Experts offer story ideas for covering health reform
Filed under: Health care reform, Health journalism
More than 30 attendees heard local experts sketch the particular challenges and issues presented by the Affordable Care Act in California in the latest “Implementing health reform in the states” panel, hosted by AHCJ’s San Francisco Bay Area chapter on Wednesday night at the San Francisco Chronicle.
The panel, one of a series sponsored by AHCJ, the Alliance for Health Reform and the Robert Wood Johnson Foundation, began with an explanation of exchanges and what’s happening with their implementation (or lack thereof) around the country by Larry Levitt of the Kaiser Family Foundation.
He posed some story ideas, such as: How vigorously will the states promote enrollment through the exchanges? What sort of variations to the ACA might emerge once states have the ability to ask for waivers in 2017?
Kim Belshe, a board member of the California exchange, and Marian Mulkey of the California HealthCare Foundation discussed the California scene, with lots of detail, touching on the state’s large undocumented immigrant population, the challenge of getting people enrolled (since the law of the land is now “performance” – which means maximum participation), new opportunities for medical professions, such as nurses, to fill gaps in care delivery, and how to ensure coordinated care during the transition period to exchanges so no patient is harmed. This is the accountability part of the ACA, and needs thought and new procedures, Belshe stressed.
Belshe noted that Medicaid (Medi-Cal) is the foundation of reform, a subject which reporters sometimes overlook. Both she and Mulkey noted that California is a national pacesetter when it comes to reform implementation - a story idea in itself.
The session was moderated by Ed Howard, executive vice president of the Alliance for Health Reform.
On Tuesday night, a similar briefing was held at the University of Southern California, featuring Walter Zelman, Ph.D., a professor and director of health science at California State University-Los Angeles; Daniel Zingale, senior vice president of the Healthy California program at The California Endowment; Anthony Wright, executive director for Health Access, a California health care consumer advocacy coalition; and Deborah Crowe, the health care and biotechnology industry reporter for the Los Angeles Business Journal. Howard, of the Alliance for Health Reform, moderated the session.
Zelman posed a number of questions about reform, mostly about exchanges. To a reporter from Orange County, he suggested a story about the origin of the individual mandate – an idea championed by Republicans early on, he noted, and opposed by Obama and many Democrats. To a question about accountable care organizations and bundling, he suggested stories about how fee-for-service medicine is anything but dead.
Wright offered a look at what’s happening in Sacramento, including a hearing held just a few hours before the briefing.
Zingale mentioned the importance of prevention, and how the ACA encourages prevention. He too pointed out how nonprofits in the state can team up with reporters to educate people about the ACA. He said that the more people know about the law, the better they like it.
From a reporter’s perspective, Crowe offered several practical story ideas that reporters can start writing about today.
John Gonzales of the California HealthCare Foundation Center for Health Reporting wrote about the panel and Michelle Levander of the California Endowment Health Journalism Fellowships program offers some of the story ideas mentioned by the panelists.
Special thanks to Colleen Paretty, chair of the Bay Area chapter, and Bill Erwin, of the Alliance for Health Reform, for contributing details about the panel discussions for this post.
Article looks at reform concepts put into practice
Filed under: Health care reform, Hot Health Headline
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.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. 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.
Growth of for-profit hospices ripe for coverage
Given the recent spate – some good, some pretty muddy, and one I think pretty eye-opening – of articles about the growth of for-profit hospices, it’s probably worth taking a look at the issue, particularly for those of you who live in communities (such as the south and west) where the for-profits are most dominant. I think it’s also important to note some of the context that some of these articles omitted. And, yes, there’s a health reform angle. Several, in fact.
MedPAC started looking into the for-profits several years ago, as the sector started growing very rapidly. It became clear that the Medicare hospice “caps” and penalties meant to discourage too many long stays weren’t working. MedPAC has made a number of payment recommendations, including one that would revamp how all hospices are paid (which would make long stays less profitable) and another focusing more narrowly on creating a separate payment scale for hospice care in nursing homes.
