TAG: "Health care reform"

UC Health & Anthem Blue Cross form alliance

New public-private partnership launched between university and health insurer.

John Stobo

Anthem Blue Cross and University of California Health — UC’s medical centers and health professional schools — announced today the launch of a groundbreaking alliance aimed at addressing some of the most critical issues facing the state’s health care delivery system.

Under this new agreement, Anthem and UC Health will focus on care innovation and California health policy development with the purpose of improving access to affordable, quality health care for California residents. The parties have named this joint venture the California Health Alliance. Both expect an enduring and productive association that will benefit the people of California.

With all five of the world-class UC academic health centers in Anthem’s network, both organizations have a long-standing history of serving residents throughout the state and are uniquely positioned to understand the health care needs of Californians. And, as the state prepares to expand health care through the Affordable Care Act (ACA), both organizations believe that today, more than ever, a collaboration of this type can effectively address the impact expected on the state’s health delivery system as more residents prepare to access medical services.

Among some of the initial areas of focus of this alliance will be the development of accountable care models to better manage costly chronic conditions and the expansion of alternate delivery systems, such as telemedicine to encourage wellness and prevention and to provide access to health care for residents in rural areas. In addition, this new alliance is expected to provide opportunities for research, analysis, literature development and policy recommendations.

“We know that residents of the state look to a future that includes access to quality health care that is affordable,” said Pam Kehaly, president of Anthem Blue Cross. “By teaming with the University of California Health, we are bringing together some of the most innovative minds to help us achieve a common goal: to improve the health and wellness of California residents.”

“As two of the state’s leading organizations, this new affiliation has the ability to revolutionize California’s health care delivery system,” said Dr. John Stobo, senior vice president for UC Health. “By coming together, we know we can develop meaningful research, policy and best practices that can be leveraged on a broader scale to help improve the state’s health care system and the health of the population at large.”

Media contacts:
Leslie Porras, Anthem Blue Cross
(818) 234-3368

University of California Media Office
(510) 987-9200

About Anthem Blue Cross:
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Additional information about Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company is available at www.anthem.com. Also, follow us on Twitter at www.twitter.com/healthjoinin, on Facebook at www.facebook.com/HealthJoinIn, or visit our YouTube channel at www.youtube.com/healthjoinin.

About UC Health:
University of California Health includes five academic health centers — UC Davis, UC Irvine, UCLA, UC San Diego and UC San Francisco — with 10 hospitals and 18 health professional schools and programs on seven UC campuses. For more information, visit http://health.universityofcalifornia.edu.

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First-ever partners in primary care summit shares lessons from field

Participants discuss successes, frustrations.

The first-ever UC San Francisco and Partners Primary Care Summit brought key players to the table to discuss how to improve patient-focused care in San Francisco as part of national health reform.

“Instead of being in our parallel universes, can we recognize our common aspirations in primary care and learn from each other?” asked Kevin Grumbach, M.D., kicking off a recent gathering at the UCSF Laurel Heights campus.

Grumbach, chair and professor in UCSF Family and Community Medicine, addressed the 160 or so people in the audience who work at three major health delivery systems in San Francisco in which UCSF is involved: the San Francisco Department of Public Health, UCSF Medical Center and the San Francisco Veterans Affairs Medical Center. UCSF residents, medical students, and nursing students also attended the summit.

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Filling the gap

UC medical centers provide vital support to health professional schools. (View chart).

John Stobo, UC Health

By John D. Stobo

At University of California Health, patient care, health professional education and biomedical research go hand in hand. The connection has become only more important during these difficult budget times.

UC’s medical centers provide vital aid to UC’s medical and other health professional schools: $522 million this year in professional services and support of research and educational programs. UC medical centers have nearly doubled their contribution over five years, helping fill in the gap from shrinking state support. Indeed, UC medical center support for UC’s health professional schools now exceeds state general fund support.

The growing support from UC medical centers has been a lifeline for UC’s aspiring doctors, dentists, nurses, optometrists, pharmacists, public health professionals and veterinarians, bolstering the nation’s largest health sciences education system. But this lifeline is under threat.

UC’s self-supporting medical centers, which receive no state general funds, operate in extremely competitive environments. Their ability to sustain support for medical education – and provide a significant amount of care to low-income people – faces key fiscal challenges:

Capital requirements: UC medical centers’ capital needs are approximately $5 billion over the next five years. To best serve patients and meet government requirements, UC medical centers have major capital commitments from electronic medical records to state-mandated seismic-safety upgrades. UC San Diego and UC San Francisco have new hospital projects under construction. UCLA’s Santa Monica medical center completed a major rebuilding project this year. UC Davis opened a new surgery and emergency services pavilion in 2010. UC Irvine opened a new hospital in 2009.

