Policy Roundtable Abstracts - AcademyHealth

Policy Roundtables 

A States-Eye View of Health Reform Implementation 

Organizer/Moderator: Alan Weil 

Sunday, June 12 * 9:00 a.m.–10:30 a.m. 

Panelists: Jane Beyer, J.D., Washington State House 

of Representatives; Carol Steckel, M.P.H., State of 

Louisiana; Christopher Koller, M.A., Department of 

Business Regulation; William Hazel, M.D.; Office of the 

Governor 

Roundtable Summary: States have a primary role 

implementing the Affordable Care Act. All three pillars of 

the approach to expanding coverage—building a health 

insurance exchange where people can purchase 

coverage using their federal tax credit, regulating private 

insurance so products are available and affordable, and 

simplifying and expanding Medicaid eligibility—rely upon 

functions performed at the state level. Many of the 

delivery system reform, public health, data collection, 

and other initiatives also rely upon state leadership. 

States are actively engaged in implementation, but they 

are also at the forefront of efforts to block 

implementation through legal and political challenges to 

the law. 

This policy roundtable will bring together leaders 

in state health policy who will discuss their experience to 

date implementing the law. They will describe the steps 

they have taken, their positive and negative views of and 

experiences with the law, and discuss how uncertainty 

affects their work. 

This session is proposed as a roundtable 

discussion with four questions posed sequentially to 

each of the panelists. This format avoids individual 

speeches, is more engaging for the audience, and 

enables panelists and the moderator to refer to each 

others’ responses and build upon them. 

Alan Weil, Executive Director of the National 

Academy for State Health Policy, will moderate the 

panel. He is a national expert on state health policy and 

the implementation of health reform at the state level. 

He will open the session with an overview of the status 

of state implementation efforts. In his remarks he will 

draw upon and summarize data NASHP is collecting that 

captures state implementation activities at a very high 

level of detail. 

Four panelists will participate: Jane Beyer, 

Senior Counsel, Democratic Caucus Staff, Washington 

State House of Representatives; William Hazel, Jr., 

M.D., Secretary of the Department of Health and Human 

Resources, Commonwealth of Virginia; Christopher 

Koller, Health Insurance Commissioner, State of Rhode 

Island; and Carol Steckel, Executive Director, Health 

Care Reform, Louisiana Department of Health and 

Hospitals (and former Commissioner of the Alabama 

Medicaid Agency and former president of the National 

Association of State Medicaid Directors). 

These panelists represent states with a variety 

of political perspectives on the law. Their expertise 

spans Medicaid, insurance, and public health. They 

represent both the executive and legislative branches. 

These panelists are highly regarded by their peers and 

are excellent presenters. 

The session will unfold with the moderator 

asking one question at a time of each of the four 

panelists. The questions are: 

1. How has the enactment of the ACA affected your 

work This question provides each panelist with the 

opportunity to briefly introduce him or herself and situate 

their knowledge and experience within the broader 

context of state health policy. 

2. What promise for improvement within the ACA is 

most salient for you What are you doing to help 

achieve that promise 

3. What risks for negative consequences as a result of 

the ACA most concern you What are you doing to help 

avoid those consequences 

4. How is the political uncertainty at the federal level 

(and at your state level if relevant) affecting your 

approach to implementation 

This panel replicates a plenary panel session at 

NASHP’s Annual Meeting held in October 2010. The 

session received a “good” or “excellent” rating (4 or 5 on 

a 5 point scale) from more than 90% of attendees. One 

staff person from a national health care foundation called 

it the best single session he had ever heard on health 

reform implementation. While the panelists will be the 

same (less one person who is not available for the 

ARM), the passage of more than 9 months since that 

conference assures that the material will be fresh. The 

varied perspectives of the four panelists assure that the 

answers to each of the four questions will differ from 

each other (as occurred at this panel at the NASHP 

conference). 

This session will provide an outstanding 

introduction to state issues related to implementation of 

health reform to health services researchers, many of 

whom (particularly those earlier in their career) have 

limited connections and access to state-level 

policymakers.

