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05/14/2015

What Is Risk Adjustment and How Is It Accomplished Under MA: A Conversation with Robert Book (May 13th)

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Risk adjustment is a statistical method by which payers can reasonably predict how much a patient's care needs are expected to cost in any given year.  In so called Fee-For-Service Medicare this matter is essentially moot since since providers are simply paid for the reimbursable services they provide their patients.  However, health care payment is rapidly moving towards fixed or pre-arranged reimbursement models.  For example, Medicare Advantage plans are paid a pre-determined or fixed per member per month fee and ACOs are incented to spend less annually than a pre-determined benchmark that amounts to an ACO's patients' historical costs risk adjusted.  Therefore, risk adjustment, or getting risk adjustment right, becomes critically important.  

During this 23 minute discussion Dr. Book explains the theory behind risk adjustment, how it's calculated for Medicare Advantage plans using hierarchical condition categories (HCC) codes and demographic data, the phenomenon known as "up coding," what CMS has done to address the issue and whether predicted costs tend to be lower than actual costs for high cost beneficiaries is a problem.

Dr. Robert Book is a Health Economist and Senior Research Director at the Health Systems  Robert_A_Book_147x220_cl
Innovation Network.   (His paper discussed during this interview was authored via his work with the American Action Forum.)  Dr. Book's work primarily focuses on modeling of the effects of the ACA.   He has also expertise in a wide variety of related issues including Medicare and Medicare Advantage pricing, provider incentives, employer-sponsored insurance, drug regulation and the economics of medical research.  Dr. Book earned his Ph.D. in economics and his MBA at the University of Chicago, an MA in computational and applied mathematics at Rice and his undergraduate in mathematics at Duke.     

Dr. Book's primer on Medicare Advantage risk adjustment is at: http://americanactionforum.org/research/primer-medicare-risk-adjustment.

For a discussion on Medicare Advantage pricing more generally see the May 6, 2013 interview with Dr. Brian Biles.   

05/08/2015

Mt. Sinai's Hospital At Home Demonstration: A Conversation with Dr. Jeffrey Farber (May 7th)

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Beyond hospital care's considerable expense and at times questionable quality, it can be often times unnecessary.  We spend over $900 billion, or one-third of all health care spending, on hospital care annually. Despite these costs the quality of hospital care can be poor if not harmful.  A 2013 study published in the Journal of Patient Safety concluded between 210,000 and 440,000 patients hospitalized annually are fatally harmed. Beyond cost and quality, according to federal Agency for Healthcare Research & Quality (AHRQ) approximately ten percent of all hospital admissions for certain chronic and acute conditions are avoidable.

During this 21 minute discussion Dr. Jeffrey Farber explains the impetus for Mt. Sinai's hospital at home or mobile acute care demonstration.  How it's funded, what patients with what diagnoses are eligible, the range of services they receive, the importance of carefully screening these patients before admission and the demonstration's anticipated results.     

Dr, Jeffrey Farber is an Associate Professor in the Brookdale Department of Geriatrics and Farber photoPalliative Medicine at the Icahn School of Medicine at Mount Sinai, he also serves as the Chief Medical Officer at Mount Sinai Health Partners, as VP of Hospital Services Utilization and as Chief Executive Officer of Mount Sinai Care, Mt. Sinai's Accountable Care Organization.  Dr. Farber completed a residency in Internal Medicine at New York Presbyterian Hospital, Columbia Campus and a fellowship in Geriatric Medicine at Mount Sinai School of Medicine.  His career interests include research in models of care for older adults, as well as clinical documentation and the medical interface with hospital finance.  He is a recipient of a federal Geriatric Academic Career Award and his research has been published in The Annals of Internal Medicine and The Journal of Hospital Medicine.

CMS's summary of Mt. Sinai's Mobile Acute Care Team (MACT) demonstration is at: http://innovation.cms.gov/initiatives/Participant/Health-Care-Innovation-Awards-Round-Two/Icahn-School-Of-Medicine-At-Mount-Sinai.html 

 

05/01/2015

The State of Alzheimer's Funding and Research: A Conversation with Robert Egge (April 30th)

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Alzheimer's Disease accounts for approximately 70% of all dementia diagnoses.  The disease affects over five million Americans or upwards of 35 million worldwide.  Disease burden is currently estimated to grow to 16 million patients in the US by 2050 with projected costs estimated at over $1 trillion.  Patients diagnosed with Alzheimer's survive three to nine years. The disease kills 500,000 deaths annually, making it the 6th leading cause of death.  The risk of the disease is believed to be largely genetic.  There are currently no treatments or medications to stop, reverse or modify its progression - the only major disease with this distinction.  

