa Lavizzo-Mourey, president and CEO of the Robert Wood Johnson Foundation (RWJF), noted earlier this year, Accountable Care Organizations (ACOs) are no longer the “mythical unicorn creatures” they once were. In just six short years following the enactment of the Affordable Care Act (ACA), ACOs have moved from a small market experiment to now being responsible for the health care—and the health care costs—of nearly 30 million Americans. While ACO performance continues to evolve, one thing is clear: ACOs were early trend-setters in the movement toward advancing population health. But when it comes to actual operations, what does “population health” look like in an ACO, particularly in ACOs led by community hospitals? Do ACOs see their role in population health management as caring for their patient populations as a whole? Patients in their catchment areas? In their communities? And how do those views “sync” with the care delivery and partnership approaches that hospital-based ACOs are actually using? The Robert Wood Johnson Foundation and Premier Inc. (in conjunction with Greenwald & Associates, LLC, National Research, LLC, and KNG Health Consulting, LLC,  set out to answer these and other questions in a comprehensive study of ACO activities and performance. The study spanned from September 2015 through May 2016 and explored population health services offered and ACO operations at nineteen hospital-based, fully integrated ACOs using surveys and telephone-based interviews of ACO leaders. The results highlight many of the tensions that ACOs are currently facing. Findings First, the ACOs define “population health” as attributable patient population health—meaning the population health of those who belong to the ACO and for whom ACOs are striving to provide high-quality care at lower cost. These ACOs’ focus is on patients with high, unnecessary health care spending, such as people with complex needs or expensive conditions. This is not a surprising early area of focus, as these patients tend to be the “heavy users” of high-cost medical services, such as the emergency department, even though, with proper care coordination and management, much of this use could be avoided and/or directed to a more appropriate ambulatory setting. Typically, population health work is seen as the purview of a particular department or program within a hospital that targets these specific types of patients for enhanced care coordination or management. What makes this narrow focus especially interesting is that the majority of the ACO leaders queried described their hospitals as in a good or very good position to provide resources that could improve overall community health—yet, that wasn’t reflected in their priority activities. Encouragingly, however, several ACO leaders described their emphasis on heavy users as being initial “low-hanging fruit” or a type of test case for change that could be expanded to include other populations in the future. A second interesting finding was the degree to which ACO activities matched up, or did not match up, against what were identified as the largest impediments to overall community health. For example, every ACO in the sample said that better behavioral health services are needed to improve community health. The next most common responses were the need for substance abuse services, more affordable prescription medications, and transportation services. But when ACO leaders were asked what sorts of community health programs and services they were either employing or planning to employ within six months, the top three answers were, instead, related to care coordination, chronic disease management, and health education. Similar to the aforementioned reasoning, this suggests that many ACOs may be taking a “walk before they run” approach, establishing basic ACO infrastructure first before tackling more targeted community needs. It also implies that an additional focus may be needed on helping ACOs to expand their view—and services—beyo[...]

