Private Health Plans Research Articles

State Associations Receive Advocacy Grants

You have accessThe ASHA LeaderASHA News1 May 2011State Associations Receive Advocacy Grants13 Groups Launch Activities for Personnel, Reimbursement Issues Eileen Crowe, and Neela Swanson Eileen Crowe Google Scholar More articles by this author and Neela Swanson Google Scholar More articles by this author https://doi.org/10.1044/leader.AN3.16052011.28 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In http://www.asha.org/Publications/leader/2011/110426/State-Associations-Receive-Advocacy-Grants.htm ASHA has awarded grants to 13 state associations to help the organizations pursue state-level grassroots advocacy projects. Six of the grants are for personnel-related projects; seven are for reimbursement-related activities. Personnel Grants Arizona, Colorado, Florida, New York, Oklahoma, and Texas will receive grants this year that address personnel issues in education or health care settings. The Arizona Speech-Language-Hearing Association is developing online information on the qualifications of speech-language pathologists, speech-language pathology assistants (SLPAs), and speech-language technicians. This information will be used as part of a grassroots effort to educate students, school administrators, state legislators, and parents. The Colorado Speech-Language-Hearing Association’s grant will be used to continue to build support for the passage of licensure for SLPs. Colorado is one of only two states that do not license SLPs. The Florida Association of Speech-Language Pathologists and Audiologists’ SLP Leadership Network will receive assistance in implementing a workload analysis in the state’s school districts. The association also will continue efforts to raise the awareness of local policymakers regarding the workload approach. The New York State Speech-Language-Hearing Association will hire a public relations firm to assess the best use of association-developed public service announcements on the role of SLPs and audiologists. The association also will create materials on the professions to enhance consumer awareness. The Oklahoma Speech-Language-Hearing Association will create a Multicultural Advisory Council to develop guidelines and recommendations for working with individuals from culturally and linguistically diverse (CLD) backgrounds and will help state universities incorporate the guidelines into existing and future academic curricula and clinical practica. The organization also will develop a database of providers experienced in the needs of the CLD population. The Texas Speech-Language-Hearing Association will use its personnel grant to develop training modules to increase the knowledge, skills, and competencies of SLPAs working in schools. They will work with education service centers to provide training to SLPAs and SLP supervisors via webinars in the various regions of the state. Reimbursement Grants Reimbursement grants support projects that improve private health plans and Medicaid reimbursement for and coverage of speech-language pathology and audiology services. Alaska, California, Idaho, Kansas, Minnesota, Virginia, and Washington will receive 2011 reimbursement grants. The Alaska Speech-Language-Hearing Association will address Medicaid speech-language pathology provider confusion and punitive audits by creating a process of collaboration with key administrators and developing a provider manual specific to speech-language pathology. The California Speech-Language-Hearing Association and the Washington Speech and Hearing Association will build a solid foundation for future health care reimbursement advocacy efforts by developing networks of audiology and speech-language pathology members to help identify and address reimbursement issues in their respective states. The California association also will develop educational seminars on reimbursement issues, based on feedback from a survey. The Washington association will research private health insurance benefits across the state to identify and expand advocacy efforts with insurers who fail to reach selected benchmarks. In Minnesota, grant funds will be used to bring together a group of stakeholders to identify and collect data on critical reimbursement issues. This information will help focus and strengthen future reimbursement advocacy efforts in the state. The Kansas Speech-Language-Hearing Association will address statewide non-coverage of hearing aids and cochlear implants by convening a working group to research the current demand for mandated insurance coverage and the possible benefits and/or costs to the state. The working group will use its research to create a bill calling for insurance reimbursement of hearing aids and cochlear implants. The Idaho Speech, Language, Hearing Association will continue its efforts to raise awareness about speech-language pathology and audiology services and to encourage SLPs and audiologists to participate in reimbursement advocacy. In 2010, Idaho developed a web video to educate stakeholders about the benefits of speech-language pathology services; the 2011 grant will help develop a similar presentation for audiology services. The Speech-Language-Hearing Association of Virginia will provide advanced training about the Virginia legislative and regulatory process in an effort to enhance advocacy for audiology and speech-language pathology reimbursement by Medicaid and private health insurance. Author Notes director of state association relations, can be reached at [email protected] for information on personnel grants. health care financing information coordinator, can be reached at [email protected] for information on reimbursement grants. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 16Issue 5May 2011 Get Permissions Add to your Mendeley library History Published in print: May 1, 2011 Metrics Current downloads: 69 Topicsasha-topicsleader_do_tagasha-article-typesleader-topicsCopyright & Permissions© 2011 American Speech-Language-Hearing AssociationLoading ...