Pension costs: UC medical centers face a growing obligation to pay pension costs. Those employer costs are projected to total nearly $3 billion over the next seven years. UC medical centers receive no state support to offset these costs.

Labor costs: UC medical centers have significant labor costs. They offer competitive compensation, which is necessary to attract and retain the nurses, doctors and other health care professionals who make UC medical centers such renowned institutions.

Health care reform: Under health care reform, reimbursement for clinical services by government and private insurers could be reduced substantially, including reimbursement rates for service and payments for graduate medical education.

The combined impact of these challenges could erase medical center margins. UC Health is working hard to address these issues. As UC Health moves into the throes of health care reform, the mutually beneficial relationship that exists between our medical centers and health professional schools must be preserved.

John D. Stobo, M.D., is senior vice president for UC Health.


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Large gaps ID’d in lifetime earnings of specialist, primary care physicians

Wage disparities could limit the success of health care reform.

J. Paul Leigh, UC Davis

A national study has found that earnings over the course of the careers of primary care physicians averaged as much as $2.8 million less than the earnings of their specialist colleagues, potentially making primary care a less attractive choice for medical school graduates and exacerbating the already significant shortage of medical generalists.

The results, published online in the journal Medical Care, lead the study’s authors to recommend reducing disparities in physician pay to ensure adequate access to primary care, which has been shown to improve health and reduce health-care costs.

“The need for primary care providers is greater than ever before and expected to grow as millions more Americans become insured under the Affordable Care Act,” said J. Paul Leigh, lead author of the study, professor of public health sciences and researcher with the UC Davis Center for Healthcare Policy and Research. “Without a better payment structure, there will be extraordinary demands on an already scarce resource.”

According to projections by the Association of American Medical Colleges, the nation is likely to face a shortage of more than 65,000 primary care physicians by 2025.

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How community health centers could offer better access to subspecialty care

Integrated system offers most comprehensive access to subspecialty care, study finds.

The Affordable Care Act will fund more community health centers, making primary care more accessible to the underserved. But this may not necessarily lead to better access to subspecialty care.

In a new study, researchers from the David Geffen School of Medicine at UCLA and colleagues investigated the ways in which community health centers access subspecialty care. They identified six major models and determined which of those six offered the best access:

Tin cup
Center providers rely on personal relationships with informal networks of subspecialists (the most prevalent model).
Hospital partnership
Center has a contract with a community hospital for subspecialty care.
Buy your own
Center hires subspecialists.
Telecommunications equipment is used to connect patients with subspecialists.
Teaching community
Centers train primary-care resident physicians and integrate subspecialists as faculty.
Integrated system
Centers are integrated with local government health systems or safety-net hospitals having subspecialist networks.Of the six, the researchers found that the “integrated system” model offered the most comprehensive access to subspecialty care.

Payment reform is needed to move community health centers toward becoming part of integrated systems. Two new initiatives of the Centers for Medicare and Medicaid Services (CMS) can help. First, the State Innovation Models initiative will provide $275 million for states to plan, design and test new payment and delivery system models that aim to involve all payers and providers in the state. Also, the CMS has issued guidance describing pathways for how states can design and implement integrated care models for Medicaid populations. The new research offers guidance for states in creating such models.

Katherine Neuhausen of the department of general internal medicine and health services research at the David Geffen School of Medicine at UCLA; Kevin Grumbach of UC San Francisco; and Andrew Bazemore and Robert L. Phillips of the Robert Graham Center for Policy Studies in Primary Care.

The research is published in the August issue of the journal Health Affairs.

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IOM committee to review GME

UCSF’s Kathy Dracup to serve on committee to address doctor shortage.

Kathy Dracup, UC San Francisco

Worsening physician shortages, an aging baby boomer population and expanding health insurance coverage as part of the Affordable Care Act have prompted the nation’s health policy experts to explore possible changes to the graduate medical education system.

The Institute of Medicine (IOM), the health arm of the National Academy of Sciences, is convening a new ad hoc committee to conduct an independent review of the system and make recommendations on how to better produce a medical workforce for the 21st century.

Kathy Dracup, R.N., Ph.D., dean emeritus of the UC San Francisco School of Nursing, is one of 21 IOM members appointed to the Committee on Governance and Financing of Graduate Medical Education, which will hold its first meeting on September 4 in Washington, D.C.

Dracup joins dozens of UCSF scientists and scholars who have served the nation by advising leaders on health policy and scientific research at national institutions. (See UCSF Goes to Washington)

At issue before the IOM committee is how federal funding, including more than $9 billion from Medicare last year, is spent on graduate medical education.

