The Daily Briefing

News for Health Care Executives

8 Lessons from the 2012 Medicare Shared Savings Participants

December 14, 2012

View the On-Demand Presentation

Watch the video Stream video recording

Download PDF Download PDF

What You'll Learn

By the end of November, CMS is expected to announce the next cohort of Medicare Shared Savings participants. The physician organizations and health systems designated as Medicare ACOs face a daunting set of decisions in a compressed period of time. Fortunately, there is much to be learned from the 115 organizations approved in 2012.

This webconference highlights the key decisions likely to face new Medicare ACOs and best practices our experts have uncovered while working with previously approved participants. Topics include:

  • How are organizations tracking and reporting the required 33 quality metrics?
  • What strategies are most effective for minimizing patient leakage from participating providers?
  • Which care management models have been most successful at engaging high-risk patients?
  • What tools are ACOs using to manage the patient data shared by CMS?
  • How do peer ACOs plan to distribute bonuses and financial incentives?

HHS likely to extend exchange deadline

Handful of Republican governors balk at exchanges

November 09, 2012

HHS is expected to extend the Nov. 16 deadline for states to declare whether they will run their own health insurance exchange, partner with the federal government, or allow the federal government to do it for them, according to several state officials, CQ HealthBeat reports.

According to CQ HealthBeat, HHS likely will set a new deadline for states that intend to create their own exchanges, and a rolling deadline for states interested in partnering with the federal government.

State decisions

A number of governors this week announced they would not create an exchange, meaning that the federal government will do so. 

  • Kansas Gov. Sam Brownback (R) on Wednesday said the cost to his state of setting an exchange would be prohibitive. In a statement, Brownback said, "My administration will not partner with the federal government to create a state-federal partnership insurance exchange because we will not benefit from it and implementing it could cost Kansas taxpayers millions of dollars."
  • Missouri Gov. Jay Nixon (D) also announced his state will allow the federal government to build the exchange, saying, "The only option for Missouri at this time is to indicate that we will be unable to proceed with a state-based exchange absent a change in circumstances." Nixon previously said he would like Missouri to run its own exchange, but voters on Tuesday approved a ballot measure prohibiting the governor from establishing a state-run exchange without legislative approval. The state Legislature does not return to session until January. 
  • Virginia Gov. Bob McDonnell (R) on Wednesday said the state would not build an exchange, citing a lack of federal guidance to make a decision before the deadline. "At this point, without further information, the only logical decision for us is to use the federal option," McDonnell said.

The announcements come after Florida Gov. Rick Scott (R) confirmed earlier this week that his state would not create its own exchange or partner with the federal government. In addition, Georgia Gov. Nathan Deal (D) on Wednesday hinted that his state would not implement its own insurance exchange, citing federal regulations that would restrict Georgia's ability to design its own program.

Avalere Health earlier this week estimated that more than one-third of states likely will defer to the federal government to operate an exchange for them and 13 states likely will partner with the federal government (Norman/Millman, Politico, 11/8; Lieb, AP/San Francisco Chronicle, 11/8; Gordon, Kansas City Public Media, 11/8; AP/Modern Healthcare, 11/8; Adams, CQ HealthBeat, 11/8).


NYC, Doctors Without Borders struggle to serve patients amid hospital closures

Officials say it could be weeks before closed hospitals reopen

November 09, 2012

New York City health providers are scrambling to meet patient needs amid the continued closure of several large hospitals, prompting Doctors Without Borders to open its first-ever U.S. clinic.

Hospitals struggle to keep up with patient needs

"This is not a tenable situation," says Lewis Goldfrank, who oversees emergency medicine at NYU Langone Medical Center and Bellevue Hospital Center. Both hospitals remain closed 10 days after they lost emergency power during and after Superstorm Sandy, which caused major power outages and flooding throughout downtown Manhattan.  

Manhattan Veterans Affairs Medical Center and Coney Island Hospital in Brooklyn also have not reopened. "There [are] just too many people," Goldfrank says, adding, "You can't dump this level of patients out on the open market."

Expressing similar concerns, UPMC biosecurity expert Amesh Adalja notes that the hospital closings have left "a whole blank spot in the lower part of Manhattan."

Bellevue—the city's flagship public hosptial—was the only Level One trauma center in the downtown area. Its ED treats more than 100,000 patients per year, often serving victims of stabbings, gunshots, terrorist attacks, and patients in police custody. Now, downtown patients with Level One trauma needs must travel to New York Presbyterian/Weill Cornell Medical Center on the Upper East Side or St. Luke's/Roosevelt Hospital on the Upper West Side.

"All systems can work at above capacity for some time without significant detriment," says Ronald Simon, Bellevue's director of trauma. But "with time, people will tire, over-worked systems will fail, and patients will suffer," Simon warns, adding that "the current status of care in Manhattan is not sustainable for any length of time."

At Beth Israel Medical Center, ambulance traffic has increased by 70% since Sandy, according to Gregg Husk, the hospital's chairman of emergency medicine. "For us, this is Guinness Book of Records territory," Husk says.

Beth Israel currently receives about 135 patients per day by ambulance, up from an average of 84 patients per day before the storm. Bellevue's staff has been working at Beth Israel, as well as other New York hospitals, to help deal with increased volumes.

