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01/29/2016

The Oral Health of Seniors and Medicare Coverage Thereof: A Conversation with Marko Vujicic (January 28th)

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The Medicare program, now in its 51st year, still does not cover oral/dental health care such as exams, X-rays, cleanings, fillings, tooth extractions and dentures.   (Medicare will cover an oral health procedure if it is incent to a serious accident or disease, for example, for surgery to treat fractures of the jaw or face or if you have oral cancer and need dental services necessary for radiation treatments.)  This is unfortunate when you consider for example: poor oral/dental health worsens overall health; less than five percent of older Americans have dental insurance of any kind; one-third of adults over 65 have untreated dental caries and over 40 percent have periodontal disease; the Affordable Care Act did not name adult oral/dental benefits as an "essential health benefit"; an overwhelming majority of adults believe dental coverage should be part of overall health coverage; for all of CMS's "innovation" demonstrations (now numbering well over 50) there are none that address improving oral/dental health for seniors; and, oral/dental health disparities are, according to the CDC, "profound."  

During this 20-minute conversation Dr. Vujicic provides his assessment of the oral/dental health of American seniors, his understanding of why the Medicare program still does not cover routine oral health care and what can be done to improve access and (insurance) coverage of oral health for seniors or Medicare eligible individuals.

Dr. Marko Vujicic is the Chief Economist and Vice President of the Health Policy Institute at the American Dental Association Vujicic(ADA).  Prior to joining the ADA Dr. Vujicic was a Senior Economist at The World Bank and also a Health Economist with the World Health Organization in Geneva, Switzerland.  Dr. Vujicic is the lead author of the book, "Working in Health" and has authored additional essays and book chapters on various health policies.  He is published in the New England Journal of Medicine, Health Services Research, Health Affairs and other policy and scholarly journals.  Dr. Vujicic is also a visiting professor at Tufts University in Boston.   Dr. Vujicic earned his Ph.D. in Economics from the University of British Columbia and his undergraduate degree at McGill University in Montreal.

For more on the work of the ADA's Health Policy Institute go to: http://www.ada.org/en/science-research/health-policy-institute

12/28/2015

The Secretary's Medicare Quality and Value Payment Goals, MACRA, MA and ACOs

If you're interested in how or how could Secretary Burwell weave together her Medicare payment goals, provisions under MACRA, the Medicare Advantage program and Medicare ACOs, feel free to read this essay I drafted earlier this month for Health Affairs.  It's titled, "Synchronizing Medicare Advantage and ACOs to Support the Secretary's Quality and Value Payment Goals." 

Happy Holidays!

It's at: http://healthaffairs.org/blog/2015/12/28/synchronizing-medicare-advantage-and-acos-to-support-the-secretarys-quality-and-value-payment-goals/

12/17/2015

The Unavoidable Interaction Between ACOs and CMS's Recently Announced Hip & Knee Replacement Bundled Payment Demonstration

If you are interested in how CMS resolved, or not, the interaction between the ACO program and the agency's recently finalized CJR (Comprehensive Care for Joint Replacement) demonstration the trade publication, Accountable Care News recently published my essay, "Missed Opportunity: CMS Fails to Address the Interaction Between the CRJ Demo and the ACO Program." This is a truly in-the-weeds issue since both the ACO program and CJR demo operate under very complicated and detailed regulations amounting to well over 500 Federal Register pages.  Here, I'll just note my conclusion.

"CMS believes the CJR demo will operate in isolation or "alongside" the ACO program having no spillover effects. The agency just simply needs to (literally) account for financial overlap when the CJR and ACO beneficiary are one in the same. This is the same silo-ed thinking the agency used in creating the BPCI. In the ecology of Medicare program however CMS can never do one thing. Providers in the demo and the ACO program interact and this interaction will be competitive if not antagonistic. What ACO providers generally will see is a flawed solution to a contrived problem. They'll see a demo that will either increase utilization and/or reduce their ability to earn shared savings. Had CMS thought synthetically or cast the CJR demo to complement the ACO program, the agency could have likely tempered over utilization, improved shared decision making and care coordination and moved a reluctant ACO provider community to gradually accept downside financial. Instead, the Medicare program, as a program, will be left compromised."

  

12/10/2015

How Do Accountable Care Organizations (ACOs) and the Medicare Advantage (MA) Program Compare?

How these two Medicare payment and delivery reform programs compare is important since the federal government needs to curb Medicare cost growth via Alternative Payment Models (APMs), moreover via ACOs, and since MA plans are not, or at least are not currently, defined as an APM.  For a discussion of how the two compare please see my essay titled, "The Need to Level The Playing Field Between Accountable Care Organizations and Medicare Advantage," recently published by AJAC, at: 

(http://www.ajmc.com/journals/ajac/2015/2015-vol3-n4/The-Need-to-Level-the-Playing-Field-Between-Accountable-Care-Organizations-and-Medicare-Advantage).   

