Since CMS’s Center for Medicare and Medicaid Innovation launched three years ago, its staff have been frequently hailed for undertaking an ambitious research agenda.
But a New York Times story this week was eye-catching for a different reason: author Gina Kolata mostly assailed Medicare’s researchers for how they’re choosing to do that research.
“Experts say the center is now squandering a crucial opportunity,” Kolata wrote in a front-page article. ”Many researchers and economists are disturbed that [CMMI] is not using randomized clinical trials, the rigorous method that is widely considered the gold standard in medical and social science research.”
But many researchers and economists that I talked to at this week’s Academy Health conference say that’s not the case at all. (And some were disturbed to learn that they were supposed to be disturbed.)
“RCTs are helpful in answering narrowly tailored questions,” Harvard’s Ashish Jha told me. “Something like—does aspirin reduce 30-day mortality rates for heart attack patients.”
“However, for many interventions, RCTs may be either not feasible or practical.”
“While RCTs may be the gold standard for testing some hypotheses, it is not necessarily the most effective or desirable model for testing all hypotheses,” agrees Piper Su, the Advisory Board’s vice president of health policy.
CMMI’s ambitious goals
On its surface, Kolata’s article is built around a reasonable conclusion: RCTs offer plenty of value in health care, and we’d benefit from more of them.
- As Jha alludes to, think of a double-blinded pharmaceutical study where half the participants randomly get a new drug and the other half get a placebo; that’s an RCT.
- The famous RAND study that found having health insurance changes patients’ behavior: An RCT.
- The ongoing Oregon Health Insurance Experiment: Also, an RCT.
And it’s fair to examine how CMMI is pursuing its research, too.
Continue reading “What the New York Times Got Wrong about Medicare’s Innovation Center”
Filed Under: THCB
Tagged: ACOs, Center for Medicare and Medicaid Innovation, CMS, Dan Diamond, health care delivery, health reform, NYT, randomized clinical trials
Feb 5, 2014
With the possible exception of one phrase — “it’s a marathon, not a sprint” — defenders of Obamacare have repeatedly invoked the same warning.
Don’t be too critical of the Affordable Care Act’s new marketplaces. Medicare Part D had a rocky rollout, too.
“In terms of confusion, lack of knowledge, and misinformation, the current situation with exchanges resembles the situation that prevailed when Part D enrollment opened,” Daniel McFadden, a UC-Berkeley economist and Nobel laureate, told the Wall Street Journal‘s David Wessel earlier this month.
Part D, “at the time that it was passed was actually less popular than the Affordable Care Act,” President Obama said in an NPR interview on Oct. 1, the day the new marketplaces launched.
There are similarities between the two programs, from the political fight over their enactment to the difficulties in making the laws a reality. But the laws differ in some important ways, too, including ones that supporters haven’t fully acknowledged.
So what can we take away from Part D? Here is a quick guide to lessons from the drug plan’s rollout.
The political environment
How it’s similar: Just as Democrats fiercely resisted Republicans’ efforts to enact a Medicare drug benefit, the GOP refused to support the Democrat-led ACA.
How it differs: While Part D is seen as successful today — 90% of seniors were satisfied, according to a 2009 survey — Democrats say that their party deserves some credit.
“We lost the policy fight, and what did we do?” asked Rep. Bill Pascrell (D-N.J.), at a hearing on Capitol Hill on Tuesday. “We went back to our districts and we told our seniors although we voted no, we … will work with the Bush administration to make it work,” Pascrell added.
Continue reading “Why the Medicare Part D-Obamacare Comparison Is Making Less and Less Sense”
Filed Under: THCB
Tagged: Dan Diamond, Health Insurance Exchanges, Medicare Part D, The ACA
Oct 31, 2013
Social security numbers allegedly passed around in clear sight. Page after page of unworkable code. And no clarity on when it will all be fixed.
Just another day of trying to log in to healthcare.gov.
Two weeks after its launch, the federal health insurance exchange is a “failure,” says the Washington Post‘s Ezra Klein. Some officials deserve to be fired, according to Robert Gibbs, who until February 2011 was one of President Obama’s closest advisers.
And those are the Affordable Care Act’s supporters.
Even the president conceded on Tuesday that healthcare.gov had “way more glitches than I think are acceptable.”
Those glitches could take months — or even years — to fix, according to reports. But there’s a key deadline looming: Jan. 1, 2014, when the ACA’s individual mandate takes effect.
Under the mandate, millions of Americans who were expected to use the exchanges to obtain health insurance will face fines if they haven’t purchased coverage by Feb. 15, raising the question of whether the mandate or other Obamacare provisions should be postponed — an uncomfortable position for an administration already trying to implement a politically divisive law.
