Connecticut Health Foundation: Tomorrow’s Health Care System Needs Community Health Workers

This policy brief from the Connecticut Health Foundation makes the case that community health workers (CHWs) can help health care systems transition away from expensive, avoidable health care to more community-based, person-centered health promotion and prevention that will also save health care system costs.  CHWs are trusted members of the communities they serve and share ethnicity, culture, language, socioeconomic status, and life experiences with community members.  While CHWs have been working on health promotion and prevention for decades, health care reform has created opportunities to integrate CHWs into health care teams and systems, using funding mechanisms intended to drive innovation, quality improvement, and payment reform.  The policy brief was authored by staff at the UMass Medical School Center for Health Law and Economics.

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Posted in Health Care Reform, Health Care Reform: Workforce Development | Leave a comment

U.S. Department of Defense: Cerner-Led Team Awarded $4.3 Billion Electronic Health Record Contract

The U.S. Department of Defense has awarded a team led by Cerner, Leidos, and Accenture a $4.3 billion, ten-year contract to modernize its Armed Forces Health Longitudinal Technology Application electronic health record system for 9.5 million active military members and retirees, according to reporting by the Washington Post.  The contract can be extended for a total of 18 years, at a total cost of approximately $9 billion.  Other bids for the lucrative contract were submitted by teams led by Epic, IBM, and Impact Advisors; and another led by Allscripts, Hewlett-Packard, and Computer Sciences.  Another team led by PricewaterhouseCoopers, Google, General Dynamics Information Technology, DSS, and MedSphere also had been competing for the contract.

The contract was awarded after efforts to update and integrate the Department of Defense’s EHR system with the Veterans Administration’s open source VistA EHR system were abandoned in 2013.    Critics have noted that the federal government’s award (and taxpayer cost) for such a large contract to develop yet another proprietary, commercial EHR is contrary to its efforts to promote interoperability in an already crowded commercial EHR market.   For example, the Center for New American Security had called for the Department of Defense to issue the contract for an open-source product rather than another proprietary one.

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National Quality Forum: Endorsements of Additional Person- and Family-Centered Care Measures

The National Quality Forum (NQF) has announced its endorsement of additional person- and family-centered care measures through its national consensus endorsement process.  The measures include several of the commonly used Consumer Assessment of Healthcare Providers and Systems surveys (for various settings of care) as well as specific measures for patients at inpatient rehabilitation facilities and long-term care hospitals, and measures of functional status and quality of life.   Detailed measure specifications and documentation of the consensus endorsement process are available on the NQF website.

Person- and family-centered care measures are increasingly being included by payers to measure patient and family experiences of health care as part of achieving the triple aim of health care reform.  The measures announced as endorsed are still subject to final appeal through NQF’s multi-step endorsement process before the endorsements are finalized.

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Gordon and Betty Moore Foundation: Roadmap for Patient and Family Engagement

The Gordon and Betty Moore Foundation has published this Roadmap for Patient and Family Engagement.  The American Institutes for Research facilitated a stakeholder process to develop the roadmap.  The roadmap includes eight strategies:

  • Patient and Family Preparation
  • Clinician and Leadership Preparation
  • Care and System Redesign
  • Organizational Partnership
  • Measurement and Research
  • Transparency and Accountability
  • Legislation and Regulation
  • Partnership in Public Policy

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There are additional resources about each of the strategies on a website supporting the implementation of the roadmap.


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Children Now: Child-Centered Health Homes in California

This policy brief from Children Now describes how child- and family-centered health homes can improve the health of California’s children.  While patient-centered health homes can improve health for all populations, children can particularly benefit because of the impact of early childhood development on lifelong health (and health costs), the dependence of children on their families and caregivers, and the complexity of certain childhood diseases and conditions that require care coordination.  The policy brief highlights how children with special health care needs and children in foster care can particularly benefit from health homes.

