BrowSeo v3 Review

BrowSeo v3 Review - BrowSeo v3 Review: Why It's The Best SEO Tool Of All Time

The Spectacular Incompetence of 3rd Party Payers

By SAURABH JHA, MD

To paraphrase Tolstoy, all competence is alike, but every incompetence is incompetence in its own way. Every time I think I've seen the horizon of incompetence, I'm dealt a surprise. The sun never sets on incompetence. In healthcare, incompetence can be found in odd places, such as three recent examples I encountered with third party payers.

Case 1: Downgrading Caviar to Boiled Salmon

A patient was referred for a CT angiogram run off – which is a CT scan of the arteries of the belly, pelvis, both legs and feet – a very detailed and costly study. The cardiologist suspected a pseudoaneurysm of the femoral artery. The exam was an overkill, I felt, as the femoral arteries could be covered in a CT angiogram of the abdomen and pelvis – you don't need to image down to the toes. I was confident that a pseudoaneurysm in the femoral artery would not extend to the arteries of the feet – it would be a world record, if it did. I suggested we stop the exam in the middle of the thigh.

“That's fraud,” warned the chief technologist, who was also an expert in billing.

“Why is it fraud to restrict the field of view to the area of clinical relevance?” I asked.

“You can't bill for a CT angiogram run off and only do the abdomen and pelvis. That's fraud.”

“Why don't we bill just for CT angiogram of the abdomen and pelvis?” I asked.

“You can't bill just for the abdomen and pelvis, the patient has been pre-authorized for a run off.”

“You mean I can't do less and bill for less when the patient has been pre-authorized for more and the insurer will pay more?” I asked.

“Exactly,” replied the chief technologist.

“So what do I need to do?” I asked.

“You need a new order from the cardiologist, and a new pre-certification number, and may have to reschedule the patient.”

I didn't want to relent so I phoned the cardiologist, but I could not get hold of him. The patient was getting annoyed and didn't wish to come back another day for the exam. The technologists were getting antsy that I was stalling the scanner. The conveyor belt had to keep moving. The show had to continue. So the patient had the more expensive CT angiogram run off instead of the cheaper CT angiogram of the abdomen/ pelvis.

There is a paradoxical billing phenomenon known as de-authorization, coined by Richard Duszak, a radiologist from Emory, where if you bill for a less resource-intensive and cheaper study than pre-authorized by the insurer, the payment is denied. Once you've asked for caviar you must eat caviar. And if you change your mind and want boiled salmon instead, that's tough.

For example, if the patient is approved for a contrast-enhanced CT of the chest and you decide contrast is not needed, or may be harmful, and do the CT without contrast, and bill for CT without contrast, the payment will be denied. Worse, the patient will be lumbered with the bill – i.e. the chargemaster, price-gouging, flesh-eating bill. Not the discounted rate offered to insurers. The chief technologist saved the patient from a billing clusterfuck. But the insurer paid more for the study than would have if my clinical judgment was allowed to dictate the billing.

Case 2: Cutting your nose to spite your face

A young man had a cardiac MRI for palpitations. During the exam I spotted a hole in the heart – a left-to-right shunt. It was an incidental finding. I thought we should get flow measurements through the aorta and pulmonary artery – it would be useful information which could help the management, because the timing of repair of shunts depends on these parameters.

“Can't do flows. He hasn't been pre-authorized for them,” said the tech.

“Just do it. Don't bill – I'll take the flak,” I offered.

“Can't, we're forbidden to do more than has been ordered,” the tech protested.

The referring cardiologist agreed and put an order for flow mapping. However, the order needed authorization from insurers. I phoned the insurer who connected me to a physician from the advanced imaging management elite squad – also known as radiology benefit managers. The chap, a most boring metronome, told me that the first line test for left-to- right shunt was an echocardiogram. I explained that the patient, a young professional with a demanding job, would have to take another day off work – we could easily nip the issue in the bud within five minutes. But the chap continued like a broken down record, “Our guidelines say echocardiogram first.”

I slammed the phone and muttered “ducking tosser” under my breath.

The patient came back another day for an echocardiogram and another day for another cardiac MRI for flow measurements because the echocardiogram was not clear enough. Imagine – two separate days of taking time off work, driving on the interstate, and finding parking, could so easily have been avoided. Not to mention that the insurer could have saved money.

Case3: Charity is fraud

I spotted a mass in the kidney at the edge of the field of view, which looked like cancer, in an elderly man having a cardiac MRI.

“Let's go lower and cover the kidneys, and the bladder,” I asked the technologist.

“I can't. That's fraud. Covering the kidneys will make this an MRI of the abdomen, which the patient doesn't have a script for.” The technologist said.

“Fraud! WTF,” I barked.

“It is Medicare fraud if you do more for the patient than what you've billed for,” explained the technologist.

I was losing my marbles – but I wasn't going to relent with this one.

“Just do it – put my name down. Say I insisted. And if it's fraud to do more than I billed for, I'll happily go to Guantanamo Bay for fraud.”

The kidneys were covered. I overcalled the finding in the kidney – the patient did not have cancer. However, the technologist was correct – it can be considered fraud to dispense billable services (such as an MRI of the abdomen) to Medicare patients without billing Medicare. This reminds me of a physician I once met, who specializes in physical medicine and rehabilitation, and runs a direct pay practice. She doesn't accept Medicare, Medicaid or any insurance. She sees kids of undocumented migrants for free one afternoon a week, but won't extend the same courtesy (i.e. waiving charges) to patients on Medicaid because she fears she might be fried for fraud.

Charity is fraud with Medicare and Medicaid. Allow that to sink for a moment.

I understand it is fraud if you buy a ticket from Philadelphia to New York and get off at Boston, but how is it fraud if you buy a ticket to Boston and get off at New York? Who makes these rules? Who are these people? Which parts of their brain light up on functional MRI? What do they eat for breakfast? How can a country which gave the world Edison, Wright brothers, and Kim Kardashian produce such imbeciles?

It is hard to maintain disdain for such buffoonery for too long because such spectacular incompetence is an art, a practiced art to be precise, but art nonetheless, and art induces wonder, eventually. But even this explanation is wrong. Third party payers are not incompetent. They may seem to be, but they're not.

The reason insurers, and Medicare, would rather pay more, than less, for an exam, that is cut off their nose to spite their face, is that they don't trust physicians. They don't trust physicians because fifty years of health economics has yielded a spectacular insight – physicians, like crack dealers, are guilty of supplier-induced demand. This meme is now structurally embedded in payers.

The information to discern between physicians inducing their demand and physicians curbing their demand is too costly to obtain. So third party payers have a blanket rule – you can neither upgrade nor downgrade an imaging study, and if you do you'll be paid nothing or will be done for fraud.

Don't get me wrong – I'm flattered that I induce my demand in healthcare (I wish I could induce my demand in other areas, too). But a costly game of chicken is being played between payers and providers. It's a game of reverse chicken actually, where both sides avoid staring at each other, and adapt to each other's pathologies. The costs of this game may be forgivable but the inconvenience to patients is inexcusable.

Disclaimer

The vignettes have been modified from their true state to protect patient health information and to protect the author from HIPAA vigilantes and bounty hunters. However, the gist of the vignettes is correct.

About the author

Saurabh Jha is a radiologist and contributing editor to The Healthcare Blog. He's a leading member of the peanut gallery. He can be reached on Twitter @RogueRad

Stevens-Johnson syndrome

Stevens-Johnson syndrome: A serious systemic (bodywide) allergic reaction with a characteristic rash involving the skin and mucous membranes, including the buccal mucosa (inside of the mouth), conjunctiva, and genital areas. Abbreviated SJS. The disease is due to a hypersensitive (allergic) reaction to one of a number of immunologic stimuli including drugs and infectious agents. Complications can include hepatitis, nephritis, gastrointestinal bleeding, pneumonia, arthritis, arthralgia, fever, and myalgia. The diagnosis of SJS is usually made when the characteristic rash appears 1 to 3 weeks after exposure to a known stimulus and it cannot be explained by another diagnosis. The treatment depends, in part, on the suspected precipitating cause. Also known as erythema multiforme.

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
We Bring Doctors' Knowledge To You

CMS's Latest Report Is Bad News For Medical Homes

By KIP SULLIVAN

The latest report  on one of CMS's “patient-centered medical home” (PCMH) demonstrations is more bad news for the “medical home” movement. According to the report, the second-year evaluation of Multi-Payer Advanced Primary Care Practice (MAPCP) Demonstration released by CMS on May 11, PCMHs are not cutting Medicare costs and are having almost no impact on quality.  Here is how the report summarized its findings on the eight states participating in the demonstration: “Our quantitative analysis [finds] very few consistent, favorable changes associated with the MAPCP Demonstration across the eight states.” (p. 11-6)

The MAPCP demo is one of three “medical home” demonstrations CMS has conducted. As of last May, CMS had released reports on two of them, the Comprehensive Primary Care Initiative and the FHQC Advanced Primary Care Practice Demonstration.

