Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Boosting research on women's health issues during the past two decades has both improved prevention and treatment and reduced deaths among women related to cardiovascular disease, breast cancer, and cervical cancer, according to a reportfrom the Institute of Medicine. At the same time, it has yielded less—but still significant—progress in reducing the effects of depression, HIV/AIDS, and osteoporosis on women.
However, other health issues important to women have seen less progress over the years, including unintended pregnancy, autoimmune diseases, alcohol and drug addiction, lung cancer, and Alzheimer's disease and dementia. Fewer gains were found to have been made on chronic and debilitating conditions that caused significant higher levels of suffering but lower death rates, an IOM panel says in a consensus report, Women's Health Research: Progress, Pitfalls, and Promise.
In addition, while progress has been made in identifying behavioral determinants of women's health—such as smoking, diet, and physical activity—few studies actually have tested ways to modify these factors among women or examined the impact of social and community factors in specific groups of women, the report added.
"Unfortunately, less progress has been made on conditions that are not major killers but still profoundly affect women's quality of life," said committee chair Nancy E. Adler, PhD, professor of medical psychology and director of the Center for Health and Community, University of California, San Francisco. "These issues require similar attention and resources if we are to see better prevention and treatment in more areas."
Also, while an expanded focus in women's health research has led to decreased rates of female mortality from some diseases, which progress has not been felt by all women. Women who are socially disadvantaged because of their race or ethnicity, income levels, or educational attainment often have been underrepresented in many research studies, the report noted.
To improve the scope of women's health research in the future, the committee recommended that:
The National Institutes of Health (NIH) support research on common determinants and risk factors that found with multiple diseases.
NIH, the Agency for Healthcare Research and Quality, and the Centers for Disease Control and Prevention develop target initiatives to increase research on the populations of women with the highest risks and burdens of disease.
Research include greater attention to assessing quality of life issues—for example, functional status or functionality, mobility, or pain—and promoting wellness.
The committee also observed that the public often has been confused by conflicting findings and opposing recommendations emerging from health research, including women's health research. Poor communication—on issues such as mammography—has led to confusion and could adversely affect the care of women, it said.
To ensure that messages are clearly conveyed—and understood by the public—the committee recommended that the Department of Health and Human Services appoint a task force to develop strategies to better communicate research-based health messages to women. These messages should: reach a diverse audience of women; increase awareness of women's health issues and treatments, including preventive and intervention strategies; and decrease confusion regarding complex and sometimes conflicting findings, the committee said.
The committee also suggested calling for all federally funded studies to develop and include a plan for disseminating findings to the public, providers, and policymakers, and establishing a national media advisory panel to explain the research findings to a variety of audiences.
Public comments can be made until Oct. 4 on the draft prepared by the National Association of Insurance Commissioners (NAIC) on medical loss ratios (MLRs). These are limits to be placed on health insurance plans beginning Jan. 1 that specify how many premium dollars may go toward medical care versus administrative costs and profits.
Some comments may include suggestions that the federal government include phasing in of the requirements in the states—specifically to avoid a sudden flight of insurers providing small market and individual coverage. The healthcare reform legislation passed six months ago calls for an MLR of 85% for insurers providing large group coverage and 80% for those providing coverage to the individual and small group health insurance market.
Concerns have been raised, though, on whether the insurers providing coverage to smaller group health markets would be able to meet the MLR requirements—due in part to higher overhead expenses and fees.
Last week, several state insurance commissioners, during a White House meeting with Obama administration members, emphasized that a phased-in approach could help avoid disruption in their states' insurance markets. Officials from Iowa and Maine specifically requested waivers to gradually phase in the MLR rules through 2014.
In a letter last week to Health and Human Services Secretary Kathleen Sebelius, Iowa Insurance Commission Susan Voss said that Iowa has had some of the lowest health insurance rates in the country, with a market that includes a large health insurance carrier and several smaller insurance carriers in the individual market. However, the state is already seeing carriers with small numbers of insurers in the individual market "announce their intent to cease business in our state," Voss said.
Among the rules included in the draft that may be welcome news for health insurers are provisions that would allow them to include spending on wellness programs and healthcare hotlines as expenses—but only in instances where the focus is on improving the quality of care. Insurers also would be permitted under the draft guidelines to exclude most federal and state taxes from MLR calculations—except for those federal income taxes on investment income and capital gains.
