The Affordable Care Act sets national minimum standards and rules for public and private insurance but affords states considerable flexibility in implementing them. The Supreme Court decision that made Medicaid expansion optional increases that flexibility and ensures there will be substantial variation across states in the proportions of residents who are insured and underinsured. Sara Rosenbaum is drawing upon her four decades of expertise in Medicaid to inform federal and state policymakers about the early effects of the expansion and how differences in state approaches might lead to disparities in the extent and quality of coverage.
Sara Rosenbaum, J.D. Harold and Jane Hirsh Professor of Health Law and Policy Chair, Department of Health Policy sarar@gwu.edu
Since 2011, the Georgetown University team led by Kevin Lucia has used its unique monitoring system to track state implementation of Affordable Care Act provisions related to private insurance markets. Through reports, blog posts, and interactive state maps, the team has informed policymakers and the media, nationally and locally, about issues as they emerge. Under this grant, the researchers continued these monitoring activities as states adjust their approaches. The team also expanded its work to study those states that have outperformed their peers in enrollment, premium affordability, and health plan quality.
Kevin Lucia, J.D., M.H.P. Senior Research Professor kwl@georgetown.edu
Following the Affordable Care Act’s first open enrollment period, some lawmakers have begun to offer concrete alternatives to the law. Under this grant, Jonathan Gruber is modeling alternatives to the Affordable Care Act as they are proposed. Using his widely respected microsimulation model, he is analyzing the effects of these proposals on the quality, affordability, and breadth of insurance coverage in the United States and on the federal budget, relative to current law.
Jonathan Gruber, Ph.D. Professor of Economics gruberj@mit.edu
This multiyear survey project is assessing the implications of the Affordable Care Act’s Medicaid expansion, the Supreme Court decision making expansion optional for states, and alternative state approaches for covering residents who are potentially eligible for Medicaid under the law. In phase 1, the research team surveyed adults with low income in three states just prior to the beginning of the expansion: Kentucky, which expanded Medicaid consistent with the law; Arkansas, which adopted a different approach; and Texas, which has declined to expand. During phase 2, the researchers are surveying residents one year later to assess trends in coverage and access to care in the three states.
Benjamin Sommers, M.D., Ph.D. Assistant Professor of Health Policy and Economics bsommers@hsph.harvard.edu
As the open enrollment period for 2015 health coverage approached, a key question was to what extent health insurers offering plans in the marketplaces would revise their premiums, deductibles, cost-sharing, and plan types from the previous year. This project enabled the research team, as well as Fund staff and grantees, to conduct broad-based analysis of annual changes in premiums, benefit design characteristics, and plan enrollment. The project produced timely information to policymakers about trends in the cost and comprehensiveness of plans sold through the marketplaces and about the implications for consumers, small employers, the federal government, and the marketplaces’ long-term viability.
Jon Gabel, M.A. Senior Fellow gabel-jon@norc.org
Over the past year, Sherry Glied’s research team made timely contributions to high-profile policy debates, including the revenue implications for states that decide not to expand eligibility for their Medicaid programs under the Affordable Care Act, and the potential effect of the law’s employer mandate on workers’ hours. Over the next year, Glied and colleagues will continue to examine key health reform policy issues, such as the Affordable Care Act’s early effects on coverage; how the “Cadillac tax” on high-cost employer plans will affect workers’ health benefits; and the accuracy of Congressional Budget Office estimates of the law’s coverage and cost effects.
Sherry Glied, Ph.D. Dean and Professor of Public Service sherry.glied@nyu.edu
As the Affordable Care Act entered its fifth year and faced another Supreme Court challenge, lawmakers offered various alternatives. Some involved modifying the current law, while others would have “repealed and replaced” the law or let states opt out of the law’s central requirements. Christine Eibner used RAND’s recently updated microsimulation model to estimate the insurance coverage and budgetary impacts of potential changes.
Christine Eibner, Ph.D. Senior Economist eibner@rand.org
Surveys conducted by private organizations like The Commonwealth Fund are critically important for quantifying the effects of the Affordable Care Act’s major insurance reforms. The Fund’s series of tracking surveys conducted over the past year have provided policymakers and the media with timely insights about the experiences of people obtaining coverage through the insurance marketplaces, Medicaid, or other sources. This project funded a fifth survey to the series, fielded at the end of the 2015 open enrollment period, and launched a new quarterly tracking survey to measure changes in the underinsured rate and the affordability of coverage and care.
Robyn Rapoport, M.A. Vice President, Health Care, Public Policy, and International Research rrapoport@ssrs.com
The Affordable Care Act sets new standards and requirements for health plans sold through the individual and small-group markets, including the law’s marketplaces. The Department of Health and Human Services’ (HHS) Notice of Benefit and Payments Parameters and additional guidance in 2014, 2015, and 2016, have guided these reforms. This project will evaluate the 2016 rule and related regulatory guidance and assess the degree to which federal policy on health plans has changed from the previous two years. It will then examine how these changes might be expected to improve the actual plans that consumers will purchase in the 2016 open enrollment period. Finally, a framework will be defined for policymakers to assess whether these improvements were actually achieved.
Chiquita Brooks-LaSure Senior Health Policy Advisor quitablasure@gmail.com
With the 50th anniversary of Medicaid as backdrop, this project developed a series of five blog posts on the evolution of Medicaid from a public assistance program to a large health insurer, laid out a conceptual framework for Medicaid as a health insurer, and explored Medicaid’s role in the coverage goals of the Affordable Care Act. The posts have informed federal and state policymakers about the current and future role of Medicaid as they consider opportunities for reform and state proposals for Medicaid expansion.
Cindy Mann, J.D. Partner cmann@manatt.com
Drawing on federal and state law, prior experience, and interviews with relevant stakeholders, this project analyzed key implications for consumers, insurers, providers, and state governments and regulatory agencies of the King v. Burwell Supreme Court decision, which challenged the Internal Revenue Service regulation that allows federal tax credits for Americans purchasing health plans through both federal and state-operated marketplaces.