MedPAC advises Congress but doesn’t set policy. And Congress has not acted on the recommendations to date – except that it did include in the 2010 health reform law a requirement that HHS review (and gives it a pathway to revamp) the hospice payment system in 2013. In addition, hospice faces about $7 billion of Medicare payment reductions over a decade under the Affordable Care Act. On top of that is the 2 percent Medicare provider cuts that will be “triggered” next year now that the supercommittee failed to agree on an alternative deficit-reduction steps.
All that being said, the recent Bloomberg piece by Peter Waldman on sales and marketing tactics by the for-profit chains was a hefty piece of reporting. It documents things like “Summer Sizzle” promotions, “Christmas Cash Blitz” and “Fall Frenzy” admission drives. The focus was pretty squarely on the business and sales practices. That is an important issue (and I haven’t seen it as well reported elsewhere ). But for those of you who may want to write about hospice, it’s not the only issue.
If you write about the growth of for-profit hospices – and some communities are now dominated by them – a few things to keep in mind.
- Don’t conflate quality and quantity. A flawed government payment system, and overly aggressive/inappropriate sales tactics (or even outright fraud) by some players isn’t always the same thing as a quality-of-care problem. A nursing home resident who ends up getting hospice care longer than he or she really should isn’t necessarily getting bad care – although they may well be getting care that Medicare shouldn’t be paying for.
- There’s a difference between large publicly-traded, investor-owned hospice chains and smaller, local for-profit hospices, which can be quite mission-driven (and low margin.) A hospice’s tax status doesn’t automatically define whether it provides good or bad patient care. (Remember the ongoing debate about which nonprofit hospitals are really “non” profit).
- Prognosis is really, really hard – particularly for the frail elderly nursing home population. It is hard to know whether a dementia patient is going to die within six months - even when there are some tell-tale danger signs of decline and deterioration. CMS did add some recertification and quality rules two or three years ago that are supposed refine the eligibility criteria - but they still aren’t a crystal ball.
- Long hospice stays may be a poor use of taxpayer/Medicare money but potentially so are very short stays. If people are only in hospice a couple of days, that often means that they got very aggressive care - which usually means very costly care until close to the end. That’s one thing if such care was what the patient/family chose. It’s another if the doctors never explained to the patient/family the likely prognosis, the likely outcome, the relative burdens and benefits of such care (and by “burdens” I don’t mean purely financial burdens). If Medicare paid for all that and then there is a mad dash for hospice to try to get pain and symptoms (physical and emotional) under control in the last few days, it’s neither good for Medicare’s bottom line nor does it give hospice the optimal circumstances for providing really good end-of-life care. Those last few days of life can be intensive for the hospice and a hospice with only very short-stay patients would be hard pressed to survive financially.
- How would small community and rural hospitals survive under some of the new payment models being discussed? Would they close? Get swallowed up by big chains? Both - i.e., first get swallowed up and then be closed because they aren’t as profitable?
- There have been several studies suggesting that patients who receive hospice care may live longer than similar terminally ill patients who do not. There was a whole spate of articles on this phenomenon back when Art Buchwald was dying – or rather when he was not dying. Most of the research I’m familiar with was on hospice care for specific cancers and heart diseases, not necessarily dementia, and not necessarily in the context of for profit hospice care for nursing home patients. But seriously ill people who get expert, interdisciplinary end-of-life care may bounce back, temporarily, and no longer fall in that six-month life expectancy category. If they really rebound, they should leave hospice care, as Buchwald did, with the right to resume it when the time comes.