Following the public comment period, the draft must be approved by additional NAIC committees and then voted on by the membership of the NAIC at its annual meeting later in October. That version will then be sent to Sebelius' office.
Two Department of Veterans Affairs secretaries—one past and one present—told the Senate Veterans Affairs Committee last week that they still stood behind their decisions to add diabetes, prostate cancer, heart disease, Parkinson's disease, and leukemia to the those conditions that VA officials can "presume" to be caused by Agent Orange exposure among Vietnam War veterans.
With associated cases and costs quickly rising, the Senate is panel is reviewing the landmark 1991 Agent Orange regulation that has set the tone in terms of how disability claims are handled in regard to the herbicide and defoliant widely used during the Vietnam War. By granting a “presumption," the VA creates a way to bypass the standard process for filing disability claims.
In 1991, rare conditions such as soft-tissure sarcoma or non-Hodgkin's lymphoma were included on the initial list that could be considered for service-related claims for Agent Orange exposure. About 5,000 of those claims have been filed over the years, according to figures released by Sen. James Webb (D-VA) at the hearing.
But gradually other conditions—many of which could be considered the "diseases of ordinary life"—have been added over the years, amounting to nearly a total of half a million new VA claims, Webb said.
Making these decisions had been difficult, but both secretaries agreed that that they made the best decisions based on the evidence available at the time.
Last year, the VA included ischemic heart disease under the VA's presumptive category for Agent Orange. Current VA Secretary Eric Shinseki told the Senate panel that the Agent Orange Act does not permit him to weigh cost impact or exclude a disease from consideration "on the basis that it is a common disease." Instead, it directs the VA to determine whether "a positive association exists for each disease discussed" in an Institute of Medicine (IOM) report.
Shinseki said that his determination that a positive association between herbicide exposure and ischemic heart disease was based on evaluation of the scientific and medical evidence supplied by IOM. He did note, though, that having just 60 days to reach a conclusion—as specified by the Agent Orange Act—was "a bit constraining [and] a little challenging."
Similarly, Anthony Principi, MD, who was VA secretary between 2001 and 2005, told the panel that three out of four studies provided by IOM showed a "positive association" between the onset of type II diabetes and Agent Orange.
Principi agreed, though, that additional research from IOM or a scientific review board addressing lifestyle issues (such as smoking or eating) or heredity would have helpful when making his decision about whether to include diabetes. "Better information would be useful," he said.
"It's a greater challenge for secretaries, when you're dealing with the diabetes, the prostate cancer, because we know if we live long enough, we're going to die of prostate cancer, as well as heart disease," Principi said. "And those confounding factors really make it very, very difficult for us."
A breast cancer screening program in Norway—which made mammographic screening available to women between the ages of 50 and 69—led to a smaller decrease in deaths by breast cancer than anticipated, according to a studyled by Harvard School of Public Health (HSPH) researchers in the latest New England Journal of Medicine.
"The observed reduction in death from breast cancer after introduction of the mammography screening program was far less than we expected," said lead author Mette Kalager, a visiting scientist at HSPH and a surgeon at Oslo University Hospital in Norway. "The results showed that other factors—such as enhanced breast cancer awareness and improved treatment—actually had a greater effect on reducing mortality from breast cancer."
In Norway, each county is required to establish multidisciplinary breast cancer management teams—made up of specialized radiologists, radiologic technologists, pathologists, surgeons, oncologists and nurses—that women enroll in before entering the national screening program.
Among women older than 70 years—who were treated by multidisciplinary teams alone and not invited to undergo mammography screening—the study found an 8% reduction in death from breast cancer. Among women ages 50 to 69 who did undergo mammography screening, a 10% decrease in breast cancer deaths was reported.
"This can be explained by treatment of multidisciplinary teams...that manage the care of the patients," the authors said. "The 10% reduction we found among women aged 50 to 69 years old being invited to mammography screening can be attributed to both the mammograms and management by multidisciplinary teams."
The authors analyzed data from 40,075 women diagnosed with breast cancer who participated in the Norwegian breast cancer screening program. With the program, which began in 1996, the researchers compared the rates of death from breast cancer among four groups of women.
