Wednesday, August 31, 2016

High Need, High Cost Patients

Been awhile since I have posted on this blog.  I have cut back on my health reform agenda as I have focused on other projects, especially on investment education in my leadership roles with AAII and with criminal justice projects, as Chair/President of Safe Silver Spring.  Also, active in politics and promotion of a preview showing of Denial" a film about a famous Holocaust denial trial.

I do post articles quite often on the following facebook page as well as my facebook page at Tony Hausner.

Recently, I noticed that the Alliance for Health Reform was sponsoring a program on: High Need, High Cost Patients.  Karen Davis, now at Hopkins was one of the key speakers.  I am a longtime fan of Karen.  Here is what I shared on facebook afterwards.  Alliance for Health Reform and Commonwealth Fund hosted a C-span forum  on High Need, High Cost Patients: Challenges and Promising Models. The paper here was part of the package and lays out some of the key issues.  The forum presenters discussed the needs and potential solutions. An excellent discussion.  Very glad that I attended.

These patients cost $21,000 per person per year which is 3 times adults with multiple chronic diseases but no ADL limits and 4 times the average adult.  

More of the Alliance program can be seen here

Here are a few thoughts that I wrote up afterwards on addressing these and related issues. Many of these are consistent with what others including the panel members have said.  
  • Greater integration of post acute services
  • Greater integration of Medicare/Medicaid programs for duals
  • A more comprehensive long term care services system that is affordable
  • Greater integration of health and other human service programs, etc. 
  • More comprehensive quality outcome measures. And greater integration of measures across services.  Each service has unique measures right now, e.g., home health and nursing homes are very different sets
  • I particularly like Atul Gawande's paper on "The Hot Spotters"
  • Electronic data systems need much greater integration.  A great deal of work needed to develop compatible systems between health care services and even within a given service. Partly tied to quality measures above but need for more consistency even within a given service, e.g., many different hospital systems.  
  • More rigorous evaluation research strategies.  CMS has gotten away from the model that we used in the first 35 years of the program.
I welcome comments on these issues and encourage folks to review the above papers.    

Tuesday, June 9, 2015

My Medicare/Medicaid Story; Blog Status

As indicated, I am doing very little blogging these days as I have cut back on my involvement in health reform in favor of other activities.  I have been posting articles of significance on a facebook page: National  Health Reform Team for Obama as well as on my facebook page.  

My Medicare/Medicaid Story

For Medicare and Medicaid's 50th anniversary which is this year, CMS has requested CMS employees and alumni to submit stories concerning our contributions to the program.  Here is what I submiited.  

I worked at CMS from 1979-2006. Where I had the privilege to work on many important projects. For 13 years, I was in the Office of Research and Demonstrations (ORD) and the remaining 13 years in the Managed Care Policy Division.  I want to single out 4 stories which have particular significance for me.

1)   The Evaluation of the Obstetrical Access Project.  

I served as the evaluation project officer for this grant.
This project was written up in the Health Care Financing Review in 1987. This project expanded the women eligible to participate in the Medicaid and included an expanded set of prenatal care services of psychosocial, health education and nutrition services. The project achieved a 33% reduction in low-birth-weight babies vs. a matched control group.  This was cited as an incredibly successful project. The study was cited as a key finding when Congress twice expanded the Medicaid prenatal care program in 1985 and 1987.  This has resulted in a tremendous increase in the number of healthy infants being born and savings both short term and long term in costs to the U.S.

2)   Home Health Prospective Payment Demonstration

From 1985-1993, I served as the evaluation project officer for this demonstration.  During this time period, I worked with the evaluation contractor, Mathematica Policy Research, to develop the case-mix system to be used in the demonstration.  The system that we developed was incorporated for the most part into the Outcome and Assessment Information Set (OASIS) which CMS (then called HCFA) implemented as written into legislation in the 1998 Budget bill.  This prospective payment system has resulted in tremendous savings to the Medicare program and is still used today.

3)   Home Health Quality of Care Demonstration

In 1985, I proposed that CMS (HCFA) develop an outcome based approach to the quality of care for home health services. This approach focused on the following outcome measures: re-hospitalizations and activities of daily living (ADLs) such as eating, bathing, dressing, toileting, and transferring.  These ADLs are considered key to successful rehabilitation of home health patients.  CMS and the Robert Wood Johnson Foundation combined to award a contract to the University of Colorado to develop such a measurement system.  I served as project officer for the first 5 years of that contract. After successful completion of that contract, which occurred after I left ORD, another contract was awarded to test these outcome measures in a demonstration. That demonstration resulted in a 25% reduction in re-hospitalizations, which represents a dramatic savings to the Medicare program.  Those measures were incorporated into the OASIS system mentioned above to ensure that not only was payment optimal but also to maximize the quality of care outcomes.  

4)   Medicare + Choice regulations

In the 1997 Budget bill, Congress authorized the Medicare+Choice program. This program significantly expanded the Medicare HMO program with many new policy features such as case mix payment, bidding, rate setting, marketing plans, access and quality of care provisions, etc.  Congress mandated that CMS (HCFA) issue interim final rules within 9 months of enactment, an incredibly short period of time for such rule development. I was tasked with coordinating the efforts of 23 workgroups which were assigned the different provisions of these rules.  Five months after enactment, we held a public meeting to layout some of our preliminary thoughts and questions and receive the public's input on these issues.  In developing the rules, we had to brief CMS officials, Department officials and OMB staff.  We published the interim final rules exactly on our deadline which was considered an incredible accomplishment. Many of these provisions were incorporated into the current Medicare Advantage program.

