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Bundled Payment and CMS's Proposal To Mandate Bundled/Episodic Payment for Hip & Knee Surgery: A Conversation with Harold Miller (September 29th)

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Bundled or episodic health care payment for a clinically defined medical episodes of care has been used since at least the 1980s.  However, recently CMS has initiated two bundled payment demonstrations, the Bundled Payment for Care Improvement Demonstration (BPCI) that bundles care for 48 (DRG) episodes of care began in 2013 and more recently CMS proposed the Chronic Care for Joint Replacement (CCJR) demonstration this past July.   Considered the middle ground between fee for service reimbursement and capitated payment the jury is still out whether bundled payments can be designed to reduce cost growth and improve care quality and patient outcomes.      

During this 22 minute conversation, Mr. Miller addresses five aspects of bundled payment and how well or not these aspects are addressed in CMS's recent CCJR proposal to mandate bundled payment for hip and knee replacement surgeries in 75 markets nationally.  Theses aspects are: how well or not bundled payment addresses the underlying problems of fee for service reimbursement and whether bundled payments incent or not care innovation; what types of patients are best served under bundled payment arrangements; how best providers can organize to be effective and efficient under these arrangements; how well bundled payments address over-utilization; and, how episodic payments can be integrated with wider care coordination and whole person care.   

HaroldMillerHarold D. Miler is the President and CEO of the Center for Healthcare Quality and Payment Reform.  He also serves as Adjunct Professor of Public Policy and Management at Carnegie Mellon University.   From 2008 to 2013, Mr. Miller served as President and CEO of the Network for Regional Healthcare Improvement, the national association of the Regional Health Improvement Collaboratives.   From 2006 to 2010, Mr. Miller serves as the Strategic Initiatives Consultant to the Pennsylvania Governor's Office of Policy Development, Associate Dean of the Heinz School of Public Policy and Management at Carnegie Mellon, Executive Director of the PA Economy League, Director of the SW PA Growth Alliance and the President of the Allegheny Conference on Community Development.   Mr. Miller has worked in more than 30 states and metropolitan regions to help physicians, hospitals, employers, health plans, and government agencies design and implement payment and delivery system reforms.  He assisted CMS with the implementation of its Comprehensive Primary Care Initiative in 2012.  Mr. Miller also serves on the Board of Directors of the National Quality Forum.

For more on bundled payment see Mr. Miller's, "Bundling Better, How Medicare Should Pay for Comprehensive Care" published September 2015, at:


Medicare, Home Health and Value-Based Purchasing: A Conversation with Sherill Mason (September 23rd)

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This past July CMS announced a proposed demonstration that would either reduce or increase a Medicare home health agency's reimbursement based on quality performance.   With a rapidly aging and growing Medicare population home health utilization and costs have risen significantly over the past decade.  Per MedPAC, between 2000 and 2012 total Medicare home health spending increased 64 percent.  However, home health agency quality performance has been limited.  For example, again per MedPAC, less than half of all Medicare home health patients in 2013 showed improvement in medication management and only 65 percent showed improvement in pain management.    

During this 22 minute discussion Ms. Mason explains the several, if not numerous reasons, why CMS announced this demonstration, how it will work, e.g., how quality will be measured or what quality metrics will be used, what are the specific financial incentives, in what states the demo will be conducted, when it will begin and for how long, and what are some of the perceived pros and cons of the demonstration as proposed.   

Sherill Mason is currently Principal, Mason Advisers, where she provides strategic planning, Sherill-mason[1]program development and operations analysis for post acute care providers including senior living and nursing home facilities, home health, hospice, long term acute care hospitals, in patient rehabilitation facilities, and long term care pharmacy.  Previously, Sherill she served as a Vice Presient to the Marwood Group, a healthcare industry consultant, as Senior Vice President at Sunrise Senior Living and as a Director at KPMG.   Among other current professional activities Sherill currently is a Guest Lecturer at the University of Pennsylvania School of Nursing.  She received her RN diploma and training at the Englewood Hospital School Nursing and a BA in American Studies from Eckerd College.  

For information regarding CMS's proposed value-based home health demonstration go to:



The White House's July Conference on Aging: A Conversation with Anne Montgomery (August 18th)

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This past July 13th the White House convened its sixth Conference on Aging.   The meeting's purpose is to identify elder care needs over the next 10 years.  More specifically the meeting is, or is typically, held to discuss improvements to the Older Americans Act (OAA).  The OAA was  signed into law in 1965 by President Johnson and has historically enjoyed Congressional support having been amended over ten times.   This Conference, the 6th, however was held despite the fact the Congress has failed to reauthorize the OAA over the past four years.  The OAA expired in 2011 though the Congress has appropriated funding since then to continue to fund OAA programming.   Among other purposes the OAA established the federal Administration on Aging and provides moneys to state agencies on aging that in turn fund health care services including nutritional programming, social service support programs (termed Long Term Services and Supports) and employment and legal protection programs.  