Congress Took 233 Days To Respond. Here’s How To Prepare For The Next Zika

Thu, 27 Oct 2016 13:46:23 +0000

Congress recently passed federal funding for the nation’s response to the Zika virus, and the manner in which they provided those funds exposed a serious flaw in the way our nation handles disease outbreaks. In the time between the White House’s initial request for funding in February and the passage of the bill in September, the outbreak escalated dramatically, nearly unchecked by federal lawmakers. The entire process took a grand total of 233 days, which is simply far too long. It did not need to be this way. Failure to Act Over the spring and summer, the Zika virus infected more than 3,300 Americans in the states and almost 20,000 in the U.S. territories. While members of Congress effectively sat on their hands, in addition to ongoing transmission from international travel, thousands of pregnant women were infected with the Zika virus in Puerto Rico, and Miami residents were infected in their own backyards. Babies are now tragically being born with microcephaly, a birth defect that often damages a child’s brain in such a way that it creates lifelong debilitation. As the number of infected Americans mounted and the pregnancies at risk continued to grow over nine long months, Congress still did not act. In fact, the federal government effectively cut local health department budgets by nearly 7 percent in the midst of this crisis. This approach is emblematic of Washington’s record of significantly underfunding America’s public health system. For example, funding for public health preparedness has shrunk by more than 30 percent over the last decade and hospital preparedness funds have been slashed by more than half. Dismantling critical infrastructure does not put us in a strong position to effectively fight major outbreaks like Zika, and we will continue to be at risk until state and local health departments are routinely funded. Quite simply, we need a way to enable quicker responses to acute disease outbreaks. Due to modern travel patterns and climate change, these viruses can find a way to jump borders and oceans with greater speed than in the past. If we are not under siege in the coming months from a known foe like pandemic flu, we should expect to be hit again soon by an emerging disease, like Zika or Ebola. Relying on a legislative body that takes months to respond is not an effective plan. A Better Funding Mechanism For Rapid Response Members of Congress finally addressed Zika, but now they must prepare the nation for the next emergency. We could save countless lives if instead of letting each new infectious outbreak turn into a political football, we created a sound funding stream for public health that can be activated swiftly and appropriately by the executive branch, instead of a vast legislative body like Congress. This solution actually already exists, and it is an essential tool that Washington has nearly forgotten: the Public Health Emergency Fund. This fund could give state and local health departments a crucial running start when an outbreak hits. The problem is that it’s almost empty, with a measly $57,000 remaining, and there are no concrete plans to replenish it. None of the $1.1 billion Congress set aside for Zika will be directed to restoring it, and there is no annual appropriation for this fund either. If this fund is financed appropriately and is readily accessible to critical health decision makers in the executive branch, we would be better able to respond to public health disasters that demand quick action, without partisan politics getting in the way. Right now, using money from the fund requires Congressional action, but this authority should actually be in the hands of the executive branch, which has shown itself to be far more nimble in emergency situations, from hurricanes to terrorist attacks. Similar to the sequence of events that occurs when a natural disaster, like a flood or tornado, strikes, a public health emergency fund would allow an immediate distribution of funds, just like the Federal Emergency Man[...]

Employer-Sponsored Insurance Enrollment Stable In 2014

Wed, 26 Oct 2016 20:05:36 +0000


Before the Affordable Care Act’s coverage provisions took effect in 2014, policy makers were concerned that new regulations, options, and penalties could cause companies to stop offering health insurance to their employees. A new study, being released as a Web First by Health Affairs, compared the extent to which US employers dropped or added this employee benefit between 2013 and 2014.

According to authors Jean Abraham, Anne B. Royalty, and Coleman Drake, there was little change between those years: 46.38 percent of private-sector employers offered coverage in both years, and 49.08 percent did not offer it in either year. Furthermore, just 3.45 percent of employers dropped coverage in 2014, and 1.10 percent added it (see exhibit below.) The authors used data from the nationally representative Medical Expenditure Panel Survey–Insurance Component.

Exhibit 1


The authors also examined the attributes of employers that dropped coverage and noted: “Small firms were more likely to drop coverage compared to large ones, as were those with more low-wage workers compared to those with fewer such workers, newer establishments compared to older ones, and those in the service sector compared to those in the blue- and white-collar industries.”

They recommend continued monitoring of the availability of employer-sponsored health insurance, “to determine whether the general stability…will persist.”

This study, part of Health Affairs’ DataWatch series, was funded by the Robert Wood Johnson Foundation’s State Health Access Reform Evaluation program and will also appear in the journal’s November issue.


Primary Care Workforce: The Need To Remove Barriers For Nurse Practitioners And Physicians