The one group of women (ages 50-69) lived from 1996 through 2005 in Norwegian counties where mammographic screening was provided every two years. A second group represented women with breast cancer in counties where screening wasn't available. The remainder study population consisted of two historical-comparison groups from 1986 through 1995 that mirrored the current groups.
The rate of death was reduced by 7.2 deaths per 100,000 person-years in the screening group (when compared with the historical screening group) and by 4.8 deaths per 100,000 person years in the nonscreening group. The difference in the reduction in mortality between the current and historical groups attributed to screening alone was 2.4 deaths per 100,000 person-years—or about a third of the total reduction of 7.2 deaths.
Only a third of the mortality reduction in the 20-year period was associated with the screening program, the researchers said. The remaining two-thirds can be linked to enhanced breast cancer awareness, [and] improved diagnostic and treatment for breast cancer," Kalager said.
Gene L. Dodaro, acting comptroller general and head of the Government Accountability Office (GAO), announced the appointment Thursday of 19 members to the board of governors for the new Patient-Centered Outcomes Research Institute (PCORI).
The institute was established under the Affordable Care Act earlier this year as a non-profit organization to assist providers, patients, healthcare purchasers, and policymakers in making informed health decisions through research. This research is designed to review relevant evidence on how diseases, disorders, and other health conditions can be appropriately prevented, diagnosed, treated, monitored, and managed.
The law directed the comptroller general to appoint 19 of the 21 members of the PCORI Board of Governors. In addition to the 19 members, the director of the Agency for Healthcare Research and Quality, Carolyn Clancy, MD, and the director of the National Institutes of Health, Francis Collins, MD, or their designees are the other two members who will serve on the PCORI Board.
The Act also directs the comptroller general to appoint not more than 15 members to a methodology committee of PCORI. A Federal Register notice calling for nominations to this committee is expected to be issued by Sept. 30.
The members of the board will be appointed for a six-year term and may be reappointed for one subsequent six-year term. The terms of the PCORI board members are staggered, with the first set of appointments made this month set at two, four, and six years.
Commissioners whose first term will expire in September 2016 are:
Eugene Washington, MD, MSc, vice chancellor, UCLA Health Sciences, and dean, David Geffen School of Medicine, University of California Los Angeles. He will serve as the chair of the PCORI Board of Governors.
Steven Lipstein, MHA, president and CEO, BJC Health Care, a nonprofit healthcare delivery system. He will serve as the vice chair of the PCORI Board of Governors.
Christine Goertz, DC, PhD, vice chancellor for research and health policy, Palmer College of Chiropractic and Palmer Center for Chiropractic Research.
Sharon Levine, MD, associate executive director for The Permanente Medical Group of Northern California, a large multi-specialty group practice within Kaiser Permanente's integrated delivery system.
Ellen Sigal, PhD, chairperson and founder of Friends of Cancer Research, a cancer research think tank and advocacy organization.
Harlan Weisman, MD, chief science and technology officer, Medical Devices and Diagnostics, for Johnson & Johnson.
Robert Zwolak, MD, PhD, a vascular surgeon at Dartmouth-Hitchcock Medical Center and professor of surgery at the Dartmouth Medical School.
Commissioners whose first term will expire in September 2014 are:
Lawrence Becker, director, Strategic Partnerships and Alliances, Xerox Corporation.
Arnold Epstein, MD, the John H. Foster Professor and Chair of the Department of Health Policy and Management at Harvard University School of Public Health, and practicing internist at Brigham and Women's Hospital.
Andrew Imparato, JD, president CEO of the American Association of People with Disabilities.
Robert Jesse, MD, PhD, principal deputy under secretary for health and national program director for cardiology, Department of Veterans Affairs.
Freda Lewis-Hall, MD, chief medical officer and senior vice president of the Pfizer Medical Division.
Grayson Norquist, MD, MSPH, professor and chairman, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center.
Commissioners whose first term will expire in September 2012 are:
Debra Barksdale, PhD, RN, associate professor, University of North Carolina (UNC) at Chapel Hill School of Nursing.
Kerry Barnett, JD, executive vice president of corporate services and chief legal officer, The Regence Group.
