- Third-party payment programs make health insurance affordable for low-income consumers by paying the health plan premium costs not covered by the ACA’s tax credits
- Third-party payment programs not only help low-income Americans afford marketplace health coverage, they also reduce hospitals’ uncompensated care costs
- Issue: Consumers’ concerns about affordability limit participation in ACA marketplaces. Funded by local hospital systems and run by independent nonprofits, third-party payment (TPP) programs improve affordability for low-income consumers by paying premium costs not covered by tax credits.
- Goal: To assess the potential of TPP to make marketplace coverage more affordable, without harming insurance risk pools.
- Methods: Interviews in May and June 2016 with program administrators, hospital systems, carriers, and consumer groups in five localities and the Washington State marketplace.
- Key Findings: The most effective local program reached 1,148 people, or 25 percent of all eligible marketplace enrollees. Other local programs served between 202 and 934 consumers; the Washington State program reached 1,133. Findings suggest that without TPP, numerous beneficiaries would have remained uninsured. Hospitals funding these programs reported net financial benefits, with declines in uncompensated care exceeding program costs. Carriers reported no adverse selection in these carefully designed programs. Conclusions: Widespread adoption of TPP could help additional low-income consumers obtain marketplace coverage. Hospitals’ financial gains from TPP programs make replication more feasible. However, broader policies, such as increased premium tax credits and cost-sharing reductions, are likely needed for major nationwide improvements to affordability.
With roughly 20 million Americans gaining coverage under the Affordable Care Act (ACA), the United States has made enormous progress in reducing the number of uninsured.Nevertheless, 28.6 million people remained without health coverage in 2016, of whom an estimated 62 percent qualified for Medicaid or marketplace coverage. As of June 2015, only 35 percent of consumers eligible for advance premium tax credits — which lower monthly health insurance payments — had enrolled in marketplace plans. Research suggests that the most important obstacle to increased enrollment has been consumers’ belief that coverage is unaffordable.
Currently, the future of the ACA remains unresolved, but the basic framework of the legislation could well remain intact. If so, stakeholders and policymakers will need to revisit these affordability concerns. A fully effective solution would likely include higher premium tax credits and cost-sharing reductions. Until such a solution is considered, more incremental strategies may be needed, like third-party payment (TPP) programs, through which health care providers pay low-income consumers’ share of enrollment costs.
History suggests that TPP programs can address low-income consumers’ affordability concerns on a large scale. Long before the ACA, Washington State’s Basic Health Program let nonprofit organizations pay the premium charges of eligible consumers using donations from safety-net providers. The state stopped most new enrollment in the early 2000s. Before then, this TPP initiative achieved significant gains, enrolling nearly a quarter of all 133,000 consumers who received subsidized coverage when the state’s Basic Health Program reached its high-water mark in 2001.
Some carriers have expressed concerns that TPP programs could skew risk pools by triggering “adverse selection,” or disproportionately high enrollment of consumers with serious health problems. For example, carriers have raised concerns about health care providers increasing their payments for kidney dialysis and other high-cost conditions by steering patients who qualify for Medicaid or Medicare to nonprofit organizations, which in turn enroll the patients into marketplace plans that pay higher reimbursement rates.After seeing “problematic” effects on consumers and risk pools, the Centers for Medicare and Medicaid Services (CMS) circulated regulations in late 2016 limiting TPP programs that focus on dialysis patients. Those regulations soon became the subject of litigation, and a broader policy debate continues around TPP programs that serve patients with specific diagnoses.
This issue brief focuses on different TPP programs: those that base eligibility on income rather than the presence of particular health conditions. Based on interviews conducted in May and June 2016 with nonprofit program administrators, hospital systems, carriers, and consumer groups in five localities and the Washington State marketplace, we examine whether income-based TPP programs can improve enrollment and retention without triggering harmful adverse selection.How We Conducted This Study.We also explore whether income-based TPP programs could be implemented on a much larger scale. For detailed information on our methods, see
Catherine H. MacLean, M.D., Ph.D., Eve A. Kerr, M.D., M.P.H., and Amir Qaseem, M.D., Ph.D., M.H.A.
