Daily Health Policy Report

Friday, September 19, 2014

Last updated: Fri, Sep 19

KHN Original Reporting & Guest Opinion

Health Reform

Capitol Hill Watch

Health Care Marketplace

Veterans Health Care

Health Information Technology

Administration News

State Watch

Health Policy Research

Editorials and Opinions

KHN Original Reporting & Guest Opinion

How Much Does That X-Ray Cost? You Can Find Out In New Hampshire

Kaiser Health News staff writer Julie Appleby reports: “New Hampshire is among 14 states that require insurers to report the rates they pay different health care providers —and one of just a handful that makes those prices available to consumers. The theory is that if consumers know what different providers charge for medical services, they will become better shoppers and collectively save billions. In most places, though, it’s difficult, if not impossible to find out how much you will be charged for medical care. And with more people enrolled in high-deductible insurance plans, there is a growing demand for accurate price information” (Appleby, 9/18). Read the story, which also ran in the Miami Herald.

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For Autistic Adults, Coverage Options Are Scarce

Kaiser Health News consumer columnist Michelle Andrews writes: “It’s getting easier for parents of young children with autism to get insurers to cover a pricey treatment called applied behavioral analysis. Once kids turn 21, however, it’s a different ballgame entirely” (Andrews, 9/19). Read the story.

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Miami-Dade County, Like Many Employers, Denied Tools To Trim Health Costs

The Miami Herald's Daniel Chang, working in partnership with Kaiser Health News, reports: "Last year, Miami-Dade County employees, retirees and dependents cost the county’s health plan about $2.25 million for medical procedures that fell under an obscure-sounding category called 'major joint replacement or reattachment of lower extremity,' according to AvMed Health Plans, manager of the county plan. But even though at least eight hospitals provided the service — which could range from a hip replacement to reattachment of a foot — no two hospitals were paid the same amount" (Chang, 9/19). Read the story.  

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Political Cartoon: 'I'm Referring You To An Arrrrrthopedist?'

Kaiser Health News provides a fresh take on health policy developments with ''I'm Referring You To An Arrrrrthopedist?" by Dan Piraro.

And here's today's health policy haiku:


Are they transparent?
Or opaque? The challenge of
decoding health costs...

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

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Health Reform

7.3 Million Who Picked Exchange Plans Paid Their Premiums

That number, which reflects the tally of people who obtained insurance via the health law, fell slightly from the estimated 8 million mark that was released in the spring. It means that at least 700,000 consumers who initially signed up for a health plan let it go.

The New York Times: Health Care Act Still Covers 7.3 Million
The Obama administration said Thursday that 7.3 million people who bought private health insurance under the Affordable Care Act had paid their premiums and were still enrolled. Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, disclosed the latest count at a hearing of the House Committee on Oversight and Government Reform (Pear, 9/18).

Los Angeles Times: Obamacare Enrollment Falls Slightly To 7.3 Million In August
Enrollment in health plans offered through the Affordable Care Act dropped slightly through this year, falling from about 8 million this spring to 7.3 million in mid-August, the Obama administration announced Thursday. The tally represents the first update the administration has provided since the April close of the open enrollment period (Levey, 9/18).

The Wall Street Journal: Obama Administration Says 7.3 Million Who Picked Health Plans On Exchanges Have Paid Premiums
The Obama administration said Thursday that 7.3 million people who picked health plans through the new insurance exchanges had paid premiums and retained their coverage as of mid-August, suggesting that at least 700,000 people who signed up for coverage earlier this year later let it go. The number of people with paid-up coverage has long been the subject of contention. ... Paying is the final step necessary for people to enroll in coverage (Radnofsky, 9/18).

Politico: 7.3 Million In Obamacare Plans, Beats CBO Forecast
The administration’s announcement that 7.3 million people are now enrolled in health insurance plans on the Obamacare exchanges immediately ignited a new round of arguments about the success or failure of the health law. ... But it’s much higher than the 6 million that the Congressional Budget Office forecast would be covered this year, a number that seemed unattainable when the botched launch of HealthCare.gov slowed signup to a crawl last October (Haberkorn, 9/18).

The Associated Press: Health Law Enrollment Now 7.3M
As expected, the latest figures showed slippage. Insurers had said that about 10 percent of their new policyholders failed to seal the deal by paying their first month’s premium. Tavenner, whose agency oversees HealthCare.gov, said the new count represents paying customers as of Aug. 15. She expects total enrollment to remain basically stable until the next open enrollment season starts Nov. 15 (9/18).

McClatchy: HHS Says 700,000 Have Lost Insurance Coverage Since May
After enrolling more than 8 million people into marketplace health insurance this year, roughly 700,000 have lost their coverage, Medicare administrator Marilyn Tavenner testified Thursday before Congress. Her surprise disclosure came during a House Oversight and Government Reform Committee hearing in which Republicans blasted Tavenner about a lack of transparency and ongoing data security problems with the HealthCare.gov website (Pugh, 9/18).

Bloomberg: Obamacare Enrollment Reaches 7.3 Million In August
The figure, announced by Marilyn Tavenner, administrator of the Centers for Medicare and Medicaid Services, is 9 percent lower than the government’s estimate in May that 8 million had signed up for Obamacare plans. That estimate didn’t reflect how many people had paid their premiums and were actually covered by health insurance. The number has been long sought by Republican lawmakers who oppose the law. Tavenner released the new figure at a hearing yesterday by the House Oversight and Government Reform Committee in Washington, where Republicans opposed to the Patient Protection and Affordable Care Act peppered her with questions about the security of the insurance website and the destruction of e-mails she wrote before the site opened for business (Wayne, 9/9).