12/09/2015

Iora Health's Novel Approach to Delivering Primary Care: A Conversation with David Judge (December 23rd)

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Much of the health care industry's effort to improve health care payment and delivery centers around improving primary care. This is largely because Americans suffer more disease/disease burden throughout their life spans compared to individuals in other industrialized countries.   This therefore makes obvious sense since primary care is the foundation upon which an effective and efficient health care/medical care program is built.  When done well primary care promotes wellness, prevents disease onset, progression, exacerbation and prevents premature death.  Primary care also moderates the need for higher cost specialty care and improves population health.  For numerous reasons, not least of which is inadequate reimbursement, primary care delivery has been sub-optimal.   New models of primary care are emerging, one termed direct primary care (noted in the ACA under Section 1301 (A) (3) and now recognized in 13 states) is showing promise in improving quality, improving patient satisfaction and lowering cost growth.      

During this 21 minute conversation Dr. Judge discusses moreover the impetus for the creation of Iora Healh, how Iora's primary care delivery model works or how it is different from traditional primary care delivery, how Iora's model is staffed, IT supported and reimbursed, with whom and how it contracts and what Iora's performance data demonstrates to date. 

Dr. David Judge serves as Iora Health's Chief Medical Officer.  Dr. Judge joined Iora in 2014 to continue his work in improving and redesigning of primary care.  Priorto , he helped found and was the David-JudgeMedical Director of the Ambulatory Practice of the Future at Mass. General Hospital.  David received his undergraduate degree in biomedical engineering and public health studies at Brown University and attended University of  Mass. Medical School.  He completed his residency training in internal medicine at Columbia Presbyterian Medical Center in New York City. 

For more on Iora Health go to: http://www.iorahealth.com/

11/30/2015

Expectations for 2016 ACA Marketplace Enrollment: A Conversation with Sabrina Corlette (December 21st)

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January 1st will mark the Affordable Care Act's (ACA) third health insurance expansion year.  Under the ACA individuals with income below 400% of poverty are eligible for insurance subsidies and individuals with incomes below 138% of the federal poverty level are eligible for state Medicaid coverage (or in the 31 states that have to date chosen to expand Medicaid coverage).  As of 2015 the ACA has expanded coverage to approximately 12 million Americans.   Medicaid expansion has added another 14 million lives.   Despite significant gains in the number of insured approximately 25 million non-elderly adults or about 11% remain without coverage.  Roughly half of these are undocumented immigrants whom are ineligible for coverage under the ACA.   Despite subsidies the cost of insurance remains the reason individuals go without coverage that frequently results in individuals going without needed care.      

During this 24 minute conversation, Ms. Corlette discusses expected 2016 enrollment numbers, premium prices, the impact pharmaceutical cost growth has had on premium costs, to what extent individuals comparative shop for plans, the number of and reasons for the un-enrolled, insurer participation and the issue of risk corridor funding (recently a presidential campaign issue). 

Sabrina Corlette is a Senior Research Fellow and Project Director at the Center on Health Insurance Reforms (CHIR) at SearchGeorgetown University's Health Policy Institute.  Prior to joining the Georgetown faculty, Ms. Corlette was Director of Health Policy Programs at the National Partnership for Women and Families.  From 1997 to 2001, Ms. Corlette worked as a professional staff member for the Senate Health, Education, Labor and Pensions (HELP) Committee.   After leaving the Hill Ms. Corlette also served as an attorney at Hogan Lovells.  She received her JD with high honors from the University of Texas and earned her undergrad degree also with honors from Harvard. 

For more on CHIR go to: http://chir.georgetown.edu/.  

11/19/2015

Will Medicare Ever Cover Telehealth & Remote Monitoring? A Conversation with Krista Drobac (November 18th)

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Telehealth and remote monitoring services generally enable physicians to treat patients and monitor their health status remotely.  Because of advances in wireless communication and biosensor technology these services are increasingly being used in the commercial health care market and as well in the Medicaid program and the VA because research shows these services can reduce acute care visits and lengths of stay, iatrogenic harm and improve patient adherence to care.  Nevertheless, the Medicare program restricts reimbursement for these services largely because CMS (the Congress and the CBO) see them moreover as duplicative (v. substitutive) services.   For example, in 2014 Medicare spent just $14 million on telehealth service reimbursement.  (Total Medicare spending in 2014 was well north of $500 billion).    

During this 18 minute conversation Ms. Drobac discusses in part how and why reimbursement for telehealth and remote monitoring services are limited under Medicare, how other payers and providers are using telehealth and remote monitoring, what the research literature suggests regarding clinical effectiveness and cost efficiency, proposed Congressional legislation and related regulatory action to broaden Medicare coverage and chances for legislative and regulatory success. 

Krista Drobac leads the Alliance for Connected Care, a 501(c)(6) coalition formed to create a statutory and regulatory Drobacenvironment in which providers are able to deliver and be adequately compensated for providing telehealth and remote monitoring services regardless of delivery location or technological modality.   Ms. Drobac was previously Director of the Health Division at the National Governors Association's Center for Best Practices.  Prior to that she was senior adviser at CMS, Deputy Director of the Illinois Department of Healthcare and Family Services and spent five years on Capital Hill where she was a Health Adviser to the Senate Majority Whip Senator Richard Durbin and served as a John Heinz Senate Fellow for Senator Debbie Stabenow.  Ms. Drobac earned her BA from the University of Michigan and her MPP from the Kennedy School of Government at Harvard. 