Performance measurement in the U.S. health care system has expanded dramatically over the past 30 years. The National Quality Measures Clearinghouse now lists more than 2500 performance measures. These measures are used in various quality-reporting, accountability, and payment programs sponsored by commercial payers, government agencies, and independent quality-assessment organizations. The Centers for Medicare and Medicaid Services (CMS) aims to base 90% of Medicare fee-for-service payments to clinicians on “value” by the end of 2018 by using performance scores.
Although most physicians view the delivery of high-quality care as a professional imperative,1 performance-measurement activities face increasing resistance from physicians and some policymakers who believe that current measures are not meaningful.2 In a recent survey, 63% of physicians said that current measures do not capture the quality of the care that physicians provide.3 Yet U.S. physician practices are spending $15.4 billion each year — about $40,000 per physician — to report on performance.3
In response to these concerns, the Performance Measurement Committee (PMC) of the American College of Physicians (ACP) developed criteria to assess the validity of performance measures (see box). Using a modified version of the method developed at RAND and UCLA for evaluating the benefits and harms of a medical intervention, we applied the ACP criteria to the measures included in the Medicare Merit-based Incentive Payment System (MIPS)/Quality Payment Program (QPP). We hypothesized that if most of the MIPS/QPP measures assessed were deemed valid using this process, physicians could have more confidence that adherence to the measured practices would result in improved patient outcomes. Conversely, if some substantial proportion of the measures were deemed not valid, the results would suggest the need to change the process by which MIPS measures are developed and selected. (For further details, see the methods section in the Supplementary Appendix, available at NEJM.org.)
ACP Measure Review Criteria.
Domain 1. Importance
- Meaningful clinical impact: Implementation of the measure will lead to a measurable and meaningful improvement in clinical outcomes.
- High impact: Measure addresses a clinical condition that is high-impact (e.g., high prevalence, high morbidity or mortality, high severity of illness, and major patient or societal consequences).
- Performance gap: Current performance does not meet best practices, and there is opportunity for improvement.
Domain 2. Appropriate Care
- Overuse: Measure will promote stopping use of a test or treatment in general population or individuals where the potential harms outweigh the potential benefits.
- Underuse: Measure will encourage use of a test or treatment in general population or individuals in whom the potential benefits outweigh the potential harms.
- Time interval: Time interval to measure the intervention is evidence-based.
Domain 3. Clinical Evidence Base
- Source: Evidence forming the basis of the measure is clearly defined with appropriate references.
- Evidence: Evidence is high-quality, high-quantity, and consistent and represents current clinical knowledge.
Domain 4. Measure Specifications
- Clarity — numerator and denominator clearly defined:
- For process measures, numerator includes a specific action that will benefit the patient, and denominator includes well-specified exclusions.
• For outcome measures, numerators detail an outcome that is meaningful to the patient and under the influence of medical care.
• Denominator includes well-specified and clinically appropriate exceptions to eligibility for the measure.
- Clarity — all components necessary to implement measure clearly defined
- Validity: The measure is correctly assessing what it is designed to measure, adequately distinguishing good and poor quality.
- Reliability: Measurement is repeatable and precise, including when data are extracted by different people.
- Risk adjustment: Risk adjustment is adequately specified for outcome measures.
Domain 5. Measure Feasibility and Applicability
- Attribution: Level of attribution specified in the measure is appropriate (measure ties the outcomes to the appropriate unit of analysis) and is clearly stated.
- Physician’s control: Performance measure addresses an intervention that is under the influence of the physician being assessed.
- Usability: Results of the measure provide information that will help the physician to improve care.
- Burden: Data collection is feasible and burden is acceptable (low, moderate, or high)
Of 271 measures in the 2017 QPP measures list, we identified and rated the validity of 86 that the committee considered relevant to ambulatory general internal medicine. Among these, 32 (37%) were rated as valid by our method, 30 (35%) as not valid, and 24 (28%) as of uncertain validity. We also determined the proportion of the measures that had been developed by the National Committee for Quality Assurance (NCQA) or endorsed by the National Quality Forum (NQF) that were rated as valid by our method. As compared with measures that were not endorsed by these organizations, greater percentages of NCQA-developed and NQF-endorsed measures were deemed valid (59% and 48%, respectively, vs. 27% for nonendorsed measures), and smaller percentages were deemed not valid (7% and 22%, vs. 49% for nonendorsed measures). (For further details on the measure review results, see the tables in the Supplementary Appendix.)
