Health Law and Policy Commons^™

A Report From The Forum Session “Implementing The Medicare Prescription Drug Benefit: Continuing Challenges For States”, Lee Partridge

National Health Policy Forum

This National Health Policy Forum Meeting Report provides an overview and discussion of a technical session that took place on July 12, 2005. The meeting was designed to re-visit issues discussed at a similar meeting in July 2004, which was intended to offer a state perspective on the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and the new Medicare prescription drug benefit. This report provides an update on the implementation issues identified in 2004—including outreach, education and enrollment; coordination of care for individuals who are “dually eligible” for Medicare and Medicaid; and the cost …

One Pill, Many Prices: Variation In Prescription Drug Prices In Selected Government Programs, Dawn Gencarelli

National Health Policy Forum

This paper updates a June 2002 National Health Policy Forum Issue Brief, "Average Wholesale Price for Prescription Drugs: Is There a More Appropriate Pricing Mechanism?" Since the release of that paper, Congress enacted the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which created a new, comprehensive outpatient prescription drug benefit and reduced Medicare’s reliance on the average wholesale price (AWP) in paying for prescription drugs. This paper discusses the continued use of AWP as well as other pricing benchmarks that pertain to prescription drugs. It explains the relevance of these pricing mechanisms to different government programs and …

Clinical Preventive Services: When Is The Juice Worth The Squeeze?, Eileen Salinsky

National Health Policy Forum

This paper provides an overview of clinical preventive services, including a definition of such services and the role of the U.S. Preventive Services Task Force in recommending which services should be routinely offered to patients. It also describes efforts to analyze the cost effectiveness of clinical preventive services and reviews the insurance coverage policies of private and public payers. Barriers to increased uptake of appropriate services are discussed and policy relevant issues are summarized.

Caring For "Ryan White": The Fundamentals Of Hiv/Aids Treatment Policy, Jessamyn Taylor

National Health Policy Forum

This background paper provides an overview of the HIV/ AIDS epidemic in the United States and discusses how treatment of the disease and the populations most affected by it have changed over time. The federal government’s domestic and global efforts in prevention, research, and treatment of the disease are highlighted. The paper outlines the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act, a set of programs that fund treatment services for uninsured and underinsured individuals living with HIV/AIDS, and places it in the context of other federal programs that fund treatment for HIV/AIDS. Policy issues for Ryan White’s potential congressional …

Keeping Track Of Care: Quality And Technology At Lifebridge Health System (Baltimore), Judith Moore

National Health Policy Forum

This one-day site visit focused on quality and technology in acute, post-acute and long-term care at Sinai Hospital and Levindale Hebrew Geriatric Center and Hospital, both components of LifeBridge Health System in Baltimore. Participants traced the treatment paths of hypothetical cardiac and cancer patients through the hospital and explored the range of home- and community-based as well as institutional care available through the geriatric center. The role of clinical information technology was highlighted in both settings.

Mental Health And Juvenile Justice: Moving Toward More Effective Systems Of Care, Jane Koppelman

National Health Policy Forum

This issue brief discusses the mental health needs of youth who are involved with the juvenile justice system, how they come into contact with the system, and the evidence of the availability and quality of mental health services for such youth. The paper also explores public policy options for avoiding dependence on the juvenile justice system as a last resort for treating youth with mental disorders.

Specialty Hospitals: Can General Hospitals Compete?, Laura A. Dummit

National Health Policy Forum

The rapid increase in specialty cardiac, surgical, and orthopedic hospitals has captured the attention of general hospitals and policymakers. Although the number of specialty hospitals remains small in absolute terms, their entry into certain health care markets has fueled arguments about the rules of “fair” competition among health care providers. To allow the smoke to clear, Congress effectively stalled the growth in new specialty hospitals by temporarily prohibiting physicians from referring Medicare or Medicaid patients to specialty hospitals in which they had an ownership interest. During this 18-month moratorium, which expired June 8, 2005, two mandated studies of specialty hospitals …

Local Coverage Initiatives: Solution Or Band-Aid For The Uninsured?, Jennifer Ryan