Wed, 26 Oct 2016 15:30:39 +0000

For the past four years, we have tracked primary care workforce numbers comparing the annual primary care residency match data with the primary care nurse practitioner (NP) graduation rates. While NP data continue to surge, the physician numbers, both allopathic and osteopathic, continue to be relatively disappointing, with only a minor increase. With 20 million people now enrolled for health care coverage under the Patient Protection and Affordable Care Act, the need for primary care providers is swelling. The minimal increase in medical school graduates entering primary care does not address the prediction by the National Center for Health Workforce Analysis of shortages as high as 20,400 physicians by 2020. Large increases in NP graduates each year are the good news in the midst of the inadequate numbers of physicians entering primary care. The challenge remains, though, to maximize the practice potential of physicians and NPs so that they both are practicing to the fullest extent of their education and training. Only then will the nation reap the full benefit of expanded access to quality primary care services and a reduction in unnecessary costs to the health care system. 2016 National Resident Matching Program Data The data we have been reporting over the past four years continue to be striking. Although not a perfect comparison with NP primary care graduation rates, the primary care resident match data are the best we have. The National Resident Matching Program (NRMP) reports on both allopathic and osteopathic matches but does not differentiate between them in their detailed data. Close to 14 percent of the U.S. matches in the NRMP report are graduates from osteopathic programs. In 2014, NRMP data disclosed that there were merely 19 more U.S. resident matches to primary care specialties— family medicine, pediatrics, and internal medicine—than in 2013. In 2015, the numbers were up to 91 more U.S. residency primary care matches. In 2016, U.S. NPRM family medicine matches numbered 58 more than in 2015. There were 13 more internal medicine matches than in 2015 and eight more pediatric primary care matches; this merely brought the pediatric match rate back up to where it was in 2013. In sum, in 2016 there were 2,044 U.S. medical student graduates matched to primary care specialties. 2016 American Osteopathic Association Match Data In addition to the NRMP data, the American Osteopathic Association (AOA) reports their own match data, the Resident Registration Program. AOA’s reported 2016 year one matches showed an increase in the match rate somewhat similar to 2016 NRMP data: 41 more family medicine U.S. osteopathic matches were reported than in 2015 (590 compared to 549). Osteopathic pediatric matches were up 14 from 2015 (65 compared to 51). Internal medicine numbers were not included as the AOA categories are different from the NRMP, making comparisons difficult. The combined total of 2016 allopathic and osteopathic U.S. primary care matches was 2,699, up 144 over 2015. The osteopathic numbers may be underreported because of the internal medicine reporting issue. When international graduates are included, the primary care match numbers for 2016 rise to 3,884 for allopathic matches and 1,060 for osteopathic matches, with an overall total of 4,944 primary care matches. Without the international match numbers, physician primary care numbers in the U.S. would be far more worrisome. When considering the entire first year NRMP match numbers for all specialties—17,057—only 12 percent of those were for primary care specialties. That percent is only slightly greater than a year ago when it was 11.6 percent and back to what it was two years ago. For osteopathic U.S. graduates, using only the AOA data, the percent of U.S. positions matched to primary care represents a very different picture: Almost 30 percent (29 percent) of U.S. osteopathic total matches occur to primary care. The osteopathic [...]

Examining The Nurse Pipeline: Where We Are And Where We’re Headed

Wed, 26 Oct 2016 15:00:31 +0000

Nurses play a central role in our health care system. Key factors determining the future supply of nurses are the number who are being educated by US nursing programs and the number entering the US after graduating from foreign nursing programs. The number of first-time takers of the National Council Licensure Examination (NCLEX), a prerequisite to become licensed as a Registered Nurse (RN), provides a good metric for the number of new nurses. The National Council of State Boards of Nursing (NCSBN), the sponsor of the NCLEX, publishes data quarterly on the number of exam takers and pass rates. While the NCSBN publishes data for first-time and repeat exam takers, the vast majority of first-time takers end up passing the exam. The data presented below—which updates my post from last year—is for first-time exam takers only, as that data represents a simpler, easy-to-understand metric of the pipeline of new nurses. First-time takers are also a direct reflection of the output of the nation’s nursing programs. Parsing The Numbers: Varying Trends Underneath An Overall Leveling Off Of Growth Well Above Historical Levels After 14 years of steady growth, the number of newly educated registered nurses in America appears to be leveling off. According to the NCSBN, the number of first-time takers in 2015 (157,843) decreased very slightly compared to the number in 2014 (157,879) (Figure 1). Even with this leveling off, the 2015 number is 130 percent higher than the first-time takers in 2001 (68,700). The trends are very different for baccalaureate (BSN) and associate degree (AD) exam takers. BSN programs require four years of education while Associate Degrees (AD) require two years. “Diploma” graduates from hospital-based programs generally require about two years of education and training. BSN first-time exam takers continued their steady, long-term growth, increasing by 2,142 in 2015 to 70,857, a growth of 3.1 percent compared to 2014. This was the 14th year of steady growth for this group, with 2015 numbers up 186 percent over 2001 (Figure 2). By contrast, for the second year in a row, the number of first-time associate degree exam takers decreased, down nearly 2,000, or 2.3 percent, in 2015 compared to 2014 (Figure 2). This could reflect a tightening job market for AD nurses, which would be consistent with anecdotes of new ADs having a more difficult time finding a job than BSNs. It is too early to know whether this is the beginning of a long-term trend. The number of new diploma-prepared nurses entering the pipeline continues to decrease. After rising between 2001 and 2006, at the height of the nursing shortage, the number has generally been declining and is down by nearly a third since 2010. The number of new foreign-educated RNs taking the NCLEX rose to its highest level in hour years. However, it is too soon to know if this is the beginning of a new trend, and the total is still only about a quarter of the peak reached in 2007 (Figure 3). Progress And Remaining Challenges Progress On Tackling Predicted Nursing Shortage; Projections Vary By Community In response to concerns with nursing shortages in the early 2000s, there was a concerted effort to increase the number of new nurses. The nation’s nursing programs have clearly responded. A recent projection of the future supply and demand for registered nurses by the federal Health Resources and Services Administration finds that some communities are likely to face a surplus, although others will likely face a shortage. One implication is that efforts to spur future growth of the pipeline should be targeted to specific communities, rather than across all communities. Progress On Increasing Percentage Of Baccalaureate Nurses But Work Remains To Meet Goal The 2010 Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, recommended that 80 percent of the nursing workforce have a BSN by 2020. Clearly[...]