During this 21 minute discussion  Ms. Montgomery discusses what issues President Obama discussed during the meeting, other or additional meeting discussion topics, what was not or insufficiently discussed, the future/near future health and social service support needs for this country's rapidly growing senior (and frail elderly) population (10,000 Americans age into Medicare every day) and what are the prospects for Congressional renewal (with adequate funding) of the OAA this fall or going into the 2nd session of Congress in 2016.    

Anne Montgomery is a Senior Policy Analyst at Altarum Institute’s Center for Elder Care and MontgomeryAdvanced Illness and is a Visiting Scholar at the National Academy of Social Insurance.  From 2007 to 2013, Ms. Montgomery served as Senior Policy Adviser for the U.S. Senate Special Committee on Aging.  She has also served as a Senior Health Policy Associate with the Alliance for Health Reform in Washington, as a Senior Analyst in public health at the U.S. Government Accountability Office and as a Legislative Aide for the House Ways & Means Health Subcommittee.   As an Atlantic Fellow in Public Policy based London in the early 2001-2002, Ms. Montgomery undertook comparative policy analysis of the role of family caregivers in the development of long-term care in the United Kingdom and the United States.  During the 1990s, she worked as a health and science journalist covering the National Institutes of Health and Congress.  Ms. Montgomery earned her MS at Columbia and her BA  at the University of Virginia.

For information about the Altarum's Center for Elder Care and Advanced Illness go to:




Tracking Implantable Medical Devices with a UDI: A Conversation with Ben Moscovitch (July 31st)

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For the past eight years the federal government has been working to create a unique medical device identification (UDI) number that would identify a medical device's manufacturer, the device's make and model, its expiration date and other information for the purposes of improving or ensuring patient safety and product improvement.   While progress has been made in establishing a UDI tracking system, we have still not implemented the use of UDIs in medical claims forms and in electronic health records (EHRs).  A UDI is particularly important since it would allow health care providers, researchers and others to track particularly implantable medical devices.   For example, annually over one million Americans receive an artificial hip or knee.  These devices can and do fail and can cause serious cognitive and neurological impairment, bone deterioration and in severe cases, amputation.  

During this 19 minute conversation Mr. Ben Moscovitch discusses the development of a UDI over the past eight years, current efforts to include a UDI data field on the medical claims form and in EHRs, why UDI adoption has not, or still not, been achieved and chances it will be achieved.    

As Officer of The Pew Charitable Trust's medical devices project, Ben Moscovitch works on federal BenMoscovitchinitiatives to enhance the data available on product performance to support medical device innovation and quality improvement.   Prior to joining Pew, Mr. Moscovitch worked on public policy communications at the National Association of Chain Drug Stores and was previously a journalist covering medical product regulation and legislation.   Mr. Moscovitch received his Master of Arts degreee from Tel Aviv University and his Bachelor's from Georgetown University.

For more on Pew's work regarding medical devices see:




"Person-Centered" Health Analytics: A Conversation with Dwight McNeill (July 14th)

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Health care analytics has typically referred to modeling insurer or payer risk or to predict patient utilization or to segment patient populations.  However, because of advances in personal or wearable medical devices, supporting software applications and the increasing use of electronic health records, individuals or patients now have the opportunity to gather their own health and medical data and information and use it to better manage their health status and/or medical needs.  This opportunity is what's become termed the democratization of health care or alternatively the emancipation of the patient.  

During this 25 minute conversation Dr. Dwight McNeill provides an overview of his recently published work, "Using Person-Centered Health Analytics to Live Longer," i.e., he unpacks four domains he identifies ("knowing me," "protecting health," "minding illness," and "managing data") that can empower, enable and equip an individual to manage their health and medical needs.  Dwight also discusses barriers to the adoption to "person-centered" analytics  and near future potential of these tools.          

Dr. Dwight McNeill is Lead Faculty for the International Institute for Analytics.  He is also President of WayPoint Health Analytics which provides consultation to organizations on health and McNeillhealthcare analytics.  During his 30-year career, he has worked in corporate settings, most recently as global leader for business analytics and optimization for the healthcare industry for IBM and previously as director of healthcare information at GTE Corporation (Verizon).  Earlier, Dwight worked for the federal Department of Health and Human Services and the Commonwealth of Massachusetts, for information companies, and in provider settings.  Dwight has published two related books on healthcare analytics in 2013: A Framework for Applying Analytics in Healthcare: What Can Be Learned from the Best Practices in Retail, Banking, Politics, and Sports; and, Analytics in Healthcare and the Life Sciences: Strategies, Implementation Methods, and Best Practices.   He has also published frequently in Health Affairs and other related journals. Dwight earned his PhD from Brandeis University in Health and Social Policy and his MPH degree from Yale University in Public Health and Epidemiology.  

For more on "Using Person-Centered Health Analytics to Live Longer" see:



"The Medical Industrial Complex": A Conversation with Rosemary Gibson (June 24th)

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With the health care industry now accounting for 18.5 percent of the nation's GDP, or a far greater percentage than any comparable nation, combined with ever continuing access, coverage (now possibly moreover the issue of under-insurance) and quality (including the frequency of patient or iatrogenic harm) health care policy students are left to wonder to what extent has health care delivery or legitimate health care delivery been compromised or even undermined by medical commerce.    