Deborah Bachrach, J.D. Partner dbachrach@manatt.com
As the Affordable Care Act moves into its fifth year, some state leaders are beginning to shift their attention from early implementation challenges to developing longer-term goals. A key tool for states may lie in so-called 1332 state innovation waivers, which allow states to propose alternatives to four central provisions of the law: the individual mandate, employer mandate, essential health benefit package, and the health insurance marketplaces. With cofunding from the Robert Wood Johnson Foundation, the project team prepared an issue brief to bring attention to the 1332 waivers, describe what innovations are possible under them, and underscore the critical guardrails in the health reform law that ensure that the 1332 waivers do not compromise the goals of expanding coverage and controlling costs.
Deborah Bachrach, J.D. Partner dbachrach@manatt.com
Drawing on federal and state law, prior experience, and interviews with relevant stakeholders, this project analyzed key implications for consumers, insurers, providers, and state governments and regulatory agencies of the King v. Burwell Supreme Court decision, which challenged the Internal Revenue Service regulation that allows federal tax credits for Americans purchasing health plans through both federal and state-operated marketplaces.
Nicholas Bagley, J.D. Assistant Professor of Law nbagley@umich.edu
Since 2013, the Fund’s series of tracking surveys has helped inform policymakers and the media about the Affordable Care Act’s effects on health insurance coverage and access to care. In the 2015 installment, most newly insured adults reported that they had previously lacked coverage for long periods and are now getting care they had been unable to afford before. This grant covered costs of additional work requested by The Commonwealth Fund the survey fielded in March–May 2015.
Robyn Rapoport, M.A. Vice President, Health Care, Public Policy, & International Research rrapoport@ssrs.com
The Commonwealth Fund’s series of tracking surveys conducted over the past year have provided policymakers and the media with timely insights about the experiences of people obtaining coverage through the insurance marketplaces, Medicaid, or other sources. This small grant covered the costs of additional work requested by the Fund in wave 2 of the tracking survey, fielded in April–June 2014.
Robyn Rapoport, M.A. Vice President, Health Care, Public Policy, & International Research rrapoport@ssrs.com
A central aim of the Affordable Care Act is to improve value and efficiency in the U.S. health care system. Part of this process involves changing how health care products are offered, paid for, and sold. William Sage and Joel Ario are identifying value-based care models that have the potential to spur providers to offer comprehensive treatment-specific bundles of health care services that come with “quality warrantees.” The investigators will then assess existing obstacles to competition in offering these “assembled” and warranted products in state insurance markets and provide practical guidance to state policymakers on how they might foster such competition.
William Sage, M.D., J.D. James R. Dougherty Chair for Faculty Excellence in Law Vice Provost for Health Affairs wsage@law.utexas.edu
The Wakely Consulting Group is providing technical assistance to two Commonwealth Fund projects related to the Affordable Care Act’s insurance reforms: a Georgetown University grant to study differences in the affordability of health plans offered in a set of states with variable insurance market characteristics and approaches to ACA implementation; and a Wake Forest University grant to analyze insurers’ justifications for premium rate changes in the individual and small-group markets, both inside and outside the ACA’s insurance marketplaces.
Julie Andrews, F.S.A., M.A.A.A. Senior Consulting Actuary julie.andrews@wakely.com
Evidence shows that successful management of complex health conditions requires the close collaboration of providers, patients, and their caregivers, and that the transparency made possible by health information technology may facilitate that collaboration. This project is developing OurNotes, a novel approach for letting patients, caregivers, and providers jointly create clinical notes and care plans within the shared electronic health record. The research team intends to pilot prototypes in five health care organizations. If successful, this testing could herald a new way to improve care management for high-need, high-cost patients.
Janice Walker, R.N., M.B.A. Assistant Professor of Medicine jwalker1@bidmc.harvard.edu
To control growth in spending on postacute care and improve outcomes for hospitalized beneficiaries, Medicare has in recent years launched three new accountable care and bundled payment initiatives that seek to shift financial risk for postacute care services to the hospitals and physicians that refer patients to postacute care providers. This project is developing three comparative market case studies to: 1) document the postacute care strategies that Medicare accountable care organizations and bundled-payment participants have adopted or are developing to contain Medicare spending; and 2) describe providers’ market responses to these strategies and the implications they may have for the quality, use, and cost of postacute services. This research will inform policymakers and health systems about how the new reforms are affecting a critical component of the care continuum for older adults.
Robert Mechanic, M.B.A. Senior Fellow, Heller School for Social Policy and Management mechanic@brandeis.edu
More than half of hospital patients discharged to a postacute care provider go to a skilled nursing facility (SNF), where around 20 percent are readmitted to the hospital within 30 days. However, hospitals that limit the number of facilities to which they discharge patients tend to have lower readmission rates than ones that do not, raising questions about how hospitals and patients select SNFs and what effect that selection has on outcomes. This project is determining how SNF characteristics—such as staffing and participation in the hospital’s network—affect patients’ risk of hospital readmission, their successful discharge, and total expenditures.
Vincent Mor, Ph.D. Professor of Medical Science Director, Center for Long-Term Care Innovation & Quality vincent_mor@brown.edu
Community health centers will likely remain a critical component of the health care safety net for the foreseeable future. Under this grant, researchers are examining how the policy and funding environment may affect health centers, particularly in states where large numbers of people are expected to remain uninsured. Focusing on four such states, the research team is determining: 1) how changes in revenue streams affect funding for uncompensated care; 2) how patient mix and demand for uncompensated care change during the initial implementation of the Affordable Care Act; and 3) how health centers respond to these changes.
Steven Wallace, Ph.D. Professor and Chair of the Department of Community Health Sciences, UCLA swallace@ucla.edu
Commonwealth Fund support for two prior phases of this project has enabled the Center for Health Care Strategies to assist states participating in the federal Financial Alignment Initiative with the design and implementation of care plans for people dually eligible for Medicare and Medicaid. This third phase continued to support states that implemented their plans in achieving integrated care for “dual eligibles” in 2015. States had opportunities to share their experiences and interact with federal officials.
Stephen Somers, Ph.D. President & Chief Executive Officer sasomers@chcs.org
With Commonwealth Fund support, the Center for Health Care Strategies established a learning collaborative to help states establish accountable care organizations (ACOs) in their Medicaid programs. Over the first two years, the collaborative assisted 10 states with developing the foundational structure for their ACO programs and incorporating nonmedical health interventions. In the third year, states will receive support as they develop sustainable payment models, integrate Medicaid ACOs into managed care environments, and build the capacity for data analysis to support broader ACO development.