- When asking whether there’s “too much” hospice care in nursing homes - don’t forget to ask what happens when there is not enough. This is the one area where I thought the Bloomberg story was incomplete – or even slightly misleading – by quoting a physician in Kansas as saying there should “never” be hospice in nursing homes. There is a lot of data – in peer-reviewed journals and medical conferences produced by academics and palliative care experts and nonprofits, not by the “industry” – that pain is poorly controlled in nursing homes, that there is overtreatment (feeding tubes being a prime example) of late-stage dementia patients in nursing homes, and that nursing home patients who could benefit from hospice/palliative care are instead sent repeatedly – often via costly ambulance-to the hospital. I met one doctor who called this care model “Our Lady of Perpetual Hospitalization.” This is a piece of the readmission issue that the health care reform law aims to address. There’s no room here to go into the convoluted mismatched incentives regarding nursing home care, but suffice it to say the revolving door won’t stop without quality end-of-life care in nursing homes – and nursing homes are often surprisingly ill-equipped to provide quality end of life care. Accountable Care Organizations, advanced medical homes, home and community based alternatives to institutional care, all part of health reform, may play a role here in coming years but it’s not going to be an overnight change.
- Hospice was not designed to be a substitute for, or side door to, Medicare-financed long-term care and it’s not the right way to pay for long-term care. Unfortunately, we don’t have a good way of paying for long-term care, nor for helping family caregivers.
- I’ve heard some rumblings – and it’s not a story I’m in a position to chase right now but may be worth looking into locally – that some groups or individuals are starting small nonprofits, specifically to flip them fast in sales to the big chains and make a lot of money. The Bloomberg piece reported on the recent uptick in acquisition of nonprofits.
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. Finally, for now at least, remember that most hospice care takes place at home, with family members as caregivers. But not all terminally ill people have family members alive, or living nearby, or hale and hearty enough themselves to provide that care at home. For them, at least for some of them, the nursing home IS “home,” and that’s where they will access hospice.
Update: Just after I finished writing this blog post, Bloomberg and Kaiser Health News wrote about a big fraud case against a hospice chain based in Arkansas, and updated the status of other investigations.
- Bloomberg: AseraCare Hospice Accused by U.S. of Defrauding Medicare
- KHN: Lawsuit Accuses Company Of Fraudulently Cycling Patients Through Nursing Homes, Hospice Care
What do you wish you knew about covering health reform?
You’ll notice today that we have launched our Core Topic pages on health reform to offer helpful reporting resources.
Joanne Kenen is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org. One of the features is something called Shared Wisdom, where we tap into the insight of our members on some new ground, on a specific reporting angle or a coverage hurdle.
I will seek out these words of advice from you every so often and also welcome your questions for the brief insights you are seeking.
My first question to you: Tell me – as a fellow reporter: “What’s the one thing you wish someone had told you during your first week on the health reform beat?”
Send your thoughts, preferably in just 100-300 words, directly to me at joanne@healthjournalism.org. I will pick out useful thoughts to highlight on the site. Thanks for your help.
Send us examples of explaining complexities of health reform on TV
I know firsthand how hard it is to explain something like an Accountable Care Organization in a 2,500-word magazine piece. I can’t begin to think how difficult it would be in a 3-minute local television news segment.
Joanne Kenen
My posts on this blog have usually highlighted print (or online equivalent) or public radio pieces. But I’d also like to highlight some good local television reporting on health reform – or address some of the obstacles (and solutions) that TV reporters face in exploring health reform.
So if you have done good work or seen good work – or if you have any ideas or thoughts worth sharing with AHCJ colleagues, email me at joanne@healthjournalism.org or find me on Twitter (@JoanneKenen) and maybe I can use it in a future post.
Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform.
Health reform: Another poll, another confused public
Every month, we all get those embargoed Kaiser Family Foundation tracking polls in our email. As I open it, I ask myself, “Now what did Americans forget they used to like about health reform this month?”
Or (and you may have heard me say this before – but it sums it up well, so allow me to repeat it) when are Americans going to figure out that this unpopular law is the sum of its popular parts?
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Remember these polls are about opinions about a law that isn’t, by and large, in effect yet. So people hear all sorts of things about it, but they aren’t actually experiencing most of it yet. We don’t know what will happen in 2014 when – if the law survives the political process and the courts – the public may finally reach the “try it you’ll like it” stage.
That brings us to a recent survey from EBRI (Employee Benefits Research Institute) and Mathew Greenwald & Associates, Inc., a Washington, D.C., market research firm. The 2011 Health Confidence Survey, which looks at trends in employer- and union-sponsored health coverage, came out a few weeks ago, based on a telephone survey conducted in May and June.