For information on the Alliance for Connected Care go to: http://www.connectwithcare.org/ 

11/11/2015

The Jimmo Settlement: Its Importance and Implementation to Date: A Conversation With Margaret Murphy (November 10th)

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In 2011 a 78 year old blind, amputated Vermont woman, Ms. Glenda Jimmo, was denied physical therapy services under Medicare because her condition was determined to not likely improve. Because Medicare therapy services via skilled nursing, home health and outpatient care never required the patient "improve" in order to receive services and because thousands of other Medicare beneficiaries along with Ms. Jimmo had been denied therapy the Center for Medicare Advocacy and Vermont Legal Aid filed a class action suit against the federal government, i.e., Jimmo vs. Katheleen Sebelius.  After 11 months of negotiations, a settlement agreement was reached in late 2012 that affirmed there is no "improvement standard" required to be met for beneficiaries to receive therapy services.  That is care would no longer be denied due to a Medicare beneficiary's lack of restoration potential. 

During this 18 minute discussion Ms. Murphy explains the impetus for the case, speculates why DHHS did not act on its own in resolving the problem, how well or effectively CMS has implemented the terms of the settlement agreement (not very well) and why the decision has received so little attention over the past three years.   

Margaret Murphy is the Associate Director of the Center for Medicare Advocacy where she works to develop the Center's legal policy and litigation strategies.  Ms. Murphy has been counsel or co- Murphycounsel in several of the Center's federal class action suites.  She serves on the Steering Committee of the Complex Care Committee of the Connecticut Medicaid Medical Assistance Program Oversight Council.  She has also been appointed by the Connecticut probate courts to represent incapacitated adults. She has also taught as an adjunct professor at Quinnipiac University Law School.   Prior to joining the Center Ms. Murphy worked for more than 20 years a a trust and estate attorney.   She is a member of the Connecticut Bar Association, serves as the Secretary of the Executive Committee of the Elder Law Section and is a member of Swift's Inn in Hartford.  Ms. Murphy earned her JD degree from the University of Connecticut School of Law and her BA from Mt. Holyoke College.  

10/26/2015

How Well Are Accountable Care Organizations Performing? (October 26th)

For those interested in the Medicare Shared Savings Program (or ACOs), please see my Health Affairs blog post (co-authored with Greg Berger) that summarizes ACO performance year two (2014).  The essay is titled, "MSSP Year Two: Medicare ACOs Show Muted Success" and can be found at:  http://healthaffairs.org/blog/2015/09/24/mssp-year-two-medicare-acos-show-muted-success/

 

10/21/2015

Is the Intensive Use of Herbicides on Genetically Modified Food Crops Endangering the Public's Health? A Conversation with Charles Benbrook (October 20th)

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Beyond numerous other benefits derived by genetically modifying foods is herbicide resistance. This allows farmers the ability to control for weed growth without killing their crop, for example, corn and soybeans.  While a foreseeable unintended consequence, the increasing or intensive use of the herbicides, specifically glyphosate, the primary ingredient in the widely used product Roundup, has caused weeds to develop resistance.   As a result glyphosate is now beginning to be used in combination with another herbicide, 2,4-D, a component of the defoliant Agent Orange, under the product name Enlist Duo.  The question begged is to what extent do these herbicides, used independently and in combination, pose a public health risk.

During this 30 minute discussion Dr. Benbrook discusses in part the evolution of the use of these herbicides, the federal governments efforts to risk assess their use, the IRAC's (International Agency for Research on Cancer) recent finding these products are probable or possible human carcinogens, the pending National Academy of Sciences' report (scheduled to be published next year) and his thoughts regarding what can be done to safeguard exposed populations.

Dr. Charles (Chuck) Benbrook, Benbrook Consulting, is a recognized expert in pest management
sytsems, pesticide use and regulation and the environmental and  public health consequences of farming system choices.  Dr. Benbrook worked in Washington, D.C. on agricultural policy issues Searchfor nearly twenty years as the agricultural staff expert on the Council for Environmental Quality, as Executive Director of the Subcommittee on Department Operations, Research and Foreign Agriculture for the House of Representatives and as the Executive Director for the Board on Agriculture at the National Academy of Sciences.   He also served for six years as Chief Scientist of the Organic Center and for three years as a Research Professor at Washington State University.  Dr. Benbrook holds a Ph.D. in agricultural economics from the University of Wisconsin at Madison, an undergraduate degree from Harvard and is the author of nearly three dozen peer-reviewed articles.        

The New England Journal of Medicine essay noted during this conversation, co-authored by Dr. Benbrook and Dr. Philip Landrigan and titled "GMOs, Herbicides and Public Health," is at:  http://www.nejm.org/doi/full/10.1056/NEJMp1505660