National Health Policy Forum

This issue brief surveys health coverage expansion initiatives that are operating on the county or local level, often without the benefit of federal funding. The paper explores the circumstances that have made these initiatives possible and considers the ongoing barriers that local policymakers face in sustaining the programs. Descriptions of four initiatives illustrate the range and variety of programs in operation today and offer both best practices and lessons learned for other communities. The paper also includes a brief analysis of the key elements that make up a successful coverage initiative. Finally, this issue brief considers the role of local …

Children With Special Health Care Needs: Minding The Gaps, Christie Provost Peters

National Health Policy Forum

This background paper examines the issue of children with special health care needs and their interaction with the health care system. Results from recent national and state surveys and studies were used to review the medical expenditures, utilization, and insurance coverage of these children. The paper also discusses weaknesses within the private and public delivery and financing systems that may hinder the access of certain families with children with special health care needs to important services.

Hospital Oversight In Medicare: Accreditation And Deeming Authority, Lisa Sprague

National Health Policy Forum

To be eligible to receive payment from Medicare, hospitals must be certified to meet certain conditions. Hospitals may gain such credentials by choosing to be reviewed by a state certification agency under contract to the Centers for Medicare & Medicaid Services or to be accredited by either the Joint Commission on Accreditation of Healthcare Organizations or the American Osteopathic Association. This issue brief looks at how accreditation of hospitals developed and how it continues to change. It considers the legal and practical reasons that a majority of hospitals choose accreditation and why some hospitals do not, along with broader consideration …

Health Insurance Coverage For Small Employers, Dawn Gencarelli

National Health Policy Forum

For workers of small employers, access to affordable health insurance coverage is a growing concern. This paper examines the problems these firms and their employees face in obtaining health insurance coverage they can afford. The degree to which these challenges become obstacles varies greatly, depending on, for instance, the size of the employer and the characteristics of its employees. Reviewed here are these challenges to access, as well as some of the efforts made through state and federal reforms to address them, including rules regarding guaranteed issue and guaranteed renewability. This paper also explores some of the more recent initiatives …

Fundamentals Of Underwriting In The Nongroup Health Insurance Market: Access To Coverage And Options For Reform, Mark Merlis

National Health Policy Forum

Although the majority of Americans with health insurance obtain coverage through their employers, many individuals must negotiate the nongroup insurance market alone. Insurers use a process called medical underwriting to identify applicants with current or recent medical problems. Because these applicants are likely to cost the insurer more in claims than a healthier person, insurers may charge them higher premiums or restrict or deny coverage. This background paper reviews the practice of underwriting, state and federal regulation of insurers offering nongroup health coverage, and several proposed options for improving access to coverage for applicants who are in poor health.

Health Savings Accounts: The Fundamentals, Beth Fuchs, Julie A. James

National Health Policy Forum

This paper explores the fundamentals of health savings accounts (HSAs). While not intended to be an exhaustive review of these accounts, it describes their intellectual and legislative origins and the mechanics of how they work, explores the early returns on how they are faring in the insurance market, and identifies major issues and controversies that they raise. The paper looks specifically at the basic rules for HSAs and the requirements for health insurance that qualifies as a high-deductible health plan (HDHP) for HSA purposes. Also considered are issues related to provider payments under HSAs and the administration of the benefit …

A New Kind Of "Outrageous Misconduct": Effects To Undermine The Law's Ability To Deter And Punish Intentional And Outrageous Corporate Behavior, Candace Howard

Student Articles and Papers

The current tort "reform" movement, if successful, will completely undermine our most effective tool for deterring outrageous corporate misconduct: the threat of punitive damages. Such "reform" would have a particularly egregious impact on the environment and public health because, due to a lack of enforcement and the undetectable nature of many pollutants, environmental offenses are often more difficult to deter than other types of offenses. The essay argues that, although rarely imposed for environmental offenses, punitive damages are especially vital in that arena because, when imposed, they are richly deserved. It concludes that, rather than tort reform, what we need …

Exploring California's Rural Health System: From The Redwood Forests To The Baja Border, Eileen Salinsky, Jessamyn Taylor

National Health Policy Forum

This three day site visit to California explored the state’s rural health system with a particular focus on the financial health of inpatient and outpatient providers and how that affects access to care. The role of telemedicine as a tool for expanding access was explored as well as the special needs of vulnerable populations such as farmworkers. Participants learned how state and federal regulation and payment policies and state budget deficits impact the viability of rural health systems.