The review comes as the Association of American Medical Colleges projects a shortage of 45,000 primary care physicians and 46,000 surgeons and specialists by 2020. Medical schools have increased enrollments over the last six years, but the number of federally funded residency training positions has been frozen since 1997.

“We’re going to be looking at the data, at the health care needs of this country,” Dracup said. “If the federal government is going to support the education of medical professionals, where should that money be distributed and how should it be distributed?”

The IOM established the committee at the request of a bipartisan group of seven U.S. senators who were prompted by calls for review from influential health policy organizations, including the Medicare Payment Advisory Council (MedPAC), the Josiah Macy Jr. Foundation and the Association of Academic Health Centers. The institute then brought together a panel that included UCSF’s Associate Dean of Graduate Medical Education Robert Baron, M.D., M.S., to outline the issues that the committee would evaluate.

Joyce Ann Viloria, a medical resident, is training in UCSF's primary care urban underserved track at San Francisco General Hospital and Trauma Center. (Click image for larger view)

Among the issues that the educational system must adapt to are a rapidly aging and increasingly diverse patient population, the growing prevalence of disability and chronic disease, and new health care innovations, the panel found. The committee will be tasked with reviewing the current number of residents and graduate medical education slots against the number needed to address those issues.

“First, are the hospitals getting paid the right amount of money and producing residents who have the right skills for practicing in the 21st century? And second, do we have the right workforce mix to meet the needs of the public?” are among the questions to be answered, Baron said.

Among the issues that the educational system must adapt to are a rapidly aging and increasingly diverse patient population, the growing prevalence of disability and chronic disease, and new health care innovations, the panel found. The committee will be tasked with reviewing the current number of residents and graduate medical education slots against the number needed to address those issues.

“First, are the hospitals getting paid the right amount of money and producing residents who have the right skills for practicing in the 21st century? And second, do we have the right workforce mix to meet the needs of the public?” are among the questions to be answered, Baron said.

The financial debate focuses on a large pot of federal funds – about $3 billion – dedicated to “patient care payments,” which go toward the higher costs taken on by teaching hospitals to train residents. Hospitals are facing proposed cuts to that funding, while some are calling for greater accountability for the existing funds.

“There’s been a growing concern about whether the money from Medicare, in particular, was being spent appropriately,” Baron explained. “Is there sufficient value for the Medicare money being spent?”

For Dracup – one of only two representatives of nursing on the diverse committee – a major question will be whether more federal funds should be put toward training nurse practitioners to help carry the burden from the projected doctor shortage. The pressure will be even greater with 32 million Americans becoming newly insured under the Affordable Care Act, she noted.

“Graduate medical education funding does go partially for nursing education, and increasingly nurse practitioners are providing care and being forecast to provide more care for the people who are uninsured,” said Dracup, who saw severe cuts to state funding of nursing education while leading the School of Nursing for a decade.

“Nurse practitioners can provide many of the same services that physicians provide, and they provide them just as safely and at lower cost,” she said.

The committee plans to hold five meetings over 18 months before issuing its recommendations.

A total of 89 UCSF faculty members have been elected to the IOM – one of the highest honors in the fields of health and medicine. Election by existing members is a recognition of outstanding professional achievement and commitment to service, and with it, members are appointed to serve on standing committees that range in topics including obesity, family planning and workplace safety, as well as special committees.

What is GME?
GME is the second phase of the formal educational process that prepares doctors for medical practice. It typically takes at least 11 years beyond high school to educate physicians before they will practice independently — four years for a bachelor’s degree, four years for medical school and three to seven years for residency (GME). Medical residents train at teaching hospitals such as UC academic medical centers, where they receive supervised, hands-on training in clinical specialties such as pediatrics or surgery. A residency can be followed by a fellowship, during which time a physician
receives subspecialty training.

UC Health: Graduate Medial Education

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How does U.S. health care compare with United Kingdom, China?

UC Riverside School of Medicine Dean G. Richard Olds will participate in Aug. 8 panel discussion.

G. Richard Olds, UC Riverside

Dr. G. Richard Olds, the founding dean of the School of Medicine at the University of California, Riverside, will be a member of a panel that will focus on health care in the United States, the United Kingdom and China.

Free and open to the public, the interactive panel discussion, titled “Healthcare in the United States, United Kingdom and China,” will take place at 5:30 p.m., Aug. 8, 2012, at the Riverside Medical Clinic, 7117 Brockton Ave., Riverside.  Light refreshments will be served.