But at this late date, what parts of the ACA can legally be delayed?
“In a sense, all of it,” Timothy Jost, a Washington & Lee law professor, told me. But “there’d be a high political price to pay. And delay could result in litigation.”
Jost was among several experts who spoke with me about the health insurance exchanges’ bumpy rollout, the ripple effects for the mandate and other provisions, and what it could all mean for implementing the ACA.
What Agencies Can and Can’t Do
When considering a delay to Obamacare, it’s important to understand the difference between statutory and discretionary deadlines.
For example, the ACA’s language directly calls for many mandatory deadlines — like rolling out the individual mandate or implementing a slew of insurance market reforms on Jan. 1, 2014.
But the agencies also have had considerable leeway on how they’ve chosen to apply the law — like choosing an Oct. 1 launch date for the exchanges, a deadline that retrospectively seems ambitious.
Continue reading “The Federal Shutdown is Over. The Health Care Fight is Just Getting Started. Here’s What May Happen Next…”
Filed Under: THCB
Tagged: ACA Implementation, Dan Diamond, GOP Repeal, government shutdown, Health Insurance Exchanges, Healthcare.gov, Individual mandate, The ACA
Oct 17, 2013
On the day that Covered California went live — the very moment that Executive Director Peter Lee declared the exchange “open for business” — staff debuted a video celebrating the launch.
The video features photos of cheerful, ethnically diverse people — spliced between scenes of California — holding up signs written in English, Farsi, Korean and other languages that all translate to “open.” (You can watch Lee unveil the video, beginning at the 10:40 mark.)
One week later, Covered California brought the video back; once again, clips of grinning men and women toting signs that read “Ya abrimos” filled time before a webinar on Tuesday where officials shared updates on the exchange’s progress.
The smiling faces and multilingual message illustrate one of California’s major challenges in rolling out the ACA: The state is arguably the most geographically and demographically diverse in the union. Expanding health coverage to seven million uninsured residents will take time and a unique strategy.
But you can also forgive Covered California officials for wanting to remind the public that their exchange is live. During much of the first week, the site often sent a different message.
What Went Wrong
Covered California’s launch was supposed to be different. The state had spent years gearing up for the exchange’s rollout on Oct. 1. It had enlisted dozens of groups to help perform outreach. It had equipped some staffers with “Keep calm and go live” t-shirts.
But a triumphant debut turned out to be an oft-frustrating one. In California, like in most of the nation, most launch day stories didn’t center on the people signing up for coverage through the new exchanges, but on all the people who couldn’t.
Continue reading “What Covered California Got Right–And What Other States Did Better”
Filed Under: Uncategorized
Tagged: Covered California, Dan Diamond, Health Insurance Exchanges, The States
Oct 10, 2013
Back in 2010 — before two elections, before the Supreme Court ruled, before the word “crisis” stopped following the words “California budget” — Kim Belshé settled on a guiding principle: “2014 is tomorrow.”
And now, it almost is.
The Affordable Care Act’s individual mandate takes effect in less than 100 days. The nation’s health insurance exchanges go live next week.
And for nearly a year, Belshé — secretary of the Health and Human Services Agency under former Gov. Arnold Schwarzenegger — was at the center of California’s efforts to begin implementing those Obamacare provisions and many others.
I interviewed Belshé, Schwarzenegger, and nearly a dozen other ex-officials and experts about whether California’s quest to lead the nation on ACA implementation actually paid off — and what it brought the state.
Why California? Why Not?
Every expert suggested that the ACA’s rapid implementation in California could be traced back to Schwarzenegger’s efforts in 2007 and 2008 to enact universal health care.
(And in some cases, even older efforts at reform. “We learned a lot from the 1990s,” says Belshé, noting that failed attempts to create purchasing cooperatives in California helped set the foundation for designing insurance exchanges more than a decade later.)
Although the Schwarzenegger plan ultimately failed, many of its components — from big elements like the exchanges to smaller pieces like guaranteed issue — ended up in the ACA. And because state leaders had already done much of the foundational work, they were better positioned to speedily roll out the national law.
Daniel Zingale, senior vice president of the California Endowment, says that Schwarzenegger’s efforts were a preview of the national ACA battle to come — which meant that many stakeholders in California had already made peace with the law’s key provisions by 2010.
“We’d had our big fights over the individual mandate here” in 2007 and 2008, says Zingale, a former health care aide to Schwarzenegger. “Democrats and labor groups had been through it [and] were ok with it.”
“But the nation hadn’t been through that yet.”
Still, California’s support for Obamacare was hardly assured. As late as January 2010, Schwarzenegger wavered on the ACA — but by April that year, he was the first Republican governor (and one of the first governors in the nation) to throw his support behind the law and begin crafting a framework for implementation.
