The Enterprise Blog | The problem with Obamacare’s bundled payments initiative

The biggest flaw in the Obama approach to bundling is that the administration is lumping the doctors’ services along with the cost of the technology that physicians use to treat patients and paying for both in the same “bundled” payment. That means that if a physician chooses to use newer but pricier drugs to treat a cancer, for example, then the cost of the medicines will come out of the doctors’ bottom line.

One year into the Obama Administration’s first test of a bundled payment arrangement—put in place for paying providers to treat dialysis patients—we are already seeing signals that this financial conflict may be leading to degradation in patient care. Over the first year that the dialysis bundle was in place, parathyroid hormone levels in the dialysis patient community rose 25%. This is a clinical parameter that is closely followed in dialysis patients for monitoring the effects of their kidney dysfunction. The rising levels may be an early indication that doctors are underutilizing certain key drugs in caring for these patients.

via The Enterprise Blog.

Does Uninsurance Affect the Health Outcomes of the Insured? Evidence from Heart Attack Patients in California by N. Meltem Daysal :: SSRN

In this paper, I examine the impact of uninsured patients on the health of the insured, focusing on one health outcome | the in-hospital mortality rate of insured heart attack patients. I employ panel data models using patient discharge and hospital financial data from California (1999-2006). My results indicate that uninsured patients have an economically significant effect that increases the mortality rate of insured heart attack patients. I show that these results are not driven by alternative explanations, including reverse causality, patient composition effects, sample selection or unobserved trends and that they are robust to a host of specification checks. My results also indicate that the primary channel for the observed spillover effects is increased hospital uncompensated care costs. Although data limitations constrain my capacity to check how hospitals change their provision of care to insured heart attack patients in response to reduced revenues, the evidence I have suggests a modest increase in the quantity of cardiac services without a corresponding increase in hospital staff.

via Does Uninsurance Affect the Health Outcomes of the Insured? Evidence from Heart Attack Patients in California by N. Meltem Daysal :: SSRN.

Does Universal Coverage Improve Health? The Massachusetts Experience

In 2006, Massachusetts passed health care reform legislation designed to achieve nearly universal coverage through a combination of insurance market reforms, mandates, and subsidies that later served as the model for national health care reform. Using individual-level data from the Behavioral Risk Factor Surveillance System, we provide evidence that health care reform in Massachusetts led to better overall self-assessed health. An assortment of robustness checks and placebo tests support a causal interpretation of the results. We also document improvements in several determinants of overall health, including physical health, mental health, functional limitations, joint disorders, body mass index, and moderate physical activity. The health effects were strongest among women, minorities, near-elderly adults, and those with incomes low enough to qualify for the law’s subsidies. Finally, we use the reform to instrument for health insurance and estimate a sizeable impact of coverage on health. The effects on coverage were strongest for men, non-black minorities, young adults, and those who qualified for the subsidies, while the effects of coverage were strongest for women, blacks, the near-elderly, and middle-to-upper income individuals.

via Does Universal Coverage Improve Health? The Massachusetts Experience.

Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm — NEJM

The largest U.S. health insurer, the Centers for Medicare and Medicaid Services (CMS), has set a triple aim: better care for individuals, better health for populations, and lower costs. Simultaneously, major efforts have been launched to make care more patient-centered, defined as “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”1 Attention to patient-centered measures and outcomes will be particularly important as CMS moves increasingly to link health care providers’ reimbursement to their performance on selected measures.

So far, assessments of quality of care and health outcomes have not incorporated patient-centeredness. Rather, measurement of quality has addressed preventive and disease-specific care processes (e.g., smoking-cessation counseling and initiation of appropriate medications after myocardial infarction). Similarly, outcomes measurement has focused on condition-specific indicators, both short-term (e.g., glycated hemoglobin levels and hypertension control) and longer-term (e.g., disease-free survival), as well as overall mortality.

via Goal-Oriented Patient Care — An Alternative Health Outcomes Paradigm — NEJM.

Healthcare reform board seeks comment on research agenda – The Hill’s Healthwatch

A panel of experts created by President Obama’s healthcare reform law is seeking public input on its draft research agenda released Monday.

The Patient-Centered Outcomes Research Institute (PCORI) aims to fund research that compares medical procedures to see which are more effective.

The 2010 health law set aside $500 million in the first five years for what it called “comparative effectiveness research,” which is controversial because some worry that it could limit medical professionals’ ability to order expensive care that could be effective for specific patients but not the general population.

via Healthcare reform board seeks comment on research agenda – The Hill’s Healthwatch.

