Mary Ellen Schneider

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

There’s been a lot of talk about the state-based health insurance exchanges set to debut in 2014 as part of the Affordable Care Act. How will they work? Will all states participate? Will they be ready on time?  Last week, the Department of Health and Human Services released a series of rules that aim to answer some of those questions.

One set of federal guidance that hasn’t gotten much attention is a final rule outlining the workings of the reinsurance, risk corridors, and risk adjustment programs in the health law. The final rule will be published in the Federal Register on March 23, the 2-year anniversary of the ACA.

Official White House Photo by Chuck Kennedy

The 127-page document isn’t exactly a quick read, but it does shed some light on how the government is trying to remove any incentives health plans might have to try to avoid enrolling people with high medical costs. The programs also are designed to make health plan costs are predictable under the exchanges so that premiums will be relatively stable.

The ACA relies on one permanent and two temporary programs to guard against the premium fluctuations that could result if some health plans were flooded with the sickest patients, while others had only healthy customers. Under the permanent risk adjustment program, HHS is seeking to spread the financial risk of the health plans by providing payments to plans that attract higher risk patients. That risk will be offset by funds from health plans that have enrolled lower risk patients. The program will apply to all non-grandfathered plans in the individual and small group markets both in and out of the exchanges.

HHS also released details on the temporary reinsurance program, which aims to stabilize premiums in the individual insurance market during the early years of the exchanges, when officials expect a lot of people with chronic or expensive medical needs to be insured for the first time. From 2014 through 2016, all health insurers and self-insurance group plans will contribute to the reinsurance program to help cover these patients.

Another temporary program is the risk corridors program. It too is designed to reduce health insurers risk of being in the exchange early on. From 2014 through 2016, exchange plans that have costs at least 3% lower than previous cost projections will pay a percentage of those savings to HHS. The government will then pass the money on to health plans whose costs were at least 3% higher than projected.

With the controversy over copay-free coverage for contraception and other women’s reproductive health benefits still raging, the Obama administration is asking the public to weigh in on how to provide such coverage for all women without making not-for-profit religious employers pay for services they object to.

In an advanced notice of proposed rulemaking released March 16, the Department of Health and Human Services, the Department of Treasury, and the Department of Labor provided details on a compromise proposed by the president last month. At that time, President Obama said that the administration would find a way for women to receive copay-free contraceptive coverage without religious employers having to pay for that service.

The advanced notice of proposed rulemaking states that religious institutions that are not exempted from the contraception coverage requirement could have their health plan separately arrange for contraception to be provided, and the health plan would pay for its own.

But many critics said the idea would fall apart for institutions that were self-insured, meaning that they directly pay for health services for their employees instead of contracting with a separate health plan. In that case, the new notice proposes three options for allowing religious institutions to avoid the contraception issue.

The options include:

• Using a third-party administrator to fund contraception coverage by using revenue from drug rebates, service fees, and disease-management program fees.

• Diverting a portion of the money the administration pays under the Affordable Care Act’s reinsurance program.

• Contracting with a separate health plan that would provide contraception at no cost.

The government will accept comments on the rule for 90 days after its official publication date (March 21, 2012). Administration officials said they will consider those comments as they move forward with a final regulation.

The Obama administration also released a final regulation on March 16 governing how the requirements of the ACA apply to student health plans. Under the rule, students will have the same protections and benefits as people who purchase health plans on the individual market. When it comes to free coverage of contraception for student health plans affiliated with religious employers, they will be treated the same way as the institution’s employee health plans, according to an administration official. The regulation does not apply to self-funded student health plans.

With the controversy over copay-free coverage for contraception and other women’s reproductive health benefits still raging, the Obama administration is asking the public to weigh in on how to provide such coverage for all women without making not-for-profit religious employers pay for services they object to.

In an advanced notice of proposed rulemaking released March 16, the Department of Health and Human Services, the Department of Treasury, and the Department of Labor provided details on a compromise proposed by the president last month. At that time, President Obama said that the administration would find a way for women to receive copay-free contraceptive coverage without religious employers having to pay for that service.

The advanced notice of proposed rulemaking states that religious institutions that are not exempted from the contraception coverage requirement could have their health plan separately arrange for contraception to be provided, and the health plan would pay for its own.

But many critics said the idea would fall apart for institutions that were self-insured, meaning that they directly pay for health services for their employees instead of contracting with a separate health plan. In that case, the new notice proposes three options for allowing religious institutions to avoid the contraception issue.

The options include:

• Using a third-party administrator to fund contraception coverage by using revenue from drug rebates, service fees, and disease-management program fees.

• Diverting a portion of the money the administration pays under the Affordable Care Act’s reinsurance program.

• Contracting with a separate health plan that would provide contraception at no cost.

The government will accept comments on the rule for 90 days after its official publication date (March 21, 2012). Administration officials said they will consider those comments as they move forward with a final regulation.

The Obama administration also released a final regulation on March 16 governing how the requirements of the ACA apply to student health plans. Under the rule, students will have the same protections and benefits as people who purchase health plans on the individual market. When it comes to free coverage of contraception for student health plans affiliated with religious employers, they will be treated the same way as the institution’s employee health plans, according to an administration official. The regulation does not apply to self-funded student health plans.

With the controversy over copay-free coverage for contraception and other women’s reproductive health benefits still raging, the Obama administration is asking the public to weigh in on how to provide such coverage for all women without making not-for-profit religious employers pay for services they object to.

In an advanced notice of proposed rulemaking released March 16, the Department of Health and Human Services, the Department of Treasury, and the Department of Labor provided details on a compromise proposed by the president last month. At that time, President Obama said that the administration would find a way for women to receive copay-free contraceptive coverage without religious employers having to pay for that service.

The advanced notice of proposed rulemaking states that religious institutions that are not exempted from the contraception coverage requirement could have their health plan separately arrange for contraception to be provided, and the health plan would pay for its own.

But many critics said the idea would fall apart for institutions that were self-insured, meaning that they directly pay for health services for their employees instead of contracting with a separate health plan. In that case, the new notice proposes three options for allowing religious institutions to avoid the contraception issue.

The options include:

• Using a third-party administrator to fund contraception coverage by using revenue from drug rebates, service fees, and disease-management program fees.

• Diverting a portion of the money the administration pays under the Affordable Care Act’s reinsurance program.

• Contracting with a separate health plan that would provide contraception at no cost.

The government will accept comments on the rule for 90 days after its official publication date (March 21, 2012). Administration officials said they will consider those comments as they move forward with a final regulation.

The Obama administration also released a final regulation on March 16 governing how the requirements of the ACA apply to student health plans. Under the rule, students will have the same protections and benefits as people who purchase health plans on the individual market. When it comes to free coverage of contraception for student health plans affiliated with religious employers, they will be treated the same way as the institution’s employee health plans, according to an administration official. The regulation does not apply to self-funded student health plans.

After 2 years of notable increases in the number of U.S. medical students choosing primary care residencies, figures from this year’s National Resident Matching Program show interest remains level.

Both the percentage and the actual number of U.S. medical students matching to residencies in family medicine, internal medicine, and pediatrics were fairly similar to figures from 2011.

Leaders in primary care said more work needs to be done to make careers in primary care attractive by closing the income gap between primary care physicians and specialists and by recognizing the importance of primary care physicians in improving health and lowering costs.

"It’s partly financial and it’s partly an issue of the status and stature," said Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians.

Dr. Weinberger said that, in addition to payment reform, medical students need to see that there’s a societal recognition of the role primary care physicians play in caring for increasingly complex patients.

The Affordable Care Act, with its emphasis on primary care, has helped to improve the status of the field among medical students, said Dr. Glen Stream, president of the American Academy of Family Physicians. But it hasn’t done enough.

There needs to be more done to address medical education debt, Dr. Stream said, and to change the medical education system so that medical schools are held accountable for producing primary care physicians.

Medical schools should be recruiting students with an interest in primary care and nurturing that interest throughout their education, he said.

Although the number of U.S. medical school seniors choosing residents in family medicine crept up slightly, Dr. Stream said that AAFP had been hoping for a bigger increase based on anecdotal reports from residency directors about the high level of interest among applicants this year. While any increase is positive, Dr. Stream said primary care has a lot of catching up to do. "We know we’re so far behind in having an adequate family medicine workforce," he said.