Olds will talk about designing a medical school for Inland Southern California.  He will be joined on the panel by the following people:

Dr. H.S. Dhillon, chair of the Department of Surgery at Riverside Medical Clinic, who will talk about the United Kingdom National Health Service of yesteryear (25 years ago);

Pawanjit Hare, a medical student at the University of Leeds, the United Kingdom, who will talk about the United Kingdom National Health Service of today;

Charles Sands, the dean of the College of Allied Health at the California Baptist University, who will discuss allied health and its effect on the quality of health care in the Inland Empire;

Dr. Albert Ma, vice chair of the Department of Anesthesiology at Riverside County Regional Medical Center, who will shed light on health care reform in China; and

Dr. Steven Larson, chief executive officer and medical director at Riverside Medical Clinic, who will talk about the “future and now” of the Inland Empire.

For more information, please call (951) 782-5177.

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Women’s health marks milestone with new preventive care benefits

Changes have “potential rippling effect on not just women’s health but also family’s health.”

Claire Brindis, UC San Francisco

Women’s health is marking a significant milestone Wednesday, as a law requiring health insurance plans to provide new preventive care benefits officially takes effect.

The benefits, adopted last year by U.S. Health and Human Services (HHS) Secretary Kathleen Sebelius, include allowing women access to annual preventive care doctor visits, support for breastfeeding equipment, domestic violence counseling, screening for human papillomavirus and contraception — all covered without a co-pay.

For UC San Francisco’s Claire Brindis, Dr.P.H., M.P.H., who served on the independent Institute of Medicine (IOM) that issued the report outlining eight key recommendations, the changes implemented Wednesday have a “potential rippling effect on not just women’s health but also family’s health.”

“It was an exciting opportunity to serve the nation and to really bring evidence to bear on women’s lives,” said Brindis, the director of the Philip R. Lee Institute for Health Policy Studies and a co-director of the Bixby Center for Global Reproductive Health. She was one of 16 health care experts on the IOM committee that wrote the 2011 report, titled “Clinical Preventive Services for Women: Closing the Gaps.”

“We really looked at where we failed to meet the needs of women and what acts as a barrier to getting access to health screenings,” she said.

“When we made the recommendations, we really did not know what was going to be the outcome, so it was extremely illuminating that all eight were adopted.”

According to an HHS report also released this week, approximately 47 million women are in health plans that must cover these preventive services at no charge. It’s being rolled out as part of the Patient Protection and Affordable Care Act (ACA) signed by President Barack Obama in 2010.

“President Obama is moving our country forward by giving women control over their health care,” Sebelius said in a statement. “This law puts women and their doctors, not insurance companies or the government, in charge of health care decisions.”

Despite cause for celebration, Brindis is cautious about challenges facing the new law, including a provision that allows some insurance providers to avoid implementing the changes for patients currently in plans. Only new and renewing plans must offer the new level of coverage, so it could take years before the benefits reach all women who are entitled to them.

Brindis also pointed to the ongoing opposition to the ACA in Congress as well as one of the most controversial provisions of the new law that requires health plans to provide free birth control to women. Courts are currently weighing lawsuits by the Catholic Church and religiously affiliated organizations, which are temporarily exempt from that provision.

“It’s this concern about government telling the church what they need to cover,” she said. “In fact, a very large proportion of Catholic women report that they use birth control, that they use contraception services.”

As the new benefits roll out, another challenge will be to educate women about these preventive services and measure its real-world impact, Brindis said. Medical and policy experts will be “keeping an eye on what’s the proof, that level of evidence, that incorporating these practices within the provision of health care actually contributes to health outcomes for women, as well as decreasing the cost,” she said.

And the work doesn’t stop there. The need to keep focusing on prevention, rather than after-the-fact treatment is more important than ever. For instance, Brindis cited studies showing that for every $1 spent on family planning, $10 are saved within 10 years.

“Health evidence is constantly being updated,” she said. “We need to have an infrastructure in place on an annual basis to look at whether there needs to be other preventive services that need to be incorporated into a health benefits package.”

Related link:
Focus on U.S. Supreme Court rules on health care law

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Considering stroke severity markedly changes hospitals’ stroke-care rankings

Reporting models for mortality that don’t consider stroke severity may unfairly skew results.

Gregg Fonarow, UCLA

As part of the Affordable Care Act, hospitals and medical centers are required to report their quality-of-care and risk-standardized outcomes for stroke and other common medical conditions. But reporting models for mortality that don’t consider stroke severity may unfairly skew these results.

Now, a UCLA-led national study has found that when reporting on 30-day mortality rates for Medicare beneficiaries hospitalized with acute stroke, using a model that adjusts for stroke severity completely alters performance outcomes and rankings for many hospitals.

