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  • 2014: The Health Care Year in Review - The Commonwealth Fund
    of the Affordable Care Act ACA is unlikely as long as President Obama remains in the White House but look for more targeted attacks possibly through the budget reconciliation process to gain some traction At the state level Republican control will likely mean slower than expected expansion of Medicaid eligibility Supreme Court takes up an ACA challenge In November the Supreme Court took up a case winding its way through the lower courts that asserts the ACA restricted insurance subsidies only to those states that establish their own marketplaces The potential ramifications of King v Burwell likely to be ruled on next June are enormous as a decision for the plaintiffs would have profound effects on the affordability and availability of individual insurance coverage and the functioning of insurance markets In any 2015 round up the Supreme Court s decision will either be a footnote or the lead Sovaldi draws attention to specialty drug prices For more than a decade spending on pharmaceuticals has been slowing but a narrow slice of the market known as specialty drugs threatens to reverse that trend In 2014 this phenomenon found its poster compound Sovaldi touted as a miracle cure for hepatitis C and priced at 84 000 per course While many patients will benefit payers and the public are starting to balk The question how many more miracle cures can our health system afford Ebola is a wake up call on global health security Despite the media frenzy the experts seem to have been right about Ebola With a little remedial work the U S health system is capable of swiftly managing an Ebola outbreak However the outbreak has served the useful purpose of drawing attention to world health security One looming threat is Chikungunya a mosquito borne disease that thanks to climate change and increased global travel has made its way to the U S from more tropical climes Extraordinarily painful Chikungunya may pose a greater threat to Americans well being than Ebola and is emblematic of new disease threats the U S will face in the 21st century Delivery system reform gathers steam More than 600 public and private accountable care organizations ACOs dot the landscape covering an estimated 20 million Americans The percent of private health insurance payments that are value based jumped from 11 percent to 40 percent in the past year according to one study Both ACOs and value based payments are part of an effort to encourage higher quality care and lower costs through increased provider accountability for cost and quality Efforts to reduce hospital acquired conditions saved 50 000 lives and 12 billion since 2010 These individual events don t remake the health system but could be leading indicators of major structural reform in cost and quality management Wiring of the health system continues Five years after the passage of the HITECH Act 25 4 billion in incentive payments have forever changed the world of health IT Eighty percent of eligible professionals and 98 percent of

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/dec/2014-health-care-year (2016-04-30)
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  • Giving Patients Control of Their EHR Data - The Commonwealth Fund
    argue that patients right to control their own information overrides other concerns Clinicians should think of themselves as guests in their patients lives and respect their rules and wishes even those that strike them as misguided or potentially compromising well being There are some exceptions note the authors such as when patients decisions about their data could affect the health of others if a person has been exposed to a public health threat like the Ebola virus for example What is most critical is communicating the options that are available to patients along with the inherent risks and consequences of withholding information An informed consent process could enable patients to restrict the release of their information to a specific medical condition or to certain providers the authors say Such a system would involve technical challenges however and providers may need to be able to override restrictions in certain circumstances like medical emergencies Conclusions Health professionals must realize that if patients do not trust the health system to protect them their relationships with clinicians will suffer they will withhold information and the value of their medical records will be undermined In the long run Blumenthal and Squires conclude clinicians as well as patients will benefit from a health information system that patients feel they can depend on to protect their privacy e Alerts and Newsletter Sign up Publication Details Publication Date December 22 2014 Authors David Blumenthal M D David Squires Contact David Blumenthal M D President The Commonwealth Fund E mail db cmwf org Summary Writer Deborah Lorber Citation D Blumenthal and D Squires Giving Patients Control of Their EHR Data Journal of General Internal Medicine published online Dec 6 2014 View full article Related Publications May 3 2016 Envisioning a Digital Health Advisor April 21 2016 Implementing New York