Preparing for Health Insurance Exchanges

Preparing for Health Insurance Exchanges

Participation in Fitness-Related Activities of an Incentive-Based Health Promotion Program and Hospital Costs: A Retrospective Longitudinal Study

A retrospective, longitudinal study examined changes in participation in fitness-related activities and hospital claims over 5 years amongst members of an incentivized health promotion program offered by a private health insurer. A 3-year retrospective observational analysis measuring gym visits and participation in documented fitness-related activities, probability of hospital admission, and associated costs of admission. A South African private health plan, Discovery Health and the Vitality health promotion program. 304,054 adult members of the Discovery medical plan, 192,467 of whom registered for the health promotion program and 111,587 members who were not on the program. Members were incentivised for fitness-related activities on the basis of the frequency of gym visits. Changes in electronically documented gym visits and registered participation in fitness-related activities over 3 years and measures of association between changes in participation (years 1-3) and subsequent probability and costs of hospital admission (years 4-5). Hospital admissions and associated costs are based on claims extracted from the health insurer database. The probability of a claim modeled by using linear logistic regression and costs of claims examined by using general linear models. Propensity scores were estimated and included age, gender, registration for chronic disease benefits, plan type, and the presence of a claim during the transition period, and these were used as covariates in the final model. There was a significant decrease in the prevalence of inactive members (76% to 68%) over 5 years. Members who remained highly active (years 1-3) had a lower probability (p < .05) of hospital admission in years 4 to 5 (20.7%) compared with those who remained inactive (22.2%). The odds of admission were 13% lower for two additional gym visits per week (odds ratio, .87; 95% confidence interval [CI], .801-.949). We observed an increase in fitness-related activities over time amongst members of this incentive-based health promotion program, which was associated with a lower probability of hospital admission and lower hospital costs in the subsequent 2 years.

Clinical attention and assistance profile of patients with amyotrophic lateral sclerosis

To evaluate the functional status of amyotrophic lateral sclerosis (ALS) patients diagnosed at this institution; to analyze hospital and palliative care; to identify patients' knowledge about home care and supportive resources. Twenty-nine patients were evaluated on the ALSFRS-R scale and two semi-structured questionnaires, at the start of the study and every four months thereafter for 1 year. ALSFRS-R score was 30.1±11.5 initially and 24.4±10.5 at 1 year. There was an increase in use of physiotherapeutic care and adaptive aids. The primary caregivers were spouses (55.2%), parents/children/cousins (20.7%), friends (10.3%) and private nurses (3.5%); 10.3% of patients had no caregivers. Basic ALS patient care was provided by the public health system. ALS patients' multidisciplinary care was provided by UNICAMP hospital and its outpatient clinics and, in some patients, complemented by a private health plan or personal expenditure. Few ALS patients were aware of the possibility of home nursing. It is necessary to implement national and regional public home nursing in addition to multidisciplinary specialized care of ALS patients.

Medicaid and Supervision in Schools

Medicaid and Supervision in Schools

Financial impact of California's new law to increase HIV screening by mandating insurance coverage

To increase HIV testing, in 2008 California's governor signed the first piece of legislation in the USA to require private health plans to cover the cost of HIV testing regardless of whether testing is related to a primary diagnosis. This study assesses the impacts of the bill on coverage, testing rate, and cost for 22,190,000 Californians. All targeted individuals had some form of coverage for HIV testing before the mandate. If minimum expansion of coverage occurs, overall expenditures on HIV testing are projected to increase by US$554,000 in the year following the adoption of the law. If testing broadens to comply with the Centers for Disease Control and Prevention (CDC) testing guidelines, annual expenditures are projected to increase by US$10,151,000. This policy change could serve as a step toward making HIV testing a routine screening test. However, the impact of this mandate largely depends on people's awareness and willingness to adopt the CDC guidelines.

Costs and usage of healthcare services before and after open bariatric surgery.