In 2012, 2,740 family medicine residency positions were offered. Of those, 94.6% were filled, with 48.2% filled by U.S. medical graduates. That compares with 2011, when 48% of the 2,708 positions were filled by U.S. graduates.

In internal medicine, more positions were added to this year’s resident match, but most were filled by international medical graduates. Overall, 5,277 internal medicine positions were offered in 2012. Of those, 99% were filled, with 55.7% of the slots being taken by U.S. medical graduates. In 2011, 57.4% of the 5,121 positions offered were filled by U.S. medical graduates.

In pediatrics, interest by U.S. medical students was also fairly consistent. This year, 98.7% of the total 2,475 positions offered were filled. U.S. medical graduates filled 70% of the pediatric positions. In 2011, U.S. medical graduates accounted for 71.2% of the 2,482 available slots.

Emergency medicine was a popular choice among residents this year. All of the 1,668 positions were filled, with 80% being taken by U.S. medical graduates.

Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields in this year’s match, according to the National Resident Matching Program.

After 2 years of notable increases in the number of U.S. medical students choosing primary care residencies, figures from this year’s National Resident Matching Program show interest remains level.

Both the percentage and the actual number of U.S. medical students matching to residencies in family medicine, internal medicine, and pediatrics were fairly similar to figures from 2011.

Leaders in primary care said more work needs to be done to make careers in primary care attractive by closing the income gap between primary care physicians and specialists and by recognizing the importance of primary care physicians in improving health and lowering costs.

"It’s partly financial and it’s partly an issue of the status and stature," said Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians.

Dr. Weinberger said that, in addition to payment reform, medical students need to see that there’s a societal recognition of the role primary care physicians play in caring for increasingly complex patients.

The Affordable Care Act, with its emphasis on primary care, has helped to improve the status of the field among medical students, said Dr. Glen Stream, president of the American Academy of Family Physicians. But it hasn’t done enough.

There needs to be more done to address medical education debt, Dr. Stream said, and to change the medical education system so that medical schools are held accountable for producing primary care physicians.

Medical schools should be recruiting students with an interest in primary care and nurturing that interest throughout their education, he said.

Although the number of U.S. medical school seniors choosing residents in family medicine crept up slightly, Dr. Stream said that AAFP had been hoping for a bigger increase based on anecdotal reports from residency directors about the high level of interest among applicants this year. While any increase is positive, Dr. Stream said primary care has a lot of catching up to do. "We know we’re so far behind in having an adequate family medicine workforce," he said.

In 2012, 2,740 family medicine residency positions were offered. Of those, 94.6% were filled, with 48.2% filled by U.S. medical graduates. That compares with 2011, when 48% of the 2,708 positions were filled by U.S. graduates.

In internal medicine, more positions were added to this year’s resident match, but most were filled by international medical graduates. Overall, 5,277 internal medicine positions were offered in 2012. Of those, 99% were filled, with 55.7% of the slots being taken by U.S. medical graduates. In 2011, 57.4% of the 5,121 positions offered were filled by U.S. medical graduates.

In pediatrics, interest by U.S. medical students was also fairly consistent. This year, 98.7% of the total 2,475 positions offered were filled. U.S. medical graduates filled 70% of the pediatric positions. In 2011, U.S. medical graduates accounted for 71.2% of the 2,482 available slots.

Emergency medicine was a popular choice among residents this year. All of the 1,668 positions were filled, with 80% being taken by U.S. medical graduates.

Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields in this year’s match, according to the National Resident Matching Program.

After 2 years of notable increases in the number of U.S. medical students choosing primary care residencies, figures from this year’s National Resident Matching Program show interest remains level.

Both the percentage and the actual number of U.S. medical students matching to residencies in family medicine, internal medicine, and pediatrics were fairly similar to figures from 2011.

Leaders in primary care said more work needs to be done to make careers in primary care attractive by closing the income gap between primary care physicians and specialists and by recognizing the importance of primary care physicians in improving health and lowering costs.

"It’s partly financial and it’s partly an issue of the status and stature," said Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians.

Dr. Weinberger said that, in addition to payment reform, medical students need to see that there’s a societal recognition of the role primary care physicians play in caring for increasingly complex patients.

The Affordable Care Act, with its emphasis on primary care, has helped to improve the status of the field among medical students, said Dr. Glen Stream, president of the American Academy of Family Physicians. But it hasn’t done enough.

There needs to be more done to address medical education debt, Dr. Stream said, and to change the medical education system so that medical schools are held accountable for producing primary care physicians.

Medical schools should be recruiting students with an interest in primary care and nurturing that interest throughout their education, he said.

Although the number of U.S. medical school seniors choosing residents in family medicine crept up slightly, Dr. Stream said that AAFP had been hoping for a bigger increase based on anecdotal reports from residency directors about the high level of interest among applicants this year. While any increase is positive, Dr. Stream said primary care has a lot of catching up to do. "We know we’re so far behind in having an adequate family medicine workforce," he said.

In 2012, 2,740 family medicine residency positions were offered. Of those, 94.6% were filled, with 48.2% filled by U.S. medical graduates. That compares with 2011, when 48% of the 2,708 positions were filled by U.S. graduates.

In internal medicine, more positions were added to this year’s resident match, but most were filled by international medical graduates. Overall, 5,277 internal medicine positions were offered in 2012. Of those, 99% were filled, with 55.7% of the slots being taken by U.S. medical graduates. In 2011, 57.4% of the 5,121 positions offered were filled by U.S. medical graduates.

In pediatrics, interest by U.S. medical students was also fairly consistent. This year, 98.7% of the total 2,475 positions offered were filled. U.S. medical graduates filled 70% of the pediatric positions. In 2011, U.S. medical graduates accounted for 71.2% of the 2,482 available slots.

Emergency medicine was a popular choice among residents this year. All of the 1,668 positions were filled, with 80% being taken by U.S. medical graduates.

Dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology, thoracic surgery, and vascular surgery were the most competitive fields in this year’s match, according to the National Resident Matching Program.

The federal government is stepping up efforts to eliminate health disparities, in part by requiring better data collection. Under Section 4302 of the Affordable Care Act (ACA), all national population health surveys sponsored by the Department of Health and Human Services must include standardized information on race, ethnicity, sex, primary language, and disability status.

Last October, HHS got the ball rolling by finalizing new data collection standards to try to get more specific information on health issues facing certain racial subgroups. Soon, the agency will begin collecting health data on lesbian, gay, bisexual, and transgender populations.

Dr. Cedric Bright, president of the National Medical Association, explains why improved data collection is essential and what individual physicians can do to combat health disparities. Dr. Bright is assistant dean of special programs and admissions in the department of medical education at the University of North Carolina, Chapel Hill.

Question: Why are these data collection requirements important in tackling health disparities?

Dr. Bright: It is clear that certain ethnic groups do not respond to management in the same way. There are both cultural and genetic differences, and because of these we must not collect data without descriptors. It’s hard to say that you have disparities if you’re not collecting the data to be able to disaggregate populations and see if indeed there are differences in outcomes.

The truth is that we can sweep issues of disparities under the carpet by not disaggregating our data. There was a proposal in California a few years ago to do away with categories, which did not pass because people understood the implications. Likewise, HHS has implemented a policy where they disaggregated the data for Latinos and for Asians and Pacific Islanders. It is my hope that they will disaggregate the data for African Americans as well. Certainly there are differences between a native African American, versus a first- or second-generation African, or versus someone from the Caribbean who is black. This will truly help us to drill down into our data sets to find more details in health experiences and outcomes.

Question: How can physicians use the subgroup data to make better clinical decisions?

Dr. Bright: Disaggregated data helps you focus on the patient in front of you. If the patient provides their self-identified racial and ethnic information and you already know the data related to those different subgroups, that allows you to tailor your communication to him or her rather than speak generally. Having this information allows us to provide better treatment options. In addition, translational research demonstrates far too often that implementation of management protocols often need to be tailored to factors such as language and culture. Having subgroup data would be important in designing systems to take advantage of these differences. This type of diversity of data will impact the future of comparative effectiveness research and clinical trials.

Question: Does the ACA do enough to address health disparities?