During this 23 minute discussion Mr. Egge discusses the work of the Alzheimer's Association, the current state of curative research and the development of a blood test to diagnose Alzheimer's before symptoms appear, the adequacy of federal funding to fight the disease, the federally-legislated "National Alzheimer's Plan" and what's being done to improve care for patients currently suffering from Alzheimer's and other forms of dementia.   

Robert Egge is the Chief Public Policy Officer and Executive Vice President of Government Affairs Eggefor the Alzheimer's Association.  Mr. Egge also serves as the Executive Director of the Alzheimer's Association's sister organization, the Alzheimer's Impact Movement.  Prior to joining the Alzheimer's Association Mr. Egge served as Executive Director of the Alzheimer's Study Group.  Prior still he served as a Project Director for the Center for Health Transformation and as Vice President for Government Affairs for the JC Watts Companies.  Mr. Egge's writings have appeared in The New York Times, the Financial Times, in Health Affairs and he has provided testimony to both US House and Senate health care committees.

For more on the work of the Alzheimer's Association go to: www.alz.org.

 

04/20/2015

Care Provided by Visiting Nurses: A Conversation with Tracey Moorhead (April 20th)

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Visiting nurse services have been delivering home-based health care since the late 19th century providing everything from maternal and child health to geriatric care.  Today their services are more frequently being sought due to an ever-increasing emphasis on keeping patients out of the hospital (and emergency department), improving care coordination, comprehensiveness and patient satisfaction and paying for care that improves quality and care outcomes and that is more cost efficient.  

During this 19 minute discussion Ms. Moorhead discusses the goals of VNAA and its members, services its visiting nurses and other home health providers deliver, health care outcomes achieved and a range of federal Medicare policy options currently under discussion to improve care in the so called "post acute" care setting.   (One factual correction: Medicare spending on post-acute care in 2013 was $59 billion.)

Tracey Moorhead is President and Chief Executive Officer of the Visiting Nurse Associations of TraceyMoorhead_webonlyAmerica (VNAA).  VNAA educates, advocates and promotes nonprofit providers of home-based care services including home health, palliative care and hospice. Previously,  Tracey served as CEO of the Care Continuum Alliance.  Prior roles also include serving as Executive Director of the Alliance to Improve Medicare (AIM), a bipartisan coalition advocating comprehensive Medicare improvements through the Medicare Modernization Act of 2003 and Vice President, Government Relations for the Healthcare Leadership Council (HLC). She was graduated from The George Washington University.  

For more about the VNAA go to:  www.vnaa.org.

 

04/14/2015

Street Sense's Effort to End Homelessness in DC: A Conversation with Brian Carome (April 14th)

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Street Sense is a tabloid newspaper that has been sold biweekly by the District of Columbia's homeless residents for the past 12 years.  The publication's focus is on homelessness and related issues confronting the poor.  DC has one the highest rates of homelessness in the country with over 2,000 individuals and families sleeping on the streets on any given night, a quarter of whom are veterans.  Unemployment, obviously a major cause of the problem, is 7.8 percent in the nation's capital or one and a half times the national average.  For DC's African Americans unemployment is 10 percent. Nearly 20 percent of DC's residents live in poverty.  Beyond homelessness, Street Sense vendors typically face a long list of health issues.  Recently however a city inter-agency council on homelessness unanimously endorsed a plan, that DC's new mayor supports, to end homelessness over the next five years.

During this 18 minute discussion Brian Carome discusses the purpose and success of Street Sense to date, it's vendors, the health and social issues they confront and his outlook for finally solving DC's homelessness problem.

Brian Carome has served as Executive Director of Street Sense since 2011.  Previously he was Unnamed[1]Executive Director at Housing Opportunities for Women, Project Northstar and A-SPAN.  He has also worked at new Hope Housing, Sasha Bruce Youthwork, the Washington Legal Clinic for the Homeless and the Father McKenna Center.  He has lectured on homelessness and at risk populations at the Catholic University of America's School of Social Service and Georgetown University Law School.  Brian was graduated from Boston College with a BA and earned an Executive Certificate form the Georgetown University's Center for Public and Non-Profit Leadership.  

To learn more about Street Sense go to streetsense.org.

  

 

03/18/2015

What's the Status of "Pay for Value" Contracting: A Conversation with David Muhlestein (March 18th)

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Health care payment is solidly moving, or moving once again, toward pay for value or value-based contracting.  This means a health care provider's reimbursement is incented or tied to a predetermined (typically annual) financial amount and/or is based on attaining certain quality care metrics.   The Medicare Shared Savings Program and private sector "accountable care organizations" are both endeavoring to lower health care cost growth and improve quality and patient outcomes via these value or performance-based contracts.  