Allen Douma, MD, CEO of Empower, LLC, and a member of the AARP Board of Directors.
Leah Hole-Curry, JD, program director for the Health Technology Assessment (HTA) program, Washington State Health Care Authority.
Harlan Krumholz, MD, Harold H. Hines, Jr. Professor of Medicine and Epidemiology and Public Health at Yale University School of Medicine.
Richard E. Kuntz, MD, senior vice president and chief scientific, clinical, and regulatory officer of Medtronic, Inc.
The number of licensed registered nurses (RNs) nationwide grew 5% to a new annual high of 3.1 million between 2004 and 2008—representing a net growth of 153,806 nurses, according to a report released Wednesday by the federal Health Resources and Services Administration (HRSA).
The youngest population of nurses also grew for the first time in 30 years, which helped "restock the pool" of RNs, according to the report. An estimated 444,668 RNs received their first U.S. license from 2004 through 2008, while about 291,000 RNs allowed their licenses to lapse, possibly indicating the substantial number of retirements that have begun to take place.
The most commonly reported initial nursing education of RNs is the associate degree in nursing (AD), representing 45.4% of nurses. Bachelor's or graduate degrees were received by 34.2% of RNs, and 20.4% received their initial education in hospital-based diploma programs. Nearly two-thirds of RNs reported working in a health occupation prior to their initial nursing education.
Fewer than half of nurses with master's degrees work in hospitals. However, more than 18% are in ambulatory care settings and nearly 12% are in academic education.
In 2008, an estimated 2,596,399 RNs were employed in nursing— representing 84.8% of licensed RNs. This was the highest rate of nursing employment since the national survey started in 1977. Also, the first increase was reported in full-time employment since 1996—rising from 58.4% of RNs in 2004 to 63.2% in 2008.
Among nurses under 50 years, 90% or more are employed in nursing positions. This percentage, though, drops to less than half of RNs over age 65.
Hospitals still remain the most common employer for RNs—increasing from 57.4% in 2004 to 62.2% of employed RNs in 2008. The increase in this percentage is the first increase since 1984. While nearly 90% of RNs under 25 years old work in hospitals, less than 53% of RNs age 55 and older work in hospitals. Fewer than half of nurses with master's degrees work in hospitals; more than 18% are in ambulatory care settings and nearly 12% are in academic education.
The most common job title of RNs in the U.S. is "staff nurse"—or its equivalent (66.3%). Between 2004 and 2008, the proportion of staff RNs increased by 2.2%. Just below 20% of RNs with graduate degrees are staff RNs, compared with 72.8% of those without a graduate degree. The next most common job title in 2008 included management and administration titles (12.5%).
Many registered nurses held more than one job in nursing, according to the report. Overall, about 12% of RNswith full-time primary nursing positions, and 14% of those with part-time primary positions have additional nursing positions.
More than half of RNs work at least 40 hours per week in their principal nursing position. Another 24.2% work 32 to 39 hours per week. A total of 19.1%t of RNs report that they worked on-call or could have been called to work (on "standby") during a typical work week in their principal nursing positions. Among RNs employed in nursing positions, 27.5% report that they worked overtime, averaging 7.5 hours per week and received pay for such work.
The average annual earnings for RNs employed full-time in 2008 were $66,973—rising 15.9% since the 2004 average of $57,785. While annual earnings are adjusted for inflation to 1980 dollars, earnings in 2008 increased only 1.7% from average inflation-adjusted 2004 earnings. The highest earnings were reported by nurse anesthetists (NAs), who averaged $135,776 per year. Staff nurses on average earned $61,706 per year.
Registered nurses with graduate degrees earned an average of at least $20,000 more than did RNs with other levels of education. In 2008, 29.3% of RNs reported they were extremely satisfied, while 51.8% reported being moderately satisfied with their principal nursing position. This compares with 2004 rates of satisfaction of 27.5% and 50.5%, respectively.
Only 11.1% were dissatisfied with their education in 2008, as compared with 13.8 in 2004. The highest rates of being moderately or extremely satisfied were reported by registered nurses working in academic education programs (86.6%), while the lowest rate of being either moderately or extremely satisfied was reported by nurses in nursing homes/extended care (74.5).
In 2008, an estimated 158,348 nurses had preparations as nurse practitioners (NPs). NPs represent the largest group of advanced practiced registered nurses (APRNs). About 35% of NPs were under 45 years old. Nearly 85% of NPs reported that they held a master's degree and 3.9% reported holding a doctorate degree. Of all NPs, 10.3% also were prepared as clinical.
On the outpatient side of primary care, attention recently has focused on the use of the medical home to provide ongoing, quality care. So what would happen if that concept were moved to an acute-care inpatient setting?
According to a study from Geisinger researchers, organizing multidiscipline teams of providers to deliver timely, coordinated, and even personalized care in a hospital—using this concept—could save thousands of patient lives a year.
In a large prospective study headed by Thanjavur Ravikumar, MD, Geisinger's director of surgical innovation, the team realized that the medical home model held answers for its continuum of care study conducted last year at the 242-bed Geisinger Wyoming Valley Medical Center in Wilkes-Barre, PA.
In essence, they say in this month's Annals of Surgery, their continuum of care study—which first looked at surgical patients and then at the medical/surgical population—borrowed tenets from the medical home model that could be used to provide patient-centered care in an inpatient setting:
Continuity through different transition points in the hospital,
Proactive interventions to prevent complications,
Early recognition of patient deterioration to provide a "timely rescue",
Multi-member team performance and quality-based rounding, and
Use of electronic health records (EHRs) for real-time information sharing.
The pilot—which was building on earlier research obtained from two New York hospitals over the past decade—sought to "improve the efficiency of the hospital workflow," while reducing hospital mortality and keeping down costs, Ravikumar said.
To be clinically effective, the hospitals needed to find ways to take care of critically ill patients successfully outside the intensive care unit. "Rather than work harder and harder, we needed to work smarter. And, we needed to work smarter with the same resources," he said.
To meet these goals, the hospital looked at a process redesign. A 13-bed progressive care unit was created and staffed by hospitalists with experience in critical care. Hospitalists were reassigned to be floor-based and charged with coordinating care and ensuring quality for patients on their assigned floor--in addition to their own patient panel.
Then, hospitalist-led multidisciplinary rounds were conducted on each of the floors daily. Rounds included nurses, care managers, pharmacists, dieticians, and physical/occupational therapists. The goal was to "predict who would do poorly and then proactively [identify them] so they don't become candidates for rapid response [teams]," Ravikumar said.
To assist in this area, they used a "hawk" (high risk) and "dove" (low risk) system of stratification for patients they saw on their rounds. "This had to be simple," he says. Patients whose providers had to look after actively on an ongoing basis were designated as "hawks"—since staff would have to "watch them like a hawk." Patients doing well at the time of rounds were called doves--"which meant they [would likely] 'fly peaceably away' soon like doves," he said.
A multidisciplinary rounding tool was developed to standardize rounds—and keep track of the "hawks" and "doves"—using an EHR system. And, wireless communication devices were used for "real-time communications" between hospitalists and other stakeholders.
Based on the reduction in hospital mortality observed in this pilot and in the prior New York studies, Ravikumar estimates that an 18% to 25% reduction in hospital mortality could occur through these changes in the system. If this figure were stretched out nationally, this system redesign could have the potential to save up to 95,000 lives a year if adopted, he adds.
While small, incremental costs are involved in additional staffing, this is overshadowed by financial savings in length of stay reduction, optimization of resource utilization, and averting complications, Ravikumar says.
"The strength of this project is not just giving [hospitals] a cookie cutter approach, It's giving them principles," he said. "Each hospital has to use its own principles to adapt to its own micro-environment to do better every year."
This means that each hospital needs to look at its own mortality data to see where additional efforts are needed to protect patients, he says. For instance, one hospital may be good at managing morbidly obese patients while another may not: that latter hospital would need to find better ways to address the healthcare needs of those patients to keep mortality rates down.
"The basic principal is that...hospitals need to function in a safer zone than they do. Everyone wants to do it. Everyone wants to prove that. That's system redesign," said Ravikumar.
The new healthcare reform law turns six months old on Thursday, and with it come new key coverage requirements that go into effect. Healthcare consumers are more likely to feel the impact of these new measures, but healthcare providers could see some changes, too, such as more patients—including those with pre-existing or chronic conditions—seeking their services.