Dr. Bright: The law seeks to address the health disparities issue head on. It established the National Partnership for Action to End Health Disparities. This partnership, in which the National Medical Association participated, developed the National Stakeholder Strategy for Achieving Health Equity. The goals of this national game plan will fall under five categories: awareness; leadership; health system and life experience; cultural and linguistic competency; and, most germane to this discussion, data, research, and evaluation. In addition, the ACA created the Patient-Centered Outcomes Research Institute, which will help us develop a keener understanding of the relative effectiveness of clinical outcomes. The law also requires reporting quality measures from Medicaid and the Children’s Health Insurance Program. This large and diverse cohort can be the basis of some evidence-based trials and comparative effective research.

Most importantly, insurance expansion is so critical because a disproportionate number of uninsured Americans are black and Latino. Our working poor often access the health care system only when there is a significant problem that stops them from being able to work. Having access to health insurance will allow people to become more proactive in improving their health.

Question: Why is the health care community having such a tough time making a dent in health disparities?

Dr. Bright: It’s multifactorial. First, there’s a component of individual responsibility. What part does an individual play in their health status? How much blame goes to those who continue to eat and do the wrong things? There’s also industry responsibility. The food industry tailors their products to maximize the number of calories, but not the nutritional value. Next, there’s government responsibility related to how we zone our neighborhoods. This is significant because we can’t have neighborhoods that don’t have access to fresh food at an affordable price. Last, there is system and provider bias. Many studies demonstrate that African Americans are not treated the same as others in the health care systems. They are not referred to specialists as often and do not get the same treatments, as shown in the Schulman study from 1999 and the Institute of Medicine’s 2003 report "Unequal Treatment."

When all of these factors are considered, it becomes clear that we have a multifaceted problem that will require coordinated efforts by individuals and industry to make a difference.

The federal government is stepping up efforts to eliminate health disparities, in part by requiring better data collection. Under Section 4302 of the Affordable Care Act (ACA), all national population health surveys sponsored by the Department of Health and Human Services must include standardized information on race, ethnicity, sex, primary language, and disability status.

Last October, HHS got the ball rolling by finalizing new data collection standards to try to get more specific information on health issues facing certain racial subgroups. Soon, the agency will begin collecting health data on lesbian, gay, bisexual, and transgender populations.

Dr. Cedric Bright, president of the National Medical Association, explains why improved data collection is essential and what individual physicians can do to combat health disparities. Dr. Bright is assistant dean of special programs and admissions in the department of medical education at the University of North Carolina, Chapel Hill.

Question: Why are these data collection requirements important in tackling health disparities?

Dr. Bright: It is clear that certain ethnic groups do not respond to management in the same way. There are both cultural and genetic differences, and because of these we must not collect data without descriptors. It’s hard to say that you have disparities if you’re not collecting the data to be able to disaggregate populations and see if indeed there are differences in outcomes.

The truth is that we can sweep issues of disparities under the carpet by not disaggregating our data. There was a proposal in California a few years ago to do away with categories, which did not pass because people understood the implications. Likewise, HHS has implemented a policy where they disaggregated the data for Latinos and for Asians and Pacific Islanders. It is my hope that they will disaggregate the data for African Americans as well. Certainly there are differences between a native African American, versus a first- or second-generation African, or versus someone from the Caribbean who is black. This will truly help us to drill down into our data sets to find more details in health experiences and outcomes.

Question: How can physicians use the subgroup data to make better clinical decisions?

Dr. Bright: Disaggregated data helps you focus on the patient in front of you. If the patient provides their self-identified racial and ethnic information and you already know the data related to those different subgroups, that allows you to tailor your communication to him or her rather than speak generally. Having this information allows us to provide better treatment options. In addition, translational research demonstrates far too often that implementation of management protocols often need to be tailored to factors such as language and culture. Having subgroup data would be important in designing systems to take advantage of these differences. This type of diversity of data will impact the future of comparative effectiveness research and clinical trials.

Question: Does the ACA do enough to address health disparities?

Dr. Bright: The law seeks to address the health disparities issue head on. It established the National Partnership for Action to End Health Disparities. This partnership, in which the National Medical Association participated, developed the National Stakeholder Strategy for Achieving Health Equity. The goals of this national game plan will fall under five categories: awareness; leadership; health system and life experience; cultural and linguistic competency; and, most germane to this discussion, data, research, and evaluation. In addition, the ACA created the Patient-Centered Outcomes Research Institute, which will help us develop a keener understanding of the relative effectiveness of clinical outcomes. The law also requires reporting quality measures from Medicaid and the Children’s Health Insurance Program. This large and diverse cohort can be the basis of some evidence-based trials and comparative effective research.

Most importantly, insurance expansion is so critical because a disproportionate number of uninsured Americans are black and Latino. Our working poor often access the health care system only when there is a significant problem that stops them from being able to work. Having access to health insurance will allow people to become more proactive in improving their health.

Question: Why is the health care community having such a tough time making a dent in health disparities?

Dr. Bright: It’s multifactorial. First, there’s a component of individual responsibility. What part does an individual play in their health status? How much blame goes to those who continue to eat and do the wrong things? There’s also industry responsibility. The food industry tailors their products to maximize the number of calories, but not the nutritional value. Next, there’s government responsibility related to how we zone our neighborhoods. This is significant because we can’t have neighborhoods that don’t have access to fresh food at an affordable price. Last, there is system and provider bias. Many studies demonstrate that African Americans are not treated the same as others in the health care systems. They are not referred to specialists as often and do not get the same treatments, as shown in the Schulman study from 1999 and the Institute of Medicine’s 2003 report "Unequal Treatment."

When all of these factors are considered, it becomes clear that we have a multifaceted problem that will require coordinated efforts by individuals and industry to make a difference.

The federal government is stepping up efforts to eliminate health disparities, in part by requiring better data collection. Under Section 4302 of the Affordable Care Act (ACA), all national population health surveys sponsored by the Department of Health and Human Services must include standardized information on race, ethnicity, sex, primary language, and disability status.

Last October, HHS got the ball rolling by finalizing new data collection standards to try to get more specific information on health issues facing certain racial subgroups. Soon, the agency will begin collecting health data on lesbian, gay, bisexual, and transgender populations.

Dr. Cedric Bright, president of the National Medical Association, explains why improved data collection is essential and what individual physicians can do to combat health disparities. Dr. Bright is assistant dean of special programs and admissions in the department of medical education at the University of North Carolina, Chapel Hill.

Question: Why are these data collection requirements important in tackling health disparities?

Dr. Bright: It is clear that certain ethnic groups do not respond to management in the same way. There are both cultural and genetic differences, and because of these we must not collect data without descriptors. It’s hard to say that you have disparities if you’re not collecting the data to be able to disaggregate populations and see if indeed there are differences in outcomes.

The truth is that we can sweep issues of disparities under the carpet by not disaggregating our data. There was a proposal in California a few years ago to do away with categories, which did not pass because people understood the implications. Likewise, HHS has implemented a policy where they disaggregated the data for Latinos and for Asians and Pacific Islanders. It is my hope that they will disaggregate the data for African Americans as well. Certainly there are differences between a native African American, versus a first- or second-generation African, or versus someone from the Caribbean who is black. This will truly help us to drill down into our data sets to find more details in health experiences and outcomes.

Question: How can physicians use the subgroup data to make better clinical decisions?

Dr. Bright: Disaggregated data helps you focus on the patient in front of you. If the patient provides their self-identified racial and ethnic information and you already know the data related to those different subgroups, that allows you to tailor your communication to him or her rather than speak generally. Having this information allows us to provide better treatment options. In addition, translational research demonstrates far too often that implementation of management protocols often need to be tailored to factors such as language and culture. Having subgroup data would be important in designing systems to take advantage of these differences. This type of diversity of data will impact the future of comparative effectiveness research and clinical trials.

Question: Does the ACA do enough to address health disparities?

Dr. Bright: The law seeks to address the health disparities issue head on. It established the National Partnership for Action to End Health Disparities. This partnership, in which the National Medical Association participated, developed the National Stakeholder Strategy for Achieving Health Equity. The goals of this national game plan will fall under five categories: awareness; leadership; health system and life experience; cultural and linguistic competency; and, most germane to this discussion, data, research, and evaluation. In addition, the ACA created the Patient-Centered Outcomes Research Institute, which will help us develop a keener understanding of the relative effectiveness of clinical outcomes. The law also requires reporting quality measures from Medicaid and the Children’s Health Insurance Program. This large and diverse cohort can be the basis of some evidence-based trials and comparative effective research.

Most importantly, insurance expansion is so critical because a disproportionate number of uninsured Americans are black and Latino. Our working poor often access the health care system only when there is a significant problem that stops them from being able to work. Having access to health insurance will allow people to become more proactive in improving their health.