“It gave us a bit of a head start,” Belshé acknowledges.
Continue reading “Did We Get It Right? A Behind the Scenes Look at California’s Healthcare Strategy”
Filed Under: THCB
Tagged: California, Dan Diamond, The States
Sep 25, 2013
The Wall Street Journal broke the news Thursday night that a “pricing glitch” is plaguing the federal health insurance exchange software … with less than two weeks to go before the exchanges are supposed to launch.
Basically, the exchange’s calculator can’t do a pretty important piece of math: How much each consumer will need to pay for his or her specific coverage.
Glitches had been somewhat expected—there had been rumblings of technical problems, despite officials’ public vows of confidence—but it doesn’t make the Journal‘s scoop less of a story. Opponents of Obamacare will use any delay to raise fresh concerns about the law’s implementation, and even the most ardent supporters of the ACA acknowledge that having working software is crucial to a working rollout on Oct. 1.
And what happens to enrollment targets if the glitches aren’t quickly resolved and would-be customers get frustrated and turn away?
There are several potential interpretations and implications here, given that this story is bound up in both politics and policy. From my perch, I’d offer these five quick reactions to the Journal‘s scoop.
1. This news is not a surprise.
When reporting on the ACA’s rollout, especially since the Supreme Court’s ruling last June, officials and analysts kept raising the same question with me: Will the exchanges be ready in time?
- Keep in mind, the exchanges are intended to combine an unprecedented mix of eligibility verification systems, subsidy calculations, and thousands of insurance products.
- Add an additional factor—the pace of ACA implementation lagged between 2010 and 2012 because of the ongoing uncertainty over whether the law was even constitutional—and the level of complexity involved in getting the exchanges off the ground really is astounding.
There have been hints that these systems might not be ready. Federal officials announced over the summer that they would scale back the exchanges’ verification requirements until 2015. And the contractors charged with designing the systems might as well be working on the Siberian insurance exchange, given how they’ve ignored media requests.
2. The federal exchange isn’t the only one with glitchy software. State exchanges are having problems, too.
Oregon has already announced that it plans to delay the formal roll-out of Cover Oregon to continue beta-testing, and California (a state that has moved exceptionally quickly to implement health reform) was weighing contingency plans for Covered California, too.
As Caroline Pearson of Avalere Health told me a few weeks ago, “if California’s talking about contingency planning, then we need to acknowledge that any number of state-run exchanges may not be fully operational by Oct. 1.”
However, the federal exchange software takes on extra importance given the sheer number of states (36) and potential customers (32 million uninsured) that will be shopping through its exchange.
Continue reading “Five Reasons the Federal Insurance Exchange Glitch May Not Be That Big Of A Deal. Knock On Wood.”
Filed Under: THCB
Tagged: ACA Implementation, Dan Diamond, federal exchanges, Health Insurance Exchanges, The ACA, The States, WSJ
Sep 20, 2013
Hospitals tend to be among the largest employers in their communities — which means that any individual decision to lay off staff can have an outsized local impact. And taken together, a dozen recent announcements seem to paint an especially dire picture for hospitals (and their communities) around the nation.
For example, NorthShore in Illinois says it will lay off 1% of its workforce. The staffing cuts “ensure NorthShore remains well positioned to deal with the unprecedented changes brought on by the Affordable Care Act,” according to a memo from the health system’s chief human resources executive.
And California’s John Muir Health is offering staff voluntary buyouts ahead of ACA implementation. “We’re being paid less, and we either stick our head in the sand or make changes for the future so patients can continue to access us for their care,” according to John Muir spokesperson Ben Drew.
When Obamacare was being debated in Congress, its opponents tried to tar it with a deadly label: “the job-killing health law.” So is the ACA finally living down to its sobriquet?
Not exactly. While the recent news makes for provocative headlines, the devil’s in the details — and the financial reports.
A Closer Look at Industry Pressures
It’s clear that something is shifting in the hospital market. After years of employment growth, hospitals’ hiring patterns have largely leveled off. Collectively, organizations shed 9,000 jobs in May — the worst single month for the hospital sector in a decade.
Some of those decisions reflect industry-wide belt-tightening, as Medicare moves to rein in health spending by moving away from fee-for-service reimbursement and penalizing hospitals that perform poorly on certain quality measures.
And uncertainty around ACA implementation is trickling down to hospital staffing decisions, economists told me. Many organizations still aren’t sure how the pending wave of newly insured patients will affect their profit margins, given that many of these individuals may be sicker and will be covered by Medicaid, which reimburses hospitals at lower rates than Medicare and private payers.