During this 21-minute discussion Dr. David Muhlestein describes the various types of pay for value contract arrangements including use of quality metrics, what types of providers sign these contracts, what have the results been to date, the keys to success or what are the challenges in succeeding under these agreements and potential downsides for providers and/or patients .   

David Muhlestein is the Senior Director of Research and Development at Leavitt Partners (LP).  He David Muhlestein 2014 directs LP's study of pay for value and accountable care contracting through LP's Center for Accountable Care Intelligence and leads the firms' quantitative evaluation of health care markets. He is an expert in using policy analysis, predictive modeling and applied analytics to understand the evolving health care landscape.  His insights have been quoted by publications including The Wall Street Journal, The Seattle Times and Modern Healthcare.  David earned his Ph.D. at Ohio State University and his JD at Ohio State's Moritz College of Law.   

For information regarding Leavitt Partners' related work see: http://leavittpartners.com/solutions/.

 

 

02/19/2015

What Health Care Coverage Do Immigrants Get?: A Conversation with Angel Padilla (February 19th)

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Over 20 million immigrants live in the US, approximately half of whom, or 11 million, are undocumented.  Because immigrants are frequently employed in low-wage jobs they largely lack health care coverage.  Legally residing residents are able to acquire coverage via the ACA's state marketplaces however they are typically required to wait five years to apply to qualify for Medicaid. Undocumented immigrants are neither able to buy marketplace coverage even if they pay the full premium nor are they typically allowed Medicaid coverage.   Last November the President announced a pathway to citizenship for undocumented immigrants but whether this will improve their ability to obtain health insurance is unclear.

During this 23-minute discussion Mr. Padilla explains the genesis of the five-year waiting period for legal immigrants to apply for Medicaid, why undocumented immigrants are unable to purchase marketplace insurance at full cost, where (and how) immigrants typically get health care services and moreover what, if any, effect will the President's executive order actions announced last November have in providing health care coverage for undocumented immigrants.      

Angel Padilla is a Health Policy Analyst at the National Immigration Law Center (NILC) where APadilla Pic (1)he works to develop and implement NILC's federal immigrant health policy agenda.  Prior to joining the NILC in 2014 he was an immigration policy consultant at the National Council of La Raza.  Prior still he served as a Legislative Assistant to Rep. Luis Guiterrez (D-IL).  Mr. Padilla also interned at the Department of Homeland Security.  He holds an undergraduate degree from the University of California at Berkeley and a graduate degree form the Princeton University's Woodrow Wilson School of Public and International Policy.

The National Immigration Law Center website is at: http://www.nilc.org/.

 

 

02/11/2015

CareConnect, New York's First Commercial Provider-Owned Health Plan: A Conversation with Alan Murray (February 10th)

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Over the past few years the lines between health care payers and health care providers have been blurring.  Some say these health care industry silos, insurance companies and acute and post-acute providers, will eventually merge.  For cost purposes, health care plans are ever-increasingly interested in improving their relationship with patients in order to provide more efficient and effective care.  Health care providers want to better control their revenue streams and be more competitive.  CareConnect, formed last year by North Shore-Long Island Jewish Health System, is New York State's first provider-owned commercial health insurance plan.  

During this 21-minute interview Mr. Alan Murray discusses the reasons CareConnect was formed, how it's structured, its patient population, how its physicians deliver care within the CareConnect network and what it is doing to improve its patient and service community's population health.  

Mr. Alan Murray is the Co-Founder, President and Chief Executive Officer of North Shore-LIJ MurrayCareConnect, the first provider owned health plan in New York State.  Mr. Murray is also currently President and CEO of North Shore-LIJ Health Plan whose offerings include a managed long-term care plan for Medicaid recipients.  Previously, Mr. Murray was VP of Managed Care for North Shore-LIJ Health System.  Mr. Murray also served for five years as a Vice President for UnitedHealthcare in New York and previously still as at WellPoint/Empire BlueCross BlueShield).  Mr. Murray's background also includes serving for over five years as a Second Officer in the British Merchant Navy.

For more on CareConnect see: http://www.nslijcareconnect.com/

01/26/2015

Blog Post: "Janitor's Insurance" (January 26, 2015)

Since we recently celebrated Martin Luther King's birthday and since, among numerous memorable comments, Dr. King observed, "of all forms of inequality, injustice in health care is the most shocking and inhumane," this blog post.  

01/14/2015

Announcing an Accompanying Blog Feature: First Posting Is Titled, "Whither Primary Care?" (January 15, 2015)

Beginning today I am launching an accompanying blog feature to complement the podcast interviews.  Please click on the "Blog" tab to read the first posting titled, "Whither Primary Care?"   

To get back to the podcast page just click on "Podcast" on the tool bar.

As with all the podcasts please feel free to offer any comments regarding the blog postings.

Thank you.

David Introcaso