The rollout of these reform measures, though, may be confusing because their actual start date will depend on when a particular health insurance plan year starts, or when it started. While the new requirements go into effect Sept. 23, these requirements for health plans will be implemented when their actual year of coverage begins (such as Jan. 1, the start of the calendar year).
In addition, "grandfathered" plans--or those plans in existence before the healthcare reform legislation was signed into law— may have to meet only some of the requirements. Other plans—specifically new healthcare plans and those that make significant changes in benefits, deductibles, copayments, or share of premium contributions—will be required to comply with most of the law's changes.
Here is an overview of the provisions that take effect September 23:
Young adult coverage: Young adults can stay on or be added to their parents' health insurance plan through age 26. These young adults do not need to live with their parents and they can be married. However, that child's spouse or children is not required to be covered under the rule.
Grandfathered plans can exclude an adult child under 26 if that child is eligible to enroll in another employer-sponsored health plan, such as a plan through his or her job unless it is the plan of the other parent's employer. But, beginning in 2014, that exclusion will not be available to them.
Approximately 2.4 million young adults are expected to be eligible for coverage under their parents' plans. In 2011, roughly 1.24 million (using mid-range estimates) are anticipated to enroll for dependent coverage; this number is expected to rise to 1.6 million in 2012 and 1.65 million in 2013.
Coverage for sick children: Insurers are prohibited from denying coverage and treatment for children under age 19 with pre-existing medical conditions, such as asthma or cancer. This impacts group plans or "non-grandfathered" individual plans.
The plans can limit when children are signed up to certain open enrollment periods. Plans, though, are not required to sell policies individually to children. (Several plans in California, Illinois, Florida, and Connecticut announced in the past week that they will not be individually selling this particular coverage option.)
Preventive care: Plans must cover a wide range of recommended preventive services, such as immunizations, well-baby care, mammograms, and colonoscopies, while no longer charging co-payments, co-insurance, or deductibles for those services. This requirement applies, though, only to new plans—and not grandfathered plans.
Lifetime and annual coverage limits: This will impact those individuals with expensive and ongoing medical treatments. Lifetime limits are banned for all plans; for those who have hit their lifetime limits, they'll be able again to access coverage.
Those plans with annual limits on health benefits coverage will be phased out: Initially, the annual limit will be no less than $750,000, but it will rise to $1.25 million in September 2011 and $2 million in 2012. The annual limits are prohibited in 2014.
The annual limits apply to new individual and group plans, along with grandfathered group plans. They will not apply to grandfathered individual plans or to so-called "mini-med" plans that offer limited benefits.
Primary care and emergency care. Plans now must allow pediatricians and obstetrician/gynecologists to obtain primary care physician status: This will eliminate requiring patients to get prior-authorization from their insurers or a primary care physician to see a pediatrician or OB/GYN.
Also, emergency services can be provided without prior approval from the plan: insurers can't charge higher co-payments or co-insurance for using out-of-network ER providers.
Rescission: While the effective date was moved by insurers to May 2010, rescission—when an insurance company retroactively cancels a policy—is now banned, except when cases of "fraud or intentional misrepresentation of material fact" occur. Patients are required to be notified before cancellation. The provision applies to all types of health insurance plans.
Appeal rights: Patients will have the right to appeal insurers' decisions through their plans' internal review processes or independent, third-party reviewers. All health plan, except a grandfathered plan, must meet new standards. With urgent medical cases, the insurer must make a decision on the appeal within 24 hours—and has to continue covering the treatments while the appeal is pending.
The benefits of increased healthcare transparency hinge on reliable and valid information—specifically in the areas of price and clinical performance, according to a white paper released this week from the American College of Physicians (ACP).
"We believe that increasing transparency in the healthcare system can be beneficial to both patients and physicians," said J. Fred Ralston Jr., MD, president of ACP. "However, unless the transparency information that is collected meets certain criteria it will not accomplish the goal of improving health care."
ACP said that for the potential benefits of healthcare transparency to be realized, the reported information needs to be:
Reliable and valid.
Transparent in its development.
Open to prior review and appeal by the physicians and other health care professionals referenced.
Minimally burdensome to the reporting physician or other health care professional.
Comprehensible and useful to its intended audience, including a clear statement of its limitations.