International Insights on Strategies to Disinvest in 

Low-Value Healthcare 

Organizer/Moderator: Sarah Garner 

Sunday, June 12 * 9:00 a.m.–10:30 a.m. 

Panelists: Alan Garber, M.D.,Ph.D., Stanford 

University; Peter Neumann, Sc.D., Tufts Medical 

Center; Adam Elshaug, MPH Ph.D, Agency for 

Healthcare Research and Quality; Mark Fendrick, MD; 

University of Michigan 

Roundtable Summary: The substantial overuse, under 

use, and misuse of existing medical care is well 

documented. A recent Commonwealth Fund survey 

indicated that 20% of U.S. community respondents 

perceived that in the last 2 years a doctor had 

recommended treatment they felt had little or no benefit. 

However, to date, international comparative 

effectiveness research (CER) and health technology 

assessment efforts have primarily focused on new and 

emerging technologies and practices. There has been 

very little attention on existing – legacy – technologies 

that were introduced prior to relatively new stringent 

assessment methodologies. Additionally, procedures or 

technologies that initially met criteria for safety, 

effectiveness (and in many jurisdictions cost 

effectiveness) may suffer from ‘indication creep’, 

whereby the indications for their use are altered beyond 

those originally considered. This may result in the 

ineffective use of otherwise effective technologies, 

resulting in ineffective care and inappropriate resource 

allocation. 

There have been a number of historical attempts 

to identify and ‘disinvest’ from existing low-value 

healthcare, including in the USA: some date back to the 

1970s. Most have however not achieved the desired 

outcome but for a number of different reasons. Including 

a focus on disinvestment from ‘softer’ technologies that 

are less politically sensitive for example cosmetic 

surgery. Also, attempts were met with criticism due to 

perceived process flaws and general resistance from 

medical lobby groups and manufacturers. These 

experiences now provide important historical insights 

regarding design and implementation of disinvestment 

strategies and a basis upon which to improve. 

The rising costs of healthcare coupled with the 

economic crisis have led to current initiatives in 

Australia, the United Kingdom, Canada and Spain. 

Interest in the US is focused on ‘value-based’ insurance 

design as a mechanism for controlling rising healthcare 

costs and promoting better healthcare outcomes. Lowvalue 

VBID, to discourage the use of low-value 

healthcare is being explored and challenges have been 

identified. A Federal request for information on the use 

of VBID in preventative services has just been released. 

While there is a strong economic imperative for 

this work for the sake of health system sustainability; 

most important, arguably, are the ethical imperative to 

patients and the best-practice imperative for purchasers 

and providers to deliver high-quality healthcare. A 

comprehensive policy approach, therefore, also entails 

considerations for how to reinvest or redistribute freed 

resources toward healthcare practices, programs and 

technologies that allow greater gains in quality and 

efficiency. 

The challenges of reducing wasteful spending in 

health care are shared internationally, but the UK and 

Australia have set course for reform into the near-term. 

Policymakers must transform the vague concept of 

‘waste’ into a clearly defined set of targets that can be 

more precisely addressed with research and policy.). 

This policy roundtable will bring together experts 

from the US, Australia and UK to discuss the 

experiences and challenges with current initiatives and 

highlight the lessons learnt. The Australian and UK 

panelists have gained insight into the additional 

difficulties with such an agenda in the US through their 

Harkness Fellowships, which have focused on low-value 

technologies. The discussion will explore the experience 

in Australasia, Canada, Europe and North America and 

highlight lessons. It will also consider the challenges for 

introducing such a policy in the US context. The 

opportunities provided by the burgeoning CER agenda 

are considered. Solutions are proposed for discussion. 

State Exchange on Health Insurance Exchanges 

Organizer/Moderator: Anne Gauthier 

Sunday, June 12 * 11:00 a.m.–12:30 p.m. 