Patricia McGinnis, M.P.P., M.P.H. Director of Delivery System Reform tmcginnis@chcs.org
As state policymakers, health system leaders, and clinicians aim to improve outcomes and lower costs for low-income populations, there is growing acceptance of the need to integrate medical care, behavioral health, and social services. States often struggle, however, with developing effective payment and delivery reform strategies across Medicaid, the Children’s Health Insurance Program, and other programs. Building on previous Fund-supported work, this project is providing technical assistance to six states to develop and test strategies for integrating physical health, behavioral health, and social service needs of low-income, vulnerable patient populations.
Mary Takach, M.P.H., R.N. Senior Program Director National Academy for State Health Policy mtakach@nashp.org
This comprehensive evaluation will help determine whether accountable care organizations (ACOs) are improving outcomes and reducing costs for the sickest and frailest Medicare beneficiaries. For each ACO, the research team will link Medicare claims information with a unique set of survey data to determine which ACO characteristics are associated with positive impact. The team also will compare use of acute-care and postacute-care providers before and after implementation of the ACO. Twenty ACOs that have reduced their care costs while maintaining quality will be selected for in-depth study.
Carrie Colla, Ph.D. Assistant Professor for Health Policy and Clinical Practice carrie.h.colla@dartmouth.edu
With Commonwealth Fund support, Dartmouth’s Valerie Lewis has explored the early development of accountable care organizations (ACOs) in low-income and minority communities and the efforts of ACO providers to improve care coordination and health outcomes for these populations. The Lewis team is now evaluating the performance of ACOs serving significant numbers of low-income Medicare patients and identifying organizational characteristics and initiatives that have had a positive impact.
Valerie Lewis, Ph.D. Assistant Professor at The Dartmouth Institute for Health Policy and Clinical Practice valerie.a.lewis@dartmouth.edu
With prior funding from The Commonwealth Fund and the Kaiser Permanente Community Benefit, Harvard’s Sara Singer and colleagues developed and validated the Patient Perception of Integrated Care survey to help identify health care organizations that provide their patients with well-coordinated, team-based care. In the next phase of work, Singer’s team is examining physician practice characteristics associated with high levels of care integration. The team also will visit 12 practices to identify integration facilitators and barriers.
Sara Singer, Ph.D., M.B.A. Associate Professor of Health Care Management and Policy ssinger@hsph.harvard.edu
Since 1996, the Mongan Commonwealth Fund Fellowship in Minority Health Policy has developed a network of physicians dedicated to reducing disparities in health care. The Fund grant for 2015–16 will support at least four M.P.H. candidates at the Harvard School of Public Health.
Joan Y. Reede, M.D., M.P.H., M.S., M.B.A. Dean for Diversity and Community Partnership Minority Faculty Development joan_reede@hms.harvard.edu
Patients with several chronic conditions experience adverse health events and receive unnecessary care at especially high rates, at least partly from having many visits with multiple providers. If health care organizations could identify instances in which this fragmentation of care creates an excessively high risk of problems occurring, then providers might be able to intervene to improve communication, care management, and, ultimately, patients’ outcomes. This project supports exploratory research to develop and test multiple definitions of fragmentation to determine which one most accurately predicts overuse of care. Results will inform development of a novel measure of care fragmentation that could help improve interventions for some of the most complex and costly patients.
Lisa Kern, M.D., M.P.H., F.A.C.P. Associate Professor lmk2003@med.cornell.edu
The Delivery System Reform Incentive Payment (DSRIP) program provides states with the opportunity to obtain waivers, along with necessary funding, to restructure the way health care is delivered to Medicaid beneficiaries. New York’s approach has been drawing interest across the country for its initiatives to reduce avoidable hospital admissions, facilitate real-time data exchange, improve disease management, and transition to value-based payment. To inform other states’ efforts, Deborah Bachrach and her team are investigating the organizational, programmatic, and financial structures that New York has set up to transform its Medicaid program.
Deborah Bachrach, J.D. Partner dbachrach@manatt.com
In 2012, Hennepin County in Minnesota formed an accountable care organization (ACO) to improve care for its Medicaid beneficiaries, many of whom require a range of costly health and social services. Since then, the ACO, Hennepin Health, has been singled out as an emerging leader among safety net health systems. This project is evaluating the effectiveness of Hennepin Health in coordinating medical and nonmedical health interventions, improving outcomes, and controlling costs.
Douglas Wholey, Ph.D., M.B.A. Professor Division of Health Policy & Management whole001@umn.edu
To achieve high levels of quality and efficiency, health systems must develop interventions that target patients with the greatest care needs and costs. This project is testing the value of a new approach to identifying high-need, high-cost patients that relies not just on measures of clinical severity but also on patients’ level of “activation”—the knowledge, motivation, and confidence essential to managing one’s own health and health care. The research team is examining the extent to which patient activation scores improve the ability of health systems to predict health and cost outcomes for this population. The findings will inform health systems of the potential value in tailoring the intensity of care management programs based on a more comprehensive risk profile.
Judith Hibbard, Dr.P.H., M.P.H. Professor Emerita jhibbard@uoregon.edu
Risk stratification, or the categorization of patients according to the level of care they require, is a crucial step in tailoring interventions to the needs of high-need, high-cost patients. Most primary care practitioners, however, currently do not use available risk scores generated by software programs, often finding them lacking in clinical meaningfulness or intuitiveness. In this project, researchers are identifying promising approaches to risk stratification that are accurate in identifying high-need, high-cost patients and responsive to physicians’ concerns. The findings will be incorporated into a tool that will subsequently be reviewed and revised in collaboration with 10 primary care sites.
David Dorr, M.D., M.S. Associate Professor and Vice Chair dorrd@ohsu.edu
In addition to a range of clinical services, complex patients also often require social services to address housing, food, and other needs. All of these services need to be well integrated. One way to foster joint accountability for the health outcomes and costs of caring for this population is to establish arrangements between providers and community-based organizations in which the financial savings generated by improvements to efficiency and quality are shared. The project team is examining existing shared-savings arrangements across health care and other sectors to identify design principles required for success. The findings will set the stage for future implementation and evaluation of shared-savings models in the Dallas–Fort Worth area.