Morbidly obese individuals are major consumers of healthcare services, with high associated costs. Bariatric surgery is an alternative for improving these individuals' comorbidities. There are no studies comparing costs before and after bariatric surgery in Brazil. The aim here was to analyze results relating to healthcare usage and direct costs among morbidly obese patients undergoing bariatric surgery. Historical cohort study on patients receiving healthcare through a private health plan in Belo Horizonte, Minas Gerais. All healthcare services and their associated costs were included in the analysis: hospitalization, hospital stay, elective outpatient consultations, emergency service usage and examinations. The analyses were treated as total when including the whole years before and after surgery, or partial when excluding the three-month periods adjacent to the operation. For 382 obese patients who underwent open bariatric operations, there were 53 hospitalizations one year before and 95 one year after surgery (P = 0.013). Gastrointestinal complications were the main indications for post-procedure hospitalizations. The partial average cost almost doubled after the operation (US$ 391.96 versus US$ 678.31). In subgroup analysis, the costs from patients with gastrointestinal complications were almost four times greater after bariatric surgery. Even in the subgroup without complications, the partial average cost remained significantly higher. Although bariatric surgery is the only path towards sustained weight loss for morbidly obese patients, the direct costs over the first year after the procedure are greater. Further studies, with longer follow-up, might elucidate whether long-term reversal of this trend would occur.

Aspectos éticos em uma disputa de mercado entre laboratórios clínicos e um plano de saúde: relato de caso

In Brazil the private health plans appear as an alternative to the public health assistance. This segment suffered great intensification in the seventies and eighties, culminating in the entry of large insurance company in the scenario of supplementary medicine. Quickly, the service providers associated with these insurance companies, consolidating them in the market and triggering a relationship of dependency. This article analyzed, in the form of a case report, a marketing dispute between clinical laboratories and a health plan, emphasizing the moral and ethical aspects involved in this episode.

Medicaid Audits To Expand in 2011

You have accessThe ASHA LeaderPolicy Analysis1 Dec 2010Medicaid Audits To Expand in 2011 Mark Kander and Laurie Alban HavensMA, CCC-SLP Mark Kander Google Scholar More articles by this author and Laurie Alban Havens Google Scholar More articles by this author , MA, CCC-SLP https://doi.org/10.1044/leader.PA2.15152010.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In The use of recovery audit contractors (RACs) to review claims, a Medicare program in effect since 2006, will be extended to state Medicaid programs beginning in April 2011. The expansion of the program emerged from the Patient Protection and Affordable Care Act (PPACA), the national health care reform legislation passed earlier this year. Recovery Audit Contractors Audits performed by RACs were mandated by the Tax Relief and Health Care Act of 2006 to identify improper Medicare payments. RACs have been free to examine all Medicare provider settings, including private practices. Hospitals, however, have been the main focus because the Centers for Medicare and Medicaid Services (CMS) has determined that hospitals have been lax in establishing edits to identify faulty claims and have not trained practitioners adequately in coding. Medicaid claims are already subject to Medicaid integrity contract (MIC) audits, which examine integrity issues and overpayments; Medicaid RACs will not replace any existing integrity or audit initiatives or programs. The RAC audits will supplement the integrity programs already in place, and will look at both overpayments and underpayments. There are other differences between the RAC and the MIC programs—the lead time for submitting documentation is longer for the RAC than the MIC, and funding for the MIC is not based on a percentage of any overpayments uncovered, as it is for the RAC program. States must submit to CMS by Dec. 31 amendments to their state plans that establish RAC programs. Full program implementation begins April 1, 2011, subject to extensions and exceptions. Audit Process RAC auditors may review automated claims data or request medical records from the provider and conduct medical reviews (directed by a physician medical director with certified coders and, in some cases, nurses and therapists). If an overpayment is discovered, providers will be expected to reimburse the Medicaid program. Otherwise, future payments will be withheld from the provider. The RAC would receive a fee equal to a designated percentage of the overpayment (established by the contract between the state and RAC). Proposed regulations allow states to determine whether RACs are paid a designated percentage or under another fee structure for identifying underpayments. Each state Medicaid agency will determine its own appeal process for providers who disagree with a RAC decision. Preparing for RAC Audits Audiologists and speech-language pathologists should review their state Medicaid policy manuals to make sure they are familiar with scope of coverage, documentation, and coding rules. Members also should review ASHA’s coding resources and guidelines for assistance in preparing claims. Medicare guidelines may also be helpful because Medicaid programs often adopt many of the Medicare rules. Author Notes Mark Kander, director of health care regulatory analysis, can be reached at [email protected]. Laurie Alban Havens, MA, CCC-SLP, private health plans and Medicaid advocate, can be reached at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 15Issue 15December 2010 Get Permissions Add to your Mendeley library History Published in print: Dec 1, 2010 Metrics Downloaded 58 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2010 American Speech-Language-Hearing AssociationLoading ...