A press release and EBRI article came out a few weeks ago, but when I looked for more details and data, I found some dated September. Because I’m going to write in pretty broad brush strokes here, including a smattering of numbers without inundating you with them, you can find more specific figures in the press release here, the November article here, and a longer discussion from September here.
Guess what? People were confused – or at least amazingly contradictory – about what they have now, as well as what they expect in the future.
For instance, people were quite satisfied with their own health coverage (amongst those that had coverage) both in terms of their health insurance plan and the actual medical care they receive. But they also thought the whole system is a mess.
Sixty percent were extremely or very satisfied with their plan (a number which surprised me given how much time people – even outside our health policy world – spend complaining about health care) and 29 percent were somewhat satisfied. People also rated the actual care they had received quite high. But more than half say the system is poor or fair; a quarter think it’s good. Only 12 percent deemed it very good and only 5 percent grade it at excellent. Naturally people were not too happy about the costs, either.
They are less confident about the future of employer- or union- provided health benefits than they used to be (NOTE: This slide began, and was sharpest, quite a few years before health reform was enacted. It’s definitely not because of the new law, in case someone tries to spin you that way).
People think that if they lose access to work-related health benefits or their employer/union stops providing them, they will have a really tough time affording their own insurance – even if they are subsidized by the employer or union.
Yet – despite those high unaffordability scores – two-thirds said they would be able to buy it. (You still with me?)
On health reform, those surveyed basically had no idea what a health insurance exchange is – which doesn’t stop them from declaring that the government can’t run them.
Just 1 percent of respondents reported that they were “extremely familiar” with health insurance exchanges in the new law. Double that amount, a whopping 2 percent, was “very familiar” “Somewhat familiar” scored 15 percent (and they can’t all be in Massachusetts). Nearly two thirds - 62 percent - said they weren’t at all familiar.
But guess what. That didn’t stop them from having strong opinions on the inability of either the state or federal government – or even private insurers – to run them.
I wonder, if they go into the exchanges in 2014, will they report being “highly satisfied” with them – and still convinced the government can’t run them? Maybe it will be a variant of “get the government hands off my Medicare.”
Which reminds us – the poll didn’t find a lot of confidence in the future of Medicare either. For what it’s worth.
Related
- Reporters can explore states’ options for creating exchanges
- Study offers context for reporting on health insurance exchanges
How might retail clinics change health care delivery in your community?
I don’t routinely blog about the work of AHCJ board members (which doesn’t mean you shouldn’t read Charles Ornstein’s latest on Florida’s slow reaction to physicians who treated and prescribed drugs under Medicaid “amid clear signs of possible misconduct.”)
But I’m making an exception to my self-imposed rule for Julie Appleby’s recent Kaiser Health News piece “The Walmart Opportunity: Can Retailers Revamp Primary Care?“
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
I’ve read other pieces about the future of retail clinics, including their potential for treating chronic disease. But I thought Appleby did a terrific job of asking – and often answering – many interlocking questions about the delivery of primary care, the management of chronic disease, the quality of care and what this all has to do with health reform.
While asking big-picture questions, she also wove in details that gave the story texture and made it a good read. If you saw my tweet, you’ll know I was particularly taken by the bit about how long-distance truckers can pull up in the parking lot of more than 600 centers to get their mandatory federal checkups.
As Appleby noted, the clinics – which sometimes lose money but bring customers into the stores – started with the low-hanging fruit, the “relatively healthy patients looking for convenient, low-cost care for simple problems.” The next stage is to try to start treating more expensive chronic diseases, such as diabetes and heart disease, which are big drivers of health care spending. Treating chronic disease, however, is definitely a problem in search of a primary care solution. As her story said:
“It’s sad that the existing health care establishment has not figured out a way to make primary care affordable and accessible,” says Jerry Avorn, a professor of medicine at Harvard. “We should not be surprised if someone outside of our world comes in and does it for us.”