Obesity And The Struggle Within Ourselves, Maxwell Gregg Bloche

Georgetown Law Faculty Publications and Other Works

The author argues that we ought to treat our eating, exercise habits, and girth as personal matters, for the most part, but that law can and should make a contribution, as an ally of our longer-term will against our immediate cravings. Law can be our ally in this fashion without command-and-control intrusion into our private lives. Such intrusion is at odds with our core beliefs and unlikely to produce public health success. It is more likely to provoke popular backlash--one reason why some who stand to gain from our unhealthy dining choices try to cast government efforts to inform these …

From International Sanitary Conventions To Global Health Security: The New International Health Regulations, David P. Fidler

Articles by Maurer Faculty

In May 2005, the World Health Organization adopted the new International Health Regulations (IHR), which constitute one of the most radical and far-reaching changes to international law on public health since the beginning of international health cooperation in the mid-nineteenth century. This article comprehensively analyses the new IHR by examining the history of international law on infectious disease control, the IHR revision process, the substantive changes contained in the new IHR and concerns regarding the future of the new IHR. The article demonstrates why the new IHR constitute a seminal event in the relationship between international law and public health …

Quality Improvement In Maryland: Partnerships And Progress, Judith D. Moore, Lisa Sprague

National Health Policy Forum

This one-and-a-half-day site visit to Easton, Maryland, explored the activities of the Delmarva Foundation, the Quality Improvement Organization (QIO) for Maryland and the District of Columbia. The program reviewed Delmarva’s responsibilities under their Medicare contract and the initiatives they have undertaken with hospitals and other providers to improve health care outcomes and to define, collect, and report quality data. Local hospital officials added their perspective on quality programs and working with Delmarva. Topics of particular interest were health information technology, patient safety, and quality reporting both to government agencies and to consumers.

The Effects Of Copayments On The Use Of Medical Services And Prescription Drugs In Utah's Medicaid Program, Leighton Ku, Elaine Deschamps, Judi Hilman

Health Policy and Management Faculty Publications

In recent years, a number of states have increased cost-sharing for low-income Medicaid beneficiaries as one approach to Medicaid cost-containment. While copayments have been most commonly applied to prescription drugs, they also have been assessed for other services, such as physician visits, hospital admission, or outpatient clinic use.

Prior research has found that when low-income patients are required to pay more for health care services or for prescription drugs, they use fewer services or medications.[2] In some cases, their health could deteriorate, with the result that they may subsequently require more expensive emergency room or inpatient hospital care. While …

The Provider System For Children's Mental Health: Workforce Capacity And Effective Treatment, Jane Koppelman

National Health Policy Forum

This issue brief examines two issues that are key to meeting children’s unmet needs for mental health care: ensuring that the provider supply is adequate and that the care delivered is effective. It describes the shortage of qualified providers to address children’s mental disorders, as well its possible causes; it describes how managed care, to a certain extent, drives practice patterns; and it discusses the gray areas in deciding which providers are most qualified to deliver what care. In addition, this paper introduces what is known about evidence-based care in children’s mental health, the extent to which it is being …

Electronic Health Records: How Close? How Far To Go?, Lisa Sprague

National Health Policy Forum

This paper looks at the central role of the electronic health record (EHR) in health information technology. It considers the extent to which EHRs are in use and initiatives designed to increase their prevalence, as well as barriers to the widespread adoption of EHRs and efforts to surmount them. Particular attention is given to such obstacles as cost, the professional culture of physicians, standardization, and legal questions.

Medicaid's Disproportionate Share Hospital Program: Complex Structure, Critical Payments, Robert E. Mechanic

National Health Policy Forum

This background paper describes the history and political evolution of Medicaid’s disproportionate share hospital (DSH) program and examines DSH as it exists today. It highlights the importance of DSH payments for the viability of safety net hospitals and considers the consequences of states’ creative financing strategies for maximizing federal Medicaid matching funds. Finally, this paper reviews several options for improving the structure and effectiveness of the DSH program.

