States responsible for health insurance exchanges for small businesses

Most of us know that in 2014, states will open health insurance exchanges (or the federal government will run a backup exchange for them) But actually states are running two exchanges – one for individuals and one for small businesses, known as Small Business Health Options Program (SHOP) exchanges.

To the consumer, they may look the same, and people may access them through the same website. But states have the option of keeping them separate (which is what most states are planning as of now) or of merging them. The February edition of Health Affairs (which AHCJ members can get access to) has a series of articles on the SHOP exchanges, and there’s a summary on the Health Affairs blog.

Some of the articles re-examine the conventional wisdom about the fiscal rational for keeping SHOP and individual exchanges separate. There’s also a one-hour webinar supported by the Commonwealth Fund on Feb. 22 that looks more closely at the role the exchanges will have in covering small businesses – and how these new insurance markets may eventually prove attractive to larger businesses as well.

Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for resources, please send them to joanne@healthjournalism.org.

Essential component of reform will require more staff, training

When we think about the growing demands health reform will place on community health centers (assuming that we are thinking about community health centers at all – and we should be) we tend to think about the shortage of primary care doctors in underserved communities, and the increasing numbers of soon-to-be-insured patients needing such care.

According to the National Association of Community Health Centers, about 20 million patients get their primary health care needs at more than 8,000 U.S. locations. I’ve seen various projections of how that will grow under health reform (depending on fun ding and other factors) but the NACHC says it could double, to 40 million, within another five years.

There’s another aspect to the community health center workforce – one that, frankly, I had never thought about until I got a release about a set of grants a few weeks ago from a small foundation that focuses on community health. The clinics don’t just need doctors and nurses. They need people who can just run the places – who can make appointments and keep records, and do the coding and billing, and handle the health IT, and do health outreach in the community, and the case management. And they need people who speak a bunch of languages and be culturally sensitive. In other words, they need all kinds of people who can do the work necessary for these clinics to become effective “medical homes.”

So the RCHN Community Health Foundation recently announced grants of about $150,000 to $200,000 each to five very different community health groups, in five quite different settings. (On the foundation’s home page you can find links to some of the coverage it has gotten.)

1. Aaron E. Henry Community Health Services Center, Clarksdale, Miss.
2. Charles B. Wang Community Health Center, New York
3. Penobscot Community Health Care, Bangor, Maine
4. Seattle Indian Health Board, Seattle
5. Wai’anae Coast Comprehensive Health Center, Wai’anae, Hawaii

The details vary, but they are developing training programs (which can be done during the work day), partnerships with local schools, community and four-year colleges, internships, outreach to potential entry-level workers who hadn’t thought of this career path, worker retention programs – with an eye both toward their own needs, their workers’ future advancement, and job creation in their communities, including veterans. In some cases, they will be designing their resources and programs with a clear eye toward having them spread, to be available and useful to other clinics, other communities.

Chances are, you won’t be covering these five specific clinics. But the challenges these grants are aimed at exist everywhere and are ripe material for covering:

• How are clinics in your areas preparing – not just expanding physically (there was a lot of money in the 2009 stimulus package for that), but how are they expanding in other, qualitative dimensions?
• Have they begun the transition to medical homes?
• Have they installed electronic medical records? (They are doing so at a faster pace than many more resource-rich practices.)
• Who is working for them?
• How are they being trained – and retained – for the coming changes in the delivery and financing of health care?

You – and your reader, listeners, and viewers – may be quite surprised by some of the innovative, change-embracing answers.

Share some health reform humor with your Tweetheart #healthpolicyvalentines

Who says health reform can’t make you laugh?

In case you have been living in a Twitter-free cave somewhere in Antarctica, you have probably seen #healthpolicyvalentines (and its half cousins #hospitalvalentines and, in a sad commentary on our times, #budgetvalentines).

It’s been going on since last week and reading it is the most fun we’ve had wasting time in quite a while. Some of the entries are not suitable for a family journalism blog (Sam, that bit about your benefit package?) but here are a few of our favorites. Go waste some time on your own, you won’t regret it.

There are dozens and dozens more – many very funny.  It can be hard to make your Twitter feed go all the way back to when it began last week, but it’s worth struggling with that “load” feature. I would include more but I have to go tweet my thanks for name brand roses now (I would have been happy with generics).

For more:

• Health Policy Valentines Tumblr page
• Dan Diamond has the background of how it came to be

Article looks at reform concepts put into practice

Here’s a recent story that touches on a whole lot of themes in health reform – without getting bogged down in a lot of jargon. Value-based purchasing. Evidence-based medicine. Shared decision-making.

Jackie Crosby of the Minneapolis Star-Tribune writes about how a Minnesota insurer, HealthPartners, has introduced a new approach for patients with low back pain. Before they get surgery, they have to get a consult on nonsurgical alternatives.