Question: Why is the health care community having such a tough time making a dent in health disparities?

Dr. Bright: It’s multifactorial. First, there’s a component of individual responsibility. What part does an individual play in their health status? How much blame goes to those who continue to eat and do the wrong things? There’s also industry responsibility. The food industry tailors their products to maximize the number of calories, but not the nutritional value. Next, there’s government responsibility related to how we zone our neighborhoods. This is significant because we can’t have neighborhoods that don’t have access to fresh food at an affordable price. Last, there is system and provider bias. Many studies demonstrate that African Americans are not treated the same as others in the health care systems. They are not referred to specialists as often and do not get the same treatments, as shown in the Schulman study from 1999 and the Institute of Medicine’s 2003 report "Unequal Treatment."

When all of these factors are considered, it becomes clear that we have a multifaceted problem that will require coordinated efforts by individuals and industry to make a difference.

Is an increased role for pharmacists in managing medications for chronic conditions one way to help save precious health care dollars? That’s the question Food and Drug Administration officials have posed in anticipation of a 2-day hearing at the end of March.

Such an idea is being met with enthusiasm from pharmacists, but with skepticism from physicians.

© Daniel Stein/istockphoto.com

The FDA wants to explore new ways of dispensing certain medications in an effort to expand access to treatment for people with common – but undertreated – medical conditions, such as hyperlipidemia, hypertension, migraine, and asthma.

In a notice announcing the potential changes, officials said some patients were missing necessary care because of the cost and time involved in seeing a physician. And some physician visits could be eliminated by making certain medications nonprescription and adding conditions of safe use, according to the notice.

In its hearing notice, the agency outlined a variety of ways that drugs could be made available over and behind the counter.

• Lengthen the time between follow up visits. Under this scenario, patients would see their physician or other health care provider for an initial prescription; the prescriber would authorize refills beyond what normally are currently allowed before a follow-up visit is required. In addition, conditions of safe use would be set for the refills. In its proposal, FDA officials noted that this approach could be used for rescue inhalers to treat asthma, or epinephrine for allergic reactions.

• Make use of new technology. A patient could use a pharmacy kiosk or website to self-screen for a particular condition; an associated algorithm would help the patient determine whether a particular medication is appropriate or contraindicated.

• Move more drugs behind the counter. Certain drugs would be reclassified as nonprescription; however, to purchase the drug, the patient would need to visit with the pharmacist. Pharmacists could potentially be involved in conducting and interpreting diagnostics including blood tests or liver function tests. Based on the results of those tests, pharmacists could help determine if a particular drug is appropriate or contraindicated.

The FDA is also considering some type of dual availability, in which certain drugs would be available both by prescription as well as nonprescription with certain conditions of safe use.

Making medications more readily available through the pharmacy has the potential to reduce costs, the FDA said.

"In addition to improved health outcomes for consumers staying on their medications, the time and attention that physicians and other health care provider expend on routine tasks related to prescription refills reduces the time that they are available to attend to more seriously ill patients," the FDA wrote in its hearing notice. "Eliminating or reducing the number of routine visits could free up prescribers to spend time with more seriously ill patients, reduce the burdens on the already overburdened health care system, and reduce health care costs."

Physicians have concerns about how the idea would be applied.

The FDA paradigm has the potential for both benefit and harm, depending on how it is applied, said Dr. Samuel Frank, a neurologist in Boston and a member of the American Academy of Neurology’s Patient Safety Subcommittee. It could work well to give patients nonprescription access to medications – for instance, in cases of intermittent, medication-responsive migraines. But there is "much potential for harm" with other neurologic conditions in which a neurologist must make a proper diagnosis and determine appropriate diagnostic tests and a treatment plan, he said.

Dr. Glen Stream, president of the American Academy of Family Physicians, said he’s concerned that the FDA’s approach would treat medical conditions in isolation, without considering the patient’s other medical problems or how the conditions developed. It also leaves prevention and wellness out of the equation, he said.

Dr. Stream said there’s an important role for the pharmacist to play in helping to manage medications as part of the patient-centered medical home. But in those cases, the pharmacist is part of a larger medical team directed by the physician, he said.

Pharmacists’ groups are supportive of the possible change, and see the potential for both cost savings and improvements in public health.

"We think it means greater access," said Ronna Hauser, Pharm.D., vice president of policy and regulatory affairs at the National Community Pharmacists Association.

The proposal would also save money, she said, by cutting down on physician office visits, as well as avoiding costly trips to the emergency department. There is the potential for significant savings simply by making asthma rescue inhalers and epinephrine autoinjectors available without a prescription. Currently, if patients are without those medications in an emergency, they often end up in the ED.

Pharmacists are ready and willing to work in collaboration with physicians, said Marcie Bough, Pharm.D., senior director of government affairs for the American Pharmacists Association.

She said that if the FDA pursued this plan, one of the roles of the pharmacist would be to communicate with physicians about what drugs are being dispensed, and to advise patients to go see their doctor when that is appropriate. Increased use of interoperable electronic health records would make that communication easier, she said. But in the meantime, pharmacists will rely on phone calls when higher-tech options aren’t available.

Is an increased role for pharmacists in managing medications for chronic conditions one way to help save precious health care dollars? That’s the question Food and Drug Administration officials have posed in anticipation of a 2-day hearing at the end of March.

Such an idea is being met with enthusiasm from pharmacists, but with skepticism from physicians.

© Daniel Stein/istockphoto.com

The FDA wants to explore new ways of dispensing certain medications in an effort to expand access to treatment for people with common – but undertreated – medical conditions, such as hyperlipidemia, hypertension, migraine, and asthma.

In a notice announcing the potential changes, officials said some patients were missing necessary care because of the cost and time involved in seeing a physician. And some physician visits could be eliminated by making certain medications nonprescription and adding conditions of safe use, according to the notice.

In its hearing notice, the agency outlined a variety of ways that drugs could be made available over and behind the counter.

• Lengthen the time between follow up visits. Under this scenario, patients would see their physician or other health care provider for an initial prescription; the prescriber would authorize refills beyond what normally are currently allowed before a follow-up visit is required. In addition, conditions of safe use would be set for the refills. In its proposal, FDA officials noted that this approach could be used for rescue inhalers to treat asthma, or epinephrine for allergic reactions.

• Make use of new technology. A patient could use a pharmacy kiosk or website to self-screen for a particular condition; an associated algorithm would help the patient determine whether a particular medication is appropriate or contraindicated.

• Move more drugs behind the counter. Certain drugs would be reclassified as nonprescription; however, to purchase the drug, the patient would need to visit with the pharmacist. Pharmacists could potentially be involved in conducting and interpreting diagnostics including blood tests or liver function tests. Based on the results of those tests, pharmacists could help determine if a particular drug is appropriate or contraindicated.

The FDA is also considering some type of dual availability, in which certain drugs would be available both by prescription as well as nonprescription with certain conditions of safe use.

Making medications more readily available through the pharmacy has the potential to reduce costs, the FDA said.

"In addition to improved health outcomes for consumers staying on their medications, the time and attention that physicians and other health care provider expend on routine tasks related to prescription refills reduces the time that they are available to attend to more seriously ill patients," the FDA wrote in its hearing notice. "Eliminating or reducing the number of routine visits could free up prescribers to spend time with more seriously ill patients, reduce the burdens on the already overburdened health care system, and reduce health care costs."

Physicians have concerns about how the idea would be applied.

The FDA paradigm has the potential for both benefit and harm, depending on how it is applied, said Dr. Samuel Frank, a neurologist in Boston and a member of the American Academy of Neurology’s Patient Safety Subcommittee. It could work well to give patients nonprescription access to medications – for instance, in cases of intermittent, medication-responsive migraines. But there is "much potential for harm" with other neurologic conditions in which a neurologist must make a proper diagnosis and determine appropriate diagnostic tests and a treatment plan, he said.

Dr. Glen Stream, president of the American Academy of Family Physicians, said he’s concerned that the FDA’s approach would treat medical conditions in isolation, without considering the patient’s other medical problems or how the conditions developed. It also leaves prevention and wellness out of the equation, he said.

Dr. Stream said there’s an important role for the pharmacist to play in helping to manage medications as part of the patient-centered medical home. But in those cases, the pharmacist is part of a larger medical team directed by the physician, he said.