As I reported in an article posted here  on May 5, those reports indicated the PCMHs in those demos are having almost no impact on quality and may be raising Medicare's costs.

The news that all three of CMS's PCMH experiments are failing is also bad news for proponents of MACRA. The PCMH is one of the three “alternative payment models” that Congress and CMS are counting on to lower Medicare's costs under MACRA. (ACOs and bundled payments are the other two.)

It is time to ask what we have learned from the “home” experiment, and either change it radically or abandon it. In this essay I will review the findings from the latest report on the MAPCP demo and comment on two features of the report that constitute clues to why PCMHs are failing: The high ratio of superficial commentary to useful data, and the absence of clearly defined independent variables. In two essays that follow this one I will ask what we can learn from the report.

Summary of the second-year evaluation of the MAPCP demo

On May 11, 2016, CMS released new information on the MAPCP demo in the form of two reports – the second-year evaluation of the demo  and the third-year evaluation.  Both were written by RTI International and two subcontractors. Because the second-year evaluation is the one that reports that PCMHs are failing to cut costs and improve quality, I will focus on that one. (The third-year evaluation presents data on the Medicare beneficiaries participating in the demo.)

The MAPCP demo is testing the PCMH notion in eight states. The demo has “multi-payer” in its title because multiple insurers – Medicare, Medicaid and insurance companies – agreed to help subsidize the PCMHs and to give them “feedback” on how they are doing. To participate in this demo, states had to have their own PCMH experiments underway, and they had to apply to CMS to add Medicare as one of the participating payers.

The second-year evaluation reports that the PCMHs have been unable to lower Medicare costs in seven of the eight states compared with non-PCMH clinics (see Table 2-9 pp. 2-38/2-39), and are having virtually no impact on the small handful of quality measures chosen for the demo (see Tables 2-6 and 2-7 pp. 2-28/29 and 2-30/31). Here are some relevant quotes:

“[O]ur analysis found hardly any evidence that the state initiatives were associated with reductions in utilization rates.” (p. 2-41)

“We observed mixed findings for process of care measures among the states.” (p. 2-26)

“For preventable hospitalizations, we found no significant differences in all eight states in terms of avoidable catastrophic events. For the prevention quality indicator composite measures, we found no differences in six out of the eight states and unfavorable findings in the remaining two states.” (p. 2-27)

Moreover, as is virtually always the case in analyses of “homes,” the cost measure RTI used to compare PCMHs to non-PCMHs did not take into account the fees CMS paid to PCMHs nor the expenses PCMHs incurred to set up and run “homes.” [1] If utilization rates are not falling, but CMS is subsidizing the “home” clinics and is incurring administrative costs to run this demo, that probably means the MAPCP demo is raising Medicare's costs.

The report contains no information on whether the PCMHs cut costs or improved quality for Medicaid. It does mention dissatisfaction with PCMH performance among some insurance companies. The first-, second-, and third-year evaluations each promised a report on the PCMHs' impact on Medicaid in a final report that will apparently be published in 2017.

There's a pony in here somewhere

In all of three of the MAPCP evaluations, the ratio of uninformative commentary to useful data is astonishingly high. The authors wrap the few nuggets of useful information in great clouds of speculative observations, anecdotes, and subjective impressions conveyed with abstract and imprecise words. Take, for example, this remark at page 2-19 about “coaching”: “Many states offered practice coaching to some extent….” Say what? How many is “many”? What does it mean to coach “to some extent”? In the sentence that follows the one I just quoted, RTI informs us that the “coaches” in the unidentified states helped clinics apply for PCMH certification. But RTI does not tell us what wisdom the coaches shared with the doctors and nurses about how to make patients healthier. In short, this sentence about coaching is like junk food: You expend energy to consume it, but you get nothing in return.

I could fill hundreds of pages with other examples of similar fluff. Below are several other examples. Note the frequent use of abstract words like “activities,” “support,” “focus,” “team,” “enhanced,” and “transformation,” as well as words that convey gross imprecision such as “sometimes,” “some,” “many,” “several,” “others,” “most,” “varied,”  and “generally.” In the following quotes, I have italicized words that drain the quotes of intellectual nutrition:

“Care managers sometimes engaged in a variety of activities….” (p. 2-17)

“Practices … varied in the degree to which they effectively used utilization data provided by payers….” (p. 2-17)

“[T]here was great variation in the level of comfort practices had with their EHRs. In the second year, practices used their EHRs to support practice transformation with varying degrees of success.” (p. 2-18)

“Several practices described an increased focus on care plan development…. In most care plans, patients worked with providers to identify goals….” (p. 7-35) [2]

The second-year evaluation is 662 pages long; the third-year evaluation is 296 pages long. The useful information in these two reports could have been presented in 100 pages.

What are we testing?

At the beginning of all three evaluations, RTI makes the bold statement that they intend to find correlations between the “improved outcomes” RTI assumes the MAPCP demo will produce and independent variables RTI calls “features.” [3] They divide these variables into features of the states' “initiatives” and features of the PCMH clinics. In the first- and third-year evaluations, RTI presents a long list of excellent questions they intend to ask about these features (this list appears in Appendix 1A in the first-year evaluation and Appendix A in the third-year evaluation). Examples of the research questions include, “What are the features of participating PCMHs?” (question 8) and, “What features of state initiatives are most responsible for the positive impacts seen?” (question 40).

But even though RTI says they will look for relationships between “features” and “improved outcomes,” nowhere does RTI explicitly identify the features they intend to treat as independent variables. The closest thing to a list of such variables is Figure 1-1 entitled “Conceptual framework for the MAPCP Demonstration evaluation” (p. 1-3). There we see boxes containing vague phrases with arrows pointing left-to-right to other boxes with vague phrases. The left-most box, entitled “MAPCP Demonstration Implementation,” contains six abstract phrases such as “practice-coaching/learning collaboratives” and “data systems/health IT/meaningful use,” while the box to the right of that one, entitled “Practice Transformation,” contains six vague and manipulative phrases including “whole-person orientation” and “commitment to quality and safety.” [4]

Let's stop here and think for a moment about just two of the flabby phrases in RTI's boxes – the “whole-person orientation” and “quality and safety” phrases. Do doctors who refuse to “transform” their clinics into PCMHs suffer from a “half-person orientation”? How is RTI supposed to distinguish between a whole-person orientation and a half-person orientation? Are non-PCMH doctors really not “committed to quality and safety”? How is RTI supposed to measure and document “commitment” or lack thereof? With a functional MRI? A lie-detector test?

If the twelve flabby concepts contained in those two boxes in Figure 1-1 constitute the independent variables RTI intends to examine, we should expect to see an explicit statement to that effect and some attempt by RTI to operationalize those flabby concepts, that is, to define them more precisely so that they can be measured. RTI does neither.

In fact, RTI informs us they can find virtually no uniformity in either the state “initiatives” or the PCMHs. RTI reports that the activities of the eight states and of the 785 participating PCMHs vary on every dimension imaginable. The state programs vary, for example, in how they define “homes,” the amount of money they pour into them, and the type of feedback they provide. PCMHs vary across and within states in the type of staff they hire, what those staff do, how they use technology, whether they attempt to track admissions of their patients, and whether they can make heads or tails of their “feedback” reports. [5]

Conclusion

RTI should never have promised CMS and its readers it would identify factors associated with “outcomes,” improved or otherwise. The definition of the PCMH offered by leading “home” advocates is flabby enough. Trying to test such a wobbly concept in eight states when each state is allowed to use a different definition is just a wild goose chase.

Is there anything at all we can learn from such a poorly designed experiment? I'll attempt to answer that question in subsequent comments.

[1] A bizarre feature of this report is the use of two control groups. RTI, perhaps at CMS's insistence, set up one control group consisting of non-PCMHs, as you might expect, and a second control group consisting of PCMHs not participating in the MAPCP. Setting up a second control group of PCMHs that only differed from the experimental group of PCMHs because Medicare was not one of the participating insurers makes no sense, especially given how poorly PCMHs are defined.