    Original URL path: http://authoring.commonwealthfund.org/publications/in-brief/2014/dec/giving-patients-control-of-their-ehr-data (2016-04-30)
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  • Health Reform: Foolish, Courageous, or Both - The Commonwealth Fund
    confusing Health care is about people s deepest hopes and fears for themselves and for their loved ones And the health care system has become a multi layered maze of huge insurance chains enormous and acquisitive provider organizations government regulation and constantly changing therapeutics This makes it easy for opponents of health reform to stir opposition by arguing fairly or not that any new program will make things worse for people who are satisfied with their insurance and their care This is precisely why President Obama felt the need to promise inaccurately as it turned out that every American who liked their insurance plan would be able to keep it under the ACA And supporters of reform have difficulty explaining any new program and motivating its beneficiaries to take advantage of it Witness the large numbers of uninsured Americans who remain unaware of the availability of subsidized insurance through the ACA marketplaces So to put it crudely why would any sane politician push a program likely to scare and confuse large numbers of people who vote in order to help small numbers who don t There are two possible responses One is that it s the right thing to do since a lack of insurance is essentially a death sentence for millions of Americans Doing the right thing however can be politically costly when Lyndon Johnson pushed through the Civil Rights Act in 1965 he gave away the southern United States to the other party for a generation A second argument for braving health reform is practical it simply has to be done to make our health system viable The private health insurance industry in the United States and our health system as a whole have been in a downward spiral that threatens the interests of all Americans including the now contentedly insured Prior to the ACA s enactment more and more people were losing insurance or being forced because of huge premium increases to purchase coverage that offers less and less protection For some years now insured Americans have been the proverbial frog in the cooking pot barely noticing as the water slowly approaches the boiling point A health care system in which year after year the cost of insurance rises faster than workers wages is not sustainable for anyone Relatively little attention has been paid to ACA reforms that attempt to make the system sustainable by tackling fundamental problems with the health care delivery system and with the structure of the private insurance markets The reason may be that insurance markets and delivery systems their problems and solutions are complex and much less interesting than the political battles surrounding covering uninsured Americans and whether currently insured Americans may face cancellation of their plans While the major long term political gains to supporters of health reform may lie in these delivery system and insurance reforms President Obama and many current congressmen and senators will likely be long gone when and if those gains materialize So ACA supporters have every

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/dec/health-reform-foolish-courageous (2016-04-30)
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  • The Supreme Court Decides to Hear King v. Burwell: What Are the Implications? - The Commonwealth Fund
    potential implications of the SCOTUS decision for the future of the coverage provisions of the ACA could be huge Currently 7 3 million Americans have purchased private insurance through ACA marketplaces of which approximately 5 million have done so through the 34 federally run marketplaces Of these individuals more than 4 million have received subsidies because they earned 400 percent of the federal poverty level or less and were not eligible for Medicaid in their states The Urban Institute estimates that by 2016 11 8 million Americans will have insurance through federal marketplaces with 7 3 million receiving subsidies This would include 1 1 million people in Texas and 931 000 in Florida alone The loss of these subsidies would make insurance unaffordable for many if not all of these newly insured individuals This would undermine the ACA s current and future success in reducing the number of uninsured Americans which dropped by an estimated 8 to 10 million during the first open enrollment period A SCOTUS ruling for the plaintiffs would also threaten other popular ACA reforms of the individual health insurance market in the United States The law prevents insurers from limiting annual and lifetime benefits and from denying or terminating coverage because of a person s health Because these provisions will tend to increase the number of privately insured with high health care costs plans need to enroll more low risk individuals to offset these added costs and to keep premiums affordable The subsidies available in marketplaces together with the individual mandate serve to attract those better risks Studies have shown that the subsidies are actually much more important in this regard than the mandate In fact without this federal support affected insurance markets might descend into a so called premium death spiral Low risk individuals will back out and premiums will increase driving away even more low risk customers until even the sickest Americans can no longer afford individual and small group coverage This would render moot the ACA s rules increasing the generosity and accessibility of private health insurance RAND has estimated that the loss of federal subsidies would increase individual premiums by 43 percent Other effects of a SCOTUS ruling for the plaintiffs in King would be to render the individual and employer mandates meaningless in affected states The individual mandate ceases to apply when Americans cannot find affordable insurance defined as plans with premiums that cost less than 8 percent of income Without subsidies most low and lower middle income Americans would no longer be able to find affordable insurance And the penalties that employers face for not offering affordable insurance to their employees apply only when their uninsured employees go to marketplaces and receive federal subsidies which would no longer exist Still another effect of a successful challenge to federal subsidies would be major financial losses for the insurance industry which has seen new growth since the ACA s implementation Since many states with federally run marketplaces have also declined to expand