Ruben Amarasingham, M.D., M.B.A.President and Chief Executive Officer ruben.amarasingham@phhs.org
In its first two years, the Medicare Pioneer ACO Model has been credited with improving the quality of physician and hospital services and reducing their cost to Medicare. This project seeks to quantify the impact of the Pioneer program on prescription drug use and spending, which are not considered in calculations of shared savings. With a specific focus on complex beneficiaries with multiple chronic conditions, the investigators are determining whether increases in pharmaceutical spending are associated with spending reductions for physician and hospital care, and whether Pioneer ACOs that have earned shared savings in the past might also achieve savings if prescription drugs were added to the total spending mix.
Yuting Zhang, Ph.D., M.S. Associate Professor of Health EconomicsDepartment of Health Policy and Management ytzhang@pitt.edu
Patients who have medical problems in addition to behavioral health conditions tend to be in poorer health, use more health services, and incur greater costs than patients with medical problems alone. While research shows that the integration of physical and behavioral health care can be an effective strategy for improving these outcomes, there is no strong measurement and improvement infrastructure to support such integration. This project will craft recommendations for a portfolio of structural, process, and outcomes measures capable of assessing the integration of physical care and behavioral health.
Harold Pincus, M.D. Professor and Vice Chair, Department of Psychiatry, Columbia University Medical Center pincush@nyspi.columbia.edu
When left unaddressed, social support needs such as stable housing, transportation, and caregiver assistance can lead to worse health outcomes and raise the costs of medical care. While many care delivery models for complex patients now include a social service component, little has been done to evaluate the extent to which nonmedical interventions improve outcomes. A promising program at Rush University Medical Center pairs high-need, high-cost patients with social workers, who connect them to community resources and then monitor their progress. To assess this model’s efficacy, the research team will measure changes in health care use, health outcomes, and patient experience following implementation.
Robyn Golden, L.C.S.W. Director of Health and Aging robyn_l_golden@rush.edu
In addition to health care, people with multiple chronic conditions or other complex health problems often require a range of social services as well. To achieve optimal health and cost outcomes, all of these services must be delivered in a coordinated fashion. This project aims to identify strategies across U.S. communities that have reduced the need for institutional care, such as hospitalization, and controlled Medicare expenditures for these patients. Through site visits and interviews with hospital staff, social service providers, and others, the research team is identifying tools and processes used to coordinate health and social services and their financing. The team also will explore coordination approaches for specific subpopulations, such as the frail elderly.
Elizabeth Bradley, Ph.D., M.B.A. Professor of Public Health elizabeth.bradley@yale.edu
This grant supported the 22nd Princeton Conference, in Princeton, NJ. For more than two decades, the annual event has brought together key policymakers and experts both in the U.S. and abroad. The topic of the 2015 conference was “Challenges Facing the U.S. Health Care System.”
Stuart Altman, Ph.D. Sol C. Chaikin Professor of National Health Policy altman@brandeis.edu
States increasingly recognize that improving health outcomes, particularly for vulnerable populations, is as much about addressing the social determinants of poor health as it is about providing high-quality medical care. Federal and state regulations, however, limit the ability of Medicaid to pay for supportive social services. Four states—Oregon, New York, Vermont, and Utah—have developed strategies to pay for certain social services within their Medicaid programs. This project will examine the development and implementation of these strategies through targeted interviews with Medicaid representatives, managed care organizations, and the Center for Medicaid and CHIP Services.
Patricia McGinnis, M.P.P., M.P.H. Director of Delivery System Reform tmcginnis@chcs.org
Over the past 19 years, the Commonwealth Fund Mongan Fellowship in Minority Health Policy has developed a network of physicians dedicated to improving the health of vulnerable populations. During the year-long degree-granting program at Harvard, physicians receive enriched training in health policy, public health, and management. Funds from this small grant are helping to support an additional fellow for the 2015–16 class.
Joan Y. Reede, M.D., M.P.H., M.S., M.B.A.Dean for Diversity and Community PartnershipMinority Faculty Development joan_reede@hms.harvard.edu
Many evaluations of patient-centered medical homes suffer from small sample sizes and questionable methods. An earlier Commonwealth Fund grant supported a meta-analysis of robust evaluations using rigorous methods. Under the leadership of Meredith Rosenthal at the Harvard School of Public Health, the project team identified 11 evaluations that meet the criteria for the meta-analysis. The Vermont Blueprint for Health, the subject of one of these evaluations, represents a distinct approach to the medical home, since its implementation is statewide and includes mostly rural practices. Because of limited funds in Vermont, this grant provided additional funds needed to generate standardized estimates for a common set of metrics to be used in the Harvard study. The inclusion of Vermont greatly increased the precision of the analytical findings while bringing diversity to the underlying evaluations represented.
Meredith Rosenthal, Ph.D. Professor of Health Economics and Policy Department of Health Policy and Management mrosenth@hsph.harvard.edu
Working collaboratively with The Commonwealth Fund, a team led by Gerard Anderson at Johns Hopkins University is using data from the Medical Expenditure Panel Survey (MEPS) to develop health system performance measures for high-need, high-cost patients. These measures as well as associated data elements will form the basis for an upcoming Fund publication describing the health care experiences of this population.
Gerard Anderson, Ph.D. Director, Center for Hospital Finance and Management, Johns Hopkins University ganderso@jhsph.edu
To honor former Commonwealth Fund President Margaret E. Mahoney (1980–1994), The Commonwealth Fund, Robert Wood Johnson Foundation, Carnegie Corporation, New York Academy of Medicine and other private donors created a fellowship program focusing on health care delivery systems for vulnerable populations, urban health issues, and early childhood development and prevention. Throughout the summer, selected fellows conduct quantitative or qualitative research projects on their related issue of choice and attend seminars on the policymaking process and leadership development. The fellowship is now in its third year.