HEALTH REFORM, ACADEMIC HEALTH CENTERS, AND FAMILY MEDICINE

The Patient Protection and Affordable Care Act (PPACA) was signed into law on March 23, 2010. In addition to expanding health insurance coverage to an estimated 32 million individuals by 2019, the bill has myriad components that will have widespread effects on the health care system.1 Academic health centers (AHCs) will be among the many institutions touched by the reforms enacted by the PPACA. Will these reforms be powerful enough to shake AHCs out of their traditional business model of delivering highly specialized services to become more integrated, patient-centered delivery systems? The PPACA will challenge the way hospitals do business. By 2014, hospitals will experience a cut in Medicaid and Medicare Disproportionate Share payments of $14 B and $22.1 B, respectively—and these cuts will fall disproportionately on teaching hospitals. Some of the cuts will be offset by decreases in uncompensated care liabilities as fewer patients are uninsured. A more fundamental challenge will come from the pressures on AHCs to become Accountable Care Organizations (ACOs). To participate in Medicare ACO pilots, hospitals and their physician staff must collaborate to improve quality of care and cost efficiency for a defined population of patients in what is in essence a Medicare Shared Savings Program. The success of an ACO will depend on strong hospital–physician alignment.2 In the ACO model, the financial incentives for an AHC would change 180 degrees. Under the traditional fee-for-service business model, AHCs tend to value primary care physicians only insofar as they are “feeders” of patients into the lucrative tertiary care clinical enterprise—with the key metric being the “downstream revenue” a practice produces for an AHC. A high-performing primary care practice that keeps its patients out of the hospital and imaging suites may be scorned as “destroying demand.” Under the shared-savings incentives of an ACO, where AHC profitability depends on achieving the best quality in the most cost-effective manner, high performing primary care practices suddenly become a business asset to an AHC.3 The reality is that the financial incentives for AHCs will not make a complete 180-degree turn in the near future. CMS will roll out ACOs in a scaled manner, and it remains unclear whether private health plans will follow suit. AHCs will therefore find themselves having to operate in a hybrid financial model. Much of their business will continue to consist of the traditional, highly remunerated tertiary care services, while for patients sponsored by payers that have shifted to an ACO payment model, the incentives will reward good primary care and integration of services. Departments of family medicine have a role to play at AHCs not only in leading the ACO effort, but also in helping AHCs to avoid succumbing to a pathologically split personality under a hybrid business model. Family medicine can help AHCs to recognize underlying principles of exemplary patient care that are applicable to both business models. The changing business model for AHCs will also have implications for their educational mission. Among the strongest influences on the educational character of AHCs are NIH research funds and the traditional AHC patient care business model, both of which reward specialization and a narrow biomedical focus. AHCs have favored higher revenue-generating specialty training over primary care positions. As Iglehart recently observed, “Since 1997, when the BBA imposed a cap on the number of GME positions that Medicare would support, teaching hospitals have created 8000 new training positions without Medicare funding, and most of them have been in subspecialty fellowship positions, not primary care. These spots led to growth in the specialties that provided revenue for the hospitals.”4 Pressures on AHCs to refashion themselves as ACOs may have a ripple effect that shifts their priorities for medical education, providing an incentive to train more primary care residents as part of a move to expand the primary care base of the clinical enterprise. Historically, the missions of departments of family medicine have not been completely in sync with the missions of AHCs. Family medicine and AHCs now have an opportunity for greater alignment of their missions. More than ever, the nation seems to understand that our health care system will not survive in the absence of a robust foundation of primary care. The policies being put into motion by the PPACA have the potential to make the institutions that have been among those most resistant to this understanding—the nation’s Academic Health Centers—appreciate that they now have a strong self-interest in a more fully developed role for primary care. This commentary was prepared by the Chair and Vice Chair of the ADFM Legislative Affairs Committee and reviewed by the ADFM Executive Committee.