For each measure, the committee rated validity with respect to five domains: importance, appropriateness, clinical evidence, specifications, and feasibility and applicability. Examples of the overall and domain ratings given to individual measures judged to be valid, not valid, and of uncertain validity are shown in the table.
Notably, among the 30 measures rated as not valid, 19 were judged to have insufficient evidence to support them. For example, MIPS measure 181, “Elder Maltreatment Screen and Follow-Up,” requires the completion of the Maltreatment Screening tool on the date of an encounter and a documented follow-up plan for all patients 65 years of age or older. Although elder abuse is a serious problem that physicians should appropriately diagnose and report, the U.S. Preventive Services Task Force has found insufficient evidence to warrant routine screening. We believe the substantial resources required to screen large populations of elderly patients for maltreatment and to track follow-up would be better directed at care processes whose link to improved health is supported by more robust evidence.
Another characteristic of measures that were not rated as valid by our method was inadequately specified exclusions, resulting in a requirement that a process or outcome occur across broad groups of patients, including patients who might not benefit. MIPS measure 236, “Controlling High Blood Pressure,” for instance, requires that a blood pressure of 140/90 mm Hg or lower be achieved in the clinic setting for all patients. Forcing blood pressure down to this threshold could harm frail elderly adults and patients with certain coexisting conditions.
We also identified measures that were directed at important, evidence-based quality concepts but had poor specifications that might misclassify high-quality care as low-quality care. For example, MIPS measure 009, “Anti-depressant Medication Management,” assesses whether patients who started taking an antidepressant medication continued taking one at 3 and 6 months after initiation. This measure does not consider patients’ reasonable preferences for switching to alternative, evidence-based interventions such as psychotherapy or electroconvulsive therapy after experiencing side effects of antidepressants.
Our analysis identified troubling inconsistencies among leading U.S. organizations in judgments of the validity of measures of physician quality. Although the ACP assessment was limited to a defined set of measures, that set was large and included the vast majority of measures that will be applied to ambulatory care internists as part of the United States’ largest physician quality-assessment program for the purpose of accountability. Our findings are striking given that the criteria we used were similar to those used by NQF and CMS. Why the disconnect?
Possible explanations include the methods used to assess measures and the characteristics of the experts who did the assessing. The RAND–UCLA appropriateness method does not classify measures as valid when there are significant disagreements among the panelists. In contrast, the NQF threshold for endorsement is close to a simple majority of panelists (60%). The ACP method thus sets a higher standard for validity. In addition, we would argue that the RAND–UCLA method can be considered more evidence-based than other methods, since favorable clinical outcomes have been demonstrated for patients treated according to standards developed with this method.4,5
It is also possible that the perspectives of the groups doing the rating contribute to differences in validity ratings. Specifically, NQF convenes multistakeholder groups, whereas the ACP committee is composed exclusively of physicians with expertise in clinical medicine and research. However, analyses of the RAND–UCLA method in which multiple panels were convened to rate identical criteria have demonstrated high levels of agreement across panels for necessary care. Hence, although changing the panel composition might result in some differences in ratings, we would not expect the variation to be large enough to explain why so many NQF-endorsed measures were rated as not valid by the ACP committee.
The fact that only 37% of measures proposed for a national value-based purchasing program were found to be valid with a standardized method has implications for physician-level performance measurement. The use of flawed measures is not only frustrating to physicians but also potentially harmful to patients. Moreover, such activities introduce inefficiencies and administrative costs into a health system widely regarded as too expensive. If developers, assessors, and public and private payers adopted a more rigorous method of assessing measures’ validity, potential problems could be identified before the measures were launched. It makes sense for practicing clinicians to participate in the development and review of measures. At the same time, a single set of standards (like those put forth by the National Academy of Medicine for clinical practice guidelines) could be developed that would allow others to evaluate the trustworthiness of performance measures.