Some of the retail clinics are already venturing into aspects of chronic care: diabetes management, weight-loss programs. (I think we can safely say that primary care physicians have not solved the U.S. obesity problem). Some employers are using the clinics for wellness and routine screening programs.
The costs tend to be lower. Appleby cited a study in the American Journal of Managed Care that costs are 30 percent to 40 percent lower than in the doctor’s office and 80 percent cheaper than in the emergency department. Consumers like the predictability and transparency of the costs (although insurance can also pay) . They don’t get pricing clarity up front at the doctor’s office or hospital.
Several provisions of the federal health law may further spur interest in the clinics. For instance, small businesses will have incentives to offer worker wellness program. The clinics may help fill in some gaps in primary care which are expected to get worse before they get better because of the pent-up demand for care that may burst out when coverage expands under the health law starting in 2014. The Association of American Medical Colleges estimates a shortfall of 21,000 primary care doctors by 2015. Not everyone agrees that there is an across-the-board shortage, as opposed to a shortage in specific underserved areas.
How clinics make the jump from flu shots and throat cultures to the far more complex task of monitoring chronic disease is not completely clear. Remember that patients, particularly older patients, often have multiple chronic diseases (i.e. diabetes and hypertension and congestive heart failure and arthritis, etc.). Some questions remain: Will the clinics turn out to be good at managing relatively stable patients in the early stage of disease – where the convenient locations and evening and weekend hours may enhance compliance? What about with the more advanced illnesses? Will the retail clinics add to fragmentation and miscommunication? Or will the clinics somehow form relationships with “new, integrated collaborations between doctors, hospitals and insurers?”
I don’t want this post to get longer than Appleby’s article so, when you read it, pay attention to the other issues she raises, and think about how they are playing out in your community:
- Scope of practice. What is the role of nurses/nurse practitioners/physicians assistants versus physicians? Turf battles can produce good sources and good stories.
- Does your state have laws about clinics directly employing physicians?
- Will clinics “skim off” healthy patients from physician practice and leave them with all the sickest and most expensive ones, without greater reimbursement? Or, by taking on some routine medical tasks, will clinics allow physicians to spend more time doctoring?
- Who are the patients? (Other than truck drivers and high school students needing sports physicals.) Are clinics just a convenient way for insured middle-class people to get routine care? (I’ve taken my son in for a throat culture at 7 p.m. when he’s feeling scratchy and I know there’s strep in his class. It’s way better than waiting until the next morning to go to the pediatrician when he might be sicker, and he has to miss school and I have to miss work. And, if he does need antibiotics, I’d have to go the drug store anyway.) Or are the clinics avoiding poorer neighborhoods, meaning the underserved stay underserved?
- Appleby didn’t mention this explicitly but it’s worth adding to the mix: To the extent the clinics are in underserved communities, are they helping low-wage hourly workers who don’t have paid sick leave or the flexibility to take an hour or two off in the middle of the day to get their kid (or their mother-in-law) to the doctor?
- Are any of the clinics – anywhere – starting to share information with patients’ primary care physicians? Or, in the case of diabetes, heart disease, etc., are they sharing information with specialists? It can be as simply as faxing something, sharing electronic medical records or using secure email. If I take my kid for that throat culture, it’s really not a catastrophe if I forget to tell his pediatrician (and I don’t need to bother if it’s negative). But for things like immunizations, or A1C levels for diabetics, or blood pressure spikes or changes in medications - someone needs to keep track of the big picture. Of course, communication isn’t all that great right now between doctors without the clinics but, since health reform has some incentives for improving coordination, where do the retail clinics fit in?
That question about integration, which Appleby raised, doesn’t yet have a clear answer. Could the clinics end up having some kind of relationship with the “medical home” or the “Accountable Care Organization” or other models of integrated care? I am not sure of all the legal or contractual problems. If someone has written about this, please chime in. But I can envision ways that clinics can be brought into the coordinated or accountable care loop. It may turn out to be in everyone’s interest – patient, physician and clinic – to do the looping.