Panelists: Kimberly Belche, Board member, California 

Health Benefits Exchange; Joan Henneberry, Director, 

Colorado's Exchange Planning grant; Bruce 

Greenstein, Secretary, Louisiana's Department of 

Health and Hospitals; Jane Cline, West Virginia's 

Insurance Commissioner 

Roundtable Summary: BACKGROUND The Patient 

Protection and Affordable Care Act (ACA) calls for the 

creation of American Health Benefit Exchanges, which 

are expected to be the source of health insurance 

coverage for 24 million Americans by 2019. These 

exchanges will provide the largest source of new health 

coverage and will be the mechanism by which $350 

billion worth of federal subsidies for coverage will be 

extended to moderate income families and individuals 

between 2014 and 2019. Successful development and 

operation of the exchanges is critical to achieving the 

promise of the ACA. The federal law lays out an 

ambitious vision for health insurance exchanges to 

perform numerous functions that do not currently exist, 

and an equally ambitious timetable for their 

development. Although states have the option to let the 

federal government run exchanges for them, few are 

likely to make this choice given the importance of 

coordinating exchanges with all other aspects of health 

care, such as Medicaid, insurance regulation, and 

population health. Thus, the success or failure of 

national health reform depends heavily upon states’ 

ability to build and operate effective exchanges.

PROPOSED PANEL The panel will feature four 

leaders from four very different states: Kimberly Belshe 

(CA), Jane Cline (WV), Bruce Greenstein (LA), and Joan 

Henneberry (CO). It will be moderated by Anne Gauthier 

(NASHP), who will present a short overview of the 

critical policy choices states are facing in creating 

exchanges. She will then conduct an interactive 

discussion among these state policymakers, covering 

their diverse approaches in addressing the following key 

policy issues in exchange design and implementation: 

1)Development of an overall vision for the exchange: To 

best take advantage of the tools and flexibility states 

have been given through ACA in creating their 

exchange, they must first decide what policy goals they 

may wish to accomplish with their exchange. An 

effective exchange could give meaning to the 

affordability standards in the federal law, and could be a 

force for efficiency and an orientation toward quality in 

the insurance and health delivery sectors. However, 

such outcomes do not arise naturally or automatically 

from the creation of an exchange. States must be active 

and at times aggressive in administering the exchange. 

2) Exchange governance structure: The exchange 

governance structure – whether a state agency, a quasipublic 

agency, or an independent not-for-profit – will 

have an important impact on which voices are heard 

most clearly when key decisions are made. Furthermore, 

the location of a state’s governance structure could have 

important implications for how nimble an exchange might 

be, the power it will have in leveraging contracts with 

both health plans and IT vendors, and how effectively it 

can monitor the exchange appeals process. 3) Eligibility 

and enrollment: An exchange must be capable of 

determining whether a given individual is eligible a 

subsidy or is eligible for other programs such Medicaid 

and CHIP. States will need to think about how their 

populations might transition between programs as their 

eligibility for various programs changes over time in 

order to ensure the receipt of continuous care. Many 

states need to consider the role of county workers and 

the interface with social service programs. And the vision 

of a first-class customer experience, with as much 

reliance on electronic interface as possible, presents 

numerous challenges and design options for states. How 

the exchange handles transitions of eligibility between 

employer-sponsored coverage, exchange coverage and 

Medicaid will determine whether consumers received 

continuous care from their providers as their income 

varies. 4 )Tools to promote affordability: How the state 

selects participating health plans will affect how 

effectively market forces will be brought to bear to 

improve quality and reduce costs. States may span the 

spectrum on how involved they may be in regulating plan 

participation within the exchange. Some may choose to 

have their exchange structured as an open marketplace 

where all federally qualified health plans may compete 

for their market share. On the other side of the spectrum, 

states may leverage their capacity as active purchasers 

of health to encourage or reward high value plans. 

States will also need to consider implementing riskadjustment 

mechanisms and controls for adverse 

selection, so that insurance markets will not only be 

affordable for even those high health needs, but also 

sustainable into the future. 5) Stakeholder engagement: 

The decisions that states make about exchanges are 

important to a myriad of stakeholders including 

consumers, health plans, employers, and health care 

providers. Each is likely to have differing views regarding 

exchange operations and goals, as well as differing 

understanding of how various design choices will affect 

them and the health care delivery system. It is important 

for states to identify their key stakeholders as well as the 

best ways to engage them in order to gain support and 

perspective on exchange development. 