Although hospitals are struggling to keep up, city officials say that patient needs are being met. "Response times for life-threatening emergencies in Manhattan are meeting FDNY Bureau of EMS goals," says New York State Department of Health's Bill Schwarz. "Turnaround times at EDs at Manhattan hospitals have remained steady, with no noticeable increases as a result of the storm impact."

New York City Health and Hospitals Corporation (HHC) spokesperson Ian Michaels says the agency does not know when hospitals will reopen. "The assessment is ongoing... we'll know more soon," Michaels says. Reopening is imperative because currently there are only nine public acute-care hospitals in New York City, and all are "operating very near capacity. There are very few beds available within the HHC system right now," Michaels says.

Doctors Without Borders opens first U.S. clinic

To help meet patient needs in the area, Doctors Without Borders has opened medical clinics in the Rockaways, a remote part of Queens that faces the Atlantic Ocean. It is the organization's first clinic inside the United States.

"A lot of us have said it feels a lot like being in the field in a foreign country," says Manhattan physician Lucy Doyle, who has worked with the organization in the Democratic Republic of Congo and Kenya. "I don't think any of us expected to see this level of lacking access to health care," she adds.

In the Rockaways, "pharmacies are closed," says Beth Israel Medical Group physician Danya Reich, adding, "Their doctors' offices are closed. They need a way to get refills of the medicines they take all the time" (Ornstein/LaFleur, ProPublica, 11/8; Honan, Reuters, 11/8).


Utah hospitals to state: Don't expand Medicaid

State hospital association favors a 'free-market solution' for low-income residents

November 09, 2012

The Utah Hospital Association (UHA) has urged the state not to participate in the Medicaid expansion, an unexpected move as hospitals nationwide ramp up campaigns to fight for the Affordable Care Act (ACA) provision.

When the Supreme Court upheld the ACA in June, the justices ruled that states can opt out of the expansion without any effect on current funding, essentially leaving the final decision up to each state's governor. So far, Republican governors in six states—Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas—have announced that they will not participate.

Where does your state stand on the Medicaid expansion? Click to expand either a quick-to-scan graphic or an interactive graphic. (Note: interactive graphic may not be optimized for mobile devices.)

For hospitals, the Medicaid expansion is expected to reduce uncompensated care costs. As such, the American Hospital Association has expressed its support for the expansion, and state hospital associations have launched local campaigns to convince state leaders to opt into it.

However, UHA in a position statement sent to health industry leaders last month said, "there are too many practical and political decisions to be made… to support the full Medicaid expansion at this time." Among the association's chief concerns is the "adverse impacts on the commercial insurance market."

According to UHA President Rob Betit, the state's hospitals are not entirely opposed to expansion. "We're in favor of a more thoughtful, graduate approach," he says, adding, "We support finding a Utah solution that works for our state, focusing on a free-market solution."

About 58,000 additional Utah residents would qualify for Medicaid under the expansion. Betit says the state might consider steering those individuals into private health plans made affordable with federal tax credits. 

As of Wednesday, Utah Gov. Gary Herbert (R) had not yet indicated whether he planned to participate in the Medicaid expansion (Stewart, Salt Lake Tribune, 11/8).


Health care CFOs among most optimistic about their industry

CFOs: Health costs among top threats to business performance

November 09, 2012

A new survey of CFO attitudes across seven industries finds that health care CFOs are more positive about the state of their industry than CFOs in most other fields.

For its Bi-Annual U.S. Mid-Market CFO Survey, GE Capital in the third quarter (Q3) of 2012 asked 500 CFOs to share their views on the U.S. economy and their outlook on a variety of important economic, industry and business-level issues. Survey respondents worked for middle-market companies in one of the following seven industries:

  • Food, beverage, and agribusiness;
  • General manufacturing;
  • Health care;
  • Metals, mining, and metal fabrication;
  • Retail;
  • Technology and business services; and
  • Transportation.

Respondents measured their sentiments about their respective fields on a scale of one to 10, where one indicates an extremely weak sentiment and 10 indicates an extremely strong sentiment.

On average, CFOs gave their industries 5.8 out of 10, down from 5.9 in Q1 of 2012. Of all the CFOs, those working in the food and beverage industry expressed the most favorable views about the state of their industry, giving it 6.2 out of 10 in Q3.

Health care CFOs’ outlook on the strength of the U.S. health care industry grew from 5.2 out of 10 in Q1 to 5.8 out of 10 in Q3. Factors that likely contributed to the increased optimism among health care CFOs include:

  • Their beliefs that he U.S. economy is stabilizing;
  • Increased expectations for industry growth over the next year;
  • Expectations that profits will remain steady or increase; and
  • Continued stability in the health care job sector.

Meanwhile, the survey also found that health care costs are among top threats to business performance in 2013 across all seven fields (Parmar, MedCity News, 10/29; GE Capital survey, Fall 2012).


Which cancers most affect life after remission?

Breast cancer survivors have similar quality of life to those who never had cancer

November 09, 2012

Survivors' quality of life can vary widely depending on the type of cancer they had, according to a study published in Cancer Epidemiology.

Researchers compared the quality of life of 1,822 cancer survivors with that of 24,804 adults without cancer. Using a 10-item questionnaire, respondents were asked to rate a number of measures, including physical functioning, depression, pain, and fatigue. The data were taken from CDC's 2010 national health survey.

