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The ACA's Little Discussed But Very Intriguing State Innovation Waiver Provision: A Conversation with Stuart Butler (October 24th)

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Section 1332 of the Affordable Car Act allows states to propose Affordable Care Act-comparable state insurance programs.   Programs would need to meet certain criteria in order to win federal waiver authority.   One state currently considering a wavier is Colorado, i.e., Colorado voters will be asked to approve a state constitutional amendment that would create in part, a financing plan that would provide universal health care to all eligible Colorado residents.       

During this 20 minute conversation Dr. Butler discusses the genesis of Section 1332, why states (blue and red) would be motivated to submit a waiver, the benefits of such waivers, how the next administration might revise current 1332 regulations and state efforts to date, for example, Colorado under its ColoradoCare initiative. 

Dr. Stuart Butler is a Senior Fellow in economic studies at the Brookings Institution.   He is also currently an Adjunct
Professor at Georgetown, a Visiting Fellow at the Convergence Center for Policy Resolution, a member of the editorial board Butler headshot jpegof Health Affairs, a member of the Board on Health Care Services of the Institute of Medicine and of the Advisory Group for the Academy of Medicine's Culture of Health program.   Prior to Dr. Butler spent 35 years at the Heritage Foundation.   Among other previous positions he was an Institute of Politics Fellow at Harvard and a member of Housing Secretary Jack Kemp's Advisory Commission on Regulatory Barriers to Affordable Housing.  Dr. Butler was educated at St. Andrews University in Scotland where he received his undergraduate degree in physics and mathematics, his Masters of Arts in economics and history and his Ph.D. in American economic history.  

Dr. Butler's JAMA Forum essay, noted during this conversation, is at:



Methods to Stabilize the State Health Insurance Marketplaces: A Conversation with Jack Hoadley (October 13th)

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UnitedHealth Group and other major health care insurers' participation in state health insurance marketplaces has caused increasing concern Affordable Care Act-created state marketplaces are becoming unstable.  Moreover, this means health care insurance consumers will have little or possibly no choice in selecting an insurance provider.  For example, in 2016 30 percent of counties throughout the US had only two insurers participating in state marketplaces (10 percent of counties had one). Beyond consumer choice, the absence of marketplace competitors threatens premium affordability.   Creating new and stable insurance marketplaces, that is by definition challenging to accomplish, has been made additionally difficult by Congressional Republican opposition to the ACA's risk corridor program, that along with risk adjustment and reinsurance, is designed to mitigate unavoidable plan financial losses in trying to appropriately price premiums for a population with an unknown health history.             

During this 25 minute conversation Professor Hoadley discusses contributing factors to state marketplace instability and
moreover four methods by which the insurance marketplaces can be stabilized: a "fall back plan;" state participation requirements; extending risk corridors and reinsurance; and, methods to improve marketplace enrollment. 

Dr. Jack Hoadley is a Research Professor at Georgetown University's Health Policy Institute where he studies health financing Hoadley portrait 1 topics including drug pricing, out-of-pocket costs and the dynamics of insurance making decisions.   In 2015 Professor Hoadley was reappointed to a second, three-year term as a Medicare Payment Advisory Commissioner (MedPAC) member.  Prior to his work at Georgetown, Dr. Hoadley held staff positions at DHHS, i.e., within the Assistant Secretary for Planning and Evaluation (ASPE) office, at MedPAC, the Physician Payment Review Commission and at the National Health Policy Forum.   Professor Hoadley has published widely on health care financing and pharmaco-economics topics and has provided testimony to numerous federal Congressional and other government panels.  He earned his Ph.D. in political science. 

Jack Hoadley and Sabrina Corlette's August 2016 paper, "Strategies to Stabalize the Affordable Care Act Marketplaces: Lessons from Medicare," is at:


"ACO Performance Year Three: What Happened And What Does It Mean?" (October 1st)

Listeners may recall last October 26th I posted a summary of Accountable Care Organization (ACO) performance year two (PY2) results that was published by Health Affairs on their blog.  This essay, that appears on "The Health Care Blog," summarizes ACO performance year three (PY3) results.  PY3 results were not much different than PY2, e.g., 29% of ACOs in 2015 (v. 26% in 2014) earned shared savings, success was again largely due to comparatively higher financial benchmarks and there was again no correlation between quality performance and financial success.  

The essay is at:



"The Poverty Industry, The Exploitation of America's Most Vulnerable Citizens," A Conversation with the Author, Daniel L. Hatcher (September 22nd)

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For this, my 101st interview, I discuss with the author, Daniel L. Hatcher, his new work, "The Poverty Industry, The Exploitation of America's Most Vulnerable Citizens."  The work is aptly summarized by Columbia University Professor Jane Spinak.  She notes on the book's dust jacket, "In the tradition of great muckracking, Hatcher has exposed how states and localities misdirected and misused public funds envisioned to benefit the most vulnerable among us." 