Jo Ivey Boufford, M.D. President jboufford@nyam.org
The Center for Medicaid and CHIP Services (CMCS) recently launched the Medicaid Innovation Accelerator Program (IAP), which supports states’ Medicaid payment and delivery system reform efforts. The Fund is supporting the work of a panel of experts to review the research literature and provide recommendations to CMCS as the agency develops technical assistance contracts to ensure the work of IAP is grounded in evidence-based research. In phase 1, the expert panel focused on high-need, high-cost patients; phase 2 will focus on primary care and behavioral health integration.
Judith Feder, Ph.D. Institute Fellow jfeder@urban.org
Harkness Fellows have an important impact on health care policy and practice, both in the United States and in their home countries. Support for a 19th class of fellows allows the Fund to continue developing promising policy researchers and practitioners from Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, and the United Kingdom.
Robin Osborn Vice President, International Health Policy and Practice Innovations ro@cmwf.org
Bringing together leading policymakers and researchers from the U.S. and 10 other countries, the 18th annual International Symposium on Health Care Policy compared strategies in the industrialized world for slowing the growth of health care expenditures. Topics included innovative approaches to provider payment reform, avoidance of “low value” care, controlling costs for prescription drugs, the high cost of medical imaging and medical devices, and reducing administrative waste in health care systems. In addition, the symposium explored examples of “frugal innovations” from low-income countries that the United States might adopt.
Robin Osborn Vice President, International Health Policy and Practice Innovations ro@cmwf.org
The Commonwealth Fund, in collaboration with the Institute for Healthcare Improvement (IHI), is taking initial steps to establish an international program for health care system innovation designed to: 1) scan the globe for solutions to problems identified in the U.S. health care system; 2) evaluate the feasibility and transferability of these innovations; and 3) where the evidence is sound, develop a pathway for U.S. adoption of best practices. This grant is testing the feasibility of such a program.
Donald Goldmann, M.D. Chief Medical and Scientific Officer dgoldmann@ihi.org
*Funded from funds approved the previous year.
The eighth in a series of grants to the London School of Economics and Political Science is supporting a team of health policy experts as it examines strategies adopted by high-income countries to slow the growth of health care expenditures. The study focuses specifically on national priorities for cost containment, the balance between health and social care spending, provider payment reform, and ways to minimize use of “low value” health services. The team will pay particular attention to the impact of cost-control efforts on high-need, high-cost patients and vulnerable populations.
Elias Mossialos, Ph.D. Professor of Health Policy e.a.mossialos@lse.ac.uk
Since 1999, the annual transatlantic forum on health care quality cosponsored by The Commonwealth Fund and The Nuffield Trust has provided a unique opportunity to build relationships among senior policymakers and health care system leaders in the United States and United Kingdom, compare innovations in health care delivery, and facilitate an exchange of ideas on improving care for chronically ill patients. The 15th U.S.–U.K. meeting compared policy approaches and delivery system models geared toward improving care for high-need, high-cost patients. Specific areas of exploration included patient engagement, health information technology, and workforce capacity.
Nigel Edwards Chief Executive nigel.edwards@nuffieldtrust.org.uk
The Commonwealth Fund’s 2015 International Health Policy Survey, the 18th in an annual series, assessed health care system performance from the perspectives of primary care physicians. Conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States, the survey explored physician approaches to managing high-need, high-cost patients with chronic illness, participation in integrated care systems, use of electronic health records that can share information electronically, financial incentives and payment arrangements, and administrative burden and insurance complexity. Using results from the Fund’s 2012 international survey as a baseline, researchers compared changes in U.S. physicians’ experiences and practice arrangements to assess the Affordable Care Act’s impact to date.
Robyn Rapoport, M.A. Vice President, Health Care, Public Policy & International Research rrapoport@ssrs.com
As countries around the world implement accountable care payment reforms to promote changes in care delivery, there are increasing opportunities for cross-country learning. Participants in this roundtable meeting learned about promising approaches and insights from abroad that could contribute to the success of U.S. accountable care reforms. Findings and lessons were disseminated to a national audience.
Mark McClellan, M.D., Ph.D., M.P.A.Senior Fellow in Economic Studies Director, Initiatives on Value and Innovation in Health Care mmcclellan@brookings.edu
Mirror, Mirror on the Wall: How the U.S. Health Care System Compares Internationally is a regularly updated and revised Commonwealth Fund report that benchmarks and ranks 11 health care systems on five dimensions of performance: quality, access, efficiency, equity, and healthy lives. It has been widely cited by high-impact media sources in the United States and internationally, including the New York Times and Washington Post, NBC, The Economist, Time, and The Atlantic, and is the most viewed publication on the Fund’s website. The report has also garnered much attention from policymakers, journalists, and researchers in the countries included in the report. Given its high profile and strong appeal to a wide range of audiences, a sixth edition is planned for 2017. To ensure the report’s continued relevance, an ad hoc external advisory group reviewed the analysis’s methodological soundness and made recommendations on how it can be enhanced.
Robin Osborn Vice President, International Health Policy and Practice Innovations ro@cmwf.org
Many health systems across low- and middle-income countries are hotbeds for innovation, with critical health needs in these resource-challenged settings driving the development of new models of care and technologies. As the United States struggles to balance affordability, quality, and access to care, particularly for its most vulnerable populations, health innovations arising in these countries represent a new source of ideas to address these challenges. Drawing from its global portfolio of frugal innovations, the International Partnership for Innovative Healthcare Delivery will analyze three models of care that offer promising approaches for the U.S. health care system. These case studies will inform the design and implementation of a U.S.-based frugal innovation pilot.
Krishna Udayakumar, M.D., M.B.A. Head of Global Innovation Associate Professor of Global Health and Medicine ku@duke.edu
The 2015 International Health Policy Survey assessed primary care physicians’ views of their country’s health care system and its capacity to ensure access to high-quality, safe, efficient, and patient-centered care. The survey included representative samples of physicians in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. Findings were released at the Fund’s 2015 International Symposium and summarized in an article for Health Affairs. This grant helped support the inclusion of Netherlands in the survey.
Philip van der Wees, Ph.D. Senior Researcher pjvdwees@xs4all.nl
This grant enabled the Fund’s international survey vender, SSRS, to oversee data collection and integration of the Dutch survey sample.