Continue reading “A Dozen Hospitals Are Laying Off Staff and Blaming Obamacare. Don’t Believe Them.”
Filed Under: THCB
Tagged: Dan Diamond, Employment, Hiring Trends, Hospitals, Obamacare, The ACA
Sep 18, 2013
As states race to implement health reform, California doesn’t want to settle for second.
“We don’t want to be a pace car state” when it comes to implementing health reform, state HHS Secretary Diana Dooley told Politico back in January 2011. “We want to be the lead car.”
It’s a metaphor that California leaders have returned to time and again. And to their credit, they’ve often succeeded.
While other states waffled, Golden State officials quickly embraced key Obamacare provisions like expanding Medicaid and creating insurance pools for individuals with pre-existing conditions.
At the same time, lawmakers crafted legislation intended to conform California’s health insurance plans to new standards under the Affordable Care Act.
And Covered California, the state’s health insurance exchange, also has drawn national attention for its speedy implementation. Among the 17 states that opted to run their own exchanges, California has “certainly [been] in the lead on getting their health plan information out … and getting the contracts signed,” Rachel Dolan, who monitors exchange activity for State Refor(u)m, a project of the National Academy of State Health Policy, said.
But the driving metaphor only extends so far.
“I don’t think it’s a race,” Dolan added, cautioning that each state might take unique approaches to exchange implementation — and objectively judging those individual strategies is impossible.
And a more essential issue might be getting lost, amid the growing number of questions over which state exchanges will be open for business on Oct. 1.
“Lots of people are asking about readiness,” said Caroline Pearson, who leads Avalere Health’s efforts to track health reform implementation. “But no one is asking about whether it matters.”
Where the States Stand on Readiness
The sprint to get the exchanges off the ground — which for some states didn’t really begin in earnest until after the Supreme Court’s June 2012 decision to uphold the ACA — has led to repeated delays and ongoing concerns.
Continue reading “The Exchanges Won’t Be Ready in Time. And it Probably Won’t Matter.”
Filed Under: THCB
Tagged: California, Dan Diamond, Health Insurance Exchanges, Obamacare, The ACA, The States
Sep 5, 2013
“Half of primary care physicians in survey would leave medicine … if they had an alternative.” — CNN, November 2008
“Doctors are increasingly leaving the Medicare program given its unpredictable funding.” – Forbes, January 2013
Doctors, it seems, love medicine so much … that they’re always threatening to quit.
In some cases, it’s all in how the question is asked. (Because of methodology, several eye-catching surveys have since been discredited.)
But physicians’ mounting frustration is a very real problem, one that gets to the heart of how health care is delivered and paid for. Is the Affordable Care Act helping or hurting? The evidence is mixed.
Doctors’ Thoughts on Medicare: Not as Dire as Originally Reported
The Wall Street Journal last month portrayed physician unhappiness with Medicare as a burning issue, with a cover story that detailed why many more doctors are opting out of the program.
And yes, the number of doctors saying no to Medicare has proportionately risen quite a bit — from 3,700 doctors in 2009 to 9,539 in 2012. (And in some cases, Obamacare has been a convenient scapegoat.)
But that’s only part of the story.
What the Journal didn’t report is that, per CMS, the number of physicians who agreed to accept Medicare patients continues to grow year-over-year, from 705,568 in 2012 to 735,041 in 2013.
Continue reading “Why Reports of the Death of Physician Participation in Medicare May Be Greatly Exaggerated”
Filed Under: Physicians, THCB
Tagged: Dan Diamond, Medicaid, Medicare, Nurse Practitioners, Physicians, Scope of Practice, The ACA, WSJ
Aug 6, 2013
An old data series got new life, when the Brookings Institution issued a report that compared health care jobs growth versus all other industries.
It’s “a truly astonishing graph,” according to Derek Thompson at The Atlantic. “I knew health care had been the most important driver of national employment over the last few years, but I had never seen the case made so starkly.”
Thompson wasn’t alone in his surprise. (Hopefully, readers of The Health Care Blog would be less astonished.) But lost within the reaction—and even mostly overlooked within the industry—is that not all health care jobs are growing, or at least not growing at the same pace.
Take a look at the following chart. It resembles the Brookings data, with one major change: The hospital employment curve has been separated from all other health care jobs growth.
Notice how hospital employment essentially flatlined across 2009—a hard year for the sector, which was still insulated compared to the rest of the economy. But many organizations pared back on staff and sought to cut non-essential services to survive the Great Recession.
Continue reading “Hospitals Lost Jobs Last Month. Should We Be Surprised?”
Filed Under: THCB
Tagged: Consolidation, Dan Diamond, Employment, health care jobs, Hospitals, Obamacare, outpatient care, Patients, The ACA
Jul 6, 2013