Pharmacists’ groups are supportive of the possible change, and see the potential for both cost savings and improvements in public health.

"We think it means greater access," said Ronna Hauser, Pharm.D., vice president of policy and regulatory affairs at the National Community Pharmacists Association.

The proposal would also save money, she said, by cutting down on physician office visits, as well as avoiding costly trips to the emergency department. There is the potential for significant savings simply by making asthma rescue inhalers and epinephrine autoinjectors available without a prescription. Currently, if patients are without those medications in an emergency, they often end up in the ED.

Pharmacists are ready and willing to work in collaboration with physicians, said Marcie Bough, Pharm.D., senior director of government affairs for the American Pharmacists Association.

She said that if the FDA pursued this plan, one of the roles of the pharmacist would be to communicate with physicians about what drugs are being dispensed, and to advise patients to go see their doctor when that is appropriate. Increased use of interoperable electronic health records would make that communication easier, she said. But in the meantime, pharmacists will rely on phone calls when higher-tech options aren’t available.

Is an increased role for pharmacists in managing medications for chronic conditions one way to help save precious health care dollars? That’s the question Food and Drug Administration officials have posed in anticipation of a 2-day hearing at the end of March.

Such an idea is being met with enthusiasm from pharmacists, but with skepticism from physicians.

© Daniel Stein/istockphoto.com

The FDA wants to explore new ways of dispensing certain medications in an effort to expand access to treatment for people with common – but undertreated – medical conditions, such as hyperlipidemia, hypertension, migraine, and asthma.

In a notice announcing the potential changes, officials said some patients were missing necessary care because of the cost and time involved in seeing a physician. And some physician visits could be eliminated by making certain medications nonprescription and adding conditions of safe use, according to the notice.

In its hearing notice, the agency outlined a variety of ways that drugs could be made available over and behind the counter.

• Lengthen the time between follow up visits. Under this scenario, patients would see their physician or other health care provider for an initial prescription; the prescriber would authorize refills beyond what normally are currently allowed before a follow-up visit is required. In addition, conditions of safe use would be set for the refills. In its proposal, FDA officials noted that this approach could be used for rescue inhalers to treat asthma, or epinephrine for allergic reactions.

• Make use of new technology. A patient could use a pharmacy kiosk or website to self-screen for a particular condition; an associated algorithm would help the patient determine whether a particular medication is appropriate or contraindicated.

• Move more drugs behind the counter. Certain drugs would be reclassified as nonprescription; however, to purchase the drug, the patient would need to visit with the pharmacist. Pharmacists could potentially be involved in conducting and interpreting diagnostics including blood tests or liver function tests. Based on the results of those tests, pharmacists could help determine if a particular drug is appropriate or contraindicated.

The FDA is also considering some type of dual availability, in which certain drugs would be available both by prescription as well as nonprescription with certain conditions of safe use.

Making medications more readily available through the pharmacy has the potential to reduce costs, the FDA said.

"In addition to improved health outcomes for consumers staying on their medications, the time and attention that physicians and other health care provider expend on routine tasks related to prescription refills reduces the time that they are available to attend to more seriously ill patients," the FDA wrote in its hearing notice. "Eliminating or reducing the number of routine visits could free up prescribers to spend time with more seriously ill patients, reduce the burdens on the already overburdened health care system, and reduce health care costs."

Physicians have concerns about how the idea would be applied.

The FDA paradigm has the potential for both benefit and harm, depending on how it is applied, said Dr. Samuel Frank, a neurologist in Boston and a member of the American Academy of Neurology’s Patient Safety Subcommittee. It could work well to give patients nonprescription access to medications – for instance, in cases of intermittent, medication-responsive migraines. But there is "much potential for harm" with other neurologic conditions in which a neurologist must make a proper diagnosis and determine appropriate diagnostic tests and a treatment plan, he said.

Dr. Glen Stream, president of the American Academy of Family Physicians, said he’s concerned that the FDA’s approach would treat medical conditions in isolation, without considering the patient’s other medical problems or how the conditions developed. It also leaves prevention and wellness out of the equation, he said.

Dr. Stream said there’s an important role for the pharmacist to play in helping to manage medications as part of the patient-centered medical home. But in those cases, the pharmacist is part of a larger medical team directed by the physician, he said.

Pharmacists’ groups are supportive of the possible change, and see the potential for both cost savings and improvements in public health.

"We think it means greater access," said Ronna Hauser, Pharm.D., vice president of policy and regulatory affairs at the National Community Pharmacists Association.

The proposal would also save money, she said, by cutting down on physician office visits, as well as avoiding costly trips to the emergency department. There is the potential for significant savings simply by making asthma rescue inhalers and epinephrine autoinjectors available without a prescription. Currently, if patients are without those medications in an emergency, they often end up in the ED.

Pharmacists are ready and willing to work in collaboration with physicians, said Marcie Bough, Pharm.D., senior director of government affairs for the American Pharmacists Association.

She said that if the FDA pursued this plan, one of the roles of the pharmacist would be to communicate with physicians about what drugs are being dispensed, and to advise patients to go see their doctor when that is appropriate. Increased use of interoperable electronic health records would make that communication easier, she said. But in the meantime, pharmacists will rely on phone calls when higher-tech options aren’t available.

Over the last 2 decades, policymakers have proposed a number of ways to change how health care is delivered by Medicare. But a new analysis from the nonpartisan Congressional Budget Office analyzed 10 major Medicare demonstrations involving disease management and care coordination or some type of value-based payments and found that most of the projects didn’t save money.

The analysis has clear implications for health policy going forward. Under the Affordable Care Act, Congress required the Centers for Medicare and Medicaid Services to pursue new payment and care delivery models including accountable care organizations (ACOs) and bundled payments. Congress also created a new Innovation Center within CMS to test other models of care. The idea behind the newly formed Innovation Center is that Medicare officials will be able to expand successful projects without returning for Congress approval.

Dr. Glen R. Stream, president of the American Academy of Family Physicians, said he expects that the leadership within Medicare will use the CBO analysis to improve future pilot projects. He said he’s hopeful that the work that the Innovation Center is undertaking will yield better results because its projects focus on broader care delivery concepts, such as the patient-centered medical home, rather than targeting only certain chronic conditions, as was done in several past demonstrations.

Looking at the six disease management and care coordination projects that Medicare had already undertaken, CBO analysts found that on average there was little to no effect on hospital admissions or regular Medicare spending. The demonstrations were more likely to reduce costs if they used care managers who had significant, direct contact with physicians and patients. However, those programs generally didn’t save enough money to cover the cost of the extra services provided.

For example, in programs with significant in-person or telephone interaction between care management and patients there was an average 7% drop in hospital admissions and a 3% reduction in regular Medicare spending. However, in order to offset the cost of care management fees, the programs would have had to reduce Medicare expenditures by 13%.

In the four demonstrations that focused on changing the financial incentives for providers, only one produced significant savings. A project that offered bundled payments to physicians and hospitals for heart bypass surgery reduced Medicare expenditures related to heart bypass by about 10% without adverse impact on patient outcomes.

Medicare was able to achieve those savings in large part because officials negotiated bundled payments that were lower than the traditional fee-for-service payments, according to CBO. The other projects, which offered bonuses for meeting quality standards or reducing spending, did not achieve significant savings for the Medicare program, CBO wrote. ☐

Over the last 2 decades, policymakers have proposed a number of ways to change how health care is delivered by Medicare. But a new analysis from the nonpartisan Congressional Budget Office analyzed 10 major Medicare demonstrations involving disease management and care coordination or some type of value-based payments and found that most of the projects didn’t save money.

The analysis has clear implications for health policy going forward. Under the Affordable Care Act, Congress required the Centers for Medicare and Medicaid Services to pursue new payment and care delivery models including accountable care organizations (ACOs) and bundled payments. Congress also created a new Innovation Center within CMS to test other models of care. The idea behind the newly formed Innovation Center is that Medicare officials will be able to expand successful projects without returning for Congress approval.

Dr. Glen R. Stream, president of the American Academy of Family Physicians, said he expects that the leadership within Medicare will use the CBO analysis to improve future pilot projects. He said he’s hopeful that the work that the Innovation Center is undertaking will yield better results because its projects focus on broader care delivery concepts, such as the patient-centered medical home, rather than targeting only certain chronic conditions, as was done in several past demonstrations.