The new findings, published in the July 18 issue of JAMA: The Journal of the American Medical Association, point to the critical need to include stroke severity in models used for reporting hospitals’ risk-standardized mortality rates.

The findings are especially relevant now, since the federal Centers for Medicare and Medicaid Services and other health care payers, such as private insurance companies, are considering including a 30-day mortality outcomes measure for acute stroke. Such risk models and performance rankings are used to assess the quality of care at hospitals, and if facilities don’t measure up, they may receive lower payments, would not be eligible for incentives and could even be fined.

Every hospital has a different mix of cases and severity levels when it comes to stroke patients. Larger hospitals — particularly those equipped with certified stroke centers, trauma units and neurological rehabilitation programs — tend to treat the more severe cases. Patients seen at these facilities are often sicker and have additional health issues, so they generally have higher mortality rates than less severe stroke patients. If the acuity of stroke cases isn’t taken into consideration, the researchers say, it can skew hospital mortality rates and outcomes measures.

“Without adjusting for stroke severity, the outcome measures may favor hospitals treating less severe strokes, regardless of whether these hospitals’ approaches to patient management contributed to better or worse patient outcomes,” said the study’s first author, Dr. Gregg Fonarow, UCLA’s Eliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson–UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA.

The research team found that more than a quarter (26.3 percent) of hospitals that ranked in the top or bottom 20 percent for risk-standardized mortality would be ranked differently using a model that adjusted for initial stroke acuity. Of those hospitals with “worse than expected” mortality, more than half were reclassified as having “as expected” mortality after adjusting for stroke severity. The esearchers found that a model that utilized a stroke severity measure demonstrated greater accuracy between actual and predicted mortality rates for Medicare stroke patients than a risk model that did not.

“Outcomes measures that do not adequately discriminate stroke mortality risk may lead to rankings based on these models that distort hospital profiling and quality assessment,” said study author Dr. Jeffrey Saver, a professor of neurology at the David Geffen School of Medicine at UCLA and director of the UCLA Stroke Center.

Fonarow also noted that it is important to carefully consider that rewarding or punishing hospitals for acute stroke outcomes on the basis of a risk model that doesn’t account for stroke severity may misalign incentives. As a result, hospitals may consider turning away patients with more severe strokes or transferring them to other hospitals after they’ve been assessed by the emergency department to avoid being misclassified as having a higher mortality risk.

For the study, the researchers used data from 782 hospitals participating in the American Heart Association/American Stroke Association’s Get With the Guidelines–Stroke (GWTG–Stroke) quality-improvement program between April 2003 and September 2009.

Specifically, they looked at 127,950 fee-for-service Medicare beneficiaries who were hospitalized for stroke and whose initial acuity level had been assessed with the National Institutes of Health Stroke Scale (NIH Stroke Scale), a bedside tool used by doctors and nurses to evaluate the effects of strokes on various areas, including consciousness, language, motor strength and sensory loss. The team also utilized corresponding administrative claims that were obtained from the Centers for Medicare and Medicaid Services.

The team compared hospitals’ 30-day mortality risk models with and without the NIH Stroke Scale information and assessed whether the hospitals performed “better than expected,” “as expected” or “worse than expected.” The researchers found that of the hospitals initially classified as having “worse than expected” mortality, 57.7 percent were reclassified to “as expected” mortality by the model with the NIH Stroke Scale.

“We found that a hospital’s variance from its expected, risk-standardized 30-day mortality outcomes, relative to its peers, frequently changed based on which risk-adjustment model was applied,” Fonarow said.

The researchers also ranked hospitals using both risk models to reflect a top 20 percent, a middle 60 percent and bottom 20 percent — all categories that are commonly used in pay-for-performance programs in which the top performers are eligible for bonus payments and the bottom performers may receive a lower penalty payment.

More than 40 percent of hospitals identified in the top or bottom 5 percent for risk-adjusted mortality would have been reclassified into the middle mortality range using a NIH Stroke Scale model, the researchers said.

“The inclusion of stroke severity may be essential for optimal ranking of hospitals with respect to 30-day mortality,” Fonarow said. “Such an outcomes measure has the potential to give both patients and clinicians important feedback concerning a hospital’s quality of care.”

A critical question confronting clinicians, hospitals, payers and policymakers is whether current and emerging measures that assess 30-day mortality are adequate for public reporting and for use in rewarding and penalizing hospitals.