Thursday, April 2, 2015

ACA misunderstandings increase; ACA Future

Please note that I plan to blog only occasionally in the future as I need to consolidate my responsibilities.

Obamacare Is 5 Years Old, and Americans Are Still Worried About Death Panels

This article indicates that the public has even a greater misunderstanding of the ACA than they did 5 years ago. Very frustrating.

Five years old, going on ten: The future of the Affordable Care Act

Henry Aaron of Brookings speculates on the future of the ACA.  Some sounds good.

Gingrich: GOP Really Doesn’t Want to Repeal Obamacare

This is both encouraging and scary.  Newt predicts the Republicans now want to achieve bipartisan legislation such as improve upon the ACA. The good news is that we may make progress. The bad news is that the public may like what the Republicans are doing and give them a stronger vote in 2016 which could lead to undermining the ACA and other laws that I support.

Some Changes in Store for 2016 Health Plans That Affect Consumers

There will be several changes in the next open season currently scheduled for 11/15 - 2/16.  Such as Access to Formulary and Provider Directory and Information about Marketplace Quality and Coverage. 

Many People Entitled to Hefty Subsidies Still Opt Against Coverage


How Much Does Cancer Cost Us?

Research Plan Could Drive 'Culture Change' In How Mental Illness Is Diagnosed, Treated

High Court Rejects Challenge To Health Law's Cost-Cutting Panel

Health Spending Explorer on the Peterson-Kaiser Health System Tracker

Thursday, March 26, 2015

Supreme Court Subsidy Decision; Quality Focus; Jobs

2) NQF Honors Consumers’ CHECKBOOK Founder Robert Krughoff with Inaugural Consumers and Patients for Quality Award

I have previously written about the advantages of Checbook's comparison of Illinois' ACA plans. I hope that this model spreads to all the other states.  Glad to see that not only have they been recognized by RWJF for this new product, but that NQF also has honored them. 

This sounds good. The devil is in the specifics.  

4) ACA-related Jobs Grow Faster in Medicaid Expansion States - Forbes Magazine andCenter for American Progress.

7) Test Your Knowledge of the Affordable Care Act’s Tax Provisions                     
With the tax filing deadline approaching, Americans for the first 

time are confronting several Affordable Care Act tax requirements 

as they fill out their returns.  A new interactive quiz from the 

Kaiser Family Foundation tests people’s knowledge about what the 

individual mandate means for taxpayers, what penalties may apply, 

and how those who receive premium subsidies through the ACA's 

Marketplaces will reconcile the amounts based on actual income.
I got only 5 of 10 correct. Tough quiz.  

Saturday, March 21, 2015

5th ACA anniversay: Many gains; Shopping apps

1) Some useful summaries 

In Its Five Years, The Affordable Care Act Has Transformed Health Care

The article puts together a well stated summary of all the key accomplishments.  Paints quite a positive picture. 

Report says there are enough doctors. 

2)  Many of you have seen much of the information below already.  However, I am extremely excited that Washington Consumer Checkbook took first place in the RWJF competition.  RWJF is one of the top health policy foundations.  Checkbook is talking about doing a webinar soon to introduce states to this tool.  I highly recommend States adopt it.  Welcome ideas on getting states involved and help with that. 

In my blog on 1/24/15 Complex: Premium Credits and Cost-Sharing Reductions; Latinos , I described how complex the calculations were for counselors (navigators) and consumers had in making plan selections.  I then showed how Checkbook solves this challenge.   Here is more from RWJF.  

Apps to Use When Shopping for Health Insurance Win National Competition


Princeton, N.J.—The Robert Wood Johnson Foundation has named Washington, D.C.-based Consumers’ CHECKBOOK as the winner of its first ‘Plan Choice Challenge,’ a nationwide competition facilitated by Health 2.0 to design a technology application that helps people evaluate their health insurance options.

“The direct-to-consumer insurance market is in its infancy, and developers can add a tremendous amount of value by helping consumers make better decisions,” said Katherine Hempstead, PhD, who directs coverage issues at the Robert Wood Johnson Foundation. “The response to this challenge has been overwhelming, and the creativity and talent on display in these applications confirms that developers will play a vital role in moving this market forward.”
The winning application, Consumers’ CHECKBOOK’s Plan Compare tool, enables consumers to scroll through all available plans on a single webpage and compare for each plan: 1) estimated average total yearly cost (premium plus out-of-pocket) for people of the same family size, ages, health status, and other characteristics as the user, 2) risk (the total cost in a very high health-care-usage year), 3) an overall quality rating that the user can personalize based on what quality dimensions matter most to the user; and 4) which of a list of preferred doctors the user has identified participate in the plan. Users can drill down for much more detail, but CHECKBOOK’s research has found that 60 percent make their choice based on these four key elements.
“We’ve been helping federal employees compare health plans for more than 35 years,” said Robert Krughoff, president of Consumers’ CHECKBOOK. “We know if they don’t get quick answers, ideally in less than five minutes, they’ll take shortcuts—like choosing based on lowest premium alone or lowest deductible—and end up wasting thousands of dollars.”

I have been collaborating with Checkbook on this initiative.  
3) new CBPP report explains why a compromise House Republican and Democratic leaders have worked out to fix the Medicare payment formula (SGR) and extend the Children's Health Insurance Program (CHIP) deserves support.