We believe that the next generation of performance measurement should not be limited by the use of easy-to-obtain (e.g., administrative) data or function as a stand-alone, retrospective exercise. Instead, it should be fully integrated into care delivery, where it would effectively and efficiently address the most pressing performance gaps and direct quality improvement. For now, we need a time-out during which to assess and revise our approach to physician performance measurement.
Article link: https://www.nejm.org/doi/full/10.1056/NEJMp1802595
Disclosure forms provided by the authors are available at NEJM.org.
This article was published on April 18, 2018, at NEJM.org.
- Qaseem A, Snow V, Gosfield A, et al. Pay for performance through the lens of medical professionalism. Ann Intern Med 2010;152:366–369.
2. Berwick DM. Era 3 for medicine and health care. JAMA 2016;315:1329–1330.
3. Casalino LP, Gans D, Weber R, et al. US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff (Millwood) 2016;35:401–406.
4. Higashi T, Shekelle PG, Adams JL, et al. Quality of care is associated with survival in vulnerable older patients. Ann Intern Med 2005;143:274–281.
5. Hemingway H, Crook AM, Feder G, et al. Underuse of coronary revascularization procedures in patients considered appropriate candidates for revascularization. N Engl J Med 2001;344:645–654.
Transforming Care focuses on new models of care, payment approaches, and patient engagement strategies that have the potential to reshape our delivery system to better meet the needs of the nation’s sickest and most vulnerable patients.
March 29, 2018 Issue
In Focus: Increasing Collaboration Among Physicians, Hospitals, and Postacute Providers to Reduce Variation and Spending
While many U.S. hospitals have concentrated on improving care transitions from hospital to home, far fewer have focused on the transition from hospitals to postacute care settings, including skilled nursing facilities. Increased awareness of variations in spending on postacute care and avoidable complications after hospital discharge — together with value-based payment arrangements — have prompted some physician groups, health systems, health plans, and postacute care providers to collaborate. Among their methods: assessing patients’ risk and identifying the most appropriate setting for them to recover and offering education to help patients regain their functionality and stay well. Better data about what works best for different patients and more aligned financial incentives among acute and postacute care providers could further these efforts.
By Martha Hostetter and Sarah Klein
The Institute of Medicine’s 2013 study of Medicare spending upended a common assumption about the biggest drivers of regional variation: it was not hospital use that accounted for the largest the differences in spending across regions, but what happened after patients emerged from hospitals and began making use of skilled nursing facilities (SNFs) and home health care. The report also traced the dramatic rise in spending on SNF use and other types of postacute care, which more than doubled from 2001 to 2011, making it the fastest-growing sector of health care.1
The rise in the use of postacute care can be traced to Medicare’s decision in the 1980s to stop paying hospitals on a fee-for-service basis and instead make payments based on patients’ diagnoses, not how long they stay. This, together with the increased prevalence of capitated payments under managed care in the 1990s, led hospitals to reduce lengths of stay. Both factors fueled demand for postacute care providers — which include skilled nursing facilities (SNFs), home health agencies, inpatient and outpatient rehab facilities, and long-term hospitals — to help patients recover after surgery or acute illness and return home.2 Demand for postacute care also increased as a function of the aging of the U.S. population and the increasing prevalence of chronic and disabling conditions, which complicate recovery.3 About two of five Medicare beneficiaries end up needing some form of postacute care after a hospitalization.4
Findings from the Commonwealth Fund Affordable Care Act Tracking Survey, February–March 2018
Tuesday, May 1, 2018
About 4 million working-age people have lost insurance coverage since 2016
The uninsured rates among lower-income adults rose from 20.9 percent in 2016 to 25.7 percent in March 2018
The marked gains in health insurance coverage made since the passage of the Affordable Care Act (ACA) in 2010 are beginning to reverse, according to new findings from the latest Commonwealth Fund ACA Tracking Survey. The coverage declines are likely the result of two major factors: 1) lack of federal legislative actions to improve specific weaknesses in the ACA and 2) actions by the current administration that have exacerbated those weaknesses. These include the administration’s deep cuts in advertising and outreach during the marketplace open-enrollment periods, a shorter open enrollment period, and other actions that collectively may have left people with a general sense of confusion about the status of the law. Signs point to further erosion of insurance coverage in 2019: the repeal of the individual mandate penalty included in the 2017 tax law, recent actions to increase the availability of insurance policies that don’t comply with ACA minimum benefit standards, and support for Medicaid work requirements.