During this 26 minute conversation Professor Hatcher discusses his motivations for writing the book, defines "poverty's iron triangle," explains how state foster care and Medicaid agencies, with the help of private contractors, monetize poverty for state financial gain, explains how states attempt to reason this behavior and offers solutions for how this malfeasance can be "reeled in."  

Daniel L. Hatcher is Professor of Law at the University of Baltimore School of Law, teaching a civil advocacy clinic and other Hatcherclasses.  Before joining the faculty in 2004, Hatcher was with the Maryland Legal Aid Bureau, serving as the assistant director of advocacy for public benefits and economic stability.  He previously worked as a staff attorney for Legal Aid representing abused and neglected children, and he represented adult clients all poverty law matters – including public benefits, housing, consumer and family law issues.  He was also a senior staff attorney with the Children's Defense Fund.  Hatcher has testified before Congress, the Maryland General Assembly and in other governmental proceedings regarding several issues affecting children and low-income individuals and families.  Professor earned his law degree at the University of Virginia and his undergraduate degree at the University of Texas at Arlington. 

For more on Hatcher's work go to:


How Providers Will Respond to MACRA Implementation (September 14th)

For those interested in how providers will likely respond to MACRA, today the Better Medicare Alliance posted my essay, "How Will Providers Respond to MACRA and What Does It Mean for Provider Participation in Medicare Advantage?"  The essay is at:

The proposed MACRA (the Medicare Access and CHIP Reauthorization Act) rule was the subject of my June 14th interview with CAPG's Mara McDermott on June 14th. 


Medicare Advantage Program Reforms Within and Beyond MACRA: A Conversation with Molly Turco (August 15th)

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Since the passage of the Affordable Care Act in 2010 CMS has been working to reform Medicare reimbursements from "fee for service" to "fee for value."  (Earlier this year Secretary Burwell noted 30% of traditional or "fee for service" Medicare reimbursements are now tied to quality or value.)  The Medicare Access and CHIP Reauthorization Act (MACRA) passed in 2015 accelerates this transition by incenting Medicare providers to participate in "fee of value" or pay for performance agreements, termed Alternative Payment Models (APMs) under MACRA, with a 5% annual bonus.  To date, commercial Medicare Advantage (MA) plans (Medicare Part D) have been immune from these reforms.   However, under MACRA beginning in performance year 2019 MA plan providers can potentially count their MA reimbursements and MA beneficiaries toward qualifying for the 5% MACRA APM bonus - if they meet the financial risk and other qualifying MACRA APM criteria.  To what extent MA plans, that now account for nearly one-third of all Medicare beneficiaries, will work with their provider partners to meet the MACRA APM qualifying criteria is unknown.      

During this 23 minute conversation Ms. Turco discusses expectations for MA plan participation under MACRA as qualifying APMs, how MA stakeholders are thinking about moving the program outside of MACRA toward improved value or reduced spending growth, CMS's MA Value Based Insurance Design (VBID) demonstration scheduled to begin in January and anticipated MA reforms under a new White House administration next year.   

Ms. Molly Turco is presently Director of Policy and Research at the Better Medicare.  Previously, Ms. Turco was a Senior Healthcare Policy Analyst with the Marwood Group.  Turco Ms. Turco also worked as a Healthcare Policy Researcher in the State of Vermont Office of Health Reform, within the University of Pennsylvania Health System and at Dartmouth Hitchcock Medical Center and the Geisel School of Medicine at Dartmouth.  Ms. Turco holds a MPH from the Dartmouth Institute for Health Policy and Clinical Practice and a BA from Middlebury College.  


What Can Be Done About Reforming the Employer Health Insurance Tax Exclusion: A Conversation with Dr. Joe Antos (August 5th)

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Excluding from taxable income the moneys employers spend in providing employees with health insurance dates back to WWII-era wage and price controls.  Today, this tax policy, that amounts to over $250 billion in lost federal tax revenue, effectively constitutes the third largest federal government expenditure on health care after Medicare and Medicaid.  Few tax experts would disagree that the tax exclusion constitutes bad policy.  Beyond lost tax revenues, the policy is, among other things, highly regressive, causes lower or stagnant wage growth, reduces health plan competition, contributes to excessive health care spending, incents the over-utilization of health care services, limits job mobility and negatively influences retirement decisions.   

During this 25 minute conversation Dr. Antos discusses the extent to which the tax exclusion is responsible for employers providing employees with health care insurance coverage, what effect would capping or phasing out the exclusion have on coverage, how best can the policy can be reformed via a Cadillac tax or otherwise, what might be done to reform the tax exclusion under a Secretary Clinton administration and how the exclusion may play into future tax reform may legislation.   

Dr. Joe Antos is the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute (AEI). Img-joeantosheadshot300x225_145016424575 Before joining AEI,  Dr. Antos served as the Assistant Director for Health and Human Resources at the Congressional Budget Office (CBO).  Dr. Antos has also held senior positions in the US Department of Health and Human Services, the Office of Management and Budget and the President's Council on Economic Advisers.  He recently completed a seven year term as Health Adviser to CBO and two terms as a Commissioner of the Maryland Health Services Cost Review Commission.  In 2013 he was named Adjunct Associate Professor of Emergency Medicine at George Washington University.   Dr. Antos earned his Ph.D. and MA in economics at the University of Rochester and his BA in mathematics from Cornell University.   