RTI then used the results of the comparison with the PCMH control group in a misleading manner. First, RTI conflated the results of the comparisons with the two control groups in the following summary of its findings on spending: “The state initiatives were associated with a slower rate of growth of total Medicare expenditures in only three of the eight MAPCP Demonstration states (Vermont, New York, and Michigan).” (p. 2-41) Upon inspecting the table that this remark refers to (Table 2-9), the reader learns that only in Vermont did PCMHs beat non-PCMHs. In the other two states, New York and Michigan, MAPCP PCMHs beat the other PCMH “control” group, but were unable to beat the non-“homes.” Is that not strange? Does it not require an explanation? RTI offered none.

RTI deepened the murk by using only the non-MAPCP PCMH comparison group to estimate whether CMS enjoyed any net savings from the MAPCP demo, that is, whether the MAPCP “homes” lowered or raised Medicare's costs when the fees CMS paid the “home” clinics were taken into account. RTI determined that only Michigan's MAPCP PCMHs achieved net savings for Medicare compared with other PCMHs in Michigan who were not in the demo. But who cares? We want to know whether the PCMHs in the demo achieved net savings vis a vis non-PCMHs. RTI made no attempt to explain why the reader should care whether one set of PCMHs outscored another. We are left to wonder whether PCMHs in any state achieved net savings, or caused a net increase in Medicare costs, compared with non-PCMHs.

[2] Here are other examples of uninformative chit-chat from the second-year evaluation of the MAPCP demo. I have italicized words that obscure rather than enlighten:

“In Year Two, participating practices continued to mature, demonstrating transformation progress.” (p. 5-11)

“The majority of the practices described an environment in which doctors … and staff members worked together as a team, supporting each other and providing enhanced patient care. Many practices held weekly meetings to talk about areas for improvement within the practice….” (p. 5-21)

“Interviewees generally believed that by continuing to focus on these chronic conditions, the state might be able to bend the cost curve and lower utilization.” (p. 5-35)

“Some practice staff indicated that the care coordinators had succeeded in reducing unnecessary ER visits….. Many clinics shared anecdotes about patients who visited the ER….” (p. 7-37)

[3] Here is how RTI articulated their aspirations at the outset of the second-year evaluation: “The goal of the evaluation is to identify features of the state initiatives or the participating PCMH practices that are positively associated with improved outcomes.” (p. 1-2. Emphasis supplied.)

[4] Here are the six vague phrases that appear in the “MAPCP Demonstration Implementation” box in Figure 1-1:

Patient-centered medical home certification;

Payments to practices from Medicare, Medicaid and private insurers;

Practice coaching/learning collaborative;

Data systems/health IT/meaningful use;

Feedback to practices;

Integration of community-based resources.

Here are the six vague phrases which appear in the “Practice Transformation” box:

Personal physician;

Physician-directed medical practice;

Whole-person orientation;

Coordinated or integrated care;

Commitment to quality and safety;

Enhanced access to care.

[5] For a more excruciating description of all the ways state PCMH programs and the PCMHs vary, see my comment on the first-year MAPCP evaluation here. http://pnhp.org/blog/2015/03/05/cms-state-sponsored-medical-home-experiment-is-a-mess

I love these girls

somebody's girls are marriage material
these girls are the hottest girls on the planet

SEMRush - Overview and Review from Jason Quinlan on Vimeo.

When Life Gives you MACRA…

By LEONARD D'AVOLIO

I was walking with colleagues debating the merits of the latest round of healthcare payment reforms when we came across the ultimate symbol of American entrepreneurialism.  A young girl had set up a lemonade stand with a sign marketing 25 cents a cup.

“I'll take one” I declared and was impressed with how confidently the young entrepreneur announced my total.  As I settled my tab my colleague stated that he too would like a cup of lemonade and was willing to pay 30 cents.  Except, he would pay half now and the other half would arrive after the cup was emptied, assuming a list of 8 pre-determined criteria were met.  Before he could finish explaining the 30 possible criteria from which she could choose, the third companion announced his thirst.  He would buy lemonade for two of the three of us!  For this, he would offer a dollar.  The catch was that two of us would receive all the lemonade we required for this flat rate.  She eyed each of us up and down carefully, gauging our potential lemonade intake and asked which two were to be covered?  To which my colleague answered, “you will not know until you sign the contract.”

As we watched her retreat into her home in a fit of tears we paused to consider just which proposal exactly was responsible for her early retirement?  The conversation quickly turned to debate as these things tend to do.

Despite our best efforts to discredit each other's proposals we ultimately concluded that all three were reasonable payment options.  What was more straightforward than paying for the amount of lemonade consumed?  And it was not at all unreasonable to demand a base level of quality – especially with an extra 5 cents on the line.  None could find legitimate fault with a flat rate, assuming we behaved as the rational consumers that we are and that the girl didn't go overboard with organic lemons and turbinado sugar.  So where did it all go wrong?

“What if,” my colleague posited, “it was not the specifics of any one of our proposals that caused our young friend to abandon her lemon-flavored ambitions?”  We leaned in to see where exactly this new train of thought might lead.

“What if instead, it was the pressure of meeting all three of our demands at the same time was to blame?”

And suddenly we felt terrible for what we had done.  Clearly the young girl wasn't ready for the rigors of running a business.  We should never have encouraged her.  Having solved the mystery we returned the empty pitcher to the abandoned stand and went on our way, returning our attention once again to more relevant topics.

-

Leonard D'Avolio Ph.D., is the CEO and co-founder of Cyft, assistant professor at Harvard Medical School, an advisor to Ariadne Labs and the Helmsley Charitable Trust Foundation.  He can be followed on twitter @ldavolio and his writings and bio appear athttp://scholar.harvard.edu/len

On The Foundation Freeway: Entering And Exiting Priority Areas With Caution

All funders, no matter their size, have big dreams and limited resources. I have yet to meet grantmakers-even the largest ones-that think they have sufficient money to tackle the myriad challenges that exist.

This is certainly true for the New York State Health Foundation (NYSHealth). With an endowment of close to $300 million, we are usually considered a mid-size foundation. Yet, these dollars pale in comparison with the health and health care needs of a large and diverse state like New York.

The state is home to more than 19 million people, including large populations of low-income and elderly people, immigrants, non-English speakers and undocumented people, homeless individuals, and people with complex and special needs. Our residents are spread over sixty-two counties, including the densest urban environments and intensely rural areas.

When you combine a burning desire to make a real impact with the realities of our large state and the relatively modest size of this foundation, the only viable path is to focus our efforts. Our board and staff agreed from our inception that we could not be all things to all people and have the kind of deep impact we sought. We agreed to be a strategic organization that would practice discipline in the pursuit of clearly defined goals, strategies, and measures of progress.

Therefore, we select a limited number of priority areas to which we make multiyear, multimillion-dollar commitments. For each area, we aspire to move the needle in a substantial and measurable way. Since our approach leaves many topics off the table, we also operate a flexible Special Projects Fund, which allows us to respond to opportunities that are timely, innovative, and can make a difference-even though they fall outside of our priority areas.

We choose priority areas in a methodical fashion. To determine where and how the foundation can have the most impact, we periodically assess a range of potential areas to see where there is a substantial and growing need, a genuine opportunity to address that need, and a clear role for NYSHealth to make a difference in light of other players and funders. We call this our “need/opportunity/niche” framework, and we have used it every few years to assess whether we are focused on the right issues with the right strategies.

When we most recently assessed our program strategies, our board and staff concluded that we had spread ourselves too thinly over time. Even with our stated goal to be focused and disciplined, the needs and opportunities were often so compelling that it was hard to say no. Officially, at that time, we had three priority areas: expanding health care coverage, improving diabetes prevention, and advancing primary care. But within those, we had what could be considered unofficial mini-programs focused on payment reform, behavioral health integration, health care delivery system changes, and oral health, to name a few. We had to return to our guiding principles and get more sharply focused.

Furthermore, the world was changing around us. Developments in the external landscape-especially the successful implementation of the Affordable Care Act (ACA) in New York State and New York State's receipt of a federal Medicaid waiver worth approximately $8 billion- shaped our thinking.

We had difficult choices to make about potential exits and new priority areas to enter. Entering a new area is relatively easier; there are usually novel issues, partners, and opportunities galore.

Exiting is much harder. An especially tough decision was to exit our work on expanding health insurance coverage, a topic we had worked on since the foundation's inception. Our post-ACA work in particular was successful: we jumped in immediately after the law was passed to ensure that New York State could implement health reform effectively. NYSHealth supported policy analysis and technical assistance to identify key issues and informed the state's decisions related to the development of its health benefit exchange (Marketplace). As the first ACA open enrollment approached, we supported education, outreach, and enrollment assistance for those who were disproportionately likely to be uninsured: low-wage workers, legal immigrants, and LGBT New Yorkers.

By the end of the first enrollment period, more than 1 million New Yorkers had received coverage through the New York State of Health Marketplace. Today, that number is a whopping 2.8 million. We are so proud that New York stands as a national leader in maximizing the opportunities presented by the ACA and dramatically extending coverage statewide. Even with those gains, there was still more work that could be done: developing opportunities to expand coverage for undocumented immigrants and others who remain uninsured, helping consumers use their coverage once they have it, and tackling the issue of the affordability of health insurance.

And yet, we claimed success and exited our work in coverage. Its time as a priority area with a dedicated budget, goals, and strategies had come to a close. The extraordinary promise of expanding health insurance coverage in New York State had largely been met; we would see diminishing returns on our investment as the number of uninsured New Yorkers continued to shrink, and given our limited resources, we could have more impact in a new area.

Ultimately, we also decided to exit our work in primary care, and to evolve our diabetes prevention work to focus more broadly on building healthy communities where residents have access to affordable, nutritious foods and safe opportunities for physical activity.

In addition, we recently identified a brand-new priority area: empowering health care consumers. Going back to our need/opportunity/niche framework, we found that this area fulfilled all of our criteria. We saw a significant need: too often, patients are marginalized rather than treated as the health care system's most important customers. We identified an opportunity: to ensure that consumers have the tools, resources, and support they need to make informed decisions about their health care. Finally, we could see a unique role for NYSHealth to work with partners and grantees to increase consumers' choice, control, and convenience. Certain stakeholders, like providers and payers, are well organized and well financed, so putting our resources to work on behalf of consumers would help balance the scales of power.

Ultimately, we shifted from three priority areas to two priority areas (plus our Special Projects Fund). As we've moved from planning to implementing, I'm confident in the decisions made by the foundation. But the process wasn't perfect, and it was not without its challenges. Three big ones come to mind:

1. Timing. We embarked on and then completed the strategic sharpening process shortly before our founding CEO decided to step down. Preparing for and managing a change to new priority areas coincident with a CEO search and a leadership transition was not ideal. The board had made decisions after a lengthy and thorough planning process, and it didn't make sense to discard that work and fully start over. We were eager to move forward with our new areas and to exit our old ones responsibly and respectfully.

At the same time, we didn't want to move too quickly in setting the parameters of our two priority areas. We wanted the new CEO to have flexibility in shaping the work. Typically, a strategic planning process would commence once a new CEO is installed. In our case, it happened the other way but ended up working well.

2. Making and Communicating Clear Decisions. It's never easy for funders to exit an area in which they have built relationships with grantees and tried to establish themselves as a trusted partner. We wanted to be upfront with our grantees and partners, particularly those working in the two areas we were exiting, about our plans. But our communications were somewhat mixed.

Narrowing to two priority areas would free us up to do more work in our Special Projects Fund. We expected that we could occasionally fund projects related to coverage and primary care through that channel. It was hard for us to imagine shutting the door entirely on those two areas if more work was needed. But keeping the door open just a crack sent a confusing and mixed message. Grantees didn't quite know whether we were in or out, because we had hedged a bit. Some were disappointed about our decisions, but more were simply confused. I don't know for sure whether it was the right or the wrong decision to remain open to ideas in the areas we had exited-that is, whether a clear “no” would have been better than a “maybe, possibly, if it's special enough.” In any case, we could have communicated our plans more clearly.

3. Entering Uncharted Territory. Our priority area that is focused on building healthy communities reflects a natural extension of NYSHealth's earlier work on diabetes management and prevention. We already knew who the players are in this area, and we tapped a number of them, both in New York and nationally, to help us shape our strategy.

That was not the case with our work in consumer empowerment, which is a trailblazing effort, rather than a clearly defined field with obvious experts and grantees. Even putting together a distribution list for our first request for proposals (RFP) was daunting.

One of our key tasks is to help define and shape the field. We are now trying to do just that: to bring some definition to the work with our “choice, control, and convenience” framework and a strategy focused on information access.

We are approaching the work with humility, and we know that we don't have all the answers. Although we have identified some partners and solicited proposals for discrete projects-such as a study of hospital prices and the development of an online shopping tool for health care consumers-the bulk of our grant funding this year in the consumer empowerment area will support projects identified through an open RFP. (We expect to award those grants this fall.) Those project ideas, and the conversations we are having with applicants, are helping to shape the parameters of our work on consumer empowerment.

Foundations that want to make a difference should be living, breathing organizations that evolve with the times. The health care environment is so dynamic these days that funders must also be ready and willing to adapt. Of course, funders should stay committed to their goals and not get distracted too easily by every new idea that comes along. But excessive rigidity or neglecting to reassess those goals from time to time is also a recipe for irrelevancy or failure.

Strategy is about hard choices-what to do and what not to do. Our experience suggests that funders should be taking on-ramps and off-ramps, and doing so with caution. Don't be afraid to change direction, but make sure the timing is right, that your turn signals are on for all to see clearly, and don't hesitate to take a road even if the final destination isn't yet fully clear.

The New API Economy (Now With Interoperability!!!)

By TAMARA ST. CLAIRE

Consumers know that their primary care doctors don't talk to their specialists, who don't talk to their pharmacists, who don't talk to their insurance providers. The rise of consumerism in healthcare may be in its infancy, but according to research recently released by Xerox, a full 64% of consumers wish their pharmacist, healthcare provider, and insurance company were more connected regarding their health.

Consider your most recent travel experience. You probably used a website like Expedia.com to look up flights, hotels, and even rental cars. With all the relevant information displayed conveniently (and often beautifully) side-by-side, you were probably able to make an informed decision and instantly book the exact travel package that suited your needs.

Now imagine your most recent healthcare experience. Scheduling the appointment was probably a painful logistical balancing act, accompanied by terrible hold music. You likely had to find and present an insurance card, possibly even filling out another set of insurance forms and a health history for the thousandth time.

After the appointment, you doubtless received an excessive number of mailings that were maybe bills or maybe not.  At this point, you might even still be unsure how much you owe, why you owe that amount, and what you can expect for your next appointment.

And you're not the only one suffering. While all this is happening, an equally painful parallel process is taking place behind the scenes, completely unbeknownst to the consumer. It starts with the care provider, who must electronically or sometimes even still manually bill the insurance company. The claim then passes from the provider to a clearinghouse, where it is checked for errors and compatibility with payer software. When the claim finally does get to the payer, the majority of them are still faxed back to providers for more information: was the procedure medically necessary? Is a referral required? The physician's office corrects the claims and sends it back through the same pipeline towards approval.

This process is a massive headache for everyone involved. Providers find themselves with huge amounts of extra administrative work, while consumers are completely shrouded from the billing process. It's almost like walking into Nordstrom's and shopping blindfolded, while trying to stay on a budget. It's just not possible.

Thankfully, there's a better way. Healthcare can look more like booking your next vacation - a more personalized, consumer-friendly experience, at a better price too. The first step in getting there is Application Programming Interfaces, or APIs. At a high level, APIs let data to break free of their silos, allowing it to move freely, and enabling the interconnected experience we all enjoy when booking travel. If properly used and widely adopted in healthcare, APIs will be transformative.

What's the API model?

APIs and their use in healthcare are on the rise for a number of reasons, including the consumerization of healthcare, the explosion of smart devices, and the arrival of a generation of tech-savvy consumers who want access to healthcare resources and information in the same way they have access to everything else in their lives-anytime, anywhere, and from any internet-connected device.

In order to better serve these tech-savvy consumers, who are increasingly charged with managing their health spending via high-deductible, HSA plans, payers and providers need to be able to exchange information in real time. Take the previous simple scenario of a fairly standard visit to your healthcare provider. In an API Economy, consumers won't need a health insurance card or to fill out any paperwork. All the relevant information can be accessed by the appropriate stakeholder on demand. Providers will be able to check eligibility and co-pay by accessing a patient profile, for example. Once the visit is complete, the EMR can trigger the claims process, sending all necessary medical information directly to payers. Claims will be immediately adjudicated in one fell swoop. What's more, consumers will know at the point of care how much they are paying and why, and what any additional prescriptions, referrals, or follow up care will cost.

With the right APIs in place in healthcare, the need for administrative questions is essentially eliminated because every stakeholder would have access to all the relevant data. The type of data exchange described in this example is fairly basic, but the API infrastructure that will allow us to eliminate countless administrative headaches – incorrect patient information, incorrect codes, duplicate claims – is the same infrastructure that will allow us to create advanced analytics and innovative service models. Furthermore, the advanced security implicit in an API model also means that even as consumers' valuable protected health information moves freely about, so to speak, it remains encrypted and secure.

The fact that we haven't moved even further in this direction is especially confusing given the fact that transitioning to an API model is not necessarily an intimidating or complex process, technically speaking. Old and new technology investments can be gradually bridged, and companies like PokitDok, with its API platform, mean organizations are spared the need to build from scratch. The pieces are in place for this transformation to happen, it's only a matter of time.