In other coverage-related news -

Oregonian: Oregon's Uninsurance Rate Cut More Than Half Following Federal Health Reforms, Researchers Say
The number of uninsured Oregonians has dropped 63 percent, from 550,000 to 202,000 people, since national health care reforms took effect, researchers say. An estimated 95 percent of Oregonians now have health coverage, up from 86 percent last year, according to a study released Thursday by Oregon Health & Science University and the Oregon Health Authority. The study results echo the anecdotal experiences of local hospitals and other providers, which say they've seen a huge drop in uninsured patients (Budnick, 9/18).

And on the Medicare Advantage front -

Reuters:  U.S. Says Medicare Advantage Enrollment At All-time High
Elderly Americans have enrolled in privately managed Medicare health plans in record numbers even as average premiums continue to rise, the U.S. Centers for Medicare and Medicaid Services (CMS) said on Thursday. The agency said the average Medicare Advantage premium would increase by $2.94 a month next year, to $33.90 per month, but 61 percent of enrollees will not see any premium increase at all. Based on Medicare Advantage bids, CMS projects that plan enrollment will grow to just over 16 million in 2015 from 15.6 million this year, an increase of 3.17 percent, spokesman Raymond Thorn said in an emailed statement (9/18).

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Will Illinois Build State Exchange? Calif. Exchange Neutral On Prop 45

Time is running out for deadlocked Illinois lawmakers to build a state-based exchange. Meanwhile, California exchange officials stay neutral on a ballot initiative to allow the state insurance commissioner to regulate rates, and MNsure is back in the political fray.

Chicago Tribune: Clock Ticking For Illinois To Form State-Run Obamacare Exchange
Unless Illinois acts quickly, it will leave hundreds of millions of federal dollars on the table that would go toward building its own health insurance marketplace, potentially upping the cost of coverage for nearly 170,000 Illinois residents. State lawmakers, unable to break a years-long standoff, have not passed a law authorizing a state-based exchange, the marketplaces created under the Affordable Care Act that allow consumers to compare and buy health coverage, often with the help of federal tax credits. As a result, Illinois was one of 36 states that relied on the federal government to host its marketplace on HealthCare.gov, the website that survived a disastrous launch late last year to enroll about 217,000 Illinoisans, 77 percent of whom received federal help (Frost, 9/18).

Sacramento Bee: California Health Exchange Stays Neutral On Proposition 45
After months of intense discussions, California’s health insurance exchange on Thursday remained on the sidelines of a Nov. 4 ballot initiative that would allow the state’s elected insurance commissioner to regulate rates. Covered California Board Chairwoman Diana Dooley, secretary of the Health and Human Services Agency, acknowledged the many concerns of the exchange and its more than 1 million consumers should Proposition 45 be approved. Among the impacts are its potential to interfere with the exchange’s role negotiating with health insurers, possible delays caused by third-party rate-challengers, unforeseen effects on federal subsidies and the risk of plans pulling out of the program. But taking a formal position against the measure could undermine the agency’s efforts to largely remain above the political fray as it enters its second year of the federal health care overhaul, Dooley said at the board’s meeting in Sacramento (Cadelago, 9/18).

California Healthline: San Diego Gearing Up For Targeted Outreach In Second Open Enrollment
Despite enrollment glitches and consumer complaints over limited and hard-to-decipher health care provider networks, the first year of coverage under the Affordable Care Act has been positive in many ways for the San Diego health care community, according to experts and stakeholders. "We have seen a decline in the number of patients that are self-pay with no insurance," said Marc Reynolds, senior vice president for payer relations with Scripps Health System. That situation is likely to improve for providers in 2015. According to Reynolds, Scripps will be in more insurers' networks next year than in 2014, potentially expanding its access to more than 75% of Covered California participants (Zamosky, 9/18).

Minneapolis Star Tribune: MNsure Back At Center Of Political Debate As Johnson, Dayton Tussle Over Issue
The decision this week by MNsure’s top-selling insurance company to withdraw from the state exchange injected Minnesota’s health care exchange efforts back into the political debate as the November election nears. Republican gubernatorial candidate Jeff Johnson sharply criticized Gov. Mark Dayton on Thursday over his management of MNsure, using its struggles as a means of questioning the incumbent DFLer’s competence on the job. Dayton has repeatedly apologized for the troubled launch of MNsure, but has talked up its benefits while charging that Johnson “doesn’t know what he’s talking about” on the issue (Condon, 9/18).

Minneapolis Star Tribune: More Than 40 Percent Of Minnesotans Rate MNsure A Failure
More than 40 percent of Minnesotans say the state’s online health insurance exchange, MNsure, has been a failure in its first year, according to a Star Tribune Minnesota poll (McGrath, Hargarten and Hutt, 9/18).

Minnesota Public Radio: ‘Routine’ Updates Frustrate MNsure Clients
Is your baby married? It's a ridiculous question. But if you just had a baby and went to MNsure to update your family status, the health exchange website may ask you anyway. That kind of routine update is proving to be a big problem for MNSure and the Minnesotans using it to buy health coverage (Sepic, 9/18).

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Va. Legislators Return To Bitter Medicaid Expansion Debate, Kill Plan Without Formal Vote

Elsewhere, Utah Gov. Gary Herbert may be gaining ground in Washington with the state's alternative Medicaid expansion plan, but the concept still faces opposition at home. 

The Washington Post: Va. Legislators Approve Budget Deal, Reject Medicaid Expansion
State legislators united across party lines Thursday to plug a $2.4 billion hole in the state budget but quickly reverted to bitter partisanship as they debated Medicaid expansion, with House Republicans ultimately killing a bill to expand the health-care program without giving it a formal vote (Vozzella and Weiner, 9/18).