PANELISTS The panelists bring rich 

perspectives and experience to these issues. Anne 

Gauthier currently directs several projects at the 

forefront of supporting states developing exchanges and 

is one of NASHP’s lead staff on interactions with federal 

officials on reform implementation. Through her work 

under HRSA’s State Health Access Program (SHAP), 

she is working with 13 states to expand coverage and 

implement reform and led a national webinar with over 

500 attendees in a format similar to that proposed here. 

She has also been an active participant in the Center for 

Consumer Information and Insurance Oversight’s 

(formerly OCIIO) early efforts to increase awareness of 

critical exchange issues, including, a presentation on 

exchange governance structures on OCIIO’s Technical 

Assistance Webinar Series in November 2010. She is 

also the project director of the recently launched State 

Health Exchange Leadership Network, a peer-to-peer 

learning community for state officials working on 

exchange implementation. In December 2010, Kimberly 

Belshé was appointed to the board of California’s newly 

established Health Benefits Exchange. Previously, Ms. 

Belshé served as Secretary of California’s Health and 

Human Service Agency, playing a critical role in the 

state’s recent passage of exchange enacting legislation. 

Additionally, she serves as chair of the Governor’s Task 

Force on Health Care Reform Implementation. Jane L. 

Cline is West Virginia’s Insurance Commissioner. In 

addition, Ms. Cline serves as President of the National 

Association of Insurance Commissioners (NAIC), as well 

as Chair of the Management Committee of the Interstate 

Insurance Product Regulation Commission. In her role at 

the NAIC, she has led the development of model 

legislation to implement the Affordable Care Act. Bruce 

Greenstein is Secretary of Louisiana’s largest agency, 

the Department of Health and Hospitals. Secretary 

Greenstein manages a budget of over $8 billion and will 

provide oversight and services in mental health, public 

health, emergency preparedness, Medicaid, health 

information technology, addictive disorders and aging 

services. Joan Henneberry was appointed in late 2010 to 

lead Colorado’s exchange efforts under the new 

governor. She recently left her position under the 

previous governor as Executive Director for Colorado’s 

Department of Health Care Policy and Financing and as 

senior health policy advisor to the Governor, developing 

and implementing health reform policies and initiatives. 

She also spent seven years at the National Governors 

Association providing consultation to states on health

care services and financing, cost containment, and 

emerging policy issues. 

IMPACT These states vary by geography, 

political and policy environments, and health care 

markets, but the individuals are all leaders in driving 

health policy broadly and in thinking through the issues 

around developing an exchange. They represent 

different positions in state government. They have all 

agreed to participate on the panel, but given their key 

roles as policymakers, their availability is subject to 

change. Clearly, they are forging new ground, and 

through this panel they will provide valuable evidence 

and expertise on early lessons learned that will go far to 

assist all states and policymakers as they move forward 

with implementation of health reform. 

Identifying, Monitoring, and Evaluating Promising 

Payment and Delivery System Innovations 

Organizer/Moderator: Stuart Guterman 

Sunday, June 12 * 4:30 p.m.–6:00 p.m. 

Panelists: Marsha Gold, Sc.D.,M.P.H., Mathematica 

Policy Research; Lawrence PCasalino, M.D.,Ph.D., 

Weill Cornell Medical College; Randall Brown, Ph.D., 

Mathematica Policy Research, Inc.; Paul Wallace, M.D.; 

The Permanente Federation, LLC. 

Roundtable Summary: The national health reform 

legislation includes a multitude of new demonstrations 

and pilots to cut costs and increase quality in our health 

care system. As Atul Gawande notes in his recent 

article, “Testing, Testing”, health reform legislation 

“contains a test of almost every approach that leading 

healthcare experts have suggested” for improving health 

care financing and delivery. 