Fundamentals Of Community Health Centers, Jessamyn Taylor

National Health Policy Forum

This background paper examines the dominant model of federal grant funding for primary care in the health care safety net: the community health center. It describes the history of the health center program and highlights key policy issues influencing health centers, such as Medicaid payment policies and medically underserved area designations. The paper also examines the recent presidential initiative to expand health centers, including a review of the process used to identify new grantees, an assessment of remaining gaps in capacity, an exploration of continuing challenges, and a discussion of unresolved policy questions.

A Report From The Forum Session "Implementing The New Medicare Drug Benefit: Challenges And Opportunities For States", Judith D. Moore

National Health Policy Forum

The National Health Policy Forum convened a meeting on July 22, 2004 to discuss state-based challenges associated with implementing the Medicare Prescription Drug, Improvement, and Modernization Act (MMA). The meeting brought together an extremely insightful and experienced group of current and former state officials and other experts to discuss key issues. In keeping with its tradition of promoting a frank, off-the-record exchange on health policy issues, NHPF does not normally prepare written summaries or reports of meetings. However, because this meeting provided vivid illustrations of the importance of state-federal collaboration for the successful implementation of the new Medicare drug benefit, …

Fundamentals Of The Prescription Drug Market, Christie Provost Peters

National Health Policy Forum

This background paper is a primer on the prescription drug market. It provides information on the fundamentals of the pharmaceutical industry and various marketplace stakeholders, including manufacturers, retailers, consumers, regulators, researchers, and purchasers. This paper also examines the various ways the federal government interacts with the pharmaceutical market. Due to the breadth of material addressed, some complex issues and relationships are presented in broad conceptual terms without extensive technical detail.

Tick-Tock: Preparing For The Next Influenza Pandemic, Eileen Salinsky

National Health Policy Forum

This paper describes the nature of pandemic influenza and highlights key challenges for responding to this disease threat. It explains how an influenza pandemic would differ from annual influenza outbreaks and examines how a pandemic virus could emerge. It also explores important issues involved in pandemic preparedness capabilities, including disease surveillance, vaccine production and distribution, antiviral stockpiling, health care system readiness, and public health containment measures. The national pandemic preparedness plan is briefly reviewed, and unresolved policy issues related to the plan’s implementation are identified.

The Promise And The Reality Of Long-Term Care Insurance, Randy Desonia

National Health Policy Forum

The aging of the nation’s population will create a surge in the need for long-term care services, putting pressure on existing funding sources and fueling demand for more. This paper examines one financing option—private long-term care insurance—and summarizes its brief history and the several critical precedents that have influenced the products as currently sold. Other topics discussed include the challenges to encouraging sales growth as well as increasing the role of this type of insurance in paying for long-term care.

Medicaid Prescription Drug Spending And Use, Brian Bruen, Arunabh Ghosh

Health Policy and Management Issue Briefs

No abstract provided.

The Economics Of Quality: Changing Incentives In Cincinnati, Lisa Sprague, Nora Super

National Health Policy Forum

This site visit focused on private market dynamics and quality improvement initiatives. Cincinnati is characterized by strong players in all sectors of the market: employers such as Procter and Gamble and General Electric, hospital systems, health plans, and physician groups with the power to “push back” in contract negotiations. The city is a pilot site for Bridges to Excellence, a pay-for-performance initiative spearheaded by GE. Cincinnati Children’s Hospital Medical Center is a grantee under the Robert Wood Johnson Foundation’s Pursuing Perfection program. Among the issues explored were physician supply, incentive structures, specialty hospitals, and information technology.

Consumer Cost Sharing In Private Health Insurance: On The Threshold Of Change, Veronica V. Goff

National Health Policy Forum

Employers are asking employees to pay more for health care through higher premium contributions, share of contribution, and out-of-pocket maximums, along with variations in deductibles, copays, and coinsurance based on choice of providers, networks, drugs, and other services. This issue brief examines consumer cost-sharing trends in private insurance, discusses the outlook for cost sharing in employment-based benefits, and considers public policies to support health care markets for consumers.