During this 27 minute conversation Ms. Gibson explains what's meant by the Eisenhower-inspired "medical industrial complex" and her use of the phrase "privatized gains and socialized losses" in this context.  She discusses the unwarranted influence of the health care industry in part by noting pharmaceutical industry behavior and the advent of so called "consumer directed health plans.  Ms. Gibson also evaluates to what extent the ACA will strike a better balance between health care and medical commerce or again the "medical industrial complex."  

Ms. Rosemary Gibson is a Senior Advisor at the non-profit Hasting Center, a research organization dedicated to addressing ethical issues in health, medicine and the environment.  Ms. Gibson is also Rosemary_gibson[1]an editor of JAMA Internal Medicine.  Previously, Ms. Gibson was a Program Officer at the Robert Wood Johnson Foundation where she addressed safety and quality issues particularly in palliative care.  Among other books Ms. Gibson is the author of Wall of Silence, The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans.  Ms. Gibson serves on numerous boards including the Consumers Union Safe Project and among others she received the Lifetime Achievement Award from the American Academy of Hospice and Palliative Medicine.  Ms. Gibson is a graduate of Georgetown University and the London School of Economics.

Information on Rosemary Gibson's book, noted during this interview (and coauthored by Janardan Prasad), The Battle Over Health Care, can be found at:



The Re-emergence of Community Health Workers & Peer Support: A Conversation with Ed Fisher (June 15th)

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The use of community health workers (CHW) dates back to the 1800s.  The impetus for these workers today is to provide peer support largely in poor or under-served communities since these communities typically suffer disparities in health care access, in the quality of health care delivery and consequently experience higher morbidity and mortality rates.  The ACA via the Center for Medicare and Medicaid Innovation is supporting CHW demonstration projects, states are testing their use via Medicaid programming and various providers are using CHW to improve self management support among high health care service utilizers.   

During this 20 minute conversation, Dr. Fisher discusses the reasons why the use of CHW is increasing, who they are and how they're trained, in what provider setting they work, their level of success, how they're accepted by clinicians and patients and how their services are reimbursed.      

Dr. Edwin Fisher is a University of North Carolina Gillings School of Global Public Health Professor and HB-fisher_ed_2013serves as Global Director for the American Academy of Family Physicians Foundation's Peers for Progress program.  Peers for Progress promotes peer support in health, health care and prevention around the world.  From 2002 to 2009 Dr. Fisher served as National Program Director for the Robert Wood Johnson Foundation's Diabetes Initiative.  Dr. Fisher has published widely in prevention, chronic disease management and quality of life addressing asthma, cancer, cardiovascular disease, smoking and weight management.  He is past-president of the Society of Behavioral Medicine and has served as a board member for the International Society of Behavioral Medicine and the American Lung Association.  He was graduated from the SUNY, Stony Brook with a Ph.D. in Clinical Psychology.       

Information on Peers for Progress is at:



Potential Republican Party Responses to King v. Burwell: A Conversation With Tevi Troy (May 28th)

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Shortly before the Supreme Court recesses in early July the Court will rule on David King v. Sylvia Burwell, the case where the plaintiffs argue the Affordable Care Act only allows for tax credit subsidies via state-run exchanges or only those, as the ACA states, "established by the state."  If the court rules in favor of the plaintiff an estimated 5 to 8 million newly insured will lose their coverage absent a subsidy because to date only 16 states plus the District of Columbia have set up state health insurance exchanges or marketplaces.  If this is the Court's ruling how might the Republican-controlled Congress react?   Regardless of the Court's decision the health care reform likely becomes a 2016 presidential campaign issue for the Republican party.  

During this 21-minute discussion, Dr. Tevi Troy outlines possible responses by the Republican controlled Congress to a Court's decision in favor of the plaintiffs, how Republican presidential candidates may shape the race's health care reform debate (moreover if the Court rules in favor of Burwell) and he addresses major aspects of the ACA that remain contentious, i.e., the employer mandate, the Cadillac tax and Medicaid reform.

Dr. Tevi Troy is currently President of the American Health Policy Institute and Adjunct Fellow at 220px-Tevi_David_Troy_HHS_2007the Hudson Institute.  Previously he served as Deputy Secretary at the Department of Health and Human Services under President George W. Bush, as Deputy Assistant and Acting Assistant to the White House Domestic Policy Council, as Policy Director for Senator John Ashcroft and as Senior Domestic Policy Adviser and Domestic Policy Director for the House Policy Committee.  Still previously he was a Researcher at the American Enterprise Institute.  His numerous writings include,"What Jefferson Read, Eisenhower Watched and Obama Tweeted, 200 Years of Popular Culture in the White House," and "Intellectuals and the American Presidency," Philosophers, Jesters or Technicians?"  Dr. Troy earned his Ph.D. in American Civilizations from the University of Texas as Austin.     

Information on Dr. Troy's latest book, ""What Jefferson Read, Eisenhower Watched and Obama Tweeted, 200 Years of Popular Culture in the White House” can be found at:




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:

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


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: