Health Services Administration Commons^™

Medicaid In 2006: A Trip Down The Yellow Brick Road?, Jennifer Ryan

National Health Policy Forum

This issue brief explores the continuing evolution of the Medicaid program on several fronts. It discusses the benefits and cost-sharing flexibility that is included in the Deficit Reduction Act of 2005 (DRA) and examines the implications of these provisions for states, beneficiaries, and providers. The paper also explores recent trends in section 1115 waiver development and considers the use of waivers as a vehicle for restructuring Medicaid financing systems and for testing completely new approaches to health care delivery. The role of section 1115 waivers in the context of the DRA and as a mechanism for continued state innovation is …

Rebalancing Long-Term Care: The Role Of The Medicaid Hcbs Waiver Program, Cynthia Shirk

National Health Policy Forum

This paper reviews the history and background of the Medicaid home and community-based services (HCBS) waiver program. It describes the eligibility, benefits, and financing structure, as well as the trends in program expenditures over time. The paper considers the contribution of the HCBS waiver program toward improving access to community-based care for Medicaid beneficiaries who are elderly and disabled and discusses the barriers that remain. This paper also summarizes the provisions included in the recently enacted Deficit Reduction Act of 2005 that may further expand Medicaid HCBS and considers how it may continue the process of redefining the concept of …

Fitness, Knowledge, Progress: Assessing Physician Qualification, Lisa Sprague

National Health Policy Forum

The informed and empowered consumer is an ideal invoked by many would-be health care reformers. An actual consumer wishing to don the mantle of power may be hindered by the scarcity of information available, particularly with respect to choosing among physicians. How is one to know who is best qualified? This issue brief looks at the basics of physician qualification and the processes by which physicians are licensed, credentialed, and board-certified. It examines how the evolution of these processes (for example, the move from lifetime certification to ongoing maintenance of certification) affects clinicians and their patients. The rise of quality …

Health Benefits In Retirement: Set For Extinction?, Mark Merlis

National Health Policy Forum

Nearly 18 million people rely on employer-provided retiree health benefits to fill gaps in Medicare’s coverage or to provide basic insurance until they reach Medicare age. Rising costs have led many employers to limit benefits, require participants to pay a larger share of the costs, or stop offering coverage at all for workers who have not yet retired. This background paper describes recent developments in retiree health benefits, possible future trends, and policy options for slowing the erosion of coverage or providing alternative ways for retirees to meet their expected medical expenses.

The Vaccine Industry: Does It Need A Shot In The Arm?, Eileen Salinsky, Cole Werble

National Health Policy Forum

This paper broadly examines the scientific, regulatory, and economic factors that contribute to constrained vaccine production capacity, periodic vaccine shortages, and perceptions of inadequate investment in new vaccine product development. It describes the vaccine development and production processes and summarizes how regulatory requirements influence these activities. Market dynamics related to vaccine supply and demand are also explored, including an examination of the industry’s cost structure, potential market size, and purchaser price sensitivity. A broad range of policy interventions designed to address shortcomings of the vaccine market are considered.

Designing Employer-Sponsored Mental Health Benefits, Rachel Sethi, Joanne Jee, Lisa Chimento, D. Richard Mauery

Health Policy and Management Faculty Publications

No abstract provided.

Redesigning Practice To Improve Care Delivery (Boston), Laura A. Dummit, Lisa Sprague

National Health Policy Forum

This site visit focused on how the practice of medicine is changing or can be changed to improve care delivery across the spectrum of patient populations. Regarded as a “medical Mecca,” Boston is home to the academic health centers and teaching hospitals where many of the nation’s physicians are trained. As a center of innovation, Boston prides itself on its high bar with respect to standards of care. Panels addressed the used of clinical information technology (IT) in the physician’s office, in the hospital, and community-wide. Participants observed how IT is being used to further the mission of community health …

Medicare Advantage Snps: A New Opportunity For Integrated Care?, Christie Provost Peters

National Health Policy Forum

Medicare Advantage special needs plans (SNPs) are a new type of coordinated care plan established by the Medicare Prescription Drug, Improvement and Modernization Act. SNPs were created to encourage greater access to Medicare managed care for certain special needs populations: the institutionalized, persons dually eligible for Medicare and Medicaid, and the chronically ill. Some view SNPs as a new opportunity to integrate acute and long-term care services as well as Medicare and Medicaid financing. Others, however, question the degree to which full integration will become a widespread reality. This issue brief examines the SNP option and the promises and challenges …

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 …

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.

Childhood Overweight: What The Research Tells Us, The Center For Health And Health Care In Schools, School Of Public Health And Health Services, George Washington University Medical Center

Center for Health and Health Care in Schools

No abstract provided.

Managed Mental Health Care: Findings From The Literature, 1990–2005, D. Richard Mauery, Lissette Vaquerano, Rachel Sethi, Joanne Jee, Lisa Chimento

Health Policy and Management Faculty Publications

No abstract provided.

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.