Looking at the six disease management and care coordination projects that Medicare had already undertaken, CBO analysts found that on average there was little to no effect on hospital admissions or regular Medicare spending. The demonstrations were more likely to reduce costs if they used care managers who had significant, direct contact with physicians and patients. However, those programs generally didn’t save enough money to cover the cost of the extra services provided.

For example, in programs with significant in-person or telephone interaction between care management and patients there was an average 7% drop in hospital admissions and a 3% reduction in regular Medicare spending. However, in order to offset the cost of care management fees, the programs would have had to reduce Medicare expenditures by 13%.

In the four demonstrations that focused on changing the financial incentives for providers, only one produced significant savings. A project that offered bundled payments to physicians and hospitals for heart bypass surgery reduced Medicare expenditures related to heart bypass by about 10% without adverse impact on patient outcomes.

Medicare was able to achieve those savings in large part because officials negotiated bundled payments that were lower than the traditional fee-for-service payments, according to CBO. The other projects, which offered bonuses for meeting quality standards or reducing spending, did not achieve significant savings for the Medicare program, CBO wrote. ☐

Over the last 2 decades, policymakers have proposed a number of ways to change how health care is delivered by Medicare. But a new analysis from the nonpartisan Congressional Budget Office analyzed 10 major Medicare demonstrations involving disease management and care coordination or some type of value-based payments and found that most of the projects didn’t save money.

The analysis has clear implications for health policy going forward. Under the Affordable Care Act, Congress required the Centers for Medicare and Medicaid Services to pursue new payment and care delivery models including accountable care organizations (ACOs) and bundled payments. Congress also created a new Innovation Center within CMS to test other models of care. The idea behind the newly formed Innovation Center is that Medicare officials will be able to expand successful projects without returning for Congress approval.

Dr. Glen R. Stream, president of the American Academy of Family Physicians, said he expects that the leadership within Medicare will use the CBO analysis to improve future pilot projects. He said he’s hopeful that the work that the Innovation Center is undertaking will yield better results because its projects focus on broader care delivery concepts, such as the patient-centered medical home, rather than targeting only certain chronic conditions, as was done in several past demonstrations.

Looking at the six disease management and care coordination projects that Medicare had already undertaken, CBO analysts found that on average there was little to no effect on hospital admissions or regular Medicare spending. The demonstrations were more likely to reduce costs if they used care managers who had significant, direct contact with physicians and patients. However, those programs generally didn’t save enough money to cover the cost of the extra services provided.

For example, in programs with significant in-person or telephone interaction between care management and patients there was an average 7% drop in hospital admissions and a 3% reduction in regular Medicare spending. However, in order to offset the cost of care management fees, the programs would have had to reduce Medicare expenditures by 13%.

In the four demonstrations that focused on changing the financial incentives for providers, only one produced significant savings. A project that offered bundled payments to physicians and hospitals for heart bypass surgery reduced Medicare expenditures related to heart bypass by about 10% without adverse impact on patient outcomes.

Medicare was able to achieve those savings in large part because officials negotiated bundled payments that were lower than the traditional fee-for-service payments, according to CBO. The other projects, which offered bonuses for meeting quality standards or reducing spending, did not achieve significant savings for the Medicare program, CBO wrote. ☐

The first graduates of the integrated 0-5 vascular surgery residency programs will hit the workforce in July, providing an early glimpse into whether trainees in this new paradigm are as prepared to handle the rigors of practice as those who spent more time in residency.

"I suppose time will tell, Dr. Richard P. Cambria, current Society for Vascular Surgery (SVS) president told an audience of thoracic surgeons.

Dr. Cambria, who is also chief of the division of vascular and endovascular surgery and codirector of the Thoracic Aortic Center at Massachusetts General Hospital in Boston, discussed the evolution of vascular surgery training over the last 5 years during in a special session at the Society of Thoracic Surgeons (STS) annual meeting that addressed mutual issues between cardiothoracic surgery and vascular surgery.

The 0-5 program was inaugurated in 2007 and arose from a variety of concerns. The scope of vascular surgery was rapidly changing with the rise of endovascular techniques, and there became a consensus feeling that this required more time for residents to be dedicated to specific vascular training. In addition there was a general dissatisfaction with the growing diffuseness of general surgery education with its tendencey to train surgeons in an ever-increasing variety of techniques, many of which had no pertinence to vascular surgerons. The session was part of a larger "STS/AATS/SVS: What’s New in Peripheral Vascular Disease Management" collaborative program.

According to Dr. Cambria, the 0-5 vascular surgery residency program allows candidates for vascular surgery residencies to match directly out of medical school into a 5-year vascular surgery residency, bypassing 2 years of general surgery residency.

Over the next 5 years, the performance of the programs’ first graduates will be assessed based on how they score on their vascular surgery board exams, if they are able to meet board certification requirements for the number of surgical cases performed, and where they get hired, he said.

But if the success of the 0-5 training program is measured only in terms of popularity, then it has already succeeded, Dr. Cambria said. Today, there are about 38 vascular surgery residency training programs open using the 0-5 pathway and there are many more applicants than available positions. The 0-5 vascular surgery residency program isn’t just the most popular option for vascular surgeons in training, it’s one of the most popular surgery training programs offered by Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship or residency programs, Dr. Cambria said.

Meanwhile, the traditional 5+2 programs, which include 2 years of general surgery residency followed by 5 years of vascular surgery residency, have a "healthy" applicant pool but are generally not oversubscribed, he said.

The roll out of the 0-5 vascular surgery training programs nationwide could hold lessons for the cardiothoracic surgery community, which has struggled with an inadequate applicant pool for their training programs.

One solution, according to Dr. Cambria, could be to expand their own 0-6 residency programs, which are akin to the 0-5 vascular surgery residency pathway.

The first graduates of the integrated 0-5 vascular surgery residency programs will hit the workforce in July, providing an early glimpse into whether trainees in this new paradigm are as prepared to handle the rigors of practice as those who spent more time in residency.

"I suppose time will tell, Dr. Richard P. Cambria, current Society for Vascular Surgery (SVS) president told an audience of thoracic surgeons.

Dr. Cambria, who is also chief of the division of vascular and endovascular surgery and codirector of the Thoracic Aortic Center at Massachusetts General Hospital in Boston, discussed the evolution of vascular surgery training over the last 5 years during in a special session at the Society of Thoracic Surgeons (STS) annual meeting that addressed mutual issues between cardiothoracic surgery and vascular surgery.

The 0-5 program was inaugurated in 2007 and arose from a variety of concerns. The scope of vascular surgery was rapidly changing with the rise of endovascular techniques, and there became a consensus feeling that this required more time for residents to be dedicated to specific vascular training. In addition there was a general dissatisfaction with the growing diffuseness of general surgery education with its tendencey to train surgeons in an ever-increasing variety of techniques, many of which had no pertinence to vascular surgerons. The session was part of a larger "STS/AATS/SVS: What’s New in Peripheral Vascular Disease Management" collaborative program.

According to Dr. Cambria, the 0-5 vascular surgery residency program allows candidates for vascular surgery residencies to match directly out of medical school into a 5-year vascular surgery residency, bypassing 2 years of general surgery residency.

Over the next 5 years, the performance of the programs’ first graduates will be assessed based on how they score on their vascular surgery board exams, if they are able to meet board certification requirements for the number of surgical cases performed, and where they get hired, he said.

But if the success of the 0-5 training program is measured only in terms of popularity, then it has already succeeded, Dr. Cambria said. Today, there are about 38 vascular surgery residency training programs open using the 0-5 pathway and there are many more applicants than available positions. The 0-5 vascular surgery residency program isn’t just the most popular option for vascular surgeons in training, it’s one of the most popular surgery training programs offered by Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship or residency programs, Dr. Cambria said.

Meanwhile, the traditional 5+2 programs, which include 2 years of general surgery residency followed by 5 years of vascular surgery residency, have a "healthy" applicant pool but are generally not oversubscribed, he said.

The roll out of the 0-5 vascular surgery training programs nationwide could hold lessons for the cardiothoracic surgery community, which has struggled with an inadequate applicant pool for their training programs.

One solution, according to Dr. Cambria, could be to expand their own 0-6 residency programs, which are akin to the 0-5 vascular surgery residency pathway.

The first graduates of the integrated 0-5 vascular surgery residency programs will hit the workforce in July, providing an early glimpse into whether trainees in this new paradigm are as prepared to handle the rigors of practice as those who spent more time in residency.