The study found that survivors of melanoma, breast, and prostate cancers had a mental and physical quality of life similar to those who never had cancer.

However, survivors of cervical, blood, and colorectal cancers and cancers with a five-year survival rate below 25% had a worse physical quality of life. In addition, survivors of cervical cancer and cancers with a low five-year survival rate reported a worse quality of life in terms of mental health.

The study found that 25% of cancer survivors had lower than normal quality of life for physical reasons, while 10% had a lower than average quality of life for mental reasons. In all, about 3.3 million U.S. residents who have survived cancer have a below average physical quality of life, and nearly 1.4 million have a below average mental quality of life, the researchers estimated.

In an interview on Tuesday, lead study author Kathryn Weaver said that the findings are important because there are several ways physicians and lawmakers can improve quality of life for cancer survivors. Addressing their needs also is vital because the population—currently about 12.6 million individuals—is expected to continue increasing, the study noted (Reichard, CQ HealthBeat, 11/6 [subscription required]).


Adhering to hospital guidelines may not reduce readmissions

Study finds wide variation in guideline adherence based on conditions

November 09, 2012

Procedural guidelines created to ensure quality hospital care do not have a significant impact on readmission rates, a new Journal of General Internal Medicine study finds.

Using 2007 Medicare hospital data, Baystate Medical Center researchers assessed readmission rates and patient outcomes for various conditions, including acute myocardial infarction (AMI), heart failure, pneumonia, abdominal surgery, cardiac surgery, and orthopedic surgery.

Researchers also determined the percentage of patients who received all of the recommended care for their respective conditions. They found that adherence to care processes varied based on the condition. For example, hospital staff completed all the recommend care processes for about 46% of abdominal surgery patients and 88% of AMI patients.

However, the researchers found little correlation between adherence to care guidelines and "meaningfully" lower readmissions rates. "Even when the associations were statistically significant, the differences in the readmission rates of high- and low-performing hospitals were small," the study says.

The team notes care protocols may have "little impact on the risk of readmission" or that the guidelines may be too broadly defined (Seaman, Reuters, 11/8; Stefan et al., Journal of General Internal Medicine, 10/16).


CNN: 10 'shocking' medical errors that can be prevented

How can patients proactively prevent never events?

November 09, 2012

CNN this week identified 10 types of preventable medical mistakes that kill patients every year and offered tips on how patients can help providers avoid them.

According to Johns Hopkins Hospital patient safety expert Peter Pronovost, fatal medical mistakes in the United States likely added up to become "the third leading cause of death" in the country. Altogether, they kill more than a quarter million patients every year and injure millions, CNN reports.

CNN's list of 10 medical errors includes:

  • Treating the wrong patient. Before procedures, patients should ask hospital staff to verify their entire name and date of birth, as well as the barcode on their hospital bracelet.
  • Leaving a piece of equipment inside a patient's body during surgery. If a patient feels unexpected pain, swelling, or fever, they should ask staff whether they might have a surgical instrument in their body.
  • Losing a patient with dementia. Family and friends of patients with dementia should consider using GPS tracking bracelets if the patient tends to wander frequently. There are cases of patients with dementia wandering off without the knowledge of hospital staff and later dying of hypothermia or dehydration.
  • Con artists pretending to be physicians. Patients should always confirm that a physician is licensed using resources available online or elsewhere.

  • Becoming more ill while waiting in the ED. Patients in overcrowded EDs may wait hours to see a physician and must be proactive if they need immediate care. Patients should call their physician on the way to the ED and ask them to alert the hospital staff.
  • Allowing air bubbles to enter the bloodstream when a chest tube is removed. Patients should ask staff about proper body positioning before having a chest tube removed.
  • Operating on the wrong body part. Charts can be incorrect or surgeons can misread them, so patients should confirm the surgical site with the nurse and surgeon before the procedure.

  • Acquiring an infection because of poor staff hygiene. Although it is an uncomfortable question, patients should ask physicians and nurses if they have properly washed their hands before being touched—even if they are wearing gloves.

  • Putting medicine in the wrong tube. Patients should ask staff to trace every tube back to the point of origin when injecting substances to avoid errors.
  • Failing to give a patient sufficient anesthesia. Patients may want to ask if a local anesthetic would work as efficiently as general anesthesia (Bonifield/Cohen, CNN, 11/5).


Weekend reads

November 09, 2012

The Daily Briefing editorial team highlights several interesting health care stories and studies that didn't quite make this week's Briefing. What are you reading this weekend? Let us know in the comments.

Dan Diamond's picks

Do Starbucks employees have more emotional intelligence than your physician? Peter Ubel, a Duke University physician and behavioral scientist, certainly thinks so. That's partly because Starbucks baristas undergo training to deal with cranky customers, learning how to read and respond to individual moods—a type of training that most doctors just don't get.

Secrets from Obama's data-driven campaign. Combing through big data, looking for insights, isn't just a health care phenomenon. TIME magazine has a fascinating story on how the president's reelection campaign managers focused on consolidating their various databases, allowing them to microtarget TV ads, collect more donations, and turn out more voters. It's also striking as news trickles out about the Romney campaign's own data-driven get-out-the-vote effort, called Project ORCA, which fell apart on Election Day.