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H.R. 2: Medicare Access and CHIP Reauthorization Act of 2015

Here is the full text of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, which repealed the Sustainable Growth Rate formula for Medicare provider payments.  The bill was signed into law as Public Law 114-10 by President Barack Obama on April 16, 2015.

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Posted in Health Care Reform, Health Care Reform: Payment Reform | Leave a comment

U.S. Department of Health and Human Services: Goal of 50% Medicare Provider Payments Based on Alternate Payment Models by 2018

In this January 2015 blog posting, Health and Human Services Secretary Sylvia Mathews Burwell announced departmental goals of changing 30% of Medicare provider payments to alternate payment models by 2016, and to 50% by 2018.  A secondary set of goals are to change 85% of Medicare fee-for-service provider payments to value-based payments, and to 90% by 2018.  The Secretary uses the formulation of the “triple aim” that she favors, “achieving better care, smarter spending, healthier people” as the overall departmental goal.  Secretary Burwell also announced the creation of a Health Care Payment Learning & Action Network at the Center for Medicare and Medicaid Innovation to support the achievement of these goals.

These goals will be supported by Congress’ repeal of the Sustainable Growth Rate formula for Medicare payments in April, which includes a transition from annual 0.5% provider rate increases to a merit-based incentive payment system beginning in 2019.  The merit-based incentive payment system combines requirements for the current Physician Quality Reporting System (PQRS), Medicare EHR Incentive Program, and Physician Value-Based Modifier.

Additional bonus payments would be available beginning in 2019 to providers who participate in alternative payment models, including shared savings through accountable care organizations and patient-centered medical homes.  Beginning in 2026, providers participating in alternate payment models may receive annual increases of up to 0.75% while those only participating in the merit-based incentive payment systems may receive annual increases of up to 0.25%.  To qualify for the maximum annual increases, providers would have to demonstrate that an increasing percentage of their Medicare revenue, or of all-payer revenue, is calculated through alternative payment methods (up to 75% by 2023).  While the percentages under the Medicare Access and CHIP Reauthorization Act of 2015 do not align precisely with the HHS departmental goals for Medicare as a payer, they continue to move the nation away from fee-for-service payments and towards value-based payments.

All these policy developments will increase pressure on Medicaid and commercial health insurance payers to align their provider payments away from fee-for-service models to value-based and alternative payment models towards the triple aim.

Posted in Health Care Reform, Health Care Reform: Payment Reform | Leave a comment

Covered California: Premium Rates, New Health Plans Announced for 2016

Covered California, the state health insurance marketplace for California, has announced the health plans and preliminary premium rates for purchasing health insurance in each of California’s 19 regions for 2016.   According to Covered California, the statewide weighted average increase will be 4 percent, which is lower than last year’s increase of 4.2 percent.  In addition, California consumers could reduce their premiums by an average of 4.5 percent, and by more than 10 percent in some regions, if they shop around and change to a lower-cost plan within the same “metal” tier of health insurance plans.  To date, Covered California has enrolled more than 1.3 million Californians in commercial health insurance, making it the largest of the state health insurance marketplaces established through the Affordable Care Act.

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The announcement also includes premium rates to be offered by two new health plans in some regions of the California marketplace, UnitedHealthcare and Oscar. UnitedHealthcare is the nation’s largest health insurance plan and Oscar Health Insurance is a health plan focused on younger members, with internet and app-based interfaces, and a 24/7 doctor on call service that focuses on technology-savvy millennials.

These preliminary rates are still subject to review by state regulatory bodies (the California Department of Managed Health Care and Department of Insurance) before they are finalized for the open enrollment for 2016 coverage, beginning on November 1, 2015 and ending on January 31, 2016.

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U.S. Supreme Court: Marriage Equality Recognized Nationwide

In its June 26, 2015 decision in Obergefell v. Hodges, the U.S. Supreme Court found a federal constitutional right to marriage equality for same-sex couples under the due process and equal protection provisions of the 14th Amendment.