How Can Research Be More Useful And Used? Lessons From A Long-Running Grant-Making Program

Tue, 25 Oct 2016 17:52:07 +0000

Getting research into the hands of policy makers at the right time, on the right topic, and in an accessible format is fraught with challenges, including research timelines that don’t align with policy making; researchers’ lack of training in, and lack of incentives for, translating findings into simpler language; and the multitude of voices and priorities that compete for policy makers’ time and attention. For nearly thirty years, staff at the Robert Wood Johnson Foundation’s (RWJF’s) program called Changes in Health Care Financing and Organization worked to overcome these challenges as they sought to generate and disseminate rigorous research to inform and strengthen health policy, a goal shared by AcademyHealth, the program’s long-time national program office. The sunset of this program, commonly known as HCFO, at the end of 2016 provides an opportunity to reflect on the effectiveness of the HCFO program’s knowledge-brokering activities and provides useful insights for similar efforts aimed at strengthening the relevance and use of evidence in health policy making. Here are some lessons we’ve learned over the years. 1. For research to be policy relevant, you get out of it what you put into it. Early on, we recognized that connecting applicants and their ideas with policy makers and their priorities was a crucial step in generating useful research. HCFO staff played an important role in brokering this communication—beginning with the initial grant application. Proposals underwent review by both methodological experts and people with policy expertise, with funding contingent in part on the reviewers’ assessments of projects’ timeliness, relevance, and potential contribution to actionable policy or practice change. Successful applicants were encouraged to incorporate policy maker feedback—provided in the form of blinded reviews—into their projects, with the end result that many HCFO-funded studies were informed by policy makers before the work even began! We continued to “bridge” researchers and policy makers throughout the research cycle. For example, when grantee and law professor Mark Hall of Wake Forest University launched a study in 2012 to understand why employer use of the Massachusetts Connector for the small-group market lagged behind expectations, HCFO staff, at the outset and midpoint of his study, connected Hall with state policy makers who helped him refine his survey instrument and ensure the study would be useful to states implementing health insurance exchanges under the Affordable Care Act. 2. Know and respect the audiences you seek to inform. In addition to connecting researchers and policy makers at the start of a research project, HCFO staff undertook several types of knowledge-brokering activities once projects concluded. Each of these activities was structured to reflect the information needs, time constraints, and other characteristics of intended research users—primarily policy makers working in state and federal government. For example, recognizing that policy makers have limited time available to read a full research article, HCFO staff frequently prepared concise written summaries of HCFO-funded research that highlighted its important implications for policy. Additionally, we periodically convened researchers and policy makers for full-day meetings that sought to summarize the state of the evidence on a policy-relevant topic (for example, managed care, risk adjustment) and identify outstanding questions in need of further exploration. Such was the case when HCFO convened approximately thirty researchers and policy makers for a 2013 meeting on the Medicare Hospital Readmissions Reduction Program, which followed an agenda designed by participating policy makers. In addition, HCFO frequently organized in-person briefings between individual grantees and small groups of relevant policy makers. These briefin[...]