The researchers noted that not all conditions need to include a clinical severity index to achieve accurate 30-day mortality risk profiling. According to Fonarow, heart attack, heart failure and pneumonia are examples of conditions for which risk models based on health insurance claims data alone have demonstrated adequate performance when compared with clinically derived data — unlike stroke. As stroke severity has been shown to be a key determinate of outcomes, it logically follows that a measure of stroke severity would be essential for optimal discrimination of risk, he said.

Fonarow added that it may take more time and a requirement from Medicare to incorporate initial stroke severity into the data-collection system. During this study, the researchers found that the NIH Stroke Scale information was recorded for only 50.7 percent of patients hospitalized for acute stroke nationwide.

The authors noted some limitations of the study, including the fact that only fee-for-service Medicare beneficiaries age 65 or older were studied and that outcomes other than 30-day all-cause mortality were not accessed.

The research, funded by the American Heart Association/American Stroke Association’s Get With the Guidelines–Stroke program, is currently supported by a charitable contribution from Janssen Pharmaceutical Companies of Johnson & Johnson. The program was previously supported by Boeringher–Ingelheim, Merck, a Bristol-Myers Squib/Sanofi Pharmaceutical Partnership and the Amercian Heart Association Pharmaceutical Roundtable.

Industry sponsors of GWTG–Stroke had no role in the design or conduct of the study; the collection, management, analysis or interpretation of the data; or the preparation, review or approval of the manuscript.

Author disclosures are included in the manuscript.

Other authors included Wenqin Pan, Ph.D.; Eric E. Smith, M.D., M.P.H.; Mathew J. Reeves, Ph.D.; Joseph P. Broderick; Dawn O. Kleindorfer, M.D.; Ralph L. Sacco, M.D.; DaiWai M. Olson, Ph.D.; Adrian F. Hernandez, M.D., M.H.S.; Eric D. Peterson, M.D., M.P.H.; and Lee H. Schwamm, M.D.

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California prepares to enact Affordable Care Act provisions

Medi-Cal expansion, creation of health benefit exchange have already begun in the state.

Ed Yelin, UC San Francisco

Long before the U.S. Supreme Court’s landmark June 28 decision on health care reform, California already had begun moving to expand Medi-Cal coverage for low income residents. The state also was the first to begin setting up an exchange through which others could obtain health insurance — all in preparation of reforms that will be enacted starting January 2014 under the federal Patient Protection and Affordable Care Act.

While the Supreme Court ruling largely let the law stand, a provision through which the federal government intended to withhold federal funds from states that fail to expand their Medicaid programs for low-income residents was struck down.

Whether strapped for funds or politically opposed to the reform act and hoping for a repeal if Republicans were to sweep November elections, elected officials in some states may be inclined to avoid expanding their coverage of the poor or establishing exchanges. But despite incessant budget woes and political gridlock, California politicians and administrators are not among those resisting the changes.

Medicaid expansion

In fact there are strong financial incentives for states to expand coverage under the controversial federal law, said Ed Yelin, Ph.D., professor of medicine and health policy with the UC San Francisco Philip R. Lee Institute for Health Policy Studies.

“As with everything in the law, for the Medicaid provisions there were two approaches — the carrot and the stick,” he said. “The penalties that were challenged were only part of it; there was also a carrot — the federal government would pay for 100 percent of the expansion for the first couple of years and 90 percent thereafter.”

Under a proposal approved by the federal government in November, 2010, California was granted $10 billion in federal funds over five years to help it move toward meeting requirements of federal health care reform for Medicaid programs, according to the state’s Department of Health Care Services. To permit the state to innovate, the federal government granted a waiver of the usual requirement that Medicaid programs be administered uniformly throughout the state. Under the waiver the state could implement new types of programs locally.

Under the waiver, the state, through its Medicaid program — called Medi-Cal — is working with counties to expand coverage for low-income households, as will be mandated by the Affordable Care Act. In addition, the state is implementing the Health Care Coverage Initiative to provide assistance for adults between ages 19 and 64 with incomes between 134 percent and 200 percent of federal poverty level.

Many seniors and individuals with disabilities who are eligible for Medi-Cal are being moved into managed care programs, which often are based on a patient-centered, “medical home” model that emphasizes continuity of care, primary care and prevention.

According to Susan Currin, M.S., R.N., chief executive officer of San Francisco General Hospital and Trauma Center, “As members of the California Association of Public Hospitals, San Francisco General and all the UC system, including the UCSF Medical Center, are part of the waiver, and it really allowed us to get ready for health care reform.”

“We have been working since 2010 on developing more of a medical home model to increase access to primary care. We’ve been able to address many quality issues, and to really get our systems in place to help us in the future.”