Robyn Rapoport, M.A. Vice President, Health Care, Public Policy, & International Research rrapoport@ssrs.com
In July 2013, the Commonwealth Fund Board approved the creation of the Breakthrough Health Care Opportunities program to identify ideas or strategies capable of disrupting the status quo in health care. In collaboration with a diverse advisory group, the program in its first year explored approaches for identifying and vetting breakthroughs that have the potential to achieve a significant reduction in health system costs or improvement in patient outcomes. A scanning network was launched to uncover potential ideas in the United States and abroad, and grants were awarded to explore the next generation of health care provider incentives and the use of mobile applications to support decision-making by patients. The new appropriation funds additional work in these areas as well as efforts to harvest, evaluate, and share ideas.
Eric Schneider, M.D., M.S. Senior Vice President for Policy and Research es@cmwf.org
The Commonwealth Fund’s scorecards are a key resource for tracking U.S. health system performance. Their findings have highlighted wide variability in performance across markets while helping to focus public and policy attention on opportunities to improve. As major federal and state reforms unfold, the scorecards’ longitudinal tracking provides policymakers and others with a crucial tool for monitoring impact over time. This authorization supports the Fund’s Tracking Health System Performance team in updating and producing the state and local scorecards and preparing briefs in collaboration with other Fund programs.
David Radley, Ph.D., M.P.H. Senior Scientist dr@cmwf.org
Since January 2014, Douglas McCarthy has overseen the Commonwealth Fund team that produces the Fund’s national, state, and local health system scorecards. In addition to the scorecards, the team, along with other staff, develops data briefs, interactive features, and infographics for the Fund. McCarthy also leads a case study team that profiles innovators in health care delivery. In 2015, he and his colleagues began to develop the Fund’s second local health system scorecard plus a new scorecard focusing on high-need, high-cost populations. They also updated the Fund’s online state data center and prepare related briefs and interactive features. McCarthy and the case study team also convened executives from leading health care organizations to track how they are innovating within rapidly evolving local environments.
Douglas McCarthy, M.B.A. Senior Research Director dmccarthy@issuesresearch.com
This small grant enabled data analyst David Radley to continue his ongoing health system tracking activities, primarily refreshing health care access performance metrics based on updates to federal survey data.
David Radley, Ph.D., M.P.H. Senior Scientist dr@cmwf.org
Payment reform is a powerful strategy for improving the value of health care. To ensure success, fundamental changes must take hold in both the public and private sectors, and they must expand over time. Researchers at Catalyst for Payment Reform are developing a scorecard on Medicare payment reform to quantify the dollars flowing to doctors and hospitals through Medicare’s payment reform programs. The new resource will inform policymakers, providers, insurers, and the public about how well Medicare’s payment initiatives align with private-sector efforts, and about how the nation’s largest health care payer reimburses providers. It also will monitor Medicare’s progress in achieving the Affordable Care Act’s payment reform objectives.
Andréa Caballero Program Director acaballero@catalyzepaymentreform.org
Over the next few years, the role of private plans in Medicare is likely to gain renewed prominence as policymakers respond to fiscal pressures created by the retirement of the baby boom generation. Researchers at the Urban Institute are analyzing Medicare Advantage data to explore: 1) the determinants of plan costs and the extent to which competition and plan structure account for cost differences across markets and types of plans; 2) how the Affordable Care Act’s increased emphasis on plan performance in setting plan payment rates is affecting plans and markets; and 3) the potential impact of “premium support” proposals on Medicare and beneficiary costs.
Stephen Zuckerman, Ph.D. Codirector and Senior Fellow, Health Policy Center szuckerman@urban.org
As hospitals implement strategies to reduce readmissions under federal initiatives, it is hypothesized that even populations and conditions not targeted also may see improvements in readmissions. This was demonstrated by the reduced rates seen between 2009 and 2012, though it remains unclear whether these resulted from public reporting, anticipated financial penalties, or other factors. This project is examining the effect of Medicare’s hospital readmissions–reduction initiatives on: 1) national Medicare readmission rates, by hospital type; 2) non-Medicare readmission rates in California, Florida, and Washington; and 3) readmission rates across all conditions. This work will shed light on the extent to which Medicare readmission reduction initiatives can drive broader, systemwide improvement in outcomes and costs.
Lane Koenig, Ph.D. President lane.koenig@knghealth.com
On July 30, 1965, President Lyndon Johnson signed landmark legislation creating Medicare and Medicaid, key elements of his administration’s vision of the “Great Society.” Reaching their 50th anniversaries, these health programs have been integrally woven into the American social fabric. As the nation faces new political, medical, demographic, and technical challenges and opportunities, significant changes are on the horizon for both programs. The National Academy of Social Insurance (NASI), the nation’s leading nonpartisan, nonprofit organization dedicated to advancing public understanding of Social Security, Medicare, Medicaid, and other vital programs, addressed some of these challenges at an annual meeting in January 2015.
Pamela Larson, M.A. Academy Fellow (formerly Executive Vice President) plarson@nasi.org
The proportion of Medicare beneficiaries in private plans has grown steadily over the past decade, but relatively little is known about the benefits offered by these plans, or their quality and costs. In addition, several policies that would expand the role of private plans substantially have been proposed. This project is analyzing the implications of Affordable Care Act provisions on the relationship between Medicare Advantage costs and payments across geographic areas and by type of plan. The researchers also are examining the potential effect of proposals to convert Medicare into a “premium support” model on plans, beneficiaries, and program spending.
Stephen Zuckerman, Ph.D. Codirector and Senior Fellow, Health Policy Center szuckerman@urban.org
The Commonwealth Fund has assembled a Council of Economic Advisors to identify trends and characteristics related to health care markets and the care delivery system that contribute to rising health care costs, as well as to provide recommendations for potential national, state, or local policy responses. This grant supports an executive director for the council, as well as the development of papers, blog posts, and other pieces analyzing trends and policy options. Cathy Schoen, who serves as executive director and develops the council’s meeting agendas with Fund staff, will also undertake one related analytic project.