Economic Grand Rounds: Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan

Economic Grand Rounds: Types of Practitioners and Outpatient Visits in a Private Managed Behavioral Health Plan

1319 Nonmedical Out-Of-Pocket Expenses: A Hidden Consequence of Hospitalization

Purpose: To calculate the nonmedical out-of-pocketexpenses (NOOPEs) incurred by families during thehospitalization of their child following orthopaedicsurgical interventions. Background: In today's healthcare climate, increased attention is being paid to the availability, affordability, and adequacy of healthcareinsurance needed to cover necessary healthcareexpenditures. Virtually, no public or private healthplan covers the entire array of health care costs. Little attention has been placed on the magnitudeNOOPES to families. NOOPEs include costs thatare directly attributed to the family's health careneeds including travel, parental food and lodging, dependent care, diminished parental wages, andincidental expenses. Expenses exeeding 10% of afamily's income are considered to constitute familyburden. Although NOOPEs are incurred by virtuallyevery family with a hospitalized child, there virtuallyno information specifically addresses the financialand psychological impact of NOOPEs on familylife. Methods: This study uses a prospective, mixedmethod design. The sampling frame consistsfamilies (N=32) whose children are hospitalizedfor orthopaedic surgeries and is stratified (2 x 2)by admission type (planned or unplanned) andlocation of family's home (local or distant) to thefacility. Families complete an online expensediary to capture the NOOPEs they have incurred. Interviews of parents conducted upon dischargefurther illuminate diary data. Descriptive statisticsand ANOVAs for key variables are calculated. Content analysis of interview data identifies commonthemes related to family life, stressors, and copingstrategies. Results: Pending.

Poster 128: Health Care Home: Back to the Future

Objective: To describe a model of health care home services for persons with physical disabilities and complex health conditions. Design: Short cycle outcomes analysis. Setting: Freestanding medical clinic, including primary care clinic, rehabilitation, and psychiatric services. Participants: Persons with disabilities aged 18 to 65 with public or private health plans. Interventions: Primary medical care coordinated through care plans, clinical pathways, prioritization of secondary conditions, short cycle process improvement, patient engagement, communication with other medical and social supports, and alternatives to clinic visits. Main Outcome Measures: Healthy Days, Secondary Conditions Surveillance Instrument, PHQ-9, Satisfaction Surveys. Results: Clients are highly satisfied with clinic services. Reimbursement business model is challenging, can be influenced by client acuity and payer mix. Review of outcomes data refined clinic services to minimize the effect of secondary conditions on self-reported overall health of clients. Short cycle review of care pathways for 7 common conditions (depression, seizures, hypertension, pneumonia, urinary tract infection, wounds, and diabetes) focused on the progression through the pathway, and the interactions of conditions. Cost-savings demonstrated in avoidance of hospitalization and readmissions, based on previous client history. Cost savings demonstrated through the use of telemedicine and phone monitoring to manage chronic conditions. Conclusions: While cost savings have been demonstrated through a strong primary care model, focusing on hospitalization and readmission prevention, cost savings to the overall system remain uncertain. This client centered model of care, incorporating coordination of medical and social supports, has potential to effectively meet client needs.

What is the price benchmark to replace average wholesale price (AWP)?