What would the API Model mean to the industry?

A shift to an API model would have at least two major impacts on healthcare:

Free the data for value-added, consumer-centric innovation and applications. With an API infrastructure, everyone will have equal access to data, meaning companies will be forced to innovate on the value of the services or analytics that can be built on top of that data. For example, we've already seen some companies like Castlight Health, Amino, and Grand Rounds take disparate, accessible (albeit in a difficult, not always API-enabled manner) data sources and create new dashboards with new metrics that consumers are actually interested in using. Moving forward, APIs can deliver these types of innovations in spades.

Improve customer service relationships with healthcare payers. Imagine a typical call to a customer service department, but the agent on the phone has a new set of information at their fingertips, like the caller's type of insurance, deductible and copay, and a list of physicians within the appropriate proximity. An API model can deliver this type of informed call center and lead to highly personalized client engagement.

Adopting an API model in healthcare gives an outdated system the versatility and flexibility it needs to tackle some of our most entrenched problems. APIs can transform insurance companies from passively paying claims to actively helping its members lead healthier lives. APIs can also transform customer care in healthcare, making it more reflective of the experience we all enjoy in retail, for example. But perhaps most importantly, APIs can support more connected, more informed consumers and providers, resulting in the higher quality care that we all deserve.

Tamara St. Claire is Chief Innovation Officer for XEROX.

Patients With Severe Schizophrenia Aren't Getting The Help They Need

Even when effectively treated, schizophrenia can be devastating, impairing a person's social and family life, ability to work, physical health, and quality of life. Those who have schizophrenia often end up alone and impoverished. Yet the effects of this disease are even worse when treatment doesn't work.

Treatment-resistant schizophrenia (TRS) is formally defined as schizophrenia that is not well controlled despite adequate trials of at least two medications - a definition that applies to between 20 to 30 percent of patients with the condition. An effective treatment exists for TRS: the anti-psychotic clozapine, which was first used to treat schizophrenia in 1971 and approved for use in the United States since 1989. Multiple studies have shown that clozapine is clearly superior to other treatment strategies for TRS, and that it is the only treatment proven to work for TRS.

Despite this evidence, in most settings only 10 percent of patients with TRS are receiving clozapine - and the percentage is often far lower than that. Although clinical guidelines unanimously recommend offering clozapine after two other medications have not worked, patients are usually given 15 to 20 different medications sequentially over the course of a decade or more before clozapine is considered.

A case could be made that nowhere in medicine is current practice more at odds with medical evidence than the persistent underuse of clozapine to treat TRS.

Of course, there are good reasons for this state of affairs. Clozapine has unique and powerful side effects and risks, which often make it a drug of last resort. The side effects can be disfiguring and potentially deadly, and include paralysis of the intestine, myocarditis (inflammation of the heart muscle), and agranulocytosis (where the bone marrow shuts down and stops making blood cells).

Because of the need to monitor for side effects, patients starting clozapine receive their pills on a weekly basis for the first six months. Before each time the patient can receive pills, he or she must be thoroughly evaluated, including a blood test, to monitor for side effects. The time between visits stretches to every other week for the next six months, and then monthly for life. That's a lot of medical visits, causing some patients and caregivers to refuse to try clozapine, but patient refusal is a relatively minor contributor to the low rate of clozapine use.

The main reason patients with TRS do not receive clozapine is relatively simple: The health care system is not equipped to provide it to them. Psychiatrists hesitate to prescribe clozapine at least in part because the need for monitoring and registration creates busywork that is not reimbursed or remunerated. While doctors are strongly motivated to help patients, it is unrealistic to expect a doctor to spend an hour each week on paperwork to help a single patient, even a very needy one, without being financially compensated - especially when that doctor might have 50 patients who need this therapy.

Some of society's most vulnerable patients desperately need effective treatment, and an effective treatment exists. However, the health system is poorly configured to provide it. Is there a way to cut this Gordian knot?

An Effective Treatment Option

There is, according to two studies my colleagues and I published in mid-June in the journal Psychiatric Services that were based on research we did for the Veterans Health Administration.

In the first study, we simulated the expected effect on costs if the use of clozapine to treat TRS went up. The results were staggering. The model predicted that for every patient who initiated a trial of clozapine, the payer (the insurance company) would save $22,000 in the first year, and more in successive years when monitoring is less extensive. The cost savings were achieved by reducing hospital days for such patients-by an average of more than 18 days per year.

Our model also spoke to the dreaded side effects of clozapine. While we found that some patients would die because of clozapine-related side effects, slightly more lives would be saved because clozapine helps prevent suicide. The model did not consider the benefit to patients and society of improved quality of life from well-treated disease - only the cost to the payer.

In the second study, we spoke with clinicians at sites within the VA health care system - five sites that prescribed high levels of clozapine (in some cases, approaching 70 percent of eligible patients) and five that prescribed the usual 10 percent or less. By analyzing the common features of the high-utilizing sites and contrasting them with the low-utilizing sites, we were able to observe some important features about the characteristics of sites that achieved higher clozapine utilization:

• High-prescribing sites had an organized clozapine clinic, staffed by pharmacists, nurses, and others, which removed the paperwork burden from the prescribing physician.


• Even when low-prescribing sites had a clozapine clinic, the clinic often did not have enough space to accommodate the patients expected to need clozapine.


• Multiple people at high-prescribing sites knew how to navigate the bureaucracy involved in getting clozapine to the patient. Low-prescribing sites often only had one person dedicated to this task, and everything ground to a halt if that person was sick, on vacation, or retired.


• High-prescribing sites provided transportation to take patients to and from their weekly clozapine appointments.

None of these interventions are all that difficult to accomplish, but they come with significant costs. That's why these two studies are so powerful when taken together. One study shows that practical but expensive strategies can feasibly increase the use of clozapine to treat TRS. The other shows that the health care system can save a lot of money if clozapine is prescribed more. The first-year, per patient savings alone would more than pay for the necessary nurses, pharmacists, drivers, and office help needed to make clozapine easier to administer - and more acceptable to doctors and the patients who would greatly benefit from it.

The problem, as will be familiar to many readers, is one of misaligned incentives. An intervention is available that would improve patients' lives and save the payer money, but this effective therapy is not being delivered because the investment to achieve this goal would need to come from a third party (here, the mental health clinic). One reasonable solution would be a shared-savings model, where the payer shares some of the savings from averted hospital days with the clinic, providing an incentive to invest in building capacity to deliver clozapine to more patients.

Let's Fix Medicare Before We Expand It, Mrs. Clinton, But Then….!

By ROGER COLLIER

Dear Mrs. Clinton –

It's probably good politics to suggest making Medicare available to some under 65s , just when Congressional Republicans are proposing to increase the Medicare eligibility age. Sometimes, though, good politics doesn't produce good policy.

Medicare may be well-regarded by most Americans, but the program has four huge weaknesses that need to be fixed before considering any expansion.

Here's what's wrong.

Medicare is absurdly, insanely overcomplicated.  When Medicare was created in 1965, it consisted of just two components, Part A hospital care and Part B physician and other care, with the split made only to gain AMA support for the legislation. Fast forward to 2016: we now also have Part C (Medicare Advantage), Part D (prescription drug), and seven versions of dual Medicare-Medicaid eligibility (in turn dependent on 50-plus states' and territories' own Medicaid regulations). And that's all before the thousands of pages regulating payments to providers. The complexity provides a lot of jobs for bureaucrats and consultants, but does little for beneficiaries.

Medicare payments are unfair to many (including taxpayers).  For beneficiaries in the fee-for-service program, Medicare currently pays all allowed provider charges (after copays and deductibles). For those choosing Medicare Advantage, the program typically pays the full premium bid by the private plan.  The effect of this misplaced generosity is that one senior's care may be subsidized by up to $5,000 a year more than another's with the same health status in the same city-with taxpayers paying the difference.

Medicare is regressive. Traditional Medicare imposes the same deductibles and coinsurance regardless of income and charges the same Part B premiums for the vast majority of beneficiaries. Similarly, Medicare Advantage plans impose the same cost-sharing for all incomes. Congress's answer has been to allow Medicaid to pay premiums or cost-sharing for lower-income seniors, but many of those potentially eligible are not enrolled, while Medicaid's rules can mean that a difference of a dollar of income make the difference between eligibility and otherwise.

Medicare is enormously (and unnecessarily) costly-and getting rapidly more so. According to the latest Medicare Trustees report, Medicare expenditures will rise from $683 billion in 2016 to $1.3 trillion in 2025. Even though Medicare per capita costs are rising slightly less rapidly than overall health care costs, the Trustees project that-unless changes to the program are made-these will increase from $12,925 in 2016 to $19,400 in 2025, far, far more than we can afford!