The FDA’s Controversial Duchenne Drug Approval And The Moral Impulse To Rescue

Tue, 25 Oct 2016 15:38:15 +0000

What can we learn from the Food and Drug Administration’s (FDA’s) controversial approval of the first drug for Duchenne Muscular Dystrophy (DMD)? Everybody at the FDA agrees: “There were major flaws in the design and conduct of the clinical trials using eteplirsen (brand-name Exondys 51).” Nevertheless, against the recommendations of the FDA’s expert panel, Janet Woodcock, director of the FDA’s Center for Drug Evaluation and Research, approved the drug under the FDA’s accelerated approval pathway for a subset of patients, approximately 13 percent of the DMD population with a gene mutation amenable to the drug’s action. Upon appeal by agency scientists who disagreed with Dr. Woodcock, FDA Commissioner Robert Califf upheld her decision, saying that both sides, in reaching their different conclusions, had exercised reasonable scientific judgment. One week later, he called for retraction of one of the papers that Sarepta Therapeutics, the maker of Exondys 51, had relied upon for data on the drug’s effectiveness. What’s going on? How can a regulator approve a drug, while simultaneously questioning the quality of the evidence about its efficacy? Has the FDA succumbed to the pleas of desperate parents and in so doing, lowered its scientific standards? Or has it demonstrated compassion and a path forward that is justifiable? My answer is that the controversial decision is defensible, but only if there is adequate follow through. Compassionate response to the most vulnerable among us is a virtue, often described as emanating from the “rule of rescue,” which calls on us to meet the needs of strangers in dire circumstances. Nothing is more dire than children living with fatal illnesses, like DMD. These children are terminally ill, there are no other viable alternatives, the drug seems to be safe, and while it is being used, it can be studied. Dr. Woodcock seemed to be making an explicitly compassionate argument based on the virtue of rescue, when she noted at a 2016 FDA advisory committee meeting that there is a great deal of effort that goes into avoiding the mistake of approving a drug that is not effective, but “there is often little consideration of another error, which is failing to approve a drug that actually works.” What’s next? But now there must be follow through. First, responsible drug development under accelerated approval calls for corporate restraint from hyperbolic claims. Indeed, in approving Exondys 51 for accelerated approval, Califf noted that statutory and regulatory provisions governing accelerated approval “require sponsors to submit promotional materials to the FDA for pre-dissemination review.” Hopefully, as the Commissioner urged, the FDA will be vigilant in ensuring that packaging and marketing materials do not overstate what is known about the drug’s efficacy. Second, if the now-required post-marketing trial does not demonstrate clinical benefit, FDA approval must be withdrawn. There are precedents for withdrawing approved indications that are later discovered to be mistaken, like Avastin, which was approved in 2008, and had approval withdrawn in 2011, when subsequent trial data showed no benefit in overall survival or quality of life and significant life threatening side effects. Nevertheless, once approved, it is hard to roll back all the consequences of a premature approval. Medicare continues to pay for Avastin, and the National Comprehensive Care Network’s 2014 guidelines for patients still list the drug as a treatment for Stage IV breast cancer. Moreover, if evidence proves lacking, insurers will refuse to pay for it (as Anthem already has), and they will deserve back up from health policymakers and others to withstand the public controversy that will arise from coverage refusals. If approval is ultimately withdrawn for Exondys 51, its use over the years until we have bett[...]

Government Files Brief In House v. Burwell; ASPE Lays Out 2017 Plans And Premiums (Updated)

Tue, 25 Oct 2016 12:07:46 +0000

October 25 Updates AARP Challenges Penalties For Employees Who Don’t Provide Health Data To Wellness Programs In May of 2016, the Equal Employment Opportunity Commission (EEOC) released final rules governing the application of the Americans with Disabilities Act (ADA) and Genetic Information Nondiscrimination Act (GINA) to employment based wellness programs. The ADA permits employers to solicit disability-related information from employees—for example through wellness program risk assessment questionnaires—only if the employee’s provision of the information is “voluntary.” GINA similarly prohibits an employer from requiring the involuntary provision of health information on family members. The EEOC rule determined that provision of health information to an employment-related wellness programs could be considered “voluntary” even though the program imposed penalties of up to 30 percent of the full-cost of self-only coverage on employees who refused to provide health information, and an additional 30 percent of the cost of sole employer coverage where both the employee and spouse refused to provide health information. On October 24, 2016, AARP (formerly the American Association of Retired Persons) filed a lawsuit in the federal district court in the District of Columbia; AARP asserts that the EEOC’s ADA and GINA rules permitting penalties to be imposed on employees and their spouses for failing to disclose health information are “arbitrary, capricious, an abuse of discretion, and not in accordance with the law.” The organization asked the court for a preliminary injunction to halt the implementation of the rule. AARP argues that the Draconian penalties that the EEOC rule allows employers to impose on employees who refuse to provide health information make the provision of that information involuntary. If self-only coverage costs $6,000, an employer could impose an $1,800 penalty on an employee who refused to provide health information and an additional $1,800 penalty if a spouse’s information was not provided. AARP characterizes this as both an irrational interpretation of the term “voluntary” and an unjustified departure from the EEOC’s long-standing prior position that employers could not penalize employees at all for refusing to provide health information. AARP argues that the EEOC rules will cause irreparable harm to employees who must disclose private medical information, and asks the court to enjoin the implementation of the rule. Court decisions in earlier litigation brought by employers have allowed employers to impose penalties on employees who refuse to provide information for wellness programs. The EEOC now allows such penalties, but must answer to the court as to how it can justify this position. CMS Reaches Out To Those In ‘Gig” Economy About Marketplaces Keeping up its steady drumbeat of announcements of new initiatives leading up to the launch of open enrollment on November 1, CMS announced on October 25 that it is partnering with seventeen “gig economy” companies that will connect freelance professionals, entrepreneurs, and customers with information and resources to encourage them to enroll through the marketplaces during the open enrollment period. Secretary Burwell discussed the development in an interview with Recode. The list of companies includes some like Uber and Lyft that provide direct services to consumers, but more companies like FlexJobs, the Freelanceers Union, or WeWork that primarily provide services and opportunities to freelancers. The companies are committed to informing the 15 million professionals with whom they work of opportunities for coverage available through the marketplaces. Original Post On October 24, 2016, the Department of Health and Human Services Secretary Sylvia Burwell and Treasury Secretary Jacob Lew filed their initia[...]