One of the principal reasons for why we have 

yet to implement the many ideas being proposed to 

reform the current delivery system is that we lack 

sufficient information on how the proposed 

organizational and financing reforms would work in 

practice. To address this knowledge gap, the Patient 

Protection and Affordable Care Act signed into law in 

March 2010 establishes Center for Medicare and 

Medicaid Innovation (CMMI) within the Centers for 

Medicare and Medicaid Services (CMS). This new 

center will facilitate the development of pilot projects and 

propose strategies to disseminate and promote the 

uptake of successful delivery system reforms. As Stuart 

Altman and Robert Mechanic note in a recent article in 

the New England Journal of Medicine, a key difference 

of demonstrations developed under the Innovation 

Center from previous Medicare-sponsored 

demonstrations is the Secretary of Health and Human 

Services’ new authority to expand pilot programs that 

successfully reduce costs or improve the quality of care. 

In a recent analysis of the prior challenges that 

have arisen when demonstration projects were used to 

inform policy, Stuart Guterman and Heather Drake of the 

Commonwealth Fund note that prior demonstration 

programs were hampered in their ability to move from 

testing innovations to their broader application in 

practice due to “limitations in the methodology and data 

available to conduct comprehensive evaluations of 

demonstrations projects” and “insufficient resources for 

developing, implementing, monitoring, and evaluating 

demonstration projects.” In this session, a panel of 

experts with a variety of perspectives will address the 

problems identified with moving from the pilot or 

demonstration phase to broader program 

implementation, including limitations in methods for 

assessing and evaluating promising interventions. This 

session will include a presentation by Marsha Gold of a 

paper she is preparing on this topic, and a panel 

discussion of the methodological issues related to 

identifying, monitoring, and evaluating promising 

payment and delivery system innovations, and the 

contribution that the health services research community 

can make to this process. 

The panel will assess and seek to identify 

solutions on the following five critical areas: 

1) Criteria used to prioritize innovations that merit an 

investment in evaluation and scale up 

2) Best practices in the design and implementation of 

the pilot intervention itself, 

3) Best practices in the design of evaluations 

4) Criteria for judging success 

5) Strategies for scaling up successful pilots 

As Guterman and Drake conclude in their paper, the 

success of the Center will depend upon its ability “to 

develop reliable methods for monitoring and evaluating 

pilot projects and analyzing the applicability of various 

aspects of individual pilots for implementation in different 

combinations and settings.” Anticipating that 

policymakers will need clear direction for meeting the 

ambitious goals set for the new CMS Innovation Center, 

this project will seek to resolve the inherent conflict 

between making quick assessments of promising 

innovations and the need to provide compelling evidence 

that the project would improve quality and or reduce 

cost. 

Potential topics for the panel members to discuss 

include the following: 

What criteria should be considered in selecting an 

innovation that merits evaluation 

What do we need to keep in mind about the 

evaluation design and methods For example: 

Should evaluation criteria include both quality and 

cost measures 

o How is context considered in the 

o 

design 

How do we move beyond randomized 

trials to explore relationships of 

causality 

What constitutes success and when and how should 

pilots be scaled up 

How do we turn what gets learned from pilots into 

system-wide policy 

The panel moderator and leader of the discussion will 

be: Stuart Guterman, vice president for Payment and 

System Reform at The Commonwealth Fund and 

executive director of the Fund’s Commission on a High 

Performance Health System. The Commission on a High

Performance Health System is charged with promoting a 

high-performing health system that provides all 

Americans with affordable access to high-quality, safe 

care while maximizing efficiency in its delivery and 

administration. The Program on Payment and System 

Reform supports the analysis and development of 

payment policy options that include incentives to 

improve the effectiveness and efficiency of health care 

delivery while curbing growth in health spending. 

Previously, he directed the Centers for Medicare and 

Medicaid Services Office of Research, Development, 

and Information. 