Paige Hill's picks

Put down the green tea. For all its health claims, green tea does not have the same diabetes-fighting properties as black tea. A new study (soon to be published in BMJ) found that the world's lowest type 2 diabetes rates are in countries where black tea consumption is highest. So make like the Brits, and pour yourself a cup of Earl Grey.

Should hospitals invest in urgent care clinics? This NPR “Shots” blog looks at how patients with a non-urgent care needs can be directed to one of the nearly 9,000 urgent care clinics in the United States. But going to another provider doesn’t mean the hospital has lost a patient—hospitals own more than 25% of these clinics. Check back on Monday for the Daily Briefing's deeper look at this story.

Neeraj Hotchandani's picks

Don’t stress out over stress. Writing in the Annals of Behavioral Medicine, Pennsylvania State University researchers found that how you react to stress your current environment can affect your health 10 years down the road. The researchers found that volunteers who were troubled by daily stressors and obsessed with them after the fact were more inclined to have chronic health problems a decade later.

Saving billions—and the planet. A Commonwealth Fund study last week found that hospitals’ environmental sustainability efforts could save the health care industry $15 billion over 10 years. Researchers examined nine hospitals and health systems that had implemented sustainability initiatives and found that they had realized significant savings as a result of their efforts.

Overweight job seekers need not apply. In Sweden, employers—especially at smaller companies—often decide not to hire job candidates who are overweight due to concerns about worker productivity, researchers say. In fact, researchers found that obese job seekers are 83% less likely to be offered a job than applicants of normal weight.

Juliette Mullin's picks

The Sandy Five. New York City residents who went without power for days have discovered an unexpected tightening of their waistbands in the aftermath of Superstorm Sandy. "[T]he extra pounds provided evidence of a disaster-psychology mind-set that took hold during Sandy: in times of crisis, New Yorkers discovered, food fills an emotional need, not just a physical one," the New York Times' Alex Williams writes. 

Medical research falls victim to Sandy. In the chaos of wind, flooding, and power outages during Superstorm Sandy, thousands of laboratory mice in medical research facilities at NYU Langone Medical Center may have drowned. According to CNN, it may take years to recover the lost research and get critical experiments back on track.


Where each state stands on ACA's Medicaid expansion

A roundup of what each state's leadership has said about their Medicaid plans

June 14, 2013


IMPORTANT NOTE FOR READERS
July 26, 2013

We are no longer updating this version of the Medicaid map, which tracked each governor's stance on the Medicaid expansion.

Check out our new Medicaid Map (Beyond the pledges: Where the states stand on Medicaid), which tracks executive and legislative action taken to achieve—or totally rule out—expansion in each state.

The Supreme Court's ruling on the Affordable Care Act (ACA) allowed states to opt out of the law's Medicaid expansion, leaving each state's decision to participate in the hands of the nation's governors and state leaders.

Based on lawmakers' statements, press releases, and media coverage, the Daily Briefing and American Health Line editorial teams have rounded up where each state currently stands on the expansion.

We will continue to update this map and list as more information becomes available. Send us news, tips, and feedback by commenting below or emailing dailybriefing@advisory.com.

Click to expand.

Embed this map on your website

Like this map? Browse our library of popular graphics

Check out more than 30 other infographics, including:

> Tactics to get your staff rowing in the right direction.
> An interactive map on pay-for-performance programs.
> A look at how your health compares to an Olympian's.
> A field guide to Medicare payment innovations.

A state-by-state look at governors' stances

Text last updated on June 14, 2013. States are categorized based on statements from governors or enacted state laws.

 * indicates a state's participation in the multistate lawsuit against ACA

NOT PARTICIPATING (13 states)