The Associated Press: GOP Resistance To Herbert’s Medicaid Plan Remains
Gov. Gary Herbert says he's made great progress negotiating an alternative Medicaid expansion plan with officials in Washington, D.C. But he may still have a tough sell at home. Some Republican state lawmakers remain skeptical of the plan and a watered-down requirement that participants work in exchange for health coverage. Federal officials won't allow a work requirement, but Herbert says they're open to a "work effort" that funnels people into job search and training programs. That evolution is frustrating, Rep. Francis Gibson, R-Mapleton, said Thursday at a meeting of the state's Health Reform Task Force (Price, 9/18).

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Capitol Hill Watch

Health Law, Medicare Remain Hot Topics In Campaign Commercials

Politico reports that, although the health law and other related issues may not be the flashpoints they were in other recent election years, they still have muscle on the campaign trail. For instance, Kentucky's Senate candidates both are running Medicare ads. In Georgia's Senate race, rural health care is part of the buzz.

Politico: Firm: Health Care Still Big In Midterms
It may not pack the punch it did a few years ago, but health care is still a potent issue in the battle for the Senate this fall. So says an analysis Thursday by the Republican data firm Deep Root Analytics that reported the issue -- which includes Obamacare and Medicare -- has been the subject of more campaign commercials than any other (Hohmann, 9/18).

The Associated Press: New KY Senate Campaign Ads Target Medicare
Kentucky's U.S. Senate candidates turned their attention to Medicare on Thursday with a pair of statewide TV ads targeting the state's roughly 800,000 seniors who benefit from the government health insurance program. Democrat Alison Lundergan Grimes turned to her grandmother once again for a starring role, only this time it was a serious discussion about her grandfather's stroke in 2000. Elsie Case, who appeared in a popular ad during Grimes' 2011 run for Secretary of State, talked about the financial pressure caused by her husband's stroke in 2000. Grimes comes from a wealthy family. Her father owns several successful businesses, and records show her family has made political contributions of more than $100,000 over the years. But in a statement released by the campaign, Case said she and her husband, who died in 2010, have always been proud people and "we wanted to do it on our own." "This is why we have to strengthen Medicare. Senator McConnell has voted over and over again to raise seniors' Medicare costs. I'll never do that," Grimes said. McConnell's campaign responded quickly with an ad on the air by midafternoon designed to show his compassion for seniors dealing with health issues (Beam, 9/18).

Georgia Health News: What Nunn, Perdue Have To Say About The Rural Care Crisis
Rural health care -- and what to do about it -- has emerged as a political issue during this election year. The topic has gained traction in the wake of four rural Georgia hospitals closing in the past two years over financial difficulties. Many others have severe cash flow problems, and rural counties have an extreme shortage of primary care physicians. A large percentage of residents have chronic health conditions. Michelle Nunn and David Perdue, in a tight race for a U.S. Senate seat in Georgia, have widely differing solutions to this crisis. In an updated election guide, produced by Healthcare Georgia Foundation, the two candidates answer a new question about rural health care (Miller, 9/18).

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Health Care Marketplace

Demand For $84,000 Hepatitis C Drug Slows

Health care providers may be waiting for other, soon-to-be-released drugs to treat hepatitis C. Also, an Indian pharmaceutical company faces Justice Department questions on pricing data for Medicaid.

The Washington Post’s Wonkblog: The New $84,000 Hepatitis C Treatment Is Losing Momentum, For Now
After recording the best launch of any drug in history, it looks like the pace is starting to slow down for Gilead Sciences' Sovaldi -- the new $84,000 hepatitis C cure that's sparking a new focus on specialty drug costs. Data released by CVS Health on Tuesday show that use of Sovaldi has slowed down since May after the drug's record-setting start last December. The slowdown can partly be explained by the health-care industry's anticipation of more hepatitis C treatments soon hitting the market, including another one from Gilead that could gain FDA approval any day now (Millman, 9/18).

Bloomberg: Indian Pharmaceutical Drug Prices Questioned By Justice Department
Indian generic drugmaker Ranbaxy Laboratories Ltd. (RBXY) was questioned by the U.S. Department of Justice on how it reports pricing data for medicines it sells through Medicaid, the U.S. health program for the poor. The Justice Department has requested documents and information through what is called a civil investigative demand. The inquiry doesn’t allege wrongdoing or propose a fine, the Gurgaon, India-based company said in a statement today. Ranbaxy said it would cooperate. Ranbaxy is being bought by Sun Pharmaceutical Industries Ltd. It has been hurt by import bans on four of its Indian facilities and increased regulatory costs. This year it also received a subpoena from the U.S. Attorney for the District of New Jersey requesting documents related to its banned ingredient factory in Toansa  (Gokhale, 9/17

The Wall Street Journal’s Pharmalot: Ranbaxy Faces Medicaid Pricing Probe By The Justice Department
Manufacturing woes are not the only issue plaguing Ranbaxy Laboratories. The generic drug maker has been asked by the U.S. Department of Justice to provide documents on pricing data provided to Medicaid, according to a filing with the Bombay Stock Exchange (Silverman, 9/18).

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When It Comes To Health Prices, Getting Information Is Difficult

New Hampshire is one of a handful of states that requires disclosure of health care prices. Also, The Miami Herald continues its coverage of the problems Miami-Dade County has in trying to get details about what it spends on health care for workers.