For more background information about the exclusion and micro-simulation data on reforming the exclusion, see Jonathan Gruber's 2011 article in the National Tax Journal, at:


What Does Performance Under Medicare's Value-based Modifier (VM) Program Suggest Concerning Physician Performance Under MACRA: A Conversation With Kelly Cleary (July 20th)

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The 2015 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) will sunset three current Medicare performance measurement and incentive payment programs in 2018.  (This year, 2016, will be the last year these programs will be measuring and rewarding Medicare physician performance.)  These are: the Physician Quality Reporting System (PQRS); the HIT Meaningful Use (MU) program; and, the Value-Based Modifier (VM) Program.  The VM Program, modified under the 2010 Affordable Care Act, is designed to incent Medicare physician performance by updating annual Part B physician payments based on their quality and cost (or spending) performance.  (The performance and payment years are two years apart, e.g., the 2016 payment year is based on 2014 performance.)     

During this 23 minute conversation Ms. Cleary explains how the VM program is designed, how physicians have performed to date under the program, the extent to which physicians use VM data to inform or improve their practice, how the program will be translated, or continue, under the MACRA Merit-Based Incentive Payment System (MIPS) and quality and value performance expectations under MIPS beginning in 2017, the first MACRA performance year.   

Ms. Kelly Cleary is a DC-based health care attorney with the firm Akin Gump.  Her work primarily concerns health care related legislative and Cleary_Kelly_highres regulatory initiatives, matters involving state and federal fraud and abuse laws and cybersecurity, privacy and data protection issues.  Prior to joining Akin Gump, Ms. Clearly clerked for the Honorable Claude M. Hilton in the US District Court for the Eastern District of Virginia.  She was graduated from Catholic University's School of Law.  While there she served as editor-in-chief of the Catholic University Law Review.   

For more on the CMS VM program go to:


"Where's The Value In MACRA?" (June 24th)

Students of the Medicare program are well aware in late April, CMS dropped its proposed Medicare Access and CHIP Reauthorization Act (MACRA) rule.  Specifically, the rule addresses MACRA Title I.   At 424 Federal Register pages the rule will make considerable changes to how CMS will, beginning in 2019, annually update Medicare Part or physician payments.  For all the Strum and Drang surrounding MACRA and regulatory implementation thereof, the proposed rule represents conventional thinking.  Despite the considerable rhetoric about moving Medicare payments from volume to value, remarkably, value goes undiscussed, i.e., value as the relationship between care outcomes and spending.  If we're serious about "bending the Medicare cost curve" and/or expecting providers to accept downside financial risk via ACOs and other models or CMS demonstrations, we'll not get there by continuing to ignore measuring for value.  

If you're interested please feel free:


Recent Efforts to Improve Quality Measurement: A Conversation with Dr. Helen Burstin (June 15th)

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Measuring health care quality and outcomes effectively and efficiently remains a daunting task.  Quality measures are largely seen as too process versus outcome focused, substantially irrelevant to patients and insufficiently aligned between and among payers.  Measuring care or care quality, ironically, can and does detract from actual care delivery, can have no relationship to spending efficiency and on its own is costly.  A recent article published in Health Affairs found physician practices spent over $15 billion in 2014 in reporting quality measures.  Concerning the Medicare program's quality measurement activities, MedPAC in a 2014 report to the Congress went so far as to state, "Medicare's current quality measurement approach as gone off the rails." 

During this 23 minute conversation Dr. Burstin briefly describes the work of the National Quality Forum (NQF), the work done by the CMS-led Core Measure Collaborative, quality measurement under the CMS proposed MACRA (Medicare Access and CHIP Reauthorization Act) rule, risk adjusting measures for socio-demographic factors, the role of PREMS and PROMS or patient reported experience and outcome measures and correlating care quality and spending or measuring for healthcare value.  

Dr. Helen Burstin is the Chief Scientific Officer at the NQF.  Prior to serving in her current position, Dr. Burstin was NQF's Senior Burstin PhotoVice President for Performance Measurement.  Prior to NQF Dr. Burstin was the Director of the Center for Primary Care at the DHHS Agency for Healthcare Research and Quality (AHRQ).  Prior to AHRQ, Dr. Burstin was an Assistant Professor at Harvard Medical School and the Director of Quality Measurement at the Brigham and Woman's Hospital in Boston.  Dr. Burstin has published more than 80 articles and book chapters on quality, safety and disparities.  She was recently selected as a 2015-2016 Baldridge Executive Fellow.  She currently is also is a Professorial Lecturer in the Department of Health and Policy and a Clinical Associate Professor of Medicine at George Washington University and serves as a preceptor in internal medicine.

For information concerning NQF go to: