Wednesday, February 25, 2015

What's at stake with Affordable Care Act challenge in the Supreme Court?

The Supreme Court has already ruled on the Affordable Care Act based on an early constitutional challenge.  But the law is back at the Court based on a challenge that hinges on just four words in the 2012 law.

CNN provides an easy to understand primer on what's at stake this time around.  Find the article, "The latest Obamacare challenge: What you need to know" here.

The article explains that the law establishes the creation of exchanges "through which individuals can purchase competitively priced health insurance".  Sixteen states and the District of Columbia have set up their own exchanges. Folks living in the other 34 states must use the exchange run by the federal government.  And the law provides federal tax credits to income eligible individuals "to help offset the cost of the policies". 

Most of us remember all of this.  States set up their exchanges where you shop for your healthcare coverage.  Lots of governors or state legislatures chose not to create their own exchanges, so their citizens go to the exchange run by the federal government.  And because everyone is supposed to sign up if they don't have coverage elsewhere, the Affordable Care Act provided federal tax credits to help lower income individuals and families buy coverage. 

Simple enough.  Except, those bringing the case that is now before the Supreme Court say the law did not authorize those tax credits for those having to use the federal run exchange.  That's where the four words in the law passed by Congress comes in. 

A synopsis from the CNN article:

The health care law provides for the establishment of "exchanges" through which individuals can purchase competitively priced health insurance. It also authorizes federal tax credits to low- and middle-income Americans to help offset the cost of the policies. Currently 16 states plus the District of Columbia have set up their own exchanges; the remaining 34 states rely on exchanges run by the federal government. Those bringing the case say that the words "established by the State" in a subsection of the law make clear that subsidies are only available to those living in the 16 states that set up their own exchanges. If the court says the IRS rule is invalid, absent some kind of action by the states or Congress, more than 5 million individuals will no longer be eligible for the subsidies, shaking up the individual market.
So this time around the law in its entirety is not at stake.  But apparently the help through tax credits for 5 million individuals is at stake.  (CNN reports that in 2014, more than 5.3 million individuals selected an insurance plan through the federal exchange.)  We'll find out if Congress goofed or not.
Here is how CNN explains it:
Those challenging the law this time say: Congress limited the subsidies in order to encourage the states to set up their own exchanges. But when only a few states acted, the IRS tried to "fix" the law and wrote a rule allowing subsidies for those living in states with state-run exchanges as well as states with federally run exchanges.
The government, defending the law, says: the language at issue is a "term of art" and that Congress always intended the subsidies to be available to everyone. ... it was clear that some states would not establish their own exchanges.
There is a little technicality that is also interesting.  Challenges must have standing - that is to say that have to show that they are being harmed by the law.  The challengers in this case are residents of Virginia, one of the 34 states that did not create their own exchange.  So these Virginia residents don't get the tax credits.  Without the tax credits they can't afford health care coverage offered through the federal exchange.  So sounds like they want the tax credit.  Apparently not.  Remember the "individual mandate" part of the Affordable Care Act - if you don't get coverage, you get a penalty? 
As CNN explains:
The crux of their argument is that if it were not for the tax credits for premiums, they could not afford health insurance and thus would be exempt from the individual mandate to purchase health insurance.

Open Notes and Patient Portals?

Who manages patient access to their health records?  What technology are you employing?  Let us know. 

This article from Reuters made us want to hear from you.

The article posted Tuesday, February 24, "Patients, doctors see benefits of sharing medical records" may be found here.

It introduces the story of a patient who began using OpenNotes when her multiple sclerosis created increasing challenges for her to remember what happened at her last appointment and what follow-ups she was responsible for.

The article cites a new paper online in the British Medical Journal which demonstrates that patient access to their records, including physician notes, can lead to more collaboration between doctor and patient and more educated, engage healthcare consumers as patients.

One metric discovered: "After one year, 99% of patients wanted to continue accessing notes. Despite initial concerns among physicians about additional work, none decided to discontinue use."  And the age of the patient was not a factor in patients using portals to access their information.

Find more information on the study here.

What experiences have you had with managing patient access to their EHR information and the use of patient portals?

Let us here from you!

Thursday, February 19, 2015

What are you seeing or reading about measles?

One article, "Measles May Be in U.S. to Stay, 15 Years After It Left" one of our members found here: By Anna Edney and Michelle Fay Cortez January 26, 2015 -

Here is a summary: 

Measles could once again become native in the U.S., as an outbreak in California linked to Disneyland has put a spotlight on a growing failure to vaccinate that’s helping the disease to spread.

While 94 percent of California kindergarteners were fully inoculated against the virus last school year, in some pockets of California, as much as a quarter of children are undervaccinated
This puts these children at risk of both contracting the disease and becoming a nexus of future spread.

Some facts cited in the article:

In 1990, 3 of every 1,000 children who got measles died from it.  

The virus is one of the most contagious pathogens known to man, and causes more serious complications in about three of 10 patients, according to the CDC.
It was declared eliminated in the U.S. in 2000
Outbreaks are instead started by people visiting from outside the U.S. or who return and bring it back.

The virus is highly contagious, spread through the air by coughing and sneezing. It is also insidious, with patients become infectious four days before the telltale rash appears.

The first vaccine became available in 1963, with the current combination shot approved in 1971. A single injection is 93 percent effective, rising to 97 percent for those who get both doses.

While the poor have long had lower rates of vaccination because of the cost, the number of unvaccinated children in other communities who don’t get their shots is growing because of worries vaccines are linked to autism. Doctors have debunked any such link.

Health experts fear "Re-establishing transmission": 

Re-establishing transmission would mean there is sustained chain of infection among U.S. citizens and the disease can no longer be considered eliminated. The CDC warned in 2012 that without high vaccination rates, measles could return.

Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said measles re-establishing itself is less likely than the U.S. developing more frequent outbreaks from imported cases.

“You have parents who don’t allow their children to be vaccinated, and they’re clustered in certain areas,” Fauci said in an interview. The parents reinforce their philosophy of not wanting to get the kids vaccinated. So you have a cadre of kids who aren’t vaccinated and someone comes in from a foreign country that does have endemic measles, and you get outbreaks.’’

While there have been a few hundred cases at most documented in the U.S. each year since 2000, 2014 saw a sharp increase to 644 cases representing 23 outbreaks, the CDC said.

The largest outbreak last year occurred among non-vaccinated Amish communities in Ohio where 382 people caught measles. California took the runner-up title with 60 residents falling sick in just the first five months of the year.


Article on Medicare Alternative Payment Models

Medicare Unveils Alternative Payment Models

Find the source article here: Christopher Cheney, for HealthLeaders Media , January 27, 2015 -

Here is the summary:
HHS officials highlight a three-year payment reform timeline, which calls for boosting fee-for-service Medicare reimbursements and increasing reimbursements linked to quality and value.

Federal officials have announced an accelerated effort to use payment reform as a mechanism to shift Medicare and the broader healthcare industry away from the fee-for-service model.

3-Year Timeline

A three-year payment reform timeline is expected to 1) boost the percentage of fee-for-service Medicare reimbursements based on alternative payment models (APM) and 2) to increase the percentage of all reimbursements linked to quality and value.

In the early phase of the payment reform initiative's implementation, APMs will be limited to three pathways: Medicare's existing accountable care organization efforts, the Pioneer ACO program and the Medicare Shared Savings Program; bundled payments; and payment models tied to patient-centered medical homes.

More ambitious value-based payment models are in the works, including episode-of-care payment for chronic illnesses and oncology care that will require providers to shoulder a significant level of cost risk.

The metrics are reported as follows -
The reform initiative calls for Medicare fee-for-service payments through APMs to rise from the current 20% level to 30% by the end of 2016. The percentage is slated to rise to 50% by the end of 2018.

It additionally calls for the percentage of Medicare payments that are linked to quality and value to reach 85% by 2016 and 90% by 2018. Existing Medicare quality and value linked payment programs include the Hospital Value-Based Purchasing (VBP) program and the Hospital Readmission Reduction Program (HRRP).

Marrying Value-Based Care Delivery With Value-Based Payment

HHS officials started foreshadowing the Medicare payment reform initiative in the fall.

In November, the Centers for Medicare & Medicaid Services released details about developing and optimizing APMs, linking fee-for-service payments to quality and value, Medicare ACO and bundled payment projects, and PCMH models.
A primary goal of the Medicare payment reform initiative is to develop and enhance the alignment between value-based healthcare delivery and value-based healthcare payment models.