Kaiser Health News: How Much Does That X-Ray Cost? You Can Find Out In New Hampshire
New Hampshire is among 14 states that require insurers to report the rates they pay different health care providers—and one of just a handful that makes those prices available to consumers. The theory is that if consumers know what different providers charge for medical services, they will become better shoppers and collectively save billions. In most places, though, it’s difficult, if not impossible to find out how much you will be charged for medical care. And with more people enrolled in high-deductible insurance plans, there is a growing demand for accurate price information (Appleby, 9/18).

Miami Herald: Health Care Price Averages Don't Give Miami-Dade Tools To Cut Costs    
Last year, Miami-Dade employees, retirees and dependents cost the county’s health plan about $2.25 million for medical procedures that fell under an obscure-sounding category called "major joint replacement or reattachment of lower extremity," according to AvMed Health Plans, manager of the county plan. But even though at least eight hospitals provided the service — which could range from a hip replacement to reattachment of a foot — no two hospitals were paid the same amount. ... The numbers, provided by AvMed, offer some insight into Miami-Dade’s employee health benefits expenses. But healthcare experts and hospital administrators say that because they are averaged payments, they also obscure details that would allow the county to truly understand and manage its labor healthcare costs (Chang, 9/18).

Meanwhile, Marketplace takes a critical look at corporate wellness programs -

Marketplace: The Shortcomings Of The Corporate Wellness Program
Corporate wellness programs have become a $6 billion industry for one, possibly flawed, reason: they help reduce companies' healthcare costs, while saving their employees money. To some degree, they have been a success. Growth in premiums has hit its lowest point in the last 16 years. A new survey by the Kaiser Family Foundation shows that 71 percent of employers believe corporate wellness programs are either "very" or "somewhat" effective at reducing spending on providing benefits for their employees, who would be rewarded with these benefits by meeting various incentives. But companies can also impose a penalty. They can charge an employee more for smoking or being overweight. It's the very reason why, says Professor Nancy Koehn of the Harvard Business School, these programs don't work (Ryssdal, 9/18).

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Veterans Health Care

In A Change, VA Auditor Says Wait Times May Have Played A Role In Deaths

In testimony before the House Committee on Veterans' Affairs, Acting Inspector General Richard Griffin says that delays in getting treatment at some VA centers may have been a factor in the deaths of some veterans.

CNN: VA Inspector General Admits Wait Times Contributed To Vets' Deaths
In a stunning reversal, the VA's acting inspector general now says that long wait times at VA health care facilities in Phoenix did contribute to a number of veterans' deaths. In a hearing before the House Committee on Veterans' Affairs Wednesday, Acting Inspector General Richard Griffin was grilled by lawmakers about the findings of his office's August report, which stated that while the investigation into 40 veterans' deaths found "poor quality of care," the office was "unable to conclusively assert that the absence of timely care caused the death of these veterans" (Devine and Bronstein, 9/18).

The Arizona Republic: Auditor Ties VA Waits To Deaths
The Department of Veterans Affairs' internal watchdog testified Wednesday that delayed treatment for thousands of Arizona veterans may have contributed to some deaths, a strikingly different emphasis than in an August report on the Phoenix VA medical center that emphasized that delayed care had not conclusively caused patient fatalities. In a frequently contentious hearing before the House Committee on Veterans' Affairs, acting Inspector General Richard Griffin defended his Aug. 26 report on the Phoenix VA Health Care System against criticism that the findings amounted to a "whitewash" to downplay the impact of delayed medical care on Arizona patients. "We are scrupulous about our independence and take pride in the performance of our mission," Griffin insisted while being grilled by lawmakers (Wagner, 9/17).

CQ Healthbeat:  VA Secretary Vows Action To Instill Accountability
Veterans Affairs Secretary Robert McDonald told a House panel Wednesday that he was "taking all the actions the law allows me to take" to instill accountability at the department and respond to a final inspector general report on allegations of scheduling manipulation and patients deaths at the facilities in Phoenix. In his first appearance before the House Veterans' Affairs Committee, McDonald said his department had put together proposals that are under review by the Office of Management and Budget, after analyzing the laws governing the VA. He declined to specify those proposals (O’Brien, 9/18).

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Health Information Technology

Some Doctors Could Face Stiff Fines Because Of Shifting CMS Rules

The physicians, who have already spent millions of dollars to set up electronic health record systems, could now face penalties because of a timing glitch in federal rules.

Politico: CMS Glitch Could Cost Doctors Millions
Physicians who just spent hundreds of millions of dollars to install new electronic health record systems will face millions in federal penalties due to a technical glitch that affects their compliance with a federal program, vendors and doctors say. "It's beyond understanding why we’d be penalized after making such an investment," said Dr. Jonathan Lowry, an eye specialist and surgeon at Morganton Eye Physicians in western North Carolina. "This was not our fault." The Catch-22 stems from the shifting rules that the Centers for Medicare and Medicaid Services (CMS) has established in a $30 billion program intended to incentivize physicians and hospitals to switch from paper to electronic health records (Allen, 9/18).

Also, in other health IT headlines -

Reuters: Electronic Health Record Providers Integrating With Apple's Mobile Health Service
Cerner Corp and Athenahealth Inc, two leading U.S. electronic health record providers, said on Thursday they are working with Apple Inc to develop applications that leverage Apple's mobile health service HealthKit. Cerner and Athenahealth representatives said they are building integrations with HealthKit and working with Apple. Previously, Apple announced a partnership with rival electronic health record company Epic Systems. Apple did not respond to a request for comment. The goal is to help doctors monitor patients with chronic conditions from home and identify health risks. HealthKit gathers data from various applications and devices, including blood pressure cuffs, accelerometers and glucose measurement systems, and makes it easier for doctors to view it all in one place. Across the United States, hospitals are rolling out pilots using HealthKit to improve [preventive] care, and potentially cut costs (9/18).