In this post, and another soon to follow, we will look at people’s recent experiences with their insurance coverage and the affordability of their health insurance and health care.1 The ACA Tracking Survey is a nationally representative telephone survey conducted by SSRS that tracks coverage rates among 19-to-64-year-olds and has focused in particular on the experiences of adults who have gained coverage through the marketplaces and Medicaid. The latest wave of the survey was conducted between February and March 2018. Forthcoming results from large federal surveys like the National Health Interview Survey will shed more light on the trends our survey has identified.2
Uninsured Rate Among Working-Age Adults Is Up Significantly Since 2016
The uninsured rate among working-age people — that is, those who are between 19 and 64 — is at 15.5 percent, up from 12.7 percent in 2016, meaning an estimated 4 million people lost coverage (Tables 1 and 2). Rates were up significantly compared with 2016 among adults with lower incomes — those living in households earning less than 250 percent of poverty (about $30,000 for an individual and $61,000 for a family of four).
By Chase Gunter May 17, 2018
In light of recent data breaches, some on Capitol Hill are looking at accelerating the move away from widespread reliance on social security numbers in government systems.
While the numbers serve as a unique identifier for Americans, they were never intended to serve as a proxy ID, and their use exposes citizens to risks of identity theft.
“We need to break the link between identification and authentication,” said chairman Sam Johnson (R-Texas) at a May 17 House Ways and Means Subcommittee hearing. “We need to figure out how to make the numbers less valuable to criminals in the first place.”
Acting Social Security Administration Commissioner Nancy Berryhill called limiting the widespread use of social security numbers and related identity theft “a broad public policy issue that must be addressed.”
“As long as the SSN remains key to accessing things of value, particularly credit, the SSN itself will have commercial value and will continue to be targeted by fraudsters,” she said.
Since the 2015 OPM breach, which exposed some 22 million personnel records, Congress passed a law prohibiting agencies from sending documents with social security numbers on them unless necessary, and now the Department of Health and Human Services has discontinued sending Medicare cards displaying SSNs.
Berryhill called these measures “an important step,” but said that “addressing identity theft requires a unified effort that includes this subcommittee and Congress, the administration and public and private experts throughout the country.”
The reason social security numbers are so valuable for hackers, making them targets in data breaches, is relatively simple, McAfee Chief Technology Officer Steve Grobman said.
“Cybercrime is a market-driven enterprise,” he said. “One of the practical ways to stop the theft is to devalue what they’re going after.”
But because of the number’s widespread use throughout the public and private sectors, simply limiting its use is easier said than done. For one, “there are many federal requirements to provide an SSN” for a range of purposes, noted Elizabeth Curda, director of education, workforce and income security at the Government Accountability Office.
Additionally, replacing a social security number is generally a “last resort,” said Berryhill, because that replacement process “may cause the victim greater problems than the ones they are trying to solve.”
Agencies have also pointed to complex technological challenges — such as legacy systems and software applications — as impediments to reducing their reliance on the number.
Jeremy Grant, coordinator of the Better Identity Coalition, said because government “is in the identity business,” consumers should be able to ask SSA or other agencies to “vouch for them with parties they seek to do business with.”
“Having agencies like SSA accept their role here may be the most impactful thing government could do to help solve our identities challenges,” he said.
As far as alternatives, Sam Lester, consumer privacy counsel with the Electronic Privacy Information Center, raised the possibility of creating more identification numbers for different purposes, and called on Congress to codify privacy protections.
Chase Gunter is a staff writer covering civilian agencies, workforce issues, health IT, open data and innovation.
Prior to joining FCW, Gunter reported for the C-Ville Weekly in Charlottesville, Va., and served as a college sports beat writer for the South Boston (Va.) News and Record. He started at FCW as an editorial fellow before joining the team full-time as a reporter.
Gunter is a graduate of the University of Virginia, where his emphases were English, history and media studies.