  • Alabama*: Gov. Robert Bentley (R) on Nov. 13 announced that Alabama will not participate in the Medicaid expansion because the state "simply cannot afford it" (Gadsden Times, 11/13).
  • Georgia*: Gov. Nathan Deal (R) in an Atlanta Journal-Constitution/Politico/11 Alive interview on Aug. 28 said, "No, I do not have any intentions of expanding Medicaid," adding, "I think that is something our state cannot afford." When asked about the insurance exchanges, Deal said "we do have a time frame for making the decision on that I think, especially on the exchanges," adding that "we have just a few days after the election in order to make a final determination on that" (Wingfield, "Kyle Wingfield," Atlanta Journal-Constitution, 8/28/12).
  • Idaho*: Gov. C.L. Otter (R) in his 2013 State of the State address delivered on Jan. 7 said that while "there is broad agreement that the existing Medicaid program is broken," the state "face[s] no immediate federal deadline" to address the situation. He added, "We have time to do this right … [s]o I'm seeking no expansion of" the program. Otter said he’s instructed the state Health and Welfare director to "flesh out a plan" that focuses on potential costs, savings and economic impact, which he plans to introduce in 2014 (Ritter Saunders, Boise State Public Radio, 1/7/13; Young, Huffington Post, 1/7; Petcash, KTVB, 1/7/13).
  • Louisiana*: Gov. Bobby Jindal (R) in an NBC "Meet the Press" interview on July 1 said, "Every governor's got two critical decisions to make. One is do we set up these exchanges? And, secondly, do we expand Medicaid? And, no, in Louisiana, we're not doing either one of those things" (Barrow, New Orleans Times-Picayune, 7/2/12).
  • Maine*: Gov. Paul LePage (R) on Nov. 16 said that Maine will not participate in the Medicaid expansion. He called the expansion and the state-based insurance exchanges a "degradation of our nation’s premier health care system" (Mistler, Kennebec Journal, 11/16/12).
  • Mississippi*: Gov. Phil Bryant (R) on Nov. 7 said Mississippi will not participate in the Medicaid expansion, reiterating previous statements that he had made about the ACA provision (Pender/Hall, Jackson Clarion-Ledger, 11/7/12).
  • North Carolina: Gov. Pat McCrory (R) on Feb. 12 announced that his state will not expand Medicaid or establish its own health insurance marketplace under the Affordable Care Act. McCrory said state officials conducted a comprehensive analysis to determine the advantages and disadvantages of expanding Medicaid and the right type of exchange option in the state, and concluded that it is "abundantly clear that North Carolina is not ready to expand the Medicaid system and that we should utilize a federal exchange." He said the review included discussions with other governors, White House officials, health care providers, and leaders in the state Legislature (Binker/Burns, "@NCCapitol," WRAL, 2/12/13; Cornatzer, Raleigh News & Observer, 2/12/13).
  • Oklahoma: Gov. Mary Fallin (R) on Nov. 19 said Oklahoma will not participate in the Medicaid expansion. "Oklahoma will not be participating in the Obama Administration’s proposed expansion of Medicaid," she said in a statement. She noted that the program would cost the state as much as $475 million over the next eight years (Greene, Tulsa World, 11/19/12).
  • Pennsylvania*: Gov. Tom Corbett (R) on Feb. 5 sent a letter to HHS saying he "cannot recommend a dramatic Medicaid expansion" in Pennsylvania because "it would be financially unsustainable for Pennsylvania taxpayers." He noted that the expansion would necessitate "a large tax increase on Pennsylvania families" (Tolland, Pittsburgh Post-Gazette, 2/5/13).
  • South Carolina*: Gov. Nikki Haley (R) on July 1 announced via Facebook that South Carolina "will NOT expand Medicaid, or participate in any health exchanges." The state Legislature is expected to make a decision on the Medicaid expansion during the 2013 session (Gov. Haley Facebook page, 7/1/12; Holleman, Columbia State, 11/9/12).
  • South Dakota: Gov. Dennis Daugaard (R) in his annual budget address on Dec. 4 said he does not plan to participate in the Medicaid expansion. "I really think it would be premature to expand this year," he said, adding that he hoped for more flexibility for the state program (Montgomery, Sioux Falls Argus Leader, 12/4/12).
  • Texas*: Gov. Rick Perry (R) in a statement on July 9 said, "If anyone was in doubt, we in Texas have no intention to implement so-called state exchanges or to expand Medicaid under ObamaCare." Perry also sent a letter to HHS Secretary Kathleen Sebelius on July 9 asserting this position. The Dallas Morning News reported that on Nov. 8, Perry reiterated his opposition to the expansion, saying, "Nothing changes from our perspective" (Office of Gov. Perry release, 7/9/12; Gov. Perry letter, 7/9/12; Garrett, Dallas Morning News, 11/11/12).
  • Wisconsin*: Gov. Scott Walker (R) on Feb. 13 announced his rejection of the Medicaid expansion. He proposed an alternative plan that would expand coverage to low-income state residents through private health care exchanges (Spicuzza, Wisconsin State Journal, 2/13/13).

LEANING TOWARD NOT PARTICIPATING (6 states)

  • Alaska*: Gov. Sean Parnell (R) on Feb. 28 expressed opposition to the Medicaid expansion. He said he will not ask the state Legislature to consider expansion this session, but he will continue to examine the issue (Bohrer, AP/Alaska Journal of Commerce, 3/1/13).
  • Kansas*: Gov. Sam Brownback (R) has punted the decision on Medicaid expansion to Kansas' Republican-controlled legislature. Lawmakers have not reached consensus on the issue, and a state budget amendment that is expected to pass would prohibit Brownback from expanding the program without the support of the legislature (Celock, Huffington Post, 5/6/13).
  • Nebraska*: Gov. Dave Heineman (R) in a statement on his website on June 28 said, "As I have said repeatedly, if this unfunded Medicaid expansion is implemented, state aid to education and funding for the University of Nebraska will be cut or taxes will be increased. If some state senators want to increase taxes or cut education funding, I will oppose them." Heineman on July 11 sent a letter to state lawmakers saying the state could not afford the expansion, but he stopped short of saying that the state will not participate in the expansion, according to Reuters (Office of Gov. Heineman release, 6/28/12; Wisniewski, Reuters, 7/11/12).
  • Utah*: Gov. Gary Herbert (R) has not yet announced a decision on Medicaid expansion. He has asked the state health department to convene a workgroup to examine cost-effective alternatives that would expand coverage for low-income residents (Dobner, Salt Lake Tribune, 4/23/13).
  • Virginia*: Although Gov. Bob McDonnell (R) has not made an official announced on the Medicaid expansion, he has expressed opposition to the ACA provision, according to the Virginian-Pilot. However, the Pilot notes, the future of the state's Medicaid expansion will likely depend on the outcome of the November gubernatorial election: Democrat Terry McAuliffe support expansion, but Republican Ken Cuccinelli opposes it (Walker, Virginian-Pilot, 4/11/13).
  • Wyoming*: Gov. Matt Mead (R) on Nov. 30 recommended that Wyoming not participate in the Medicaid expansion, but added that his position could change in the future and urged "everyone to keep an open mind on this." The state legislature will make the final decision on whether to expand the program, the AP/Jackson Hole Daily reports (Brown, Wyoming Tribune Eagle, 12/1/12; Graham, AP/Jackson Hole Daily, 12/1/12).