Two Years and Counting, January 4, 2012, Brook 307 (1): 41 — JAMA

In less than 2 years, all US citizens and legal US residents will have health insurance—except individuals who are willing to pay a penalty for not buying insurance. The United States is on the verge of joining the civilized world.1 Of course, this outcome will occur only if, among other things, the US Supreme Court does not rule that the Patient Protection and Affordable Care Act is unconstitutional, if US and state governments can enact the necessary policies and regulations, and if the health insurance exchanges required to implement the law will work. Whether a proponent or a critic of this law, most will agree with the undeniable fact that a new era in US medicine and US health care begins in less than 2 years.

The key question is what potential measures should be monitored to determine both anticipated and unanticipated effects of the new law

via Two Years and Counting, January 4, 2012, Brook 307 (1): 41 — JAMA.

The Patient Protection and Affordable Care Act of 2010 (PL 111-148)

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act, setting in motion a historic and, for many, a long-awaited radical change to the current American health care system. Section 2951 of the PPACA addresses provision and funding of maternal, infant, and early childhood home visiting programs. The purpose of this article is to acquaint the reader with the legislative odyssey of home visitation services to at-risk prenatal and postpartum women and children as delineated in the PPACA and to discuss the nursing practice and research implications of this landmark legislation. Few question the need for more rigorous methodology in all phases of home visitation research. Public health nursing may provide the comprehensive approach to evaluating effective home visitation programs.

via The Patient Protection and Affordable Care Act of 2010 (PL 111-148).

The New Wave of Innovation: How the Health Care System Is Reforming—A Resource for Journalists from The Commonwealth Fund – The Commonwealth Fund

The Affordable Care Act—also known as national health reform—will transform the U.S. health care system in many ways. Some provisions, such as coverage for young adults, small-business tax credits, and new quality initiatives, are already in place. Other major reforms, including Medicaid expansion and new state health insurance exchanges for individuals and small businesses, will take effect in 2014. Yet even before health reform has been fully implemented, the health system has started—quite literally—to re-form itself. That’s partly because of the parts of the law that are already in effect. But many hospitals, physicians, employers, insurers, and states are also anticipating the changes ahead and preparing for them now, and discovering new ways to improve access and quality, and control rising health care costs as they do.

The result: experimentation—across the health care system. The new emphasis is on primary care, care coordination, and chronic disease management. With this shift in health care delivery comes new ideas for payment models and financial incentives that take a broader view of health management than the traditional fee-for-service structure. The aim is to allocate more resources to up-front preventive and primary care, as well as care coordination, reducing the need for costly acute and emergency care services down the road.

This report shines a light on emerging innovations, providing examples from different sectors across the country, to inform journalists and others of the different ways in which the system is reforming itself. It may also provide ideas for journalists who are interested in exploring the early effects of health reform and the implications for the future.

via The New Wave of Innovation: How the Health Care System Is Reforming—A Resource for Journalists from The Commonwealth Fund – The Commonwealth Fund.

Not Running a Hospital: Did I say unintended consequences?

Given that many poor-performing hospitals also have fewer resources, they may suffer disproportionately from financial penalties for high readmission rates. As we seek to improve care for patients with heart failure, we should ensure that penalties for poor performance do not worsen disparities in quality of care.

via Not Running a Hospital: Did I say unintended consequences?.

When Public Health and Genetic Privacy Collide: Positive and Normative Theories Explaining How ACA’s Expansion of Corporate Wellness Programs Conflicts with GINA’s Privacy Rules by Jennifer Bard :: SSRN

The Patient Protection and Affordable Care Act of 2010 (ACA) contains many provisions intended to increase access to and lower the cost of health care by adopting public health measures. One of these promotes the use of at-work wellness programs by both providing employers with grants to develop these programs and also increasing their ability to tie the price employees pay for health insurance for participating in these programs and meeting specific health goals. Yet despite ACA’s specific alteration of three different statues which had in the past shielded employees from having to contribute to the cost of their health insurance based on their achieving employer-designated health markers, it chose to leave alone recently enacted rules implementing the Genetic Non-Discrimination Act (GINA), which prohibits employers from asking employees about their family health history in any context, including assessing their risk for setting wellness targets. This article reviews how both the changes made by ACA and the restrictions recently put place by GINA will affect the way employers are likely to structure Wellness Programs. It also considers how these changes reflect the competing social goals of both ACA, which seeks to expand access to the population by lowering costs, and GINA, which seeks to protect individuals from discrimination. It does so by analyzing both positive theories about how these new laws will function and normative theories explaining the likelihood of future friction between the interests of the population of the United States as a whole who are in need of increased and affordable access to health care, and of the individuals living in this country who risk discrimination, as science and medicine continue to make advances in linking genetic make-up to risk of future illness.

via When Public Health and Genetic Privacy Collide: Positive and Normative Theories Explaining How ACA’s Expansion of Corporate Wellness Programs Conflicts with GINA’s Privacy Rules by Jennifer Bard :: SSRN.