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Administration News

Obama Orders Plan To Reduce Peril Of Antibiotic Resistance

The measures include incentives to develop new drugs, tighter control of existing ones and better tracking of resistant microbes. "Super bugs" are thought to cause 23,000 deaths and two million illnesses in the U.S. every year and $20 billion in spending.

The New York Times: U.S. Aims To Curb Peril Of Antibiotic Resistance
The Obama administration on Thursday announced measures to tackle the growing threat of antibiotic resistance, outlining a national strategy that includes incentives for the development of new drugs, tighter stewardship of existing ones, and improvements in tracking the use of antibiotics and the microbes that are resistant to them (Tavernise, 9/18).

The Washington Post: Obama Directs Federal Agencies To Ramp Up Efforts To Deal With Antibiotic Resistance
After years of warnings from the science and medical communities about the depletion of the world’s arsenal of effective antibiotics, President Obama directed federal agencies Thursday to significantly ramp up their efforts to deal with the threat (Ellis Nutt, 9/18).

The Wall Street Journal: Obama Orders Plan Against Antibiotic Resistance
The White House unveiled new measures on Thursday to try to preserve the effectiveness of infection-fighting drugs as strains of bacteria become increasingly resistant to the existing arsenal of antibiotics. The moves signal a growing concern over drug-resistant infections, which are linked to two million illnesses and 23,000 deaths in the U.S. each year, according to the Centers for Disease Control and Prevention. Some infections are almost entirely untreatable because the appropriate antibiotics have been rendered powerless (Tracy and Burton, 9/18). 

Reuters: White House Calls For Task Force To Tackle Antibiotic-Resistant Bugs
The U.S. government will set up a task force and presidential advisory council to tackle the growing threat of antibiotic resistance, setting a Feb. 15 deadline for it to outline specific steps, White House advisers said on Thursday. The secretaries of Defense, Agriculture and Health and Human Services will set up the task force to advise on steps to ensure the remaining medically important antibiotics available to treat humans stay effective and look at their use in animal feed. Antibiotic resistance in bacteria has led to "super bugs" linked to 23,000 deaths and 2 million illnesses every year in the United States, and up to $20 billion in direct health care costs (9/18).

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State Watch

State Highlights: Kan. Employment Support For Those With Mental Illness

A selection of health policy stories from California, Kansas, Washington state and Maryland.

San Jose Mercury News: Drugging Our Kids: California Calls For New Checks On Psych Meds For Foster Kids
In a significant step toward curbing the overuse of psychiatric drugs in California's foster care system, doctors will soon be required to get extra authorization to prescribe antipsychotics, a new safeguard to protect some of the state's most overmedicated children. Beginning Oct. 1, a state pharmacist must verify the "medical necessity" of each antipsychotic prescription before the medications can be given to children who are 17 and younger and covered by Medi-Cal, the state's health program for the poor that also includes foster children (De Sa, 9/18).

Kansas Health Institute News Service: Kansas To Expand Employment Support To Mentally Ill
The Kansas Department for Aging and Disability Services has been awarded a five-year, $3.9 million federal grant to expand employment services for Kansans with severe mental illness, including those with a mental illness and co-occurring substance disorder. KDADS received the grant to expand individual placement and support services from the federal Substance Abuse and Mental Health Services Administration, an agency within the U.S. Department of Health and Human Services. The Enhancing Supported Employment in Kansas (ESEK) project is designed to help people with mental illness achieve steady employment in mainstream competitive jobs, either part-time or full-time (9/17).

Seattle Times: Planned Parenthood ‘Office Visit’ Via App Gets You Birth Control
“Isn’t there an app for that?” Turns out there is, if what you’re after is birth control or a test for a sexually transmitted infection. In the latest example of fast-growing “telemedicine,” video conferencing that virtually extends medical expertise, Planned Parenthood is rolling out a pilot project for real-time “office visits” that bring patient and medical provider face to face on a smartphone, tablet or personal computer. Fueling the Planned Parenthood Care project, under way in Washington and Minnesota, is a “horrible statistic,” says Chris Charbonneau, president and CEO of Planned Parenthood of the Great Northwest: “People are sexually active for six to nine months before they get a really reliable birth-control method” (Ostrom, 9/18). 

Kansas City Star: Hospital Will Start Billing Health Insurers For Claims In Auto Accidents Instead Of Collecting From Auto Insurance Settlements
Truman Medical Center in Kansas City has agreed to stop a billing practice that involves refusing to accept a patient’s health insurance. The concession is part of a proposed settlement valued at $478,000 to dispose of a lawsuit against the hospital. Truman Medical Center allegedly didn’t file health insurance claims for some patients injured in auto accidents, which allowed it to avoid the deep discounts typically required by health insurers. It could then seek more money for its medical services, mainly from auto insurance settlements. In court documents, the hospital said it is ready to stop the billing method and provide some financial relief to more than 180 patients who were subjected to the billing practice. The hospital said it will partly reimburse those who have already paid their bills and seek no further payments from those who haven’t (Everly, 9/18).

Baltimore Sun: A Push For Paid Family Leave
A growing movement of workers -- and their supporters in Annapolis and Washington -- wants to make the [paid leave] benefit universal. Democrats in Congress have proposed a fund that would pay a worker up to two-thirds of his or her monthly wages for 12 weeks to care for a new child or an elderly family member. California, New Jersey and Rhode Island have expanded their state disability insurance programs to cover family leave. The Obama administration has offered grants for other states to study how they might also offer the benefit. In Maryland, Del. Heather Mizeur proposed a paid family leave program modeled on California's during her unsuccessful campaign this year for the Democratic gubernatorial nomination. In California, a portion of the state payroll tax paid by employees goes into a fund. Eligible workers on family leave can draw on that fund to cover a portion of their salary (King and Campbell, 9/19).