An article on the front page of the Wall Street Journal on October 6, 2006, thrust into the public media the otherwise esoteric controversy concerning the use of average wholesale price (AWP) as the primary basis for reimbursements to pharmacies for pharmaceuticals in the United States. Although used widely for nearly 40 years, AWP had been criticized prior to this investigative report as unreliable, subject to manipulation, and not representative of the actual purchase price for pharmaceuticals. The Wall Street Journal article, based on a tentative settlement of litigation in which First DataBank (San Francisco, CA) and the McKesson Corporation (San Francisco, CA) were accused of unilaterally increasing AWPs, included the findings that (a) at least since 2003, AWP was not based on calculation of an "average" wholesale price but instead reflected the pricing of McKesson Corporation, a single drug wholesaler; and (b) AWP had undergone a systematic change beginning in 2001 when First DataBank had converted its markups of wholesale acquisition cost (WAC) to a common multiplier of 1.25,1 effectively increasing the AWP by 4% for AWPs that were previously calculated using a multiplier of 1.20. In March 2009, the future of AWP became uncertain as a result of circumstances surrounding the court settlement of the litigation that had begun in 2005 against First DataBank. On March 17, 2009, U.S. District Court Judge Patti B. Saris approved the proposed settlement of 2 civil action lawsuits filed by private health plan payers of pharmaceuticals against the 2 largest publishers of AWP, First DataBank (along with wholesaler McKesson) and Medi-Span (Indianapolis, IN, subsidiary of Wolters Kluwer Health). On March 30, 2009, Judge Saris signed a final order and judgment certifying the class (of "Private Payor" purchasers) which settled 2 national class action lawsuits against the 2 largest publishers of AWP. As part of the formal settlement, Medi-Span and First DataBank agreed to adjust the markup factor used to calculate AWP downward to 1.20 times WAC "for any prescription pharmaceutical" that had "a mark up factor basis from WAC to AWP in excess of 1.20" for the 1,442 specific national drug code (NDC) numbers that were listed in the court complaint. The "rollback" of AWP as a result of reducing the WAC/DP (direct price) multiplier to no more than 1.20 was implemented by First DataBank and Medi-Span on September 26, 2009, 180 days from the date of the judgment, as ordered. At the same time, these AWP publishers voluntarily implemented price modifications to all products that had a WAC markup greater than 1.20. This decision expanded the list of NDC numbers from the 1,442 specified in the lawsuit to well over 50,000 items. The expanded list included both prescription and nonprescription (over-the-counter [OTC]) items, both active and inactive NDC numbers on the drug database, as well as a variety of markup factors. The adjusted AWPs had markup factors that ranged from 1.20 to 1.33. About two-thirds to three-fourths of the NDC numbers with adjusted AWPs had a pre-settlement WAC markup of 1.25. This U.S. District Court decision on March 30, 2009, was also accompanied by separate announcements from the defendants Medi-Span and First DataBank that they would voluntarily discontinue publication of AWP.

Lessons On Health Reform From Across The Waves

From the Editor-In-Chief Health AffairsVol. 29, No. 8: Lessons From Around The World Lessons On Health Reform From Across The WavesSusan DentzerPUBLISHED:August 2010Free Accesshttps://doi.org/10.1377/hlthaff.2010.0743AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth reformSystems of carePrimary care The United States is among the world’s leading exporters in the brisk trade of ideas for financing and delivering health care. But in this issue of Health Affairs , insights from abroad flow our way, as several of our authors reflect on health reforms in other industrialized nations. Spain is in the spotlight for having won the World Cup, but its health system scores high as well, write Jeffrey Borkan and colleagues. The nation emerged from the Franco dictatorship in 1975 socially and economically behind much of the rest of Europe. But the demise of the old order cleared the deck for sweeping changes in health care, along with much else. Planners concentrated on building an infrastructure focused on primary care. A key goal was that no citizen in this nation roughly the size of Texas—and with a population today of forty-one million—was to be more than fifteen minutes away from a primary care site.‘Leadership And Commitment’ The results have been impressive, the authors report, contributing to longer life expectancy and lower infant mortality than in the United States. The lesson for America—now embarked on its own primary care reinvention effort (see Health Affairs , May 2010)—may simply be that a modern democracy truly can plan and implement system restructuring at both the national and local levels. Spain’s example shows that what it takes is “sustained, bipartisan leadership and commitment toward health care transformation,” Borkan and colleagues write. Thus apprised of what advanced nations can do, we then head north and east to Switzerland, where Tsung-Mei Cheng interviews the former Swiss health minister, Thomas Zeltner. Zeltner recently stepped down from his post after nineteen years, during which he helped implement major reforms in the 1990s and thereafter.Rediscovered Switzerland, Zeltner notes, had at the time imported the idea of “managed competition” among competing private health insurance plans pioneered by longtime Health Affairs contributor Alain Enthoven. Zeltner notes the irony that Switzerland, with its private health plans and individual mandate, has now been “rediscovered” as a source of inspiration for the U.S. health reform. But as the Cheng-Zeltner dialogue makes clear, it’s not sensible to reduce another country’s complicated health system to just one or two bullet points. As successful as the Swiss system has been, it’s been governed by laws and regulations that place the emphasis on “management” as much as on “competition.” Specifically, Zeltner points to his nation’s requirement that health plans and providers negotiate with each other over prices—with the Swiss government watching over the negotiators’ shoulders and determining prices if negotiations fail.So most health systems are complicated, and most also face problems common across many nations. Spain struggles with rapidly rising costs. The Swiss are shocked about how much they pay for health coverage, and health care providers aren’t sufficiently transparent about the health outcomes they produce for patients. And nobody, apparently anywhere, is content with the state of the health care workforce. Spain has one of the lowest ratios in the European Union of general practitioners to population. Switzerland wants its nurses to stay on the job longer, and thinks it will need a third more personnel to cover long-term care needs within about a decade.Reforms Without EndMost important, perhaps, is the lesson that health reforms, once enacted, are never truly finished. As Zeltner puts it: “You end one reform and you start the next one. It’s a never-ending task.” Perhaps there’s another lesson there for all of us—including politicians who preach either that the Affordable Care Act is an optimal fix or that repealing it will clear the way for more perfect reforms for all time.Lest we fool ourselves that even reformed health systems will automatically produce better health, David Williams, Mark McClellan, and Alice Rivlin address underlying social and economic determinants. Williams served as staff director, and McClellan and Rivlin as panel members, of the Robert Wood Johnson Foundation Commission to Build a Healthier America.Pointing to statistics showing that many Americans’ health is slipping relative to the health of people in other countries, the authors call for major changes in “where and how Americans live, learn, work, and play.” After all, better health is among those nonimportable commodities we’ll have to create right here at home. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 August 2010 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF downloadCited byEl buen gobierno de los servicios de salud de producción pública: ideas para avanzarCiência & Saúde Coletiva, Vol. 16, No. 6