‘Dual eligibles’ pingpong between programs, getting stuck along the way
Filed under: Government, Health care reform, Health policy
The phrase “dual eligibles” has always been a mouthful for describing people old enough (or disabled enough) to be on Medicare and poor enough to be on Medicaid.
M.C. Kim, a cardiac patient quoted in Anna Gorman’s nice Sunday Los Angeles Times piece on the “duals,” comes up with a clear and easy-to-grasp alternative image: pingpong patients.
M.C. Kim had four heart attacks in as many years. Each time, he left the hospital not knowing why his heart had failed.
When he tried to enter a cardiac rehabilitation program to learn how to reduce the odds of having more heart trouble, the Medicare office told him to call Medicaid. The Medicaid office told him to call Medicare. In the end, he said, both denied coverage.
“I was like a pingpong ball,” said Kim, 51, who lives in Los Angeles. “Nobody wanted to take responsibility.”
So Kim kept returning to the emergency room, racking up expensive medical bills for taxpayers.
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The “duals” get their doctors and hospitals paid for by Medicare, and their long-term care by Medicaid. (That’s overly simplistic, but you get the main idea.) As they go back and forth between settings, they get caught between two systems that should mesh but often are more like mismatched gears that grind and jam and make noise and get stuck.
Care transitions, a weak point in the health care system in the first place, are particularly disastrous for this population. In fact, the mismatched incentives and insane amount of built-in levers to shift costs may increase the number of care transitions -which boosts costs and create all sorts of opportunities for mishaps and miscommunication that can harm patients.
Gorman’s story is a nice illustration, giving examples from both the elderly and the disabled. She puts a face behind the red tape.
The health reform law takes some steps toward solutions - although this is a tough problem and it’s certainly too soon to say that the reform law will fix it.
A few pieces of a potential solution:
CMS now has a special office on the duals. I interviewed Director Melanie Bella for Kaiser Health News earlier this year. She has testified at least twice before committees in Congress: On June 21 (PDF) she went before the U. S. House Committee on Energy & Commerce, Subcommittee on Health and on Sept. 21 (PDF) she was before the U. S. Senate Committee on Finance. Her testimony can give you an idea of what steps her office is taking and which part is relevant to your state or community.
Medicaid managed care, advanced medical homes, ACOs, penalties for high readmission rates, payment bundling and other reforms may eventually provide better coordinated care for the “duals.” Some of the new programs for the elderly encouraged by the law, such as Independence at Home, may also help. There are more details about delivery system and the duals in this Kaiser Family Foundation brief.
The Alliance for Health Reform also did a whole briefing on this topic a few months ago. This link will take you to resources, an archived webcast, and a transcript (for those of you who would rather skim than watch the webcast)
The SCAN Foundation also has a lot of material on the duals on its website, including this report on state-based solutions.
Health reform: Story shows how rival systems work toward accountable care
We hear a lot about accountable care organizations.
What about “accountable care?”
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
A lot of the reporting on ACOs (accountable care organizations) has focused on the effort to get them up and running in various forms under Medicare. One model, “Shared Savings,” got off to a bumpy start when hospitals and other health care providers recoiled at a clumsy and complicated proposed rule. That was recently revised to make it less risky and less cumbersome for potential participants. We should be hearing more about who has been chosen to take part in another form of ACOs, the “Pioneers,” in early- to mid-November.
But the reporting sometimes focuses so much on rules and regs that it leaves people confused about what accountable care – not just accountable care organizations – might really look like, or at least what the early steps toward creating accountable care looks like. That’s why I liked a recent story from Minnesota Public Radio, on how two rival health care systems have teamed up to try to do a better – and more cost-effective job. (The quotes here are from the Web version of Elizabeth Stawicki’s piece “Healthcare rivals’ partnership improves patient satisfaction, lowers costs.” The link will take you to the full audio version.)
Minnesota has moved further than much of the country toward integrated health systems, and the state has quite a few quality initiatives going on as well. The story looks how two rival nonprofit systems in the Twin Cities area, HealthPartners and Allina Hospitals and Clinics, have begun to break down some traditional barriers and practices and work together in an “accountable” way.