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/nov/the-supreme-court-decides-to-hear-king (2016-04-30)
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  • Keeping Covered: The Affordable Care Act’s First Reenrollment Period for Marketplace Plans - The Commonwealth Fund
    well above the threshold that makes them eligible for tax credits will receive special update notices People who do not contact the marketplaces by December 15 will receive tax credits in 2015 that will be identical to what they were in 2014 This means that someone who did not update their information could automatically pay a higher premium because they are a year older and could miss out on a higher advance tax credit if their income decreased or could owe more in taxes in 2015 if their income increased People who received tax credits in 2014 and who did not give permission to the marketplaces to request their tax information are also urged to visit the marketplaces for a redetermination of their eligibility If they do not do so by December 15 they will not receive tax credits in 2015 Will I Have the Same Health Plan in 2015 Like most health insurance policies through employers enrollment in marketplace plans lasts for one year Consumers who still want coverage for 2015 can either reenroll in their current plan if their insurer is offering the plan in 2015 or go back to the marketplaces and shop for a new plan Auto enrollment While consumers can shop for a new plan HHS has sought to make the reenrollment process as automatic as possible The Affordable Care Act s consumer protections include guaranteed renewal of health insurance policies for individuals and employers who want to renew their policies But insurers can discontinue plans if they meet certain federal criteria So some 2014 plans will not be available in 2015 The federal government requires carriers to follow a standardized process to help consumers auto enroll in a new marketplace plan if they are interested in doing so Insurer notices to consumers HHS requires health insurers to send notices containing key information to people with health insurance through the marketplaces and the individual market outside the marketplaces by November 15 3 The notices will tell consumers whether their plan is available for renewal or is being discontinued if they are being auto enrolled in a new product their plan s 2015 premium and other critical information Will the Benchmark Plan Change in 2015 The amount of someone s tax credit is calculated as the difference between their required contribution as a share of their income depending on their income 2 01 9 56 of income in 2015 and the premium of the second lowest cost silver plan a k a the benchmark plan sold in the marketplaces People can apply their tax credit to any plan with the individual paying the difference if the premium is higher than the benchmark or pocketing the savings if it is lower Many state marketplaces could have a new benchmark plan in 2015 because of changes in relative premiums for plans offered on the marketplaces This means that if someone stays in a plan that is no longer the second cheapest silver benchmark plan they will probably pay

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/oct/keeping-covered (2016-04-30)
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  • Electronic Health Records: The New Lightning Rod in Health Care - The Commonwealth Fund
    led to reforms that are profoundly disruptive to providers threatening the bottom lines of hospitals and the cherished autonomy of physicians The pressures on physicians and hospitals go by many names pay for performance risk sharing reduced Medicare payments for high cost procedures accountable care organizations bundled payments hospital purchases of physician practices and more One facet of society s effort to improve our health system s performance is the Health Information Technology for Economic and Clinical Health HITECH Act a major federal investment in EHRs that began in 2009 and has rolled out in phases In 2009 83 percent of U S physicians and 90 percent of hospitals were managing patient information on paper This was at a time when the Internet smartphones iPads and the cloud were revolutionizing virtually every other sector in our economy including the non medical lives of many health professionals and their families That one of our most information intensive industries accounting for 18 percent of gross domestic product has so steadfastly resisted the modernization of its information management practices is puzzling to say the least Nevertheless the economic incentives created under the HITECH Act have profoundly changed the information management landscape in the U S Five years after its passage 81 percent of physicians and 97 percent of hospitals have EHRs that qualify for incentive payments from the federal government An interesting question is why as Texas Presbyterian illustrated so many providers seem to attribute so many of their current discontents to EHRs rather than to any of the many other changes that are jarring their equilibrium I think the answer is severalfold First EHRs are in clinicians faces in unique ways For providers to do their jobs they have to access and record patient data through their EHR dozens even hundreds of times a day By comparison all the other intrusions roiling the health care world can seem like so much distant thunder distressing but more easily ignored or forgotten in the press of daily work Second current EHRs are imperfect They are harder to use than they should be and the infrastructure to support their interoperability is underdeveloped Providers are absolutely right to be unhappy about these aspects of the electronic health information revolution and to demand improvements from vendors Those improvements will come but will take time Third providers unhappiness with EHRs reflects profound underlying dysfunctions in our health care system Surveys of physicians reveal that some but by no means all are dissatisfied with their EHRs but large majorities also report that they observe clinical value for their patients mistakes avoided drug interactions detected preventive services delivered that might have been overlooked That physicians see the value but still have negative feelings about EHRs speaks to an asymmetry of benefits and costs Patients gain but clinicians and hospitals incur costs in dollars time and disrupted routines that current payment systems federal incentives included only partly cover The problem is an old one Fee for service compensation rewards volume but