LEANING TOWARD PARTICIPATING (1 states)

  • New York: Gov. Andrew Cuomo (D) in a statement on his website on June 28 said he was "pleased the Supreme Court upheld the [ACA]" and looks forward "to continuing to work together with the Obama administration to ensure accessible, quality care for all New Yorkers." On July 26, Danielle Holahan—project director for New York's health insurance exchange planning—said the state "largely meet[s] the federal required Medicaid levels already." Although Cuomo's office has not officially announced a decision, the Associated Press reported on Nov. 13 that New York will expand Medicaid (Office Gov. Cuomo release, 6/28/12; Grant, North Country Public Radio, 7/27/12).  

PARTICIPATING (26 states and the District of Columbia)

  • Arizona*: The Arizona Legislature on June 13 approved a fiscal year 2013-2014 budget blueprint that includes a plan to expand the state's Medicaid program under the Affordable Care Act. Gov. Jan Brewer (R)—who in January announced her support for the expansion, which would extend Medicaid coverage to about 300,000 additional state residents—is expected to the sign the budget measure (Viebeck, "Healthwatch," The Hill, 6/13; Schwartz, Reuters, 6/13/13; Christie/Silva, AP/Yahoo! News, 6/14/13).
  • California: Gov. Jerry Brown (D) in a statement on June 28 said the Supreme Court’s ruling “removes the last roadblock to fulfilling President Obama’s historic plan to bring health care to millions of uninsured citizens.” California got a head start on expanding its Medicaid program in November 2010 with its “Bridge to Reform” program, which aimed to bring at least two million uninsured Californians into Medicaid (Office of Gov. Brown release, 6/28/12; DeBord, “KPCC News,” KPCC, 6/28/12).
  • Colorado*: Gov. John Hickenlooper (D) on Jan. 3 announced that his state will participate in the expansion. In a news release, his office said the move would extend Medicaid coverage to about 160,000 low-income residents and save Colorado an estimated $280 million over 10 years without affecting the state's general fund (Stokols, KDVR, 1/3/13; Wyatt, AP/Denver Post, 1/3/13).
  • Connecticut: Gov. Dannel Malloy (D) was among the first governors to sign up for the Medicaid expansion after the ACA was enacted in March 2010. Soon after the Supreme Court ruling on June 28, Malloy said “it’s great … [and a] very important decision for the people of Connecticut. 500,000 people would have lost coverage if Republicans had their way” (Davis, WTNH, 6/28/12).
  • Delaware: Gov. Jack Markell (D) in a statement on June 28 said, "The Supreme Court's ruling enables Delaware to continue to implement provisions of the Patient Protection and Affordable Care Act to provide access to health care benefits for Delawareans." He added, "On the Medicaid front, Delaware already voluntarily expanded the state's Medicaid coverage program in 1996 to cover many Delawareans not previously covered" (Office of Gov. Markell release, 6/28/12).
  • District of Columbia: D.C. Mayor Vincent Gray (D) in a statement on June 28 said, "The District is not at risk of losing any Medicaid funding as a result of this ruling, because District officials have already begun implementation of the ACA's Medicaid-expansion provisions and will continue to implement the expansion" (Executive Office of the Mayor release, 6/28/12).
  • Florida*: Gov. Rick Scott (R) on Feb. 20 announced that the state will participate in the ACA’s Medicaid expansion, citing HHS’s conditional support for a waiver to shift most of the state’s Medicaid beneficiaries into a managed-care program. However, Scott said that Florida would only participate in the expansion for three years before reevaluating the decision. Supporters of the ACA heralded Florida’s shift as a major reversal; Scott mounted his successful campaign for governor in 2010, in part, by being one of the nation’s foremost critics of President Obama’s planned health reforms (Kennedy/Fineout, Associated Press, 2/20; Office of Gov. Scott release, 2/20/13).
  • Hawaii: Gov. Neil Abercrombie (D) in a statement on June 28 welcomed the Supreme Court's ruling and said the ACA "is our ally" in the effort to "support a health care system that ensures high quality, safety and sustainable costs." Pat McManaman, director of the state Department of Human Services, said Hawaii's Medicaid eligibility requirements in July would fall in line with the law' guidelines, meaning an additional 24,000 people will be eligible for the program by 2014 (Office of Gov. Abercrombie release, 6/28/12).
  • Illinois: Gov. Pat Quinn (D) on June 28 praised the court's decision and said he "will continue to work with President Obama to help working families get the healthcare coverage they need," including expanding Medicaid (Office of the Governor release, 6/28; Thomason, Rock River Times, 7/3/12; Ehley, Fiscal Times, 8/20/12).
  • Kentucky: Gov. Steve Beshear (D) on May 9 announced that Kentucky will participate in the Medicaid expansion. He called the decision "the single-most important decision in our lifetime for improving the health of Kentuckians" (Halladay, Louisville Courier-Journal, 5/9/13).
  • Maryland: Gov. Martin O'Malley (D) in a statement on June 28 said the Supreme Court's decision "gives considerable momentum to our health care reform efforts here in Maryland," adding that the state will move forward to implement the overhaul (Office of the Governor release, 6/28/12).
  • Massachusetts: Gov. Deval Patrick (D) in late June said Massachusetts is "an early expansion state as you know and we're expecting further resources from the federal government to sustain the experiment here in Massachusetts." Patrick called the ruling "good news for us" (Walker, YNN, 6/28/12).