Sherry Glied, Ph.D. Dean and Professor of Public Service sherry.glied@nyu.edu
There is little information on how the prices health care providers charge insurers and patients are set, and which factors are responsible for high prices. This project is analyzing a newly available large private insurance claims database to: 1) assess variation in hospital and physician prices within and across health care markets and the factors correlated with this variation; 2) examine the association between health care prices and patient outcomes; and 3) ascertain how much prices have risen over time and how this growth differs by market and type of provider. The Commonwealth Fund’s Council of Economic Advisors is providing technical guidance for this project.
Zack Cooper, Ph.D. Assistant Professor Department of Health Policy and Management zack.cooper@yale.edu
This grant supports the development of an approach for assessing the relative value of care provided in U.S. hospitals. Value will be measured based on the difference between the actual and expected number of “high-value” discharges produced by hospitals, after controlling for health status and sociodemographics, and the amount of resources used. Focusing on Medicare beneficiaries with acute myocardial infarction, heart failure, or pneumonia, the research team will assess the usefulness of its measurement approach in determining to what extent value changes over time, if hospitals in the same region tend to deliver similar value, and how value varies by health condition within a hospital. This work will advance understanding of how cost and quality measures can be combined to assess health care value.
John Romley, Ph.D. Research Assistant Professor romley@healthpolicy.usc.edu
Health care policies should encourage the rapid development of innovative drugs that improve disease outcomes or cure disease, while avoiding high spending that does not reflect value. This project will describe how current pharmaceutical policies are addressing the challenge of innovation and cost. The researchers also will develop a framework for considering alternatives that might lead to higher-value pharmaceutical use and innovation. Ideal policies would provide strong financial incentives to support the development of valuable treatments but also would prevent high prices that do not reflect value and prevent utilization of more costly treatments when less costly but similarly effective options are available. Since it is difficult to develop actual policies that meet this ideal, this project will describe trade-offs and promising directions for pharmaceutical policies that could enhance both valuable innovation and cost control.
Mark McClellan, M.D., Ph.D., M.P.A. Senior Fellow in Economic Studies Director, Initiatives on Value and Innovation in Health Care mmcclellan@brookings.edu
Several recent analyses have documented wide variation in prices and identified price increases as a key driver in cost growth. In this project, researchers are using an all-payer claims database from Massachusetts to distinguish the proportions of cost growth for patients with similar diagnoses that are the result of changes in practice intensity, negotiated price levels for specific providers, and referrals to different provider types. These trends will be investigated for specific private payers and Medicaid. This initial work will inform the policy community on the sources of cost changes for different insurers over time and their relationship to utilization changes. If this approach for decomposing cost growth trends is successful, a second phase of work will correlate the cost trends to various alternative payment models implemented by payers in Massachusetts.
Ariel Pakes, Ph.D. Professor apakes@fas.harvard.edu
The Commonwealth Fund’s annual Bipartisan Congressional Retreat offers members of Congress and their key staff the opportunity to engage in substantive dialogue about timely health policy issues, in an environment removed from partisan politics, jurisdictional debates, and media pressures. Besides providing the Fund with a way to reach an influential audience, the retreat also is an opportunity to highlight key Fund research and analysis and build working relationships with members of Congress, administration officials, and their staff. The 2015 retreat provided participants with a valuable opportunity to begin analyzing results from the 2014 coverage expansions and the effect of delivery system changes and payment reforms on the cost and quality of care.
Edward Howard, J.D. Executive Vice President edhoward@allhealth.org
Alliance for Health Reform briefings conducted in 2015 were a valuable resource for congressional staff, journalists, and members of the broader Washington policy community seeking timely health policy information and analysis. Meanwhile, the annual Congressional Staff Retreat, held in January 2015, provided an opportunity for dozens of senior health staff from both parties to engage in an informal, off-the-record exchange of ideas with a variety of health policy experts. The retreat has proven to be an effective way for linking influential policy staff with the Fund, its grantees, and other policy experts.
Edward Howard, J.D. Executive Vice President edhoward@allhealth.org
In response to the growing size and scope of federal initiatives to reform Medicaid, the National Association of Medicaid Directors (NAMD) is establishing a national network to help its 56 member states and territories confront the common challenges they face. Each month, program directors participating in the Medicaid Reform Network will convene by phone or webinar to address a specific reform-related issue—for example, rapid-cycle evaluation and improvement strategies, nontraditional workforce payment incentives, or quality improvement. After each session, NAMD staff will produce a summary memo for all state policymakers. An advisory group of state Medicaid directors will provide guidance for the network’s activities.
Kathleen Nolan, M.P.H. Director of State Policy & Programs kathleen.nolan@medicaiddirectors.org
In January 2014, the National Governors Association Center for Best Practices, with Commonwealth Fund support, convened officials from 39 states and territories, along with federal agency personnel and policy experts, for a national meeting on health system transformation. The event focused on issues faced by all governors’ offices: managing change, driving toward a higher-value health system, deploying health information technology, and developing workforce. This grant supports a second annual multistate meeting to expose state officials to innovations in health system transformation, foster information exchange, and build learning networks.
Frederick Isasi, J.D., M.P.H. Division Director fisasi@nga.org
This project provided a forum for state policymakers from all 50 states to convene telephonically to discuss the impact of the King v. Burwell decision, learn from designated experts, and identify options to move forward with health reform implementation. To disseminate the results of the discussion, the National Academy for State Health Policy summarized key findings in a brief and distributed it to the organization’s broad network.
Patricia Riley President and Executive Director triley@nashp.org
The Federal–State Implementation Project (F–SIP) was launched in July 2010 to coordinate nongovernmental research efforts with the work of federal agencies around the implementation of the Affordable Care Act. Under this grant, F-SIP is continuing to engage various stakeholders, convene strategic conversations, identify unmet research needs, and coordinate the efforts of federal officials, researchers, policy stakeholders, and funders.
Faith Mitchell, Ph.D. President and Chief Executive Officer fmitchell@gih.org
A large portion of Medicaid expenditures is driven by a small segment of the beneficiary population with high health care needs and expenses. To develop high-quality, more coordinated, and more efficient statewide systems of care for these “super utilizers,” state policy changes on multiple fronts are required. The National Governors Association Center for Best Practices has been on the cutting edge of this work with states, working closely with seven states for the past year through its Super Utilizer Policy Academy. This small grant enables the provision of additional targeted technical assistance through the Innovator State Learning Lab. Selected states participate in a one-and-a-half-day visit to an “innovator” state and participate in a series of conference calls. Lessons learned during the project will be widely disseminated.