“Right now, as the state continues putting together the health benefit exchange, there is a lot of discussion going on about access to a basic health plan for people with incomes above what qualifies for Medi-Cal eligibility,” Currin said.

“It’s tricky,” she added, especially in considering benefits for those with incomes at 200 percent of poverty level or less.

“They don’t have a lot of money,” she said. “You want to make it affordable enough so that they choose to be covered and to not be penalized for not obtaining coverage.”

“Before the 2010 waiver, Currin said, “We didn’t really have funding to put into place the systems needed to coordinate care and to provide more access to patients. In addition, we now have increased the number of primary care residents, because we see the need to have more primary care physicians out in the community. That was part of the waiver, too.”

“The state really understands the need to control costs, but also to give more access to people who don’t have care, and to have that care be coordinated in a way that is not wasteful.”

Health benefit exchanges

Exchanges are intended to be marketplaces through which individuals and small businesses are expected to be able to buy competitively priced health plans, backed by federal tax subsidies and credits.

The federal government awarded the state $39 million in August 2011 — to create a three-year business and operational plan, to start development of information technology infrastructure, and to conduct consumer outreach.

At a June 29 UCSF panel discussion on the Supreme Court’s decision, Jaime King, J.D., Ph.D., a professor at UC Hastings College of the Law, discussed exchanges and litigation surrounding the act. While 27 states have starting planning, “Lots of states have been sitting on their hands,” she said.

In the aftermath of the Supreme Court’s decision to uphold the law, she said, “A lot of states are shocked.”

Shocked or not, leaders of all states must present blueprints to the federal government within days of the November elections, King said. “If they can’t develop their own state exchanges, they will have less power to tailor them to their needs, and the federal government will run them.”

As explained by Janet Coffman, Ph.D., assistant adjunct professor with the UCSF Philip R. Lee Institute for Health Policy Studies, states have the flexibility to decide whether to have one or two exchanges. “One population is individuals who do not have coverage through their jobs, and there is a second group who are employees for small businesses, which will be eligible to buy insurance through the exchanges,” according to Coffman.

Families who earn more than allowed under the new, higher income cutoff for Medicaid eligibility, but who take home no more than 400 percent of poverty-level earnings, will receive subsidies for insurance premiums purchased through the exchange, as well as deductions for co-payments and other forms of cost-sharing, Coffman said. “It’s likely to be more affordable than what they can get on their own,” she said.

“Health insurers will no longer be permitted to deny or refuse to renew coverage for persons with pre-existing conditions,” Coffman added. Health status should not affect premiums except for smokers.” The law does allow for some variation in premiums based on broad age categories, family size, and geographic location, she said.

The exchanges will fill an important gap in access to health insurance, according to Coffman. “Currently, it is very difficult for persons to obtain affordable health insurance unless they can get it through their jobs or are eligible for Medicare or Medi-Cal, which are available only to senior citizens, persons with disabilities and some persons with low incomes.”

Insurance exchanges and reimbursement

Insurance companies are not forced to offer plans through the exchanges, Coffman said. But based on her tracking of state health care reform legislation that was being championed by some state legislators in 2007 while Arnold Schwarzenegger was governor — which she views as having been similar to the Affordable Care Act — Coffman expects that if states build the exchange, insurance providers will come.

The work being done by the state now is “predicated on the assumption that private health insurers will want to sell products through the exchange,” she said. “I think it is likely that some health plans will be participating.”

Hospitals and health care providers also need to participate for the reforms to be a success, said panel speaker Andrew Bindman, M.D., professor of medicine, health policy, epidemiology and biostatistics at UCSF, director of the University of California Medicaid Research Institute and director of UCSF’s Primary Care Research Fellowship. As it stands, many practices will not accept Medi-Cal patients.

Part of the reason for this is that California has “among the lowest reimbursement rates in the country,” for Medicaid programs Bindman said at the UCSF forum. “The state continues to be in court arguing for lower provider reimbursement rates,” he said.

It is important that more physicians choose to practice primary care, according to Bindman. “We have been facing declining interest in primary care,” he said. Patients are likely to take advantage of improved access to health care. “Deferred health care may increase demand,” Bindman said, “increasing the need for health care providers.”

Along with the demand for primary care physicians, the need for other health professionals, including advanced practice nurses, is expected to increase, according to David Vlahov, Ph.D., R.N., dean of the UCSF School of Nursing.

“The new law increases the need for advanced practice nurses, because there are millions of previously uninsured people who are gaining access to health care, and nurses are appropriate providers to expand quality care,” he said. “Advanced practice nurses with physicians and other health professionals will step up to meet the need not only in primary care, but also in specialty care, inpatient care, outpatient care and community health.”