If they still opt for surgery, they can have it. But the thinking is (based on what other health systems have learned) that many will opt for physical therapy and rehabilitation once they learn more about the pros and cons, risks and benefits, of all their options.

“Patients can still see a surgeon if they wish. But after this visit, they’ll be better informed about all of their options, and can make decisions more aligned with their own values,” the story quoted  Dr. Thomas Marr, HealthPartners’ medical director of clinical relations as saying.

“In general, it’s a bad thing when the doctor and patient can’t determine the treatment without interference from the insurance company or the government,” spine surgeon Jeffrey Dick was quoted as saying. But this is an exception, he said. Surgery is appropriate for only about one out of eight low back pain patients he sees. Getting them into appropriate care from the start can save money – not to mention years of lingering back pain.

“These aren’t HealthPartners criteria,” he added. “These are treatment algorithms for low-back pain that we all should be following – but maybe haven’t been by all practitioners.”

The story also noted how HealthPartners is working with stakeholders and monitoring patient reaction and satisfaction to minimize criticism and misunderstandings.

So what are those health reform themes?

Value-based purchasing – loosely translated – is paying for what works.

Evidence-based medicine is what it sounds like – and the evidence is that a lot of back surgery is unnecessary. Sounds simple but it’s not always practiced – even in those cases where the evidence is strong. Sometimes it’s even derided as “cookbook medicine.” Financial incentives are certainly one big impediment: surgeons, hospitals, etc., make money from procedures that may not always be the best choice for the patient. Practice patterns – how physicians are taught and what’s done in the medical culture of a given hospital or community – play a role. And patients often want treatments they don’t need because they don’t understand that it’s not necessary, or they think surgery is a reliable quick fix.

Some researchers exploring medical decision-making have found that physicians are a lot more likely to talk about why to have a certain procedure, including back surgery, than why not. Clinicians and researchers are beginning to develop models for “shared decision-making” and there’s even a bit of language in the health reform law to promote it.

So are there programs like this rolling out in your local hospitals or health plans? We’d like to hear more. It will be interesting, too, to watch how people react to the HealthPartners and similar ventures. Will patient/beneficiary attitudes begin to change? Will they come to understand that more isn’t always better? Will they be glad to find out they really don’t need surgery? Or will there be a backlash about choice and control. The answer may depend on whether patients feel the decision is shared, or imposed.

Journalists should learn about study design, evidence-based medicine

Earlier this month I saw on Twitter one of those collisions between journalism and wonkdom. Maybe “collision” isn’t the right word; maybe it was some kind of interspecies mating dance. Anyhow, the gist of it was that we, journalists, don’t know how to evaluate evidence and someone should step in and teach us.

So I stuck in my two cents (or, rather, my two tweets) pointing out that, yes, there is a need for training and, yes, there are places to get the training, including through AHCJ. (See more after the Twitter discussion.)

So, before I remind you about those resources, just a word on why we need them:

On the surface, it may seem that AHCJ houses two kinds of health journalists – those of us who report on the science side of things, and those of us who are more in a policy world. But some of us do both – and research/evidence/evaluating science are also becoming an increasing part of the underpinnings of policy beats. Value-based purchasing, comparative effectiveness, benefits of screening/prevention, quality measures, outcome research … these are all part of the health care reform story.

That doesn’t mean all of us must become  economists/biologists/epidemiologists/statisticians. Old fashioned reporting – including calling experts who can help us make sense of numbers  – is certainly part of the job. But it’s also good to have some sense of what the experts are talking about, what these numbers mean. Why a study on N=16 patients doesn’t really tell us that much. What do we mean by “endpoints,” “outcomes,” “progression?” What’s relative versus absolute risk? Etc.

So for those of you who haven’t  taken a cyber-stroll through the AHCJ website, take five minutes and check out tip sheets, resources and slim guides. Of particular relevance to this discussion is Gary Schwitzer’s slim guide, “Covering Medical Research.”  There’s also a tip sheet/PDF presentation by Schwitzer on “Understanding studies.” His Health News Watchdog blog is also useful.

Reporting on Health (at USC) also has a lot of useful resources, and this essay “Tricks of the Trade: Finding Nuggets in the River of Medical Studies” is a good entry point to understanding data. It’s by Lauran Neergard, a longtime Associated Press health and science writer.

In addition,  there’s a course called Medicine in the Media, sponsored by National Institute of Health’s Office of Medical Applications of Research.  It’s free, but you have to apply, and there’s not room for everyone.  I know of at least one recent summer (the only one I, personally, could have managed the timing!) it wasn’t given, and as of now, there’s nothing on the website about this year. But you can sign up for email notifications, so if you are interested, do that now because the deadline in past years has been early.

The Poynter Institute has some online modules, too. Lots of the focus is on new media and writing and story telling, but there is a math basics refresher for those of you who haven’t taken it since the SATs, some online Excel training, and a unit on reporting on nonprofits