The Health Care Payment Learning And Action Network: Supporting Effective Action On Alternative Payment Models

Tue, 25 Oct 2016 11:45:10 +0000

Better care, smarter spending, healthier people—the Triple Aim. The Health Care Payment Learning & Action Network (LAN) has been working to support health care providers in achieving these goals by speeding adoption of effective alternative payment models (APMs). We and our partners—HHS, states, private payers, providers, employers, consumer groups and others—believe that by better aligning health care payments with higher-value approaches to care, we can drive improvements across the delivery system that translate to better patient outcomes. We know the payment reform journey is messy and difficult. But with rising health care costs, unfulfilled opportunities to improve care, and increasing frustrations with fee-for-service (FFS) payment methods, it is a necessary and increasingly urgent journey. The LAN aims to promote effective payment reforms by highlighting innovations, aggregating expertise, sharing lessons learned on what is working and not working, and identifying promising ways health care payers can work together more effectively to implement reforms. We are committed to laying the groundwork for the accelerated development and implementation of APMs that provide better support and more flexibility to serve the needs of patients and providers. As a start on accelerating progress, the LAN has offered a common vocabulary for describing and discussing APMs. The LAN’s APM Framework and white paper show a progression of categories from traditional fee-for-service, or volume-based, payments to value-based payments that consider care quality and clinical and cost effectiveness. In particular, LAN Category 3 payments include APMs that remain based on a FFS structure (e.g., an accountable care organization (ACO) with providers paid by FFS but with shared savings if quality and total cost benchmarks are met), and Category 4 APMs are based primarily on population-level payments (e.g., a bundled episode payment model paid prospectively or a partial capitation model like Medicare’s Next Generation ACO program). As illustrated in the figure below (reproduced from the Framework white paper), the Framework does not suggest all health care payments should be fully capitated. Rather, given broad recognition of significant problems with FFS-only payments—and widespread efforts to reform those payments—the aim is to support a successful shift toward value-based care, by establishing a common array of terms and set of conventions for measuring the use and impact of different APMs. The Urban Institute Brief And Health Affairs Blog Post In a September 19, 2016, brief released by the Urban Institute with an accompanying Health Affairs Blog post, Robert Berenson et al. discuss the LAN’s APM Framework as a guide for value-based payment reform. The authors highlight important challenges in addressing operational barriers to provider adoption of APMs—challenges the many contributors to the LAN are working to address as they implement payment reforms. The authors imply the LAN Framework is intended as a march to capitated payment, rather than a guide for supporting effective payment reform. As use of the Framework to track payment reforms increases, we view this as an opportunity to clarify its intended use, as well as describe some of the LAN’s payment reform tools and activities alongside the Framework. No One-Size-Fits-All-Solution The purpose of the LAN is not to advocate for a one-size-fits-all solution, but to make it easier for members of the health care community to link payments to value. Effective APMs should improve coordination of care, enhance health investments, eliminate incentives for inappropriate procedures, and reduce administrative burdens for providers, all of which can improve health outcomes and lower costs. We intend to update the Framework on a regul[...]