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/oct/ehrs-the-new-lightning-rod-in-health-care (2016-04-30)
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  • Assessing the Affordable Care Act: The Record to Date - The Commonwealth Fund
    uninsured It s important to keep in mind that this is CBO s estimate of the difference between the projected number of uninsured nonelderly people had the ACA not passed 54 million and that with the law 42 million Estimates from several private and government surveys for time periods in the first half of 2014 point to very good performance on this measure as well The Commonwealth Fund Affordable Care Act Tracking Survey conducted in April May and June found the percent of adults ages 19 64 who were uninsured had declined from 20 percent just prior to open enrollment to 15 percent which means there were an estimated 9 5 million fewer uninsured adults Surveys by Gallup RAND and the Urban Institute conducted around the same time arrived at similar estimates for working age adults The first large scale government survey data released in September found that as early as February before the surge in enrollment in late March the number of uninsured working age adults had fallen by nearly 4 million from 2013 levels GRADE GOOD TO EXCELLENT 4 Is the quality of insurance improving Is underinsurance declining and are people satisfied with their plans In 2012 The Commonwealth Fund estimated that 30 million people ages 19 to 64 with health insurance had such high out of pocket costs relative to their income that they were underinsured 1 Last year we set a decline of 5 million underinsured adults in 2014 as a reasonable performance measure No good data exist yet on this indicator a problem that The Commonwealth Fund is working to address through ongoing surveys In the meantime the Fund s Affordable Care Act Tracking Survey found that more than two thirds of adults with marketplace plans rated their health insurance as good very good or excellent in June GRADE PENDING Now for the extra credit 5 Are people using their new insurance to get health care In the Commonwealth Fund Tracking Survey conducted in April May and June 60 percent of people who had new coverage through the marketplaces or Medicaid said they had already used their coverage to get health care 62 percent reported that they would not have been able to access or afford this care previously People with new coverage appear to be getting the doctors they want and getting appointments with wait times consistent with U S averages GRADE EXTRA CREDIT 6 Is growth in health care costs moderating The ACA has a health care delivery system reform and cost control agenda though these provisions have received less attention than the insurance reforms This agenda includes testing alternative ways of paying for health services as well as new ways of organizing health care providers to provide coordinated care In 2013 national health care costs are estimated to have increased 3 6 percent annually the fifth consecutive year of spending growth below 4 percent Over the next decade medical spending is expected to increase at a rate of 5 7 percent compared

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/sep/assessing-the-affordable-care-act (2016-04-30)
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  • Drugs and Dollars - The Commonwealth Fund
    like cystic fibrosis CF is not one disease but many each caused by a unique genetic abnormality Scientists can dramatically improve treatment if they develop drugs that specifically correct the different problems created by each genetic defect This approach is sometimes called personalized medicine In fact it might be more accurately called scientific design It substitutes laser guided attacks on disease for the traditional approach which is more like carpet bombing The clinical results can be dramatic enhancing both length and quality of life but the costs are also eye popping Kalydeco the first CF drug targeting a specific underlying genetic defect will cost 294 000 a year for each of the 1 200 patients who will benefit out of about 30 000 with CF in the U S for a total cost of 353 million annually Already state Medicaid programs and insurers are balking at the costs of both Sovaldi and Kalydeco The nation s total prescription drug bill grew a whopping 12 percent over the 12 month period ending May 2014 according to the Altarum Institute The obvious question is why drug companies are charging such seemingly exorbitant amounts for these new products One reason is because they can Their patents grant them a monopoly on life saving treatments A second reason is that because the drugs are so precisely targeted they may benefit relatively small numbers of patients Companies claim they have to charge more per user to recoup the costs of drug development Nevertheless critics argue that prices are higher than needed to make back those costs plus a healthy profit Gilead Science which makes Sovaldi is reporting net income approaching 6 billion for the first half of 2014 four times what it earned during the same period a year ago In any case if more and more of these drugs come on line the aggregate expense of providing them to eligible patients seems likely to skyrocket This would create huge new challenges in balancing high health care costs against other pressing societal imperatives such as education housing transportation infrastructure and the very research and development that has spawned the new treatments To prepare for this impending challenge a number of options exist First comparative effectiveness research to assess the added value of new agents will be essential Some will have near miraculous effects but others will not add much to existing care Second we must find ways to make new treatments affordable and to prevent drug manufacturers from earning extraordinary profits using the monopoly powers granted them under current patent law As priced now a string of Sovaldis and Kalydecos could force reconsideration of the extent and duration of today s patent protections Third and relatedly the Food and Drug Administration FDA needs to do everything it can to ensure that less expensive alternative drugs become available as soon as possible In this regard the FDA has been slow to establish a regulatory pathway for generic and bio similar alternatives to new biological products that

    Original URL path: http://authoring.commonwealthfund.org/publications/blog/2014/jul/drugs-and-dollars (2016-04-30)
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