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The Health Policy Program invites you to join us at an event tomorrow from 12 to 2pm to discuss the controversial issue of end-of-life care, and the implications it holds for patients, families, providers and yes -- even those who pay for the care. While last year's contentious health reform debate painted the issue in harsh and often equivocal terms, the choices around end-of-life care are complex and deeply personal and are not a simple contrast between cure vs. care.

At the event, Moving Beyond Death Panels, a distinguished panel of experts will discuss the implications of the most recent Dartmouth Atlas, "Quality of End-of-Life Cancer Care for Medicare Beneficiaries Regional and Hospital-Specific Analyses." This study reinforces previous findings that the end-of-life care patients receive often falls short of their desires and wishes, and those of their families. All health care, including -- if not especially -- that which comes at the end of life, must be responsive to patients' needs and respectful to their personal values.

Lunch will be available at noon. To RSVP or see a full list of speakers, click here. If you can't make it in person, be sure to follow along on our Twitter account, NewHealthDialog. We'll be live-tweeting under the hashtag #nafevents. We hope to see you there!

Senate Republicans eager for a face-to-face with the new CMS Administrator Don Berwick got their wish. Dr. Berwick appeared today before the Senate Finance Committee for a hearing on the future of Medicare and Medicaid. Democrats focused their questions on how Dr. Berwick and the Affordable Care Act could improve the American health care system, while Republicans focused on Berwick’s nomination (he took office as a recess appointment, without formal Senate confirmation) and the length of the hearing. (The hearing was cut short by a vote on food safety legislation on the Senate floor, which irked many committee members -- Senator Hatch called the time available “pathetic”).

Berwick opened his testimony by recalling his father’s long career as a general practitioner, and what he had learned from it -- Berwick’s vision of health care is responsive, embedded in a community and connected to it, and focused on the needs of patients and families. The health care world today is full of new and wonderful technologies, Berwick said, and is much more complicated -- compared to what his father could do in his day, our current health system can work miracles ... when everything goes right.

The votes are in. State insurance regulators, from the National Association of Insurance Commissioners (NAIC), voted unanimously Thursday morning on definitions for the Medical Loss Ratio (MLR). The “medical loss ratio” refers to the amount of money insurers spend on providing actual health and medical care to their customers. The Affordable Care Act sets minimum standards for the MLR -- large, group insurers have to spend at least 85 percent of their money on medical care (it’s 80 percent for small group or individual policy insurers). That means that only 15 percent can go to expenses that don’t specifically improve patient health, like administrative overhead and advertising costs.

The NAIC spent the week in Florida trying to reach a consensus on MLR policy -- answering questions like: what counts as “medical” spending? Will the MLR calculation take place at the state or national level? And how do we account for changes in the role of brokers in the new insurance marketplace? HHS will rely heavily on the NAIC recommendations to craft final regulations.

The latest Health Wonk Review is up over at the Healthcare Talent Transformation blog. Review host Peggy Salvatore's theme is something she believes is even more headline-worthy than the recent six month anniversary of comprehensive health reform...Aliens! That's right, the United Nations just appointed our first ambassador for extraterrestrial contact. In the spirit of "take me to your leader," Salvatore runs down the list of terrestrial leaders in health -- from Texas legislators to doctors to economists to the HHS, and more. Check it out! (It includes Joanne Kenen's post on whether Atul Gawande made it safe for us to all talk about end of life care again -- what it means to care for a patient when there is no cure for a patient.)

The latest edition of the Health Wonk Review is up over at the Colorado Health Insurance Insider, hosted by Louise Norris. We've got a pretty straightforward theme this round -- health care costs, politics, and the economics of health care were the themes of the day. Be sure to check out all the great posts, including our own Shannon Brownlee's discussion of Don Berwick and the debate over alternative medicine.

Let’s talk about risk for a moment. Statistically, you are far more likely to experience a fatal accident in the car on the road than you are in an airplane. But somehow, hurtling through the sky thousands of feet in the air just feels more risky than being planted firmly on the ground. We perceive that we’re taking on more risk in an airplane than we are in a car, statistics be damned. According to a recent article in Health Affairs, a similar phenomenon happens to doctors when they think about malpractice. And it doesn't diminish all that much even when their states impose caps on malpractice damages.