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Health Policy Research

Research Roundup: Home Health Nurses' Workloads; Readmissions At The VA

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Urban Institute/Robert Wood Johnson Foundation: Year-to-Year Variation In Small-Group Health Insurance Premiums: Double-Digit Annual Increases Have Been Common Over The Past Decade
In anticipation of next year's premium announcements and given some information already made public, concerns have surfaced about the potential for double-digit percent increases in nongroup and small-group health insurance premiums. This analysis shows that, although average annual increases in small-group premiums over the past 13 years averaged roughly 5.5 percent, double-digit average premium increases are common for states and large metropolitan areas. ... The ACA's market reforms, which prohibit insurers in the small-group and nongroup insurance markets from varying premiums based upon health status or claims experience of the enrollees, should decrease year-to-year premium variation (Blumberg and Holahan, 9/17). 

Medical Journal: Home Health Agency Work Environments And Hospitalizations
An important goal of home health care is to assist patients to remain in community living arrangements. Yet home care often fails to prevent hospitalizations and to facilitate discharges to community living .... Home health nurses work more hours than nurses in almost any other setting. ... All nursing characteristics of home health agencies were drawn from the University of Pennsylvania Multistate Survey of Nursing Care and Patient Safety. Nurses provided detailed information about their work environment, nursing experience and education, job satisfaction, and burnout. ... The primary findings of this study were that home health agencies with good environments have lower rates of nurse burnout and acute care hospitalizations, and higher rates of discharges to community living (Jarrín, Flynn, Lake and Aiken, October 2014).

JAMA Surgery: Descriptive Analysis Of 30-Day Readmission After Inpatient Surgery Discharge In The Veterans Health Administration
The Centers for Medicare and Medicaid Services (CMS) report a national average all-cause 30-day readmission rate of approximately 18% .… Using 2 large national databases, we examined trends of all-cause 30-day readmission rates and mean POHLOS [post-operative hospital length of stay] following major surgery in 9 specialties at [Veterans Health Administration] facilities .... the overall readmission rate significantly declined from 12.9% to 12.2% during the 10-year period concurrent with a significant decrease in mean POHLOS from 10.6 to 9.2 days. ... The readmission rate ranged from 9.0% (urology) to 16.6% (cardiac) and the mean POHLOS ranged from 5.9 days (urology) to 17.4 days (plastic). The readmission diagnoses were diverse, but postoperative infections, UTI, and pneumonia were common for all specialties (Han, Smith and Gunnar, 9/17).

Health Affairs: Employee Choice
[T]he Affordable Care Act (ACA) created Small Business Health Options Program (SHOP) Marketplaces in each state. SHOP Marketplaces were intended to [create] … a mechanism for employee choice, in which small-business employees can select from among multiple insurers and health plans …. federal regulations have made implementation of employee choice voluntary until 2016. This feature has not yet been made available in federally run SHOP Marketplaces. ... detractors have raised concerns that employee choice may overwhelm employees with too many choices or result in higher premiums in the SHOP if higher-risk employees can select more comprehensive plans than lower-risk employees. ... both small employers and their employees are likely to continue to need personalized assistance with the plan selection process and can be expected to continue to use the services of agents and brokers (Dash and Lucia, 9/18).

Pioneer Institute: The Undisclosed Cost Of Developing An Affordable Care Act State Exchange In Massachusetts
While the state has moved forward with new contractors following its first failed attempt at launching an ACA-compliant website, there has been little transparency about the full taxpayer cost of the state-based exchange. Estimates often have been released piecemeal, and they never examine the full cost of the project across multiple agencies involved in the work. ... Pioneer Institute staff [attempted] to compile an accounting of the money that has been committed to the project so far. ... Our estimates put the cost of getting the ACA exchange up and running at over $600 million, all of which will pay for systems to administer health care, not care itself. When you add in the cost of temporary coverage and healthcare claims paid on those programs under the ACA, you are looking at a price tag closer to $1 billion just in Massachusetts (Archambault, 9/17). 

Here is a selection of news coverage of other recent research:

USA Today: Pre-Diabetes, Diabetes Rates Fuel National Health Crisis
Americans are getting fatter, and older. These converging trends are putting the USA on the path to an alarming health crisis: Nearly half of adults have either pre-diabetes or diabetes, raising their risk of heart attacks, blindness, amputations and cancer. Federal health statistics show that 12.3% of Americans 20 and older have diabetes, either diagnosed or undiagnosed. Another 37% have pre-diabetes, a condition marked by higher-than-normal blood sugar. That's up from 27% a decade ago. An analysis of 16 studies involving almost 900,000 people worldwide, published in the current issue of the journal Diabetologia, shows pre-diabetes not only sets the stage for diabetes but also increases the risk of cancer (Ungar, 9/15).

Reuters: Fewer Hospitalizations For Diabetic Vets Using VA's Home-based Care
For older U.S. military veterans with multiple chronic conditions, including diabetes, taking advantage of home-based primary care from the U.S. Department of Veterans Affairs (VA) was linked to fewer hospitalizations, in a recent study. Some VA medical centers in the U.S. offer home-based primary care, in which a physician supervises a health care team that provides services in the veteran’s home, rather than through regular clinic visits. ... authors note the program could potentially improve compliance with medications and ensure that patients understood their care plans. It could also improve coordination of social and support services, referrals and specialty care. ... according to results in JAMA Internal Medicine (Doyle, 9/16). 