After a year, they saved about $6 million - “bending the cost curve” so health care costs rose just 3 percent, down from 8. Patient satisfaction scores rose. The systems didn’t disclose to Stawicki how much they had to invest to get the new programs started; the conventional wisdom (or perhaps the conventional optimism is a better term) is that savings will increase over time, making up for that initial spending.
Her report gave some very concrete - and easy to understand - examples about how the two systems came together to try to improve care in financially responsible ways. None of them are brand new - I’ve encountered or read about other hospitals and health care systems introducing similar care improvement and physician feedback initiatives. But that doesn’t mean they aren’t interesting, particularly in the context of rival health plans working together in what they call an ACO “learning lab. The two systems:
- They shared data with doctors about their patterns of prescribing name brand versus generic drugs. The prescription rates for generic drugs rose and cut total medical costs by about $1 million.
- They made available lower cost options to the emergency department by expanding urgent care.
- Primary care clinics provided additional support to high-risk patients with chronic problems to prevent hospital admissions.
They also stopped elective induced labor before 39 weeks, cutting complications and C-sections.
So is any of this happening in your community? If so, there’s a story in it. And if not – well, there’s a story in that too.
Do small businesses in your area know about tax credit for offering coverage?
There’s been a fair amount of coverage about the lower-than-expected enrollment in high-risk pools created by the federal health reform law. Another available benefit – a tax cut for certain small businesses that offer coverage to workers – is also eliciting less of a response so far than the White House had anticipated.
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The tax credit hasn’t gotten a whole lot of attention, but an uptake update was tucked away in that annual Kaiser Family Foundation report on employer health benefits. The overall report got a lot of front-page press, but it’s worth taking a look at the small business tax credit too (and h/t to my colleague Jason Millman at Politico).
The Affordable Care Act provides a temporary tax credit for small employers – defined as having 25 full-time workers or the equivalent – with average wages less than $50,000. But not many know about it, or that they may be eligible, according to the survey. The White House has estimated that up to 4 million small businesses may be eligible for credits, which are meant to defray part of the insurance costs
The survey found that 29 percent of firms with fewer than 50 employees that offer health coverage tried to find out if they were eligible, and 65 percent did not. Of small businesses that did not offer insurance, half said they were aware of the tax credit and 48 percent said they did not know about it. Of those that were aware, only 13 percent said the availability of a credit had not led them to consider whether to start offering insurance to their workers
The tax credit can cover up to 35 percent of premiums. It rises in 2014 for two years for businesses buying coverage for workers through the insurance exchanges. To qualify, the business has to pay at least half the worker’s premium. Remember these smaller, lower-paying firms do NOT have to cover their workers, although the tax credit and some exchange features aim to encourage them to cover workers. Only larger employers have to contribute or pay a fee.
This is a pretty easy story to localize. How are businesses in your areas learning about the credit – or why aren’t they hearing about it? Perhaps more interesting – are they hearing misinformation? If so what’s the source of that?
The IRS says it’s working on improving outreach via the tax software industry, insurance brokers, agents and carriers, accountants and the small-business community. Do you see any signs of such outreach in your community? How much confusion do you find – do small businesses think they will have the same obligations as large employers? Do they understand the role of exchanges in helping the small-business market?
Related:
-
Join us in Atlanta
for Health Journalism 2012
Fellowship applications
due Feb. 27
New at HealthJournalism.org
- Data gives depth to investigation of patient safety
- What reporters should know about Alzheimer’s and related dementias
- Apply for fellowships to attend Health Journalism 2012
- AHCJ asks Supreme Court to permit broadcast of arguments in health reform case
- Tips for print, online journalists to embrace broadcast opportunities
- Numbers reveal how often, or how rarely, states check doctors’ disciplinary records
- How I did it: Falsified charts in nursing homes linked to patient care
- Access Denied: Looking at a lack of health care availability
- Transparency & medical errors: Public reporting of patient harm is a potent force