While the issue of transparency in price information delivered by providers for a healthcare service seems straightforward, "in actuality it is quite complex," the study said.
Besides being transparent, any methodology used to publicly report price needs to contain adequate protections to ensure the reporting of reliable and valid price information, ACP recommended. In addition, price information provided to patients or consumers should be readily available and "presented in a manner that is easily understood and reflective of its limitations."
Price also should never be used as the "sole criterion for choosing a physician or any other healthcare professional." Price should only be considered along with the “explicit consideration” of the quality of services delivered and/or the effectiveness of the intervention, ACP noted.
For increasing the use of clinical performance transparency, ACP called for looking at clinical quality, resource use, and experience of care, which is the patient's view of care received from a provider.
Among its recommendations, ACP called for physicians and other healthcare professionals to have timely access to "assessed performance information prior to public reporting and the availability of a fair and accurate appeals process."
It also called for expansion of public reporting of physician performance differences that take into account technical capabilities to report "reliable, valid, and useful differences." ACP also said it supported the collection of both public and private data by trusted third-party entities so that physician and other clinician's performance "can be assessed as comprehensively as possible."
"Until they have access to accurate and useful information about what they are purchasing, both regarding price and clinical performance," Ralston said, "patients will not have the ability to make truly informed decisions regarding their healthcare."
Enrollment in Medicare Advantage plans, which provide services to about a quarter of the nation's Medicare beneficiaries, is predicted to go up by about 5% in 2011, while premiums on average will dip by 1% from this year, the Centers for Medicare & Medicaid Services (CMS) announced Tuesday.
While the monthly premium decrease is small—from an average of $36.14 this year to $35.69 in 2011 (a 45-cent reduction)—the drop was unexpected among those who follow the Medicare program. For 2010, the plans saw on average a 15% increase in premium costs. CMS officials said they held down rate increases by negotiating with the insurers that sponsor the Medicare Advantage plans.
"Despite the claims of some, Medicare Advantage remains a strong, robust option for millions of seniors who choose to enroll or stay in a participating plan, said CMS Administrator Donald Berwick, MD. "The Affordable Care Act gave us new authority to negotiate with health plans in a competitive marketplace."
CMS Deputy Administrator Jonathan Blum said the administration negotiated with 300 Medicare Advantage plans to push down proposed premiums and cost-sharing increases that Medicare considered too high—bringing them "into more affordable ranges," he said.
With negotiations, the plans improved their benefits by about 5% (or about $13 per member per month) on average. However, seven Medicare plans offered by three insurers declined to change their bids, and CMS denied those bids, Blum said.
Aside from the new healthcare reform bill giving CMS officials new power to negotiate, CMS now can take steps to:
Consolidate low-enrollment and duplicative plans so beneficiaries have "meaningful differences" between plans offered by the same organization.
Set limits on out-of-pocket expenses.
Cover preventive services with no cost sharing.
Limit plan cost-sharing for skilled nursing care, chemotherapy, and renal dialysis to the amounts paid by beneficiaries in original Medicare.
The projected increase in Medicare Advantage beneficiaries will occur a year before Medicare will freeze payments to the plans, as stipulated under the new healthcare reform legislation. Blum attributed the increased membership to insurers providing "better value for beneficiaries."
However, even with lower costs, all beneficiaries should review their current health and drug plans coverage and shop around for what's available and meets their needs for next year, said Blum, who is also director of CMS' Center for Medicare. The new enrollment period is open from Oct. 1 through Nov. 15.
Nearly the same rate of Medicare beneficiaries who have access to a Medicare Advantage plan today will have access to a Medicare Advantage plan in 2011 (99.7%), according to CMS. About 5% of non-employer beneficiaries enrolled in Medicare Advantage and stand-alone prescription drug plans will need to choose a new health plan or original Medicare in 2010 because their current plan is not renewing their contracts with Medicare in 2011.
Most of these "non-renewals" occurred when private fee-for-service plans made business decisions to leave Medicare in certain areas of the country—largely because of a 2008 law that ensures protections for beneficiaries enrolled in these plans in certain areas of the country. All but 2,300 enrollees in Medicare Advantage plans that no longer participate in Medicare will have a choice of enrolling in a different plan.