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As a result of this decision, same-sex couples will be able to marry in every state throughout the U.S. (and every U.S. territory), and all past marriages entered into in states with marriage equality (through a court decision, legislation, or ballot initiative) must be recognized as valid marriages in every state and U.S. territory.   After the U.S. Supreme Court’s 2013 decision in U.S. v. Windsor, the federal government already recognized all same-sex marriages for the purposes of federal law, including the administration of federal health and human services programs.

Health insurance plans now must adjust their applications to recognize same-sex marriages in and from every state, and all health care organizations and providers should adjust their intake and registration forms to recognize same-sex marriages.  Electronic health record systems also should be adjusted to appropriately identify same-sex couples when they are married.

There is speculation that most employers will stop offering employer-based health insurance coverage to the domestic partners of employees (offered as an alternative when marriage equality was not legally available in all states), and require employees who are in same-sex relationships to become married to retain spousal coverage.  However some employers are continuing to offer domestic partner coverage both to heterosexual and to gay and lesbian couples (including younger couples who do not wish to get married, and older couples – including those in retirement but still eligible for employee benefits – who do not wish to get married).


Posted in Demographic Data, Demographic Data: Sexual Orientation, Lesbian, Gay, Bisexual and Transgender Health | 2 Comments

Centers for Medicare and Medicaid Services: Final Rule for Medicare Shared Savings Program Accountable Care Organizations

On June 9, 2015, the Centers for Medicare and Medicaid Services (CMS) published this final rule that significantly revises the requirements for the Medicare Shared Savings Program accountable care organizations (ACOs) established through section 3022 of the Affordable Care Act (ACA).  Since the implementation of the Medicare Shared Savings Program in 2012, there are now over 400 ACOs participating in the program, serving over 7.3 million Medicare fee-for-service beneficiaries.

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In a fact sheet accompanying the publication of the final rule, CMS summarizes the major changes to the program:

  • Increasing the emphasis on primary care services in the beneficiary assignment methodology and adding nurse practitioners, physician assistants, and clinical nurse specialists as primary care providers;
  • Streamlining data sharing to provide improved access to data necessary for accountable care organization (ACO) health care operations such as quality improvement and care coordination, while maintaining beneficiary protections;
  • Adding a new performance-based risk option (Track 3) that includes prospective beneficiary assignment and a higher sharing rate;
  • Providing ACOs choice of symmetric threshold for savings and losses under performance-based risk tracks;
  • Addressing participation agreement renewals including allowing eligible ACOs to continue participation under the one-sided model (Track 1) for a second agreement period;
  • Establishing a waiver of the 3-day stay at Skilled Nursing Facilities rule for beneficiaries that are prospectively assigned to ACOs under Track 3;
  • Refining the methodology for resetting benchmarks to help ensure that the program remains attractive to ACOs and continues to provide strong incentives for ACOs to improve the efficiency and quality of patient care, and generate savings for the Medicare Trust Funds; and
  • Refining eligibility, ACO governance, and other requirements, including a streamlined process for current Pioneer ACOs to convert to Medicare Shared Savings Program ACOs.

While most of these changes focus on the methodologies for calculating the shared savings available to program ACOs, there are significant changes to Medicare beneficiary assignment, notice, and opting out of data-sharing that are important from a beneficiary perspective.

CMS did not resolve all the potential issues on adjusting benchmarks for the shared savings calculations on a regional rather than individual ACO basis, deferring those decisions to additional rulemaking expected later this fall.

It is expected that these changes will encourage existing program ACOs to renew their participation for additional three-year cycles, as well as encourage additional health care organizations to apply to join the program.

One important technical note is that this is the first time that CMS has used its authority under  ACA section 3021 to certify that elements of a Center for Medicare and Medicaid Innovation Program, the Pioneer ACO model, has demonstrated sufficient quality improvement and cost reduction to be applied to other CMS programs, such as this Medicare Shared Savings Program.

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