What's the answer?  Three fixes.

One:  Streamline the program structure. Consolidating the four program parts into a single whole, with all current Part B and D services available to all beneficiaries, will reduce administrative costs and enhance access. Eliminating the need for dual eligibility as described below will do even more.

This is consistent with past consolidation proposals from MedPac, the Bowles-Simpson Commission, the Commonwealth Fund, the Bipartisan Policy Center, and individual members of Congress, but more sweeping and more effective.  It means a single premium and, potentially, a single deductible and out-of-pocket limit to protect beneficiaries against unexpectedly high medical expenses-something current Medicare fails to do. It also means that all Medicare beneficiaries will have a full range of medical coverage, including prescription drugs, guaranteed-again, something Medicare now fails to provide.

Two:  Tie premiums, deductibles, and out-of-pocket limits to income. Medicare has to be made affordable for all seniors without imposing the humiliation of applying for Medicaid on the less well-heeled. This can be done either directly by making all beneficiary costs income-dependent, or indirectly by offering a “gold” coverage option with lower deductibles and out-of-pocket limits for a higher premium that is subsidized for low-income seniors.

Either option could eliminate the need for expensive and inefficient Medigap insurance, as well as protecting lower-income seniors from having to choose between applying for Medicaid and risking financial disaster.

Three:  Move to an equitable “guaranteed contribution” approach. Various forms of premium support have been recommended by bipartisan commissions over the past twenty years as the fairest answer to controlling Medicare costs. The guaranteed contribution approach would differ significantly from that proposed by Congressional Republicans in that beneficiaries choosing coverage options below the benchmark cost would share in the program savings.

All beneficiaries would be guaranteed a choice of traditional fee-for-service and private plan options, and all beneficiaries would be assured that an option would be available for no more than their basic premium cost (with shared savings for lower-cost options). The Congressional Budget Office has estimated that such an approach could cut Medicare spending by up to $45 billion a year, not counting possible additional savings from more effective competition. Although critics have complained that such an approach would mean some beneficiaries would pay more than their basic premium unless they were willing to choose a less expensive plan, this is a far better option for controlling Medicare spending than cutting coverage, increasing all premiums, or slashing provider payments.)

So, imagine if these changes were made.

The result would be a fairer program with less administrative burden, less likely to bankrupt either the government or individual seniors, and one more in line with modern insurance than with the ideas of fifty years ago.

It would be one that could accept enrollees below the age of 65, as you have suggested, Mrs. Clinton, on a pay-as-you go basis (since under-65s would not be entitled to the same level of subsidies as over-65s). In fact, it could replace Obamacare for over-55s-a politically popular move that would give enrollees more choices, potentially lower costs, and reduce taxpayer spending.

Senator Sanders' supporters would love it as a possible step towards Medicare-for-All (but without costing a hundred thousand insurance jobs), President Obama would be pleased to see his liking for an Obamacare public option being implemented, Republicans would hate it, and you'd be back in charge of healthcare innovation. Why wait?

Roger Collier is the founder of the Campaign for a Rational Healthcare System (www.rational-healthcare.com). He was formerly CEO of a national healthcare consulting firm.

Avulse

Avulse: To separate or tear away a body part, as from an accident or surgery. While playing football, he avulsed a spinous process.

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
We Bring Doctors' Knowledge To You

Rural America: A Primer for Washington Officials, Columnists and Dartmouth Economists

By NIRAN AL-AGBA

Earlier this week , physicians in small private practices and rural areas breathed a collective sigh of relief.  There is a possibility the implementation of changes to physician reimbursement (known as MACRA) could be delayed.  Thank you, Mr. Slavitt, for listening.  I am grateful to Orrin Hatch (R-UT) and Ron Wyden (D-OR) for keeping our rural needs in mind.  We have a window of opportunity for rural health care to survive but we must communicate our needs as physicians and patients' loud and clear.

Whether in reference to health care or public education, trying to increase quality while simultaneously decrease costs is an unrealistic proposition.  Physicians in rural areas simply have fewer resources at their disposal.  Adding insult to injury, Medicare payments to rural physicians are dramatically less than those of their urban counterparts for equivalent services, a point driven home by the fact 470 rural hospitals have closed in the past 25 years.  Does it cost less to stitch up a laceration in a remote Alaskan village than in New York City?  I doubt it.  The expenses incurred obtaining supplies may be even greater for remote locations.

In order to set primary care physicians up for success, it is imperative those in charge understand our challenges.  Rural physicians are alone, save for our spouses running our medical practices while we see patients.   For physicians to be successful, additional revenue would be necessary to meet the expensive health IT burdens placed on us by this new payment model.  Creating “virtual” groups to consolidate reporting will still require provision of a “virtual” assistant because it is more administrative burden than we can handle.  Our profit margin is too narrow to accommodate additional employees.

I am not convinced time and money spent implementing new technology does anything to improve patient care; I am fairly certain, however, conversations with my patients provide considerable value.  Can you not extract the information from claims, like private insurance companies already do?  If we have to hire an additional employee, who is going to pay them? The solution is relatively simple; shift the burden of data collection from small practices to elsewhere or increase reimbursement so meeting your demands becomes feasible.

Preserve what we have in rural America until you have more clarity where we are heading in the future.  According to a report on Rural Participation in the Medicare Shared Savings Program, rural providers already deliver value and quality within our existing infrastructure.  Adjusted for lower volumes, Medicare spending per beneficiary is 3.5% less.  Physician spending is 18.4% lower overall compared to our urban peers. We have strong personal relationships with our patients, operate at the top of our capabilities, and keep care local whenever possible.  I fail to see the problem with our old-fashioned style of practice. In fact, maybe you should use us as models of efficiency or cost-containment for larger conglomerates.

Being in a small or rural practice is extremely challenging.  In rural America, 75% of exchange consumers had incomes less than 250% of the federal poverty level.  Every family in my practice who obtained insurance through exchanges met criteria for Medicaid, known in Washington State as Apple Health.  24% of rural children live in poverty.  We are surrounded by Health Professional Shortage Areas (HPSA's) and Mental Health Professional Shortage Areas because primary care physicians are spread entirely too thin.   The elderly and poor in rural areas deserve access to quality health care.  What happens to those people if small practices cannot keep their doors open as a result of overreaching government mandates?

According to the National Rural Health Association, 10% of physicians practice in underserved areas despite the fact 25% of the population lives there.  One-third of automobile accidents occur in rural areas, however two-thirds of the deaths from these accidents occur on rural roads.  Rural residents are more likely to die from injury due to delays in care.  I have direct experience, recently providing road side care after an accident while awaiting EMS arrival for 15 minutes.  Delays are related to increased travel distance and personnel limitations.

Extrapolate for a moment what could happen if numerous small practices closed in rural areas.  Can you imagine if one third of strokes occurred in rural areas, but two-thirds of stroke deaths were rural due to significant delays in receiving timely treatment?  It makes no sense to cripple our livelihood when we provide lifelines to underserved and disadvantaged populations.

Rural residents have fewer resources, significant geographic obstacles, and the acuity level of their medical problems is far greater.  These detrimental conditions drive tremendous health disparity.  We need to spend our time healing, comforting, and having conversations with patients, instead of reporting their medical problems and immunization status to non-physician statisticians.

For physicians in small or rural practices with scarce resources and deteriorating infrastructure, it will require significant investment for us to undergo meaningful transformation.  Either learn more about the challenges small or rural practices face, provide waivers (like No Child Left Behind did) for exemptions, invest in our infrastructure, or leave solo physicians and our practices alone.  Do not try to fix what I am not convinced is broken.

People Post: Staff And Board Changes At Foundations; Job Opening: Foundation President

In June, Becky Hayes Boober left the Maine Health Access Foundation, where she was a senior program officer. She is now vice president of community impact at the Maine Community Foundation (MaineCF) and is working out of its Ellsworth office. She told me in an e-mail, “As part of our strategic planning, we are exploring goals related to health, such as opioid addictions and aging.” MaineCF is refining its new strategic plan, so more information will be forthcoming. Her new boss is Steve Rowe, former president of the Endowment for Health, which is in New Hampshire.

I missed it! Nicole Collins Bronzan joined the staff of the Robert Wood Johnson Foundation (RWJF) in autumn 2015 as a communications officer. She came there from ProPublica, a nonprofit investigative news outlet, where she was communications director. “When not working toward a Culture of Health,” among the things Nicole may be doing is running, “seeking out chocolate, or bemoaning the latest grammatical indiscretion,” her RWJF bio says.

