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3 posts from March 2017

03/27/2017

Playing Dice with the State Marketplaces: CMS' Proposed Market Stabilization Rule (March 22nd)

In mid-February CMS published a proposed rule intended to "stabilize" the state insurance marketplaces.  This essay, posted on The Health Care Blog last Wednesday, is my critique of the proposed.   What's actually amazing about the proposed is CMS admits the proposed changes have a 50-50 chance of succeeding, i.e., CMS summarizes the proposed changes by stating "on the one hand" the proposed changes may work, "on the other hand" they may not.  Imagine if this was the standard for drug approvals?

The essay was originally titled, "Playing Dice with the State Marketplaces: The Administration's Admittedly Ambiguous Market Stabilization Proposed Rule."  The editor changed the titled.  

http://thehealthcareblog.com/blog/2017/03/22/the-incredible-self-destructing-healthcare-marketplace/

03/13/2017

Does Pay for Performance Improve Care and Lower Spending? A Conversation with Stephen Soumerai (March 15th)

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Over approximately the past decade the health care industry has become increasingly committed to financially incenting physicians and other clinicians, or tying performance to reimbursement.  Commonly termed "pay for performance"(P4P), these arrangements are increasingly employed in the Medicare (i.e., under the Medicare Access and CHIP Reauthorization Act, or MACRA) and Medicaid programs and by commercial insurers, most notable accountable care models and bundled payment arrangements.   One might assume because P4P models are now common there is research evidence that demonstrates they are effective in, again, improving care quality, patient outcomes and lowering spending growth.  That is not the case.  For example, a systematic review published by Cochrane in 2011 found "there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."  Among other examples, for all the attention the Massachusetts' Alternative Quality Contracts (AQCs) have received since they were launched in 2009, it remains unclear if they have reduced spending or spending growth.   Because P4P models have not proved out, payers and providers, for example, England's National Health Service and in the US the integrated, 12 hospital system, Geisinger Health, have substantially reduced incentive payments or are returning to paying providers straight salaries.            

During this 27 minute conversation, Professor Soumerai discusses his interest in the P4P topic, describes P4p arrangements, summarizes his and others' review of the research evidence relative to the effectiveness of P4P arrangements and suggests model designs that may be more effective.  

Stephen B. Soumerai is Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care SsoumeraiInstitute.  He also co-chairs the Statistics and Evaluative Sciences concentration within Harvard University’s health policy Ph.D. program.  Dr. Soumerai recently served as International Trustee for the Canadian Health Services Research Foundation.  Dr. Soumerai has published more than 250 original scientific articles in leading scientific journal, such as the New England Journal of Medicine and the Journal of the American Medical Association.  He is well known nationally and internationally for his work on the impacts of health policies and methods to improve the quality of medical practice.  He frequently advises Congress, state legislatures and federal and international agencies on the design of drug cost containment, coverage and quality-of-care policies, evidence-based health policy and his research has been used extensively to support expanded economic access to medications in Medicaid and Medicare. He is the recipient of numerous honors including numerous article of the year awards from national and international scientific societies, named lectureships, and is the recipient of the Everett Mendelsohn Excellence in Mentoring Award from the Harvard University Graduate School of Arts and Sciences.

Professor Soumerai's 2015 and 2016 CDC articles noting in this discussion are at: https://www.cdc.gov/pcd/issues/2015/15_0187.htm and https://www.cdc.gov/pcd/issues/2016/16_0133.htm

03/07/2017

Proposed House Republican Changes to Medicaid: A Conversation with Matt Salo (March 6th)

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Late today, or within a few hours after this interview was completed, the House Republicans proposed ACA repeal or reconciliation legislation.  The legislation includes repealing Medicaid expansion under the Affordable Care Act (ACA).  More specifically, House Republicans propose repealing the  federal enhanced match rate for eligible beneficiaries on December 31, 2019 though states can keep the enhanced match rate for those Medicaid eligible before January 1, 2020 but only for those that do not have a break in Medicaid eligibility for more than one month after that January 1, 2020..  Moreover, the proposed legislation would reform federal Medicaid funding by creating a per capita cap model starting in 2020.  This means federal funding would be benchmarked to 2016 for the five Medicaid enrollee categories: the elderly; blind and disabled; children; non-expansion adults; and, expansion adults.  Year- over-year federal spending increases would be pegged to the medical care component of the Consumer Price Index (CPI).   While there is not yet a Congressional Budget Office (CBO) score for the proposed legislation, that's schedule for mark up on Wednesday, estimates by the Center for Budget and Policy Priorities (CBPP) project that if the 32 states that expanded Medicaid coverage under the ACA wanted to keep it, the cost to these states would be approximately $280 billion over the next decade.  CBPP also estimates that per capita caps will  increase the state's share of Medicaid costs, excluding expanded coverage, by another $280 billion also over 10 year budget window.   

During this 25-minute interview, Executive Director of the National Association of Medicaid Directors (NAMD), Matt Salo, discusses the mission of NAMD, his understanding of House Republican legislation to fundamentally reform the Medicaid program, the challenges with either Medicaid block grants or per capita caps, and other related policy issues the NAMD is working to resolve.  

Mr. Matt Salo has served as Executive Director of NAMD since 2011.  NAMD is a non-partisan association representing all 56 of Salothe nation's state and territorial Medicaid Directors.    Prior to NAMD, Mr. Salo spend 12 years at the National Governors Association where he  worked to forward the Association's health and human services policy agenda.   Prior still Mr. Salo worked for five years as a health policy analyst at the American Public Human Services Association.   Mr. Salo also spent two years as a substitute teacher in the Alexandria, VA public school system. Mr. Salo holds a BA in Eastern Religious Studies from the University of Virginia.

For more on the NAMD go to: http://medicaiddirectors.org/

For more on House ACA repeal or reconciliation legislation go to: 

https://energycommerce.house.gov/hearings-and-votes/markups/markup-committee-print-and-h-res-154

https://waysandmeans.house.gov/event/markup-budget-reconciliation-recommendations-repeal-replace-obamacare/