Can Reform's Prevention Incentives Help to Bend the Cost Curve?

On my various trips to Boston for conferences and meetings, I make a point of having dinner with a close cousin. Our conversations invariably turn to the issue of health care and its reform. While hardly an advocate of comprehensive health reform, my cousin has taken the position that reform would be unnecessary if people took care of themselves. More specifically, he sees much of our current health care spending crisis as emanating from our sedentary lifestyles, poor health habits, lack of discipline regarding exercise and food consumption, and failure to follow recommendations for annual physical exams and other periodic preventive care. body is like a car, I recall him saying. You need to maintain it and every once in a while you have to look under the hood. My cousin does have a point regarding our reluctance to comply with good health practices and recommended preventive care, and I suspect that many others feel the same. Indeed, there can be ample personal rewards for such behavior as well as rewards to society at large. In the context of health reform, promoting preventive care and health-enhancing behaviors are part of the arsenal of cost-containment strategies in the Patient Protection and Affordable Care Act (PPACA), and a recent study sees the use of recommended preventive services as having the potential to reduce loss of life and achieve cost savings (Maciosek et al. 2010). However, in light of the fanfare and push for preventive care and other health-related practices, a critical issue is whether we can expect individuals to respond to reform's incentives for preventive activities, whether the vagaries of human behavior will impede such responses, and most importantly, whether such care can indeed be expected to reliably yield cost savings. In what follows, I explore the issue of whether we should expect incentives for more preventive care to yield substantive savings, and thus to what extent we can expect prevention and good health behaviors to make a meaningful contribution to bending the cost curve. The PPACA and Incentives for Prevention The PPACA includes a variety of provisions directed toward the use of preventive health services and wellness activities. number of these measures entail administration and information gathering: creating administrative bodies to coordinate federal prevention efforts, establishing a national prevention strategy, expanding funds for public health programs, developing evidence-based recommendations for using clinical and community preventive services, and devising outreach campaigns for preventive benefits, among others (this and the following summary are drawn from the Kaiser Family Foundation 2010). The law also includes provisions to eliminate out-of-pocket costs for 41 preventive services rated A or by the U.S. Preventive Services Task Force (2010). It does so by eliminating cost sharing for such services covered by Medicare, and by increasing federal medical assistance to states (by one percentage point) that offer and B preventive services under Medicaid and also remove cost sharing. Additionally, the law authorizes Medicare coverage for personalized prevention plan services, provides incentives for Medicare and Medicaid beneficiaries to enroll in and complete behavior modification programs, and requires Medicaid to cover tobacco cessation programs for pregnant women. Finally, consistent with cost-containment goals, the PPACA permits the Secretary of the Department of Health and Human Services (DHHS) to modify or eliminate Medicare coverage of preventive services as recommended by the task force. Reform also eliminates out-of-pocket costs for and B preventive services for enrollees in qualified private health plans (beginning in September), and such plans are also required to provide, with no out-of-pocket costs, recommended immunizations, preventive care for children and adolescents, and additional preventive care and screening for women. …

Navigating the Coding and Reimbursement Maze

Navigating the Coding and Reimbursement Maze

Coordinated Medicare Cut Readmissions

Coordinated Medicare Cut Readmissions

Medicare Private Health Plans Versus Medicare Savings Programs: Which Is the Better Way to Help People With Low Incomes Afford Health Care?

Medicare Private Health Plans Versus Medicare Savings Programs: Which Is the Better Way to Help People With Low Incomes Afford Health Care?

THE ECONOMIC EFFECT OF AGE‐RELATED HEARING LOSS: NATIONAL, STATE, AND LOCAL ESTIMATES, 2002 AND 2030

To the Editor: Age-related hearing loss (mild to functionally deaf) affects approximately 18% of U.S. population aged 65 and older.1 After arthritis and hypertension, it is the third most commonly reported chronic condition in this age group.2 Although not life threatening, this condition can significantly diminish a person's quality of life and has been linked to depression, social isolation, and poor physical function in older adults.3–5 Moreover, care for hearing loss is typically paid out of pocket, adding significant financial burden to the individual.1,6 Few studies have examined the economic effect of this emerging public health problem.1,6 The present analysis addresses this gap by evaluating direct medical costs and costs attributable to lost productivity for this condition in the United States. Estimates are presented at the national, state, and local levels for 2002 and 2030, using California and Los Angeles (LA) County as illustrative cases. Using a stepwise, prevalence-based simulation model, national estimates of the prevalence of hearing loss in those aged 65 and older were applied to the national, California, and LA County populations for 2002 and 2030. Multiple data sources were used, including the 2000 U.S. Census, the Survey of Income and Program Participation, and the California Department of Finance. Total direct medical costs incurred during the first year of hearing loss treatment were estimated using California's Medicaid (Medi-Cal) coverage data. Included in these calculations were the costs for audiometric screening, diagnostic audiological evaluation, binaural hearing aids, and hearing aid fitting. Where appropriate, estimates were adjusted for healthcare inflation. For the 2030 estimates, factors such as the expected increase in life expectancy and the prevalence of preexisting hearing problems in present-day baby boomers (aged 45–64) who will reach age 65 by 2030 were accounted for. Lost productivity costs attributable to the group aged 65 and older were extrapolated using data previously collected.6 In 2002, approximately 6.4 million Americans aged 65 and older reported having some form of hearing loss (mildly to functionally deaf). The total costs of first-year treatment of this condition in this age group in 2002 was approximately $1,292 per person or $8.2 billion nationally, $855 million in California, or $229 million in LA County (Table 1). By 2030, these costs would increase to approximately $51.4 billion nationally, $6 billion in California, and $1.4 billion in LA County. It was also estimated that the 2002 lost productivity costs attributable to hearing loss in this age group were approximately $1.4 billion nationally, $149 million in California, and $40 million in LA County. By 2030, these costs would increase to $9 billion, $1 billion, and $253 million, respectively. These findings suggest that the financial and societal burden of treating age-related hearing loss will increase substantially in the upcoming decades. Much of this burden will fall disproportionally on older adults, because most public and private health plans provide minimal to no coverage for degenerative hearing loss. Poor and underserved older adults are likely to feel this burden the most, adding a new dimension to health disparities. Although these projections are conservative and probably underestimated the costs of hearing loss in the United States, they have policy and planning implications for many cities, community-based organizations, and agencies that provide services to older adults. For example, these data may assist advocacy groups or health professionals in their efforts to advocate for or implement best practices that help reduce modifiable risk factors of hearing loss such as smoking, uncontrolled diabetes mellitus, stroke, and occupational noise exposure.1,3 If adopted, this “preparative” approach may represent an important step toward reducing and controlling the economic and social costs of age-related hearing loss, hopefully making the condition a less isolating, painful experience. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to the analysis, interpretation, and presentation of the data and helped draft the letter or revised it critically for important intellectual content. This analysis was conducted as part of Dr. Stucky's medical school thesis (unpublished) at the Charles Drew University of Medicine and Science, College of Medicine. Sponsor's Role: No sponsor.