Peter Currie has been named senior vice president of program strategy and innovation at the California Health Care Foundation (CHCF). A licensed psychologist, he comes to CHCF from Inland Empire Health Plan, a public plan serving more than 1.1 million members in California's Riverside and San Bernadino counties. He was senior director of clinical transformation and integration there. According to a foundation spokesperson, “CHCF is dedicated to creating a health care system that works for all Californians, particularly underserved populations. This includes looking at the needs of the whole person and integrating behavioral . . . and physical needs, conditions and treatments.” The spokesperson pointed out that “behavioral” here refers to both mental health and addiction. Currie starts his new position on August 1.

Emma Dugas, a former senior communications officer at CHCF, who worked at the foundation for five years, left her post there this summer “to pursue opportunities with grassroots organizations working at the frontline of change,” she told me in an e-mail.

Aidil Ortiz Hill joined the Kate B. Reynolds Charitable Trust in June as a Health Care Division program officer who serves the central North Carolina region. (The foundation is located in Winston-Salem, North Carolina.) Hill is co-founder of Youth Empowered Solutions (YES!) and team lead for its substance use prevention work. YES! is a nonprofit “that works in North Carolina and around the country to empower youth to create community change,” according to a foundation press release.

Matt James is now a visiting scholar at the David and Lucile Packard Foundation. His tenure there began in March 2016 and goes through September 2017. Carol S. Larson, Packard Foundation president and CEO, said in a March press release, “We are especially pleased to have the opportunity to collaborate with Matt on bringing awareness to the role philanthropy can play in mitigating climate change.” James most recently led Next Generation, “a start-up communications, research and policy nonprofit,” according to the release. Health Affairs readers may remember him from his time at the Henry J. Kaiser Family Foundation, where he at one time was senior vice president for media and public education. While at Kaiser, he helped develop and launch Kaiser Health News, the release reminded me. Read a 2005 Health Affairs GrantWatch article by Matt James and coauthors titled “Leveraging the Power of the Media to Combat HIV/AIDS.”

Mara Leff recently joined the Jewish Healthcare Foundation (JHF), in Pittsburgh, as a program associate. She is working on the foundation's long-term care and aging team and on JHF's efforts to improve behavioral health services for adolescents. She most recently worked as an independent marketing and communications consultant, according to the April/May issue of JHF's newsletter, The Window. She holds a master's degree in public health, behavioral health, and communications from the University of Pittsburgh's Graduate School of Public Health.

Stephen H. Lockhart has joined the Packard Foundation's board of trustees, according to a January press release. A board-certified anesthesiologist, he is chief medical officer for Sutter Health, a health system in northern California. He also holds a master's degree in economics from Oxford University, where he was a Rhodes Scholar.

Judith Monroe became president and CEO of the CDC Foundation in February. She was previously director of the Office for State, Tribal, Local and Territorial Support at the Centers for Disease Control and Prevention. Before that, Monroe was Indiana's health commissioner.

Judith Rodin, president of the Rockefeller Foundation, announced in a June e-alert her intention to “transition out” of the position once her successor has been identified. She noted that she is “especially proud of two major fields” that the foundation “developed and championed” under her leadership. “The first is impact investing-private investment capital that generates both financial return and social impact.” The second is the study and practice of resilience, an effort “to help people, communities, and institutions around the world build resilience against the mounting physical, social, and economic challenges of the 21^st century.” A Wall Street Journal article about Rodin's announcement mentioned that she is the foundation's first female leader and that she “stressed forging corporate partnerships to further philanthropic projects.”

Job Opening:

The Health Foundation for Western and Central New York is seeking a new president. The position is based in Buffalo. As GrantWatch previously reported, Ann Monroe is stepping down from the presidency. For details about the position, read more here.

Leukemia, acute

Leukemia, acute: Cancer of the blood cells (leukemia) that progresses rapidly, as opposed to chronic leukemia which progresses slowly. The two major types of acute leukemia are acute lymphoblastic leukemia (ALL) and acute myelocytic leukemia (AML).

MedTerms (TM) is the Medical Dictionary of MedicineNet.com.
We Bring Doctors' Knowledge To You

Government Requests Input On Possible Contraceptive Coverage Compromises

In Zubik v. Burwell, the Supreme Court vacated and remanded six federal appellate judgements on whether an accommodation for employers that object to providing contraceptive coverage under the Affordable Care Act's preventive services coverage mandate violated the Religious Freedom Restoration Act. (RFRA) Five out of six circuits (and three other circuits whose decisions were not before the Court) had upheld the accommodation while one (the Eighth Circuit) had struck it down.

The Supreme Court's remand order asked the appellate courts to afford the parties:

an opportunity to arrive at an approach going forward that accommodates petitioners' religious exercise while at the same time ensuring that women covered by petitioners' health plans “receive full and equal health coverage, including contraceptive coverage.”

The Court had earlier, following oral argument in the case, asked the parties to brief the question of:

whether and how contraceptive coverage may be obtained by petitioners' employees through petitioners' insurance companies, but in a way that does not require any involvement of petitioners beyond their own decision to provide health insurance without contraceptive coverage.

It concluded based on the briefs it received that there might be an approach that would be acceptable to the plaintiff employers but not compromise seamless contraceptive coverage for women covered by their group health plans. (The cases also concern contraceptive coverage for students covered by student health plans, but the Supreme Court's deliberations have focused on coverage under group health plans.)

On July 21, 2016 the Departments of Health and Human Services, Labor, and Treasury, which are responsible for implementation of the ACA, released a “request for information” (RFI) seeking further input from interested parties on possible alternatives to the current accommodation. The RFI requests a response from entities that object to the current accommodation; it also asks other stakeholders who are not parties to the litigation, such as insurers, third-party administrators, and women who need contraceptives, how possible accommodations would affect them.

Under the current accommodation, employers that object to providing contraceptives to their employees for religious reasons may either

1. self-certify their objection to their insurer or third-party administrator using an EBSA form 700, or

2. inform HHS of their objection identifying their insurer or TPA so that it can in turn authorize the insurer or TPA to provide coverage.

The agencies maintain that this complies with the requirements of RFRA, noting that eight of the nine appellate courts that have now considered the accommodation held that it does not substantially burden the plaintiffs' exercise of religion; the agencies also maintain, as some of those courts also held, that the accommodation is the least restrictive means of furthering the government's compelling interest in ensuring women's seamless access to contraceptive coverage. Nevertheless, the RFI states, because of the government's commitment to religious freedom and desire to find an acceptable accommodation reconciling the beliefs of employers and the interests of female employees, it is enquiring further whether another accommodation might be acceptable to all parties.

What's In The RFI?

Alternative Accommodations

The RFI focuses on three issues. First, is there an alternative to the two methods of providing notice of a religious objection described above that religiously objecting employers might find more acceptable? The plaintiffs had proposed that they would simply contract with insurers for coverage that did not include contraceptives without providing any additional notice to their insurer, the federal government, or their employees. The insurer would then separately notify employees that it would provide contraceptive coverage to covered women without cost and independent of the employer's health plan.

The departments ask whether this accommodation would be acceptable to objecting organizations, and if not, what further procedures or systems would work. The RFI also asks if organizations specifically object on RFRA grounds to informing their insurers that they object to contraceptive coverage “on religious grounds,” or to a requirement that the notice to the issuer be provided in writing or using a particular form. The RFI asks insurers and other stakeholders whether this approach would be burdensome for them and, if so, how the burden might be mitigated. In particular, what effect would this proposed accommodation have on the access of women to seamless contraceptive coverage?

Contraceptive-Only Policies

Second, the Zubik plaintiffs had proposed that contraceptive coverage be provided to women covered by their group health insurance plans through insurance policies that only covered contraceptives and in which the women would have to affirmatively enroll. The RFI asks whether this alternative procedure would in fact resolve the RFRA claims of objecting organizations. It also asks if this procedure would be feasible for health insurers and permitted under state laws. The RFI further enquires what effect this procedure would have on the access of women covered by group health plans to obtain seamless coverage to contraceptive services. And again, it asks whether there might be acceptable alternatives other than separate insurance policies for resolving the RFRA objections of objecting parties.

Self-Insured Plans

Third, and finally, the RFI addresses the issue of self-insured plans, which was not addressed by the Supreme Court's supplemental briefing order. While insurers have an independent legal obligation to provide contraceptive coverage, third-party administrators that administer self-insured plans must be authorized either by the group health plan sponsor or by the government to provide particular forms of coverage, including contraceptive coverage. This authorization is provided by the current accommodation, but is rejected by the objecting organizations.