"I suppose time will tell, Dr. Richard P. Cambria, current Society for Vascular Surgery (SVS) president told an audience of thoracic surgeons.

Dr. Cambria, who is also chief of the division of vascular and endovascular surgery and codirector of the Thoracic Aortic Center at Massachusetts General Hospital in Boston, discussed the evolution of vascular surgery training over the last 5 years during in a special session at the Society of Thoracic Surgeons (STS) annual meeting that addressed mutual issues between cardiothoracic surgery and vascular surgery.

The 0-5 program was inaugurated in 2007 and arose from a variety of concerns. The scope of vascular surgery was rapidly changing with the rise of endovascular techniques, and there became a consensus feeling that this required more time for residents to be dedicated to specific vascular training. In addition there was a general dissatisfaction with the growing diffuseness of general surgery education with its tendencey to train surgeons in an ever-increasing variety of techniques, many of which had no pertinence to vascular surgerons. The session was part of a larger "STS/AATS/SVS: What’s New in Peripheral Vascular Disease Management" collaborative program.

According to Dr. Cambria, the 0-5 vascular surgery residency program allows candidates for vascular surgery residencies to match directly out of medical school into a 5-year vascular surgery residency, bypassing 2 years of general surgery residency.

Over the next 5 years, the performance of the programs’ first graduates will be assessed based on how they score on their vascular surgery board exams, if they are able to meet board certification requirements for the number of surgical cases performed, and where they get hired, he said.

But if the success of the 0-5 training program is measured only in terms of popularity, then it has already succeeded, Dr. Cambria said. Today, there are about 38 vascular surgery residency training programs open using the 0-5 pathway and there are many more applicants than available positions. The 0-5 vascular surgery residency program isn’t just the most popular option for vascular surgeons in training, it’s one of the most popular surgery training programs offered by Accreditation Council for Graduate Medical Education (ACGME)-accredited fellowship or residency programs, Dr. Cambria said.

Meanwhile, the traditional 5+2 programs, which include 2 years of general surgery residency followed by 5 years of vascular surgery residency, have a "healthy" applicant pool but are generally not oversubscribed, he said.

The roll out of the 0-5 vascular surgery training programs nationwide could hold lessons for the cardiothoracic surgery community, which has struggled with an inadequate applicant pool for their training programs.

One solution, according to Dr. Cambria, could be to expand their own 0-6 residency programs, which are akin to the 0-5 vascular surgery residency pathway.

With less than 2 years to go before the Affordable Care Act’s state-based health insurance exchanges launch, the federal government issued its framework for how these one-stop insurance shops should be structured and how states can determine who can enroll.

The Department of Health and Human Services on March 12 released a final regulation outlining what states need to do to get their exchanges ready by Jan. 1, 2014.

The regulation offers significant flexibility in how to accomplish those tasks. For instance, it will be up to each individual state to decide if it will run its exchange through an existing agency, form a nonprofit entity to operate it, or partner with other states on a regional exchange. States also will have the power to set additional requirements – above the federal exchange standard – for health plans seeking to participate in the exchange.

Under the final rule, exchanges will offer a simple, Web-based system for individuals and small businesses to determine eligibility and to shop for insurance.

Individuals will use a single application to check eligibility for federal subsidies and to enroll in a health plan. That means states will need to coordinate between Medicaid, the Children’s Health Insurance Program, and the health plans in the exchange to process applications.

The rule also outlines how small business owners can purchase insurance for their employees through the Small Business Health Options Program (SHOP). Under the rule, small businesses can choose a level of coverage and then allow their employees to select any qualified health plan within that level. Employers can also choose to offer coverage through a single plan in the exchange.

In 2014 and 2015, states will be able to set the size of the small group market for participation in SHOP at either 1-50 employees or 1-100 employees. In 2016, all employers with up to 100 employees will be able to participate in SHOP. Starting in 2017, states will be able to open up SHOP to businesses with more than 100 employees.

The federal government also is giving states more time to prepare their exchanges. Under the Affordable Care Act, states were required to have their exchange plans approved by HHS by Jan. 1, 2013, but the new final rule allows states to get "conditional approval" from HHS on that date, even if they can’t demonstrate complete readiness.

States that are preparing to launch their own exchange but won’t be ready by Jan. 1, 2014, can apply to HHS to begin operating their exchange in 2015 or later.

In the meantime, HHS is preparing to step in with a federally run health exchange in any state that isn’t prepared to launch by 2014. The agency has yet to issue regulations on how the federally run exchanges will be run.

The March 12 final rule combines two proposals issued last summer. The first, published on July 15, 2011, proposed a framework for building the exchanges. The second, published on Aug. 17, 2011, contained the proposed standards for eligibility to enroll in health plans and subsidy programs.

With less than 2 years to go before the Affordable Care Act’s state-based health insurance exchanges launch, the federal government issued its framework for how these one-stop insurance shops should be structured and how states can determine who can enroll.

The Department of Health and Human Services on March 12 released a final regulation outlining what states need to do to get their exchanges ready by Jan. 1, 2014.

The regulation offers significant flexibility in how to accomplish those tasks. For instance, it will be up to each individual state to decide if it will run its exchange through an existing agency, form a nonprofit entity to operate it, or partner with other states on a regional exchange. States also will have the power to set additional requirements – above the federal exchange standard – for health plans seeking to participate in the exchange.

Under the final rule, exchanges will offer a simple, Web-based system for individuals and small businesses to determine eligibility and to shop for insurance.

Individuals will use a single application to check eligibility for federal subsidies and to enroll in a health plan. That means states will need to coordinate between Medicaid, the Children’s Health Insurance Program, and the health plans in the exchange to process applications.

The rule also outlines how small business owners can purchase insurance for their employees through the Small Business Health Options Program (SHOP). Under the rule, small businesses can choose a level of coverage and then allow their employees to select any qualified health plan within that level. Employers can also choose to offer coverage through a single plan in the exchange.

In 2014 and 2015, states will be able to set the size of the small group market for participation in SHOP at either 1-50 employees or 1-100 employees. In 2016, all employers with up to 100 employees will be able to participate in SHOP. Starting in 2017, states will be able to open up SHOP to businesses with more than 100 employees.

The federal government also is giving states more time to prepare their exchanges. Under the Affordable Care Act, states were required to have their exchange plans approved by HHS by Jan. 1, 2013, but the new final rule allows states to get "conditional approval" from HHS on that date, even if they can’t demonstrate complete readiness.

States that are preparing to launch their own exchange but won’t be ready by Jan. 1, 2014, can apply to HHS to begin operating their exchange in 2015 or later.

In the meantime, HHS is preparing to step in with a federally run health exchange in any state that isn’t prepared to launch by 2014. The agency has yet to issue regulations on how the federally run exchanges will be run.

The March 12 final rule combines two proposals issued last summer. The first, published on July 15, 2011, proposed a framework for building the exchanges. The second, published on Aug. 17, 2011, contained the proposed standards for eligibility to enroll in health plans and subsidy programs.

With less than 2 years to go before the Affordable Care Act’s state-based health insurance exchanges launch, the federal government issued its framework for how these one-stop insurance shops should be structured and how states can determine who can enroll.

The Department of Health and Human Services on March 12 released a final regulation outlining what states need to do to get their exchanges ready by Jan. 1, 2014.

The regulation offers significant flexibility in how to accomplish those tasks. For instance, it will be up to each individual state to decide if it will run its exchange through an existing agency, form a nonprofit entity to operate it, or partner with other states on a regional exchange. States also will have the power to set additional requirements – above the federal exchange standard – for health plans seeking to participate in the exchange.

Under the final rule, exchanges will offer a simple, Web-based system for individuals and small businesses to determine eligibility and to shop for insurance.

Individuals will use a single application to check eligibility for federal subsidies and to enroll in a health plan. That means states will need to coordinate between Medicaid, the Children’s Health Insurance Program, and the health plans in the exchange to process applications.

The rule also outlines how small business owners can purchase insurance for their employees through the Small Business Health Options Program (SHOP). Under the rule, small businesses can choose a level of coverage and then allow their employees to select any qualified health plan within that level. Employers can also choose to offer coverage through a single plan in the exchange.

In 2014 and 2015, states will be able to set the size of the small group market for participation in SHOP at either 1-50 employees or 1-100 employees. In 2016, all employers with up to 100 employees will be able to participate in SHOP. Starting in 2017, states will be able to open up SHOP to businesses with more than 100 employees.