Frederick Isasi, J.D., M.P.H. Division Director fisasi@nga.org
The Center for Medicaid and CHIP Services (CMCS) recently launched the Medicaid Innovation Accelerator Program (IAP), which supports states’ Medicaid payment and delivery system reform efforts. The Fund is supporting the work of a panel of experts to review the research literature and provide recommendations to CMCS as the agency develops technical assistance contracts to ensure the work of IAP is grounded in evidence-based research. The panel will ensure that priorities that emerge are applicable, relevant, and driven by those with insight into state policy. Under this project, the expert panel will focus on “super utilizers” of health care services.
Judith Feder, Ph.D. Institute Fellow jfeder@urban.org
Since 2010, The Commonwealth Fund has supported the Association of Health Care Journalists’ successful fellowship program allowing midcareer reporters to examine a local health system to determine what makes it effective or ineffective in delivering high-value care to its community. Fourteen fellows have completed, or are currently completing, fellowships since the program’s inception. The grant supports the program for another two-year term, based on the continuing need for such journalist training and the promise shown in the past four years. Under the new grant, eight fellows will produce in-depth stories, in various media formats, that spotlight a health system and translate what makes it effective, or ineffective, in delivering the right care at the right price.
Len Bruzzese Executive Director bruzzesel@missouri.edu
The Commonwealth Fund’s Communications Department partners with numerous organizations and individuals to distribute the foundation’s work to key stakeholders, including policymakers, academics, delivery system leaders, and the general public. The renewal of this authorization will provide the essential support to proceed with and continue to improve our communications activities and partnerships in four main areas: publications development and dissemination; media services; web design and content development; and licensing. All four are integral to successful dissemination of the Fund’s work.
Barry Scholl Senior Vice President for Communications and Publishing bas@cmwf.org
In 2015, Martha Hostetter, partner at Pear Tree Communications, Inc., will again support the Commonwealth Fund’s communications team by: 1) editing reports, briefs, and blog posts; 2) writing journal article summaries; 3) posting materials on the Fund website; 4) creating email alerts and tweets to promote new publications; 5) developing infographics; and 6) providing strategic advice and project management for Web content development. Hostetter also will help research, write, edit, and produce six issues of the new Fund newsletter Transforming Care.
Martha Hostetter, M.F.A. Partner mh@cmwf.org
Since 2002, The Commonwealth Fund has partnered with Health Affairs to support the periodical’s efforts to disseminate timely research, analysis, and commentary on important health care policy issues to public and private leaders and decision-makers. As the Affordable Care Act’s health care coverage and delivery system reforms continue to be rolled out, Health Affairs is committed to publishing the latest research on health care access and quality, insurance enrollment, cost trends, and options for addressing the needs of vulnerable populations. This grant helps the journal continue its mission of informing leaders in health policy and health care delivery and enriching national dialogue.
Alan R. Weil, J.D., M.P.P. Editor in Chief, Health Affairs aweil@projecthope.org
This grant supported three annual projects of the Association of Health Care Journalists for 2015: the annual Health Journalism conference, Rural Health Journalism Workshop, and the Regional Health Journalism Workshop. These opportunities are useful for journalists in parts of the country that do not typically have many local training opportunities for covering important health and health care issues.
Len Bruzzese Executive Director bruzzesel@missouri.edu
This grant supports a third year of Columbia Journalism Review’s dedicated online health care section, “The Second Opinion.” With about five online stories produced per month, “The Second Opinion” gives journalists a trusted source to help them navigate the complex issues surrounding the Affordable Care Act.
Elizabeth Spayd Editor in Chief and Publisher liz.spayd@columbia.edu
A project of the Nebraska Press Association Foundation, the Rural Health News Service Pilot Project brings information about important health care issues to rural communities in Nebraska, South Dakota, and Colorado. Through a distribution of two columns each month to small, local newspapers that otherwise would not be able to afford to provide substantive health news coverage, the service is able to inform populations in those states about key health care system changes. This grant continues the Nebraska pilot for another 12 months and expands the project to Indiana.
Allen Beermann Executive Director abeermann@nebpress.com
Lisa Simpson, M.B., B.Ch., M.P.H., F.A.A.P. President and Chief Executive Officer lisa.simpson@academyhealth.org
Lisa Simpson, M.B., B.Ch., M.P.H., F.A.A.P. President and Chief Executive Officer lisa.simpson@academyhealth.org
Sean Gibbons Executive Director sgibbons@comnetwork.org
Bradford Smith President bks@fdncenter.org
John Feather, Ph.D. Chief Executive Officer jfeather@giaging.org
Faith Mitchell, Ph.D. President and Chief Executive Officer fmitchell@gih.org
Michelle Greanias, M.B.A. Executive Director mgreanias@gmnetwork.org
Diana Aviv President and Chief Executive Officer diana@independentsector.org
Sharon Stapel, J.D. President and Executive Director sstapel@npccny.org
Ronna Brown, J.D. President rbrown@philanthropynewyork.org
Lisa Pool Executive Director lisa@tagtech.org
Lee Hiltzik, Ph.D. Assistant Director and Head of Donor Relations and Collection Development lhiltzik@rockarch.org
Tim Johnson Executive Director tjohnson@gnyha.org
Lindsay Pettus
Richard Mollot, Esq. Executive Director richard@ltccc.org
Pamela Larson, M.A. Executive Vice President plarson@nasi.org
Elena Rios, M.D., M.S.P.H. President nhma@nhmamd.org
Esther Dyer, D.L.S., M.L.S. President and CEO erdyer@nmfonline.org
Jo Ivey Boufford, M.D. President jboufford@nyam.org
David Whitlinger Executive Director dwhitlinger@nyehealth.org
Kathryn O'Neal-Dunham Chief Operating Officer kdunham@philanthropynewyork.org
Ronda Kotelchuck, M.R.P. Executive Director rkotelchuck@pcdcny.org
James R. Tallon, Jr. President jtallon@uhfnyc.org