USA Today: Schizophrenia Is Eight Different Diseases, Not One
New research shows that schizophrenia is not a single disease, but a group of eight distinct disorders, each caused by changes in clusters of genes that lead to different sets of symptoms. The finding sets the stage for scientists to develop better ways to diagnose and treat schizophrenia, a mental illness that can be devastating when not adequately managed, says C. Robert Cloninger, co-author of the study published today in the American Journal of Psychiatry (Szabo, 9/15). 

Reuters: Study Shows Downward Trend In Sovaldi Utilization
Over the last several months there has been a "plateau and downward trend" in the use of Gilead Sciences Inc's controversial $1,000-a-pill hepatitis C treatment, Sovaldi, a CVS Health Corp analysis showed. The study, encompassing data from May through August 2014, suggests that another surge of patients will begin therapy when newer treatments of similar effectiveness and shorter duration are introduced later in the year (Grover, 9/17).

MedPage Today: Generic Statins Boost Patient Adherence, Outcomes
Going off-brand for statin medication modestly improved adherence and cardiovascular outcomes, an observational study showed. The average proportion of days covered by a filled statin prescription was 77% when starting on a generic compared with 71% when initiating a brand-name version ... , said Joshua J. Gagne, PharmD, ScD, from Brigham and Women's Hospital and Harvard Medical School in Boston, and colleagues (Phend, 9/15).

Medscape: Antibiotic Surveillance Reduces Readmission, Study Finds
An antibiotic stewardship program that guided individual prescriptions during a 6-month period significantly reduced rates of readmission due to infection, report researchers presenting here at the Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC). It is well established that antibiotic stewardship programs can reduce the rate of antibiotic use, but very few have been able to demonstrate patient benefit, which is controversial, said lead investigator Fredrik Resman, MD, from Skåne University Hospital in Malmö, Sweden (Johnson, 9/16).

Seattle Times: Women Obtaining Free Birth Control Rises Rapidly
More American women are getting free birth control in the wake of the Affordable Care Act, which requires most private insurance plans to pay for contraception with no co-pay or other out-of-pocket costs. The percentage of women with private insurance coverage getting free oral contraception, or the pill, rose from 15 percent in the fall of 2012 to 67 percent this spring. The ACA’s free birth control mandate went into effect January 2013. Free access to other forms of pregnancy prevention also rose, according to research conducted by the Guttmacher Institute and published online Thursday in the journal Contraception. The study found that the proportion of women paying nothing for the vaginal ring rose from 20 percent to 74 percent; those using injectable contraceptives with no out-of-pocket costs increased from 27 percent to 59 percent; and those using the IUD free rose from 45 percent to 62 percent  (Stiffler, 9/18).

Philadelphia Inquirer: ER Waiting Times Vary Significantly, Studies Find
When it comes to emergency room waiting times, patients seeking care at larger urban hospitals are likely to spend more time staring down the clock than those seen at smaller or more rural facilities, new research suggests. The findings are from two research letters in the Sept. 15 issue of JAMA Internal Medicine. The first study focused on medical records concerning adult patients seen at almost 3,700 different emergency rooms across the country in 2012 and 2013. Nearly three-quarters of the ERs were in non-teaching hospitals. Almost two-thirds of the ERs were at private non-profit facilities. And, slightly more than half were located in an urban setting (Mozes, 9/18).

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Editorials and Opinions

Viewpoints: Ezekiel Emanuel's Choice Of An Age To Die; New Enrollment Numbers Still Confusing

The Atlantic: Why I Hope To Die At 75
Seventy-five. That’s how long I want to live: 75 years. This preference drives my daughters crazy. It drives my brothers crazy. My loving friends think I am crazy. They think that I can’t mean what I say; that I haven't thought clearly about this, because there is so much in the world to see and do. To convince me of my errors, they enumerate the myriad people I know who are over 75 and doing quite well. They are certain that as I get closer to 75, I will push the desired age back to 80, then 85, maybe even 90. I am sure of my position. ... But here is a simple truth that many of us seem to resist: living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived (Ezekiel J. Emanuel, 9/17).

The New York Times: When Medicine Is Futile
My father would have been thrilled to read "Dying in America," a new report by the Institute of Medicine that argues that we subject dying patients to too many treatments, denying them a peaceful death. But he would have asked what took us so long. A physician from the late 1950s to the late 1990s, my dad grew increasingly angry at how patients died in this country, too often in hospitals and connected to machines and tubes he knew would not help them (Barron H. Lerner, 9/18).

Bloomberg: Obamacare Enrollees Are Paying Premiums. We Think.
Marilyn Tavenner, the head of the Centers for Medicare & Medicaid Services, just told Congress that 7.3 million people have paid premiums and are currently enrolled in exchange policies. ... The administration says that this figure only includes people who have "paid their premiums." But what does that mean? That they paid a premium at least once? Or that they are current on their premium payments? ... One thing to note is what this means for the future: The administration needs to nearly double this enrollment in order to reach the CBO’s projection of 13 million exchange policies in 2015. How easy will that be? (Megan McArdle, 9/18).

The New Republic: Obamacare Critics Said Obama Was 'Cooking the Books.' New Data Shows He Wasn't.
On Thursday, HHS finally offered an official assessment [of paid enrollment]. As of August, the department says, paid enrollment was 7.3 million. That's less than 8 million, obviously, but don't take that as a sign that things have gone wrong. As Igor Volsky of ThinkProgress notes, the insurance market isn't static. Some people will change their insurance coverage during the course of a year, because they pick up or leave jobs that offer benefits. ... If you're an Obamacare dectractor, there are plenty of arguments that you can make legitimately. ... But one thing you can't say is that the enrollment numbers are bogus. They look like the real thing (Jonathan Cohn, 9/18).