The federal government also is giving states more time to prepare their exchanges. Under the Affordable Care Act, states were required to have their exchange plans approved by HHS by Jan. 1, 2013, but the new final rule allows states to get "conditional approval" from HHS on that date, even if they can’t demonstrate complete readiness.

States that are preparing to launch their own exchange but won’t be ready by Jan. 1, 2014, can apply to HHS to begin operating their exchange in 2015 or later.

In the meantime, HHS is preparing to step in with a federally run health exchange in any state that isn’t prepared to launch by 2014. The agency has yet to issue regulations on how the federally run exchanges will be run.

The March 12 final rule combines two proposals issued last summer. The first, published on July 15, 2011, proposed a framework for building the exchanges. The second, published on Aug. 17, 2011, contained the proposed standards for eligibility to enroll in health plans and subsidy programs.

Hospitalists are under increasing pressure from hospital administrators to do their part in reducing preventable readmissions. But while there are some proven programs aimed at improving the discharge planning process, there are still plenty of unanswered research questions.

Dr. Devan Kansagara of the Oregon Health and Science University, Portland, and of the Portland VA Medical Center has been studying hospital readmissions and transitions of care for the past several years. As the director of the evidence synthesis program at the medical center, he led a review of readmission risk prediction models and found that most of them perform poorly (JAMA 2011;306:1688-98). He published a study in the Journal of Hospital Medicine, looking at the use of a brief, scripted phone-based needs assessment in chronically ill Medicaid managed care patients (2012;7:124-30).

In an interview with Hospitalist News, Dr. Kansagara detailed some of the gaps in knowledge and what may be ripe for future evaluation.

Hospitalist News: Do we know what interventions work best to reduce readmission rates?

Dr. Kansagara: There are some interventions that have worked. Eric Coleman’s care transitions program, Mary Naylor’s discharge work, and Project RED (Re-Engineered Discharge) have all been proved to work in randomized controlled trials. But in terms of knowing which of these interventions worked best and in what populations they should be used, I don’t think we know that yet. All of these interventions have some similar elements. For instance, there is a bridging component that involves educating patients both in and out of the hospital. That may be a component that’s helpful. But there was a recent review in Annals of Internal Medicine looking at several different types of transitional care interventions and many of them didn’t work (2011 Oct. 18;155:520-8). I don’t know that it’s entirely clear that we’ve pinpointed the elements that will bring down readmission rates.

HN: What research questions are still unanswered when it comes to preventing readmissions?

Dr. Kansagara: We really don’t know which components of the interventions are most important. We also don’t know how many readmissions are actually preventable and what makes them preventable. Another really interesting and completely understudied area is at the other end of the care continuum. What happens as people are getting sick and on their way into the emergency department or the hospital? People haven’t looked broadly at what is happening in the community and the outpatient practice setting.

HN: How important is it to assess a patient’s risk for readmission?

Dr. Kansagara: A lot of people have tried to develop models to predict the risk of readmission, and most of these models don’t work very well. We don’t have a gold standard way of identifying patients at high risk for readmission. But rather than focusing too much energy and attention on quantifying a patient’s risk for readmission, it’s probably more important to develop a system for identifying patient factors that can contribute to readmission risk that might not be readily collected in the medical record. These would be things like housing status, health literacy, substance abuse issues, distance to follow-up care, and the feasibility of them following up.

Hospitalists are under increasing pressure from hospital administrators to do their part in reducing preventable readmissions. But while there are some proven programs aimed at improving the discharge planning process, there are still plenty of unanswered research questions.

Dr. Devan Kansagara of the Oregon Health and Science University, Portland, and of the Portland VA Medical Center has been studying hospital readmissions and transitions of care for the past several years. As the director of the evidence synthesis program at the medical center, he led a review of readmission risk prediction models and found that most of them perform poorly (JAMA 2011;306:1688-98). He published a study in the Journal of Hospital Medicine, looking at the use of a brief, scripted phone-based needs assessment in chronically ill Medicaid managed care patients (2012;7:124-30).

In an interview with Hospitalist News, Dr. Kansagara detailed some of the gaps in knowledge and what may be ripe for future evaluation.

Hospitalist News: Do we know what interventions work best to reduce readmission rates?

Dr. Kansagara: There are some interventions that have worked. Eric Coleman’s care transitions program, Mary Naylor’s discharge work, and Project RED (Re-Engineered Discharge) have all been proved to work in randomized controlled trials. But in terms of knowing which of these interventions worked best and in what populations they should be used, I don’t think we know that yet. All of these interventions have some similar elements. For instance, there is a bridging component that involves educating patients both in and out of the hospital. That may be a component that’s helpful. But there was a recent review in Annals of Internal Medicine looking at several different types of transitional care interventions and many of them didn’t work (2011 Oct. 18;155:520-8). I don’t know that it’s entirely clear that we’ve pinpointed the elements that will bring down readmission rates.

HN: What research questions are still unanswered when it comes to preventing readmissions?

Dr. Kansagara: We really don’t know which components of the interventions are most important. We also don’t know how many readmissions are actually preventable and what makes them preventable. Another really interesting and completely understudied area is at the other end of the care continuum. What happens as people are getting sick and on their way into the emergency department or the hospital? People haven’t looked broadly at what is happening in the community and the outpatient practice setting.

HN: How important is it to assess a patient’s risk for readmission?

Dr. Kansagara: A lot of people have tried to develop models to predict the risk of readmission, and most of these models don’t work very well. We don’t have a gold standard way of identifying patients at high risk for readmission. But rather than focusing too much energy and attention on quantifying a patient’s risk for readmission, it’s probably more important to develop a system for identifying patient factors that can contribute to readmission risk that might not be readily collected in the medical record. These would be things like housing status, health literacy, substance abuse issues, distance to follow-up care, and the feasibility of them following up.

Hospitalists are under increasing pressure from hospital administrators to do their part in reducing preventable readmissions. But while there are some proven programs aimed at improving the discharge planning process, there are still plenty of unanswered research questions.

Dr. Devan Kansagara of the Oregon Health and Science University, Portland, and of the Portland VA Medical Center has been studying hospital readmissions and transitions of care for the past several years. As the director of the evidence synthesis program at the medical center, he led a review of readmission risk prediction models and found that most of them perform poorly (JAMA 2011;306:1688-98). He published a study in the Journal of Hospital Medicine, looking at the use of a brief, scripted phone-based needs assessment in chronically ill Medicaid managed care patients (2012;7:124-30).

In an interview with Hospitalist News, Dr. Kansagara detailed some of the gaps in knowledge and what may be ripe for future evaluation.

Hospitalist News: Do we know what interventions work best to reduce readmission rates?

Dr. Kansagara: There are some interventions that have worked. Eric Coleman’s care transitions program, Mary Naylor’s discharge work, and Project RED (Re-Engineered Discharge) have all been proved to work in randomized controlled trials. But in terms of knowing which of these interventions worked best and in what populations they should be used, I don’t think we know that yet. All of these interventions have some similar elements. For instance, there is a bridging component that involves educating patients both in and out of the hospital. That may be a component that’s helpful. But there was a recent review in Annals of Internal Medicine looking at several different types of transitional care interventions and many of them didn’t work (2011 Oct. 18;155:520-8). I don’t know that it’s entirely clear that we’ve pinpointed the elements that will bring down readmission rates.

HN: What research questions are still unanswered when it comes to preventing readmissions?

Dr. Kansagara: We really don’t know which components of the interventions are most important. We also don’t know how many readmissions are actually preventable and what makes them preventable. Another really interesting and completely understudied area is at the other end of the care continuum. What happens as people are getting sick and on their way into the emergency department or the hospital? People haven’t looked broadly at what is happening in the community and the outpatient practice setting.

HN: How important is it to assess a patient’s risk for readmission?

Dr. Kansagara: A lot of people have tried to develop models to predict the risk of readmission, and most of these models don’t work very well. We don’t have a gold standard way of identifying patients at high risk for readmission. But rather than focusing too much energy and attention on quantifying a patient’s risk for readmission, it’s probably more important to develop a system for identifying patient factors that can contribute to readmission risk that might not be readily collected in the medical record. These would be things like housing status, health literacy, substance abuse issues, distance to follow-up care, and the feasibility of them following up.