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UC Berkeley experts diagnose health care reform

Legal, policy, economic experts discuss Supreme Court ruling on the ACA.

UC Berkeley panel discussion

On the first Monday after the Supreme Court’s decision on the Patient Protection and Affordable Care Act, a half-dozen UC Berkeley experts in constitutional law, public policy, economics, and health law and policy rendered their judgments on the ruling during a panel discussion at Berkeley Law. Health care economics, the challenges of implementing a complex law about which the public is deeply divided and the powerful role of politics were all put under the X-ray.

Calling Republican outrage over the ruling “all about politics,” moderator John Ellwood, a professor of public policy, noted that challenges to the ACA were raised “within a nanosecond” of its signing by President Obama in March 2010. For starters, numerous states challenged provisions on expanding healthcare coverage under Medicaid, the program that covers vulnerable individuals of limited means and is funded jointly by the federal government and the states. (The high-court justices, by a 7-2 vote, nullified the federal government’s ability to withhold all Medicaid funding for states that fail to expand Medicaid coverage under the reform.)

Now, in the wake of the decision upholding the law’s so-called individual mandate, “The Republicans are committed to repealing the Affordable Care Act,” Ellwood said. The path to do that would be clear were they both to regain the presidency and take control of the House and Senate in the fall election, he added. Short of that development, it’s still “going to be very messy,” he predicted. The reform’s determined opponents will wage a long campaign to “strangle ACA — and in the process, they’ll make it very inefficient.”

Constitutional-law expert Jesse Choper said that one of the most significant implications of the high-court ruling is in limiting Congress’s power to “make all laws which shall be necessary and proper” for executing its enumerated powers. “It’s the first time in 100 years that the court has put an important limitation on the ‘necessary and proper’ clause,” he said.

Several panelists gave a nod to the law’s potential to significantly expand access to health care. But “whether or not the expanded coverage is going to be affordable in the long run, that is the central question now,” said Stephen Shortell, dean of public health.

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Supreme Court ruling on Medicaid causes concern

Health disparities could grow across the nation.

Helene Levens Lipton, UCSF

As Thursday’s Supreme Court ruling on the health care law is examined, experts are citing concerns about the Medicaid decision, which could end up insuring fewer Americans as states opt out of expansion.

The high court ruled that the Affordable Care Act could not force states to extend Medicaid coverage to 16 million Medicaid patients by threatening to withhold federal funding. The act’s provision to expand Medicaid, scheduled to take effect in 2014, is key to insuring more Americans.

Medicaid serves U.S. citizens or legal permanent residents, including low-income adults, their children, and people with certain disabilities. Poverty alone does not necessarily qualify someone for Medicaid, which is the largest source of funding for health care services for people with limited income in the nation.

“This ruling is disappointing because now some states will be able to opt out of providing health insurance to the most vulnerable among us, our nation’s poor,” said Helene Levens Lipton, Ph.D., a professor of health policy in the UC San Francisco School of Pharmacy’s Department of Clinical Pharmacy and faculty member of the Philip R. Lee Institute for Health Policy Studies in the UCSF School of Medicine.

“The beauty of the health care law as it was written is that it had a ‘stick’ to states that opt out of Medicaid expansion by running the risk of losing the federal share of the state’s Medicaid dollars,” she said. “Now that stick is gone.”

Ed Yelin, Ph.D., professor of medicine and health policy in UCSF Institute for Health Policy Studies, says the federal financial incentives for expanding Medicaid remain.

“As with everything in the law, for the Medicaid provisions there were two approaches — the carrot and the stick. The penalties that were challenged were only part of it; there is also a carrot — the federal government would pay for 100 percent of the expansion for the first couple of years and 90 percent thereafter.”

Yellin, who has been a longtime policy expert at UCSF, says one of the reasons the Affordable Care Act received support is because it aims to insure more people. “When President Clinton tried in the early 1990s to reform the health care system, he didn’t have the support of the health insurance industry, the hospitals or the doctors on board. The reason that they came on board this time is that with the growth in the proportion of the population that is uninsured, it became untenable for health care institutions and individual providers to provide free care for the uninsured.”

As cash-strapped states decline to expand coverage, Lipton is concerned that health disparities across the country will increase. Medicaid coverage already varies widely from state to state as the criteria for eligibility and the scope of benefits differ. Even California is cutting back on Medicaid funding, she said.

“California has a generous history of coverage in terms of benefits and choice of provider, but even here, the state has been slicing and dicing away at Medi-Cal in the face of the huge deficits,” she said.

Lipton asserts that this issue will need further analysis and discussion in the coming weeks and months.

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