The Washington Post’s Plum Line: On Health Care, Obama And The ACA Can't Win No Matter What
As you know by now, almost all the news about the implementation of the Affordable Care Act has been positive. Millions of people now have coverage. The rate of uninsured is at its lowest in decades. More insurers are lining up to participate in the exchanges. Many conservative states are coming around to expanding Medicaid and insuring their poorer citizens. There’s been no premium "death spiral." Growth in premiums and overall spending are slowing significantly. All terrific. Yet as we’ve discussed before, President Obama doesn’t get much credit for these developments (Paul Waldman, 9/18). 

Los Angeles Times: Don't Turn Down A Medi-Cal Gift, Gov. Brown
The 2010 federal healthcare reform law let states expand Medicaid, the joint federal-state health insurance program for the poor, largely at federal expense. California is one of 27 states that have taken up Washington's offer, and well over 1 million newly eligible residents signed up for coverage when the expansion went into effect this year. The response has strained the system, however, causing the backlog of enrollment applications at county offices to surge to 900,000 at one point before falling to about 350,000 this month. Adding to the workload, previous years' Medi-Cal enrollees are asking the same county offices for help in filling out the new, lengthy forms required to renew their benefits (9/18).

National Review: How Avikcare Would Fix Medicaid
Medicaid is a mess, and a very expensive one at that — the health-insurance program for low-income Americans is administered by states but has dozens of federal mandates and rules that drive up Medicaid costs. In response, the states cook up creative financing techniques to shift more costs back to the feds. The end result, among other things, is higher taxes for everyone and poorer care for Medicaid patients. In his new health-care plan, Avik Roy, a fellow at the Manhattan Institute, proposes changes to the Medicaid system that would end the state-federal finance battle, give each entity clear cut responsibilities, and improve Medicaid patients’ access to quality care (Callie Gable, 9/18).

The Wall Street Journal: Low-Wage Workers Feel The Pinch On Health Insurance
We did not see big changes in employer-based coverage in the Kaiser-HRET annual Employer Health Benefit Survey released last week. Mostly this is good news, particularly on the cost side where premiums increased just 3%. But one long-term trend that is not so good is how this market works for firms with relatively large shares of lower-wage workers (which we define as firms where at least 35% of employees earn less than $23,000). These low-wage firms often do not offer health benefits at all (Drew Altman, 9/18).

The New York Times’ Opinionator: A Chance To Go From Hard Lives To Healing
Like too many young men in his East Oakland neighborhood, 21-year-old Shaka Perdue spent the earlier part of his youth "living like I was becoming a statistic," as he put it. At 16, he landed in juvenile hall after robbing a pedestrian in broad daylight. Two years later a friend was shot right in front of him in a drive-by. ... Perdue still hangs out in the neighborhood — but he now wears a stethoscope around his neck. He is one of 90 or so graduates of EMS Corps, a pioneering five-month program spearheaded by the Alameda County Health Care Services Agency that trains young men of color to be qualified emergency medical technicians (Patricia Leigh Brown, 9/18).

Los Angeles Times: To Fight Ebola, Create A Health Workforce Reserve Force
A recent projection of the West Africa Ebola outbreak is that it now may take 12 to 18 months to control and will infect 100,000 people. President Obama announced the deployment of 3,000 military troops, more than a hundred Centers for Disease Control and Prevention personnel and millions of dollars to help stem the tide. How did the outbreak get so out of control? (Michele Barry and Lawrence Gostin, 9/18).

The Washington Post: Our Excessive Tolerance Of Suicide
From Belgium comes news that a mentally disturbed prisoner is to be granted government help in committing suicide. A typically shallow ethical debate ensued — isn't assisted suicide for a prisoner a bit too close to capital punishment? — before the trump card of individual autonomy was played. "Regardless, he's a human being," said Jacqueline Herremans, the head of Belgium’s right-to-die association, "a human being who has the right to demand euthanasia." This is the culmination of a certain line of moral reasoning: the human right to cease to be a human being (Michael Gerson, 9/18). 

The Hill: Why Won't Medicare Cover Effective Obesity Drugs?
With several drugs already on the market and others in the pipeline, we should expect access to these medications to begin reversing the alarming obesity epidemic, right? Not so fast. Last year, the American Medical Association (AMA) formally recognized obesity as a disease. Since then, many private and public health programs, including the Federal Employee Health Benefits Program (FEHBP), now offer prescription drug coverage for obesity medications. Unfortunately, patients relying on Medicare Part D don’t receive the same benefits as most federal employees and those with private insurance (Jennifer Nieto Carey, 9/19).

The Atlantic: Why I'm Becoming A Primary-Care Doctor
At medical schools, general medicine is often considered unchallenging and quaint, even though primary-care doctors are what our nation needs most from its medical schools. ... Primary care is where there are the greatest gaps in public health and the most job opportunities for recent graduates. But medical students, at least the ones I know, still shun it. I am planning on applying in family medicine in the 2015 Match, the national system that pairs medical school graduates with slots in residency-training programs. As I prepare my application, I’ve been doing a lot of thinking about why my career choice seems so unimaginable to so many of my classmates. Why do students at elite medical schools think primary care is boring? (Mara Gordon, 9/18).

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Andrew Villegas

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Shefali Luthra

The Kaiser Daily Health Policy Report is published by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. (c) 2014 Kaiser Health News. All rights reserved.