The RFI asks whether there is any reasonable alternative means through which women covered by the self-insured plans maintained by the objecting employers can receive contraceptive coverage through the same third-party administrators that administer the rest of their group health plans and that would be acceptable to objecting organizations. Alternatively, is there any other approach that would satisfy the RFRA objections of objecting organizations and yet provide coverage through their third-party administrators?

At this point, eight cases involving the contraceptive issue have been remanded to eight separate appellate court to find some kind of compromise solution to the intractable issue that the Supreme Court dodged, no doubt crippled by its lack of a majority approach on the issues in litigation. It is difficult to see how the appellate courts are to proceed. Is each to order separate briefs and separately arrive at a new accommodation?

In the meantime, the Supreme Court has blocked the government from imposing penalties or fines on the plaintiffs for failing to provide the notice to the government required by the accommodation, since it already knows of their objection from the litigation. But the Court also specified that “[n]othing in [its] opinion . . . is to affect the ability of the Government to ensure that women covered by [plaintiffs] health plan 'obtain, without cost, the full range of FDA approved contraceptives.'”

The RFI signals the intent of the government to move forward on the issue. The public has 60 days from the date of Federal Register publication to respond to the RFI. The RFI would need to be followed by a proposed rule and another comment period before any new accommodation can be implemented. It is likely that this issue will have to be resolved by the next administration.

Income Data-Matching Thresholds

On July 21, 2016, CMS also released a guidance announcing a change in how it is going to verify household income when applicants apply through the marketplaces for advance premium tax credits and cost-sharing reduction payments. When applicants apply for financial assistance, HHS verifies their eligibility from trusted data sources such as tax filings from prior years. When income information is not available from trusted data sources or attested income varies significantly from that shown by other sources, the marketplace generates a “data matching issue” and the applicant is required to provide documentation to verify attested income.

Until now a data matching issue has been generated if the income attested by an applicant was more than 10 percent less than income shown by trusted data sources. When the income that applicants claim is significantly less than the amount shown by data sources, there is the possibility that the applicants will receive more financial assistance than they are entitled to and will have to pay the excess back at tax filing time. The 10 percent threshold has proven too narrow, however, and in the 2017 payment rule HHS stated that it was going to change the threshold. The July 21 guidance effectuates this intention.

As of the 2017 open enrollment period, the federally facilitated marketplace will not require additional documentation if the annual income attested by an applicant is no more than 25 percent or $6,000 (whichever is greater) lower than the income shown from trusted data sources. Of course, consumers who receive more financial assistance than they are entitled to will have to pay it back at filing time, subject to repayment limits. If no information is available from trusted data sources, HHS will still require documentation.

State-based marketplaces may propose to HHS thresholds for the generation of data matching issues that do not exceed the 25 percent or $6,000 threshold applied by the FFM but are not less than the current 10 percent threshold.

CMS Releases 2017 Enrollment Manual For Individual And Small Business Marketplaces

On July 19, 2016, the Centers for Medicare and Medicaid Services released the Federally-facilitated Marketplace (FFM) and Federally-facilitated Small Business Health Options Program (FF-SHOP) Enrollment Manual for the fourth (2017) marketplace open enrollment period. The 167 page manual covers in detail the rules and procedures governing the FFM and FF-SHOP, issuers of qualified health plans (QHPs) and qualified dental plans (QDPs) in the FFM and FF-SHOP, qualified individuals and employers who apply for coverage in the FFM and FF-SHOP, and brokers and agents (including web-brokers) and others who assist applicants and enrollees. The manual applies in FFM states and in State-based marketplace states that use the FFM or FF-SHOP enrollment platforms.

Topics covered by the manual include:

• Enrollment in the individual marketplace (including data matching issues, redeterminations and renewals, auto-enrollment, premium payment due dates, and free look provisions under state law);


• Enrollment in FF-SHOP (including minimum participation rates, special enrollment periods, premium payments, terminations, and renewals);


• Direct enrollment in the individual market through insurers or web-brokers;


• Special enrollment periods;


• Premium payments (focused on terminations for nonpayment and grace periods, including complex situations spanning more than one coverage year, and rules governing minimum premium payment thresholds, but also including situations involving over-billed and under-billed premiums);


• Terminations (including terminations due to death and aging off);


• Retroactivity;


• Reinstatements following mistaken disenrollments;


• Reconciliation of enrollments between the FFM and QHP/QDP insurers; and


• Generation and reconciliation of 1095-A tax reporting forms by FFMs.

The manual also includes appendices with a sample welcome letter, non-payment notice, termination letter, and mandatory attestation.

The manual does not plough any new ground. As far as I can see, everything in it has appeared in earlier regulations or guidance. It does, however, set out comprehensively in one place all of the rules and procedures governing the FFM and FF-SHOP and the individuals and entities to which they relate. It describes exhaustively, in flow charts and tables as well as text, the technical details of the transactions in which the FFM and FF-SHOP engage. The text is by and large quite readable and full of examples illustrating the rules and procedures it describes.

The manual tracks quite closely enrollment manuals from prior years (although it is issued much earlier this year), but does contain several new open enrollment period 2017 innovations. These include:

• The specific rules and procedures that are being used by the FFM for redeterming eligibility for QHP enrollment and eligibility for advance premium tax credits and cost-sharing reductions for 2017;


• The 2017 auto-reenrollment hierarchy for situations in which the plan an individual was enrolled in for 2016 is not available for 2017;


• The new “vertical choice” option for the FF-SHOP under which employer can permit employees to choose among QHPs offered at different metal levels by the same insurer in states where it is allowed (Alaska, Delaware, Florida, Georgia, Illinois, Iowa, Kansas, Louisiana, Maine, Missouri, Montana, Nevada, New Hampshire, North Dakota, Ohio, Oklahoma, Texas, Virginia, and Wisconsin);


• New special enrollment period rules;


• The completely automated policy-based payment system for paying QHP insurers, which is fully operational for the first time in 2017 after having been phased in during 2016; and


• A new chapter on 1095-A reporting.

FAQs On Agents And Brokers

One of the topics addressed is the role of agents and brokers in the FFM. On July 18, 2016, CMS released at its REGTAP.info (registration required) website a number of frequently asked questions (FAQs) regarding agents and brokers. The FAQs primarily repeat information that has been provided before, such as guidance on translations and taglines (web-brokers in existence for at least a year must as of the beginning of open enrollment 2017 translate all consumer content on their websites into any language that reaches 10 percent or more of their state's population); mandatory disclosures by web-brokers (that their website is not the official Healthcare.gov website and may not display all data on qualified health plans offered in the state); and how web brokers can make available their Web sites and HHS data connections to other agents and brokers. The information found in the FAQs is also included in the enrollment manual.

The FAQs clarify that agents and brokers may not use automation retention and loading of consumer information functionality on a third-party site to submit a completed application to the Federally-facilitated marketplace. They must rather use the FFM's single streamlined application form. Agents and brokers can either directly enroll consumers through an insurer's or web-based broker's website, using their own user-IDs and accounts, or assist consumers “side-by-side” without having access to the consumer's user ID, password, or account.

An Area Of Concern: Fees Charged To Consumers By Agents And Brokers

The FAQ repeats earlier guidance that where a web-broker has “invested significant resources to develop special software to assist consumers with selection and enrollment in QHPs offered through the FFM,” and the agent or broker offers “a bona fide service of value that goes beyond the traditional assistance provided by an agent or broker registered with the FFM, it may be appropriate to allow for the collection of an additional fee” The guidance continues

If permitted under state law, agents, brokers, and web-brokers that elect to pass on these types of costs to consumers for selecting and submitting QHP applications offered through the FFM through a non-FFM website should provide a disclaimer to consumers that: 1) clearly discloses the amount and reason for the fee, and 2) informs the consumer that he/she can apply through the FFM website (Healthcare.gov) at no cost.

The consumer must also be permitted to withdraw from the web-broker enrollment process and enroll through Healthcare.gov at any time.

Brokers and agents have played a very significant role in enrolling consumers in marketplace plans. At a time when a number of insurers have eliminated or significantly cut commissions for marketplace enrollment, guidance permitting brokers and agents to charge marketplace enrollees directly for their services is troubling. The lack of clarity in the guidance as to what a “bona fide service of value” might look like makes the guidance even more problematic.

Rather than suggesting that brokers and agents can charge consumers for enrollment, federal and state regulators should rather ensure that insurers are paying agents and brokers for their services to the insurer, particularly when the insurer included commissions in their approved rate structure or when an insurer has eliminated commissions in ways-such as refusing commissions for special enrollment periods only-that strongly suggest that the reason for doing so is to avoid high-cost enrollees, .

CMS maintains a broker and agent webpage with many more resources for agents and brokers.