  • Michigan*: Gov. Rick Snyder (R), in a statement released on Feb. 6, announced that his fiscal year 2014 budget proposal includes a plan to expand the state’s Medicaid program under the Affordable Care Act. The plan would extend Medicaid benefits to about 320,000 eligible residents. Snyder said the plan contains safeguards that will ensure the financial stability of the program and protect against changes in the government’s financial commitment to the expansion (Office of Gov. Snyder release, 2/6/13).
  • Minnesota: Gov. Mark Dayton (D) said in a statement on June 28, 2012, said, "Today's ruling will be met with relief by the Minnesotans whose lives have already been improved by this law." On Feb. 19, 2013, Dayton signed a bill authorizing expansion the state (AP/KARE 11, 2/19/13).
  • Missouri: Gov. Jay Nixon (D) on Nov. 29 announced that Missouri will participate in the Medicaid expansion. Nixon said he will include the expansion in the state budget proposal he submits to lawmakers. "We're not going to let politics get in the way of doing the best thing for our state," he said (Crisp, "Political Fix," St. Louis Post-Dispatch, 11/29/12).
  • Montana: Gov. Steve Bullock (D) in January 2013 said he planned to expand Medicaid in Montana. However, the state Legislature defeated all bills that would expand the state health care program in 2013. On the last day of the legislative session, Bullock said, "Let me be clear, we will reform healthcare in Montana. We will do it with or without the Legislature's help" (Johnson, Billings Gazette, 1/5/13; KXLH, 5/2/13).
  • Nevada*: Gov. Brian Sandoval (R) on Dec. 11 announced that the state will participate in the Medicaid expansion. "Though I have never liked the Affordable Care Act because of the individual mandate it places on citizens, the increased burden on businesses and concerns about access to health care, the law has been upheld by the Supreme Court," Sandoval said in a statement, adding, "As such, I am forced to accept it as today’s reality and I have decided to expand Nevada’s Medicaid coverage" (Damon, Las Vegas Sun, 12/11/12).
  • New Jersey: Gov. Chris Christie (R) in his Feb. 26 budget address announced that New Jersey will participate in the Medicaid expansion. The ACA provision is expected to extended Medicaid coverage to about 300,000 uninsured New Jersey residents (Cheney, Politico, 2/26/13).  
  • New Hampshire: Gov. Maggie Hassan (D) in her Feb. 14 budget address said that New Hampshire will opt into the ACA's Medicaid expansion because "it's a good deal...[that will] allow us to save money in existing state programs, while increasing state revenues." A state report estimates that the expansion will cost New Hampshire about $85 million through 2020, but will bring in $2.5 billion in federal funds and help reduce the number of uninsured residents from roughly 170,000 to 71,000 (Ramer, AP/Seacoastonline.com, 2/14)
  • New Mexico: Gov. Susana Martinez (R) on Jan. 9 announced that her state will participate in the Medicaid expansion, which potentially could extend health coverage to nearly 170,000 additional low-income uninsured residents. Martinez noted that contingency measures will be established if federal funding for the expansion diminishes, which would mean scaling back the expansion by dropping newly covered beneficiaries from the Medicaid rolls (Schirtzinger, Santa Fe Reporter, 1/9/13; Reichbach, New Mexico Telegram, 1/9/13).
  • North Dakota*: Gov. Jack Dalrymple (R) in January said the politics associated with the ACA should not prevent North Dakota from participating in the Medicaid expansion. In April 2013, he signed a legislation that expanded Medicaid in the state (AP/Prairie Business Magazine, 4/16/13).
  • Ohio*: Gov. John Kasich (R) on Feb. 4 announced that the state will be participating in the Medicaid expansion, the Cleveland Plain Dealer reports. He made the announcement in his two-year budget announcement, but warned that Ohio would "reverse this decision" if the federal government does not provide the funds it has pledged to the expansion (Tribble, Cleveland Plain Dealer, 2/4/13).
  • Oregon: Gov. John Kitzhaber (D) said on June 28 that he is confident that the Oregon Legislature will approve a state Medicaid decision. In an interview with the Oregonian just hours after the Supreme Court issued its ruling on the ACA, Kitzhaber said, "We'll make a decision on whether or not to expand the Medicaid program really based on, I think, the resources we have available in the general fund for that purpose going forward" (Budnick, Oregonian, 6/28/12).
  • Rhode Island: Gov. Lincoln Chaffee (I) in a statement on his website on June 28 said, "I have fully committed to ensuring Rhode Island is a national leader in implementing health reform whatever the Supreme Court decision, and this just reinforces that commitment." According to Steven Costantino, the state's secretary of health and human services, "The expansion is easy to do and makes sense." Moreover, on July 12, USA Today reported that Chaffee planned to participate in the expansion (Chaffee statement, 6/28/12; Wolf, USA Today, 7/12/12; Radnofsky et al., Wall Street Journal, 7/2/12).
  • Vermont: Gov. Peter Shumlin (D) on June 28 said Vermont's Medicaid program already meets the requirements under the health reform law's Medicaid expansion (Steimle, WCAX, 7/1/12).
  • Washington*: In an email responding to a query by American Health Line, Karina Shagren—a deputy communications director in Gov. Chris Gregoire's (D) administration—in early July said "the governor supports the Medicaid expansion—and Washington will move forward." U.S. Rep. Jay Inslee (D)—who supports the expansion—was elected governor on Nov. 6 (Shagren email, 7/5/12; Washington Secretary of State website, 11/12/12).
  • West Virginia: Gov. Earl Ray Tomblin (D) on May 2 announced that West Virginia will participate in the Medicaid expansion. "At the end of the day, we have weighed the options and believe expanding Medicaid is the best choice for West Virginia," he said (Boucher, Charleston Daily Mail, 5/2/13).