We attended an event this morning, Medical Liability and Emergency Care, to mark the release of the September issue of Health Affairs. (Not that September Issue.) We got to listen to the minds behind the articles talk about some major issues in the health policy world -- medical malpractice reform, avoiding and managing medical errors, and problems surrounding emergency room use. Emily Carrier, Senior Health Researcher at the Center for Studying Health System Change, and one of the co-authors of the article about physician perception of malpractice risk, explained the article’s main conclusions.

This is the third post in our series on Accountable Care Organization or ACO. We are exploring what exactly constitutes an ACO, why we’re trying to make them work, and what they have to do with the new health reform law. In this post, we look at how ACO payment structures can promote high value care. Part I can be found here, Part II is here.

Payment Structures

ACO payment systems are all about encouraging doctors to spend less money on care while improving the quality. Changing how doctors distribute health care resources, through payment incentives, is crucial to the ACO concept.

The current "fee-for-service" payment structure that encourages volume of health care over value is just what it sounds like. Every health care service is reimbursed at a certain value; more services lead to more reimbursement. There's nothing inherently wrong with paying health providers for all of the services they perform -- the problem is there is no counterbalance to discourage overutilization or use of unnecessarily costly treatments. The ACO model starts the move away from fee-for-service. There are different ways to structure ACO payments. Two basic approaches are the shared savings model and the partial capitation model.

As we work to implement health reform and reshape our health care system so that we pay for value and quality of services instead of quantity, health systems across the US will test various strategies. One quality improvement concept generating a lot of buzz is the Accountable Care Organization. The ACO concept is popular, but the definition is still vague. In a series of blog posts this week, we will attempt to answer the question of what exactly constitutes an ACO, why we’re trying to make them work in the first place, and what they have to do with the new health reform law.

What is an ACO?

Accountable Care Organizations (ACOs) are a relatively new concept, dating back to around 2006 in their current incarnation. A lot of the foundation for the ACO concept comes from the work of the Dartmouth Institute for Health Policy (which looks at variation in Medicare spending levels across the country -- we’ve written about their work on many occasions) and MedPAC (more here and the ACO report is here).

The latest edition of the Health Wonk Review is up over at the Workers’ Comp Insider blog. In celebration of the "Dog Days" of summer, the review covers all the "hot" issues in health policy right now -- everything from controlling costs and reforming payment structures to health technology and ethics.

During the dog days of summer -- named for the rising of Sirius, the Dog Star, between July 24th and August 24th way back in Ancient Rome -- it was said that "the seas boiled, wine turned sour, dogs grew mad, and all creatures became languid, causing to man burning fevers, hysterics, and phrensies." We won't say exactly how accurate we think this description is today...but we will point out that it is supposed to hit 101 degrees this weekend here in the District (and maybe even 105 if you factor in the humidity).

Be sure to tune in to today's alternative town hall event from New America in California, Putting the Care in "Obamacare," where state leaders will discuss the challenges and opportunties associated with the implementaion of health care reform. Panelists will discuss questions such as how the experience of health care will change for patients in California, what we can do to successfully implement reform and promote high quality care, and how reformers can build on the high-value care models already in play in the state.

If health reform implementation is getting you down and you have a moment of nostalgia for the fight for passage...we've put together a link-rich, color-coded guide to what happened,  The History of Health Reform.  Whether you were with us through the whole debate, or you are looking for a retrospective -- the timeline below shows the who, what, and when of the debate about health coverage, cost and quality. We've taken many of  the primary sources we've found useful since the 2008 campaign and assembled them in this timeline. You'll find links to legislation, proposals, CBO scores, letters and reports from stakeholders, relevant articles, transcripts, and videos.

The moment health reform passed, the countdown to implementation started. Next up is the launch of state-based high risk pools, where Americans with pre-existing conditions can get coverage. Starting today (a little over the 90 days required by law, but still an achievement that reflects round-the-clock efforts at HHS and hard work in the states), people who have been denied coverage for more than six months can enroll. The pools, now called “Pre-Existing Condition Insurance Plans” will provide coverage starting Aug. 1 and will end when the  health insurance exchanges open in 2014. 

"For too long, Americans with pre-existing conditions have been locked out of our health insurance market," HHS Secretary Kathleen Sebelius said in a statement today. "The Pre-Existing Condition Insurance Plan gives them a new option... This program will provide people the help they need as the nation transitions to a more competitive and fair market place in 2014."