Participating through an alternative expansion model (4 states)

  • Arkansas: Gov. Mike Beebe (D) in February announced that HHS had approved a plan to expand coverage to expansion-eligible residents through the health information exchanges. As with the Medicaid expansion, the federal government has agreed to cover 100% of the premiums for the first three years and 90% of the premiums after 2020 (Ramsey, "Arkansas Blog," Arkansas Times, 2/26/13).
  • Indiana*: Gov. Mike Pence (R) has proposed a plan to expand coverage to expansion-eligible residents through Indiana's Healthy Indian Plan (Sikich, Indianapolis Star, 4/1/13).  
  • Iowa*: Gov. Terry Branstad (R) on May 22 said he will support a compromise deal that would extend health insurance coverage to 150,000 low-income state residents through a new state plan or through the state's insurance exchange. The Senate approved the compromise deal on May 22, and the House approved it on May 23 (Lucey, AP/Modern Healthcare, 5/23/13; Petroski, Des Moines Register, 5/24/13).
  • Tennessee: Gov. Bill Haslam (R) on March 27 announced in an address to a joint session of the General Assembly that the state will not participate in the Medicaid expansion. Instead, he said he favors an alternative option, under which the state would use federal funds to shift Medicaid-eligible residents into private health plans (Humphrey, Knoxville News Sentinel, 3/27/2013; Goodnough, New York Times, 3/27/13).


Member asks: How do you compensate physicians in a Medical Home?

Look beyond rewarding productivity and, instead, incent alignment with your institution's goals

November 09, 2012

I'm looking to change our current physician compensation models for employed physicians away from a 100% RVU productivity model. As we move more toward Patient Centered Medical Homes within our practices, I need to develop a compensation model that encourages our primary care physicians to collaborate in a team-based approach to care that utilizes physician assistants, nurse practitioners, and other providers. What guidance can The Advisory Board offer?

Here's our immediate response: It's critical not to get stuck in the old ways of fee-for-service where such a model doesn't apply.

That's especially true in many service lines where compensation structures are increasingly moving toward pay-for-performance models, particularly as hospitals transform how they deliver care—such as through the Patient-Centered Medical Home.

We think it's time for many hospitals to look beyond rewarding productivity and, instead, focus on incorporating incentives that align with your institution's broader goals.

Here are some resources that should prove helpful. The Medical Group Strategy Council's Next-Generation Physician Compensation study details structural components, specialty-specific approaches, and strategic lessons to help you establish an incentive-driven compensation model.

    Financial Leadership Council and Health Care Advisory Board members can check out the webconference or podcast discussing the study.

In addition, our study on Transforming Primary Care lays out compensation strategies that incent collaboration, performance, and better care economics. For guidance on how hospital leaders can modify physician compensation structures in order to secure physician buy-in for team goals, see these five lessons on crafting strategy-aligned PCP compensation and leveraging payment incentives to support practice transformation.

    Check out the full book of tactics on transforming your institution's primary care strategy and navigating the transition from fee-for-service to accountable care.


Daily roundup: Nov. 9, 2012

Bite-sized hospital and health industry news

November 09, 2012

  • California: Voters in El Monte and Richmond on Tuesday rejected proposals to impose the nation's first penny-per-ounce taxes on sodas and sugary drinks. Altogether, 76.8% of El Monte voters and 66.9% of Richmond voters rejected the proposal (Baertlein, Reuters, 11/7).

  • Florida: Bayfront Medical Center in St. Petersburg and its clinics will become for-profit facilities in early 2013 through a joint venture with Naples-based Health Management Associates (HMA). For-profit HMA will own an 80% stake in the joint venture, while Bayfront will retain a 20% stake (Selvam, Modern Healthcare, 10/25 [subscription required]).

  • Maine: Eastern Maine Medical Center—which serves more than 40% of the state's population—will expand and modernize its Bangor facility. The $250 million project will expand bed capacity from 350 to 411 and update surgery, cardiac, woman, and infant services. The hospital hopes to raise the funds for the project by April and complete the project by 2017 (AP/Atlanta Journal-Constitution, 11/8).