The panelists will include: Marsha Gold, Ph.D., a 

senior fellow at Mathematica Policy Research in 

Washington, DC. She is a nationally known expert on 

health care delivery and financing, especially in 

managed care and public programs such as Medicare 

and Medicaid. Her expertise covers trends in the 

organization and financing of medical care and its 

implications for access to care. 

Lawrence Casalino, M.D., Ph.D., Chief of the 

Division of Outcomes and Effectiveness Research and 

The Livingston Farrand Associate Professor of Public 

Health in the Department of Public Health at Weill 

Cornell Medical College. His research focuses on the 

organization of physician and hospital practice. 

Randall Brown, Ph.D., an expert in health care 

policy issues related to care for the chronically ill, longterm 

care, managed care, and quality of care. He is 

nationally known for his evaluations of care coordination 

and disease management programs for Medicare 

beneficiaries, as well as studies of long-term care issues 

and Medicare managed care. 

Paul Wallace, M.D., medical director for Health 

and Productivity Management Programs at Permanente 

Federation and senior advisor for the Care Management 

Institute (CMI) and Avivia Health, the Kaiser Permanente 

disease management company established in 2005. 

Since 1997, his full-time focus has been administrative 

and development endeavors in the application of 

evidence-based medicine within disease management, 

measurement of clinical performance, technology 

assessment, and use of the electronic medical record. 

The Ongoing Politics of Health Reform 

Organizer/Moderator: Walter Zelman 

Monday, June 13 * 8:00 a.m.–9:30 a.m. 

Panelists: Walter Zelman, PhD, California State 

University, Los Angeles; Mollyanne Brodie, PhD, 

Kaiser Family Foundation; Len Nichols, PhD, George 

Mason University; Alan Weil, JD; National Academy for 

State Health Policy 

Roundtable Summary: I propose to offer a policy panel 

focused on the ongoing politics of health reform. The 

panel will explore the political elements of the ongoing 

debate over health reform and the efforts of some to 

repeal or alter it and others to defend it and move it 

forward. While reform has passed it is clear that the 

political struggle around it goes on, with a variety of 

efforts underway to undermine or repeal it. While few 

expect reform to be repealed in the near term, efforts at 

the state and national levels still threaten its 

implementation and conceivably, the election of 2012 

could be, in large part, a referendum on reform. 

Specifically, the panel will look at such factors as 

public opinion, support and opposition of activities of 

various interest groups, positions of key political and 

partisan organizations, and messaging and other 

strategies being deployed by reform supporters and 

opponents. It will also review those health reform 

constructs that are engendering the most controversy 

and how the different stakeholder and political 

organizations are addressing those issues both in terms 

of content and message. 

The panel will focus on both federal and state 

government activities. At the federal level the panel will 

review political activity in both Congressional and 

regulatory arenas. The purpose here is not to explore 

the substantive proposals at issue. It is assumed that 

those will be thoroughly addressed by other ARM 

sessions. The purpose here is to look at the political side 

of the reform equation: interest group efforts, public 

mobilization, electoral considerations, media and 

messaging strategies, etc. Specific policy areas may be 

addressed, but primarily to the extent that they are being 

highlighted by reform opponents or supporters as part of 

the larger reform debate, and to the extent that those 

policy areas may still be open to a larger negotiation on 

reform policy. Looking ahead, the panel will discuss the 

role the ongoing health reform debate may assume in 

2012 elections. 

Regarding health reform politics in the states, 

the panel will focus primarily on the efforts of the states 

to establish the health reform infrastructure necessary to 

implement reform. Most specifically the panel will review 

Exchange-focused discussions and activities in the 

different states. It will review how political leadership in 

the various states –especially governors and 

legislators—are approaching the exchange issue. E.g. 

are Republican governors taking the view that while they 

oppose reform and may fight it in court proceedings they 

are still going to support creating the exchange 

infrastructure should their efforts to roll back reform fail 

Or, are at least some taking the view that the process of 

creating (or failing to create exchanges) is part and 

parcel of the larger effort to undermine reform To this 

end, an effort will be made (data permitting) to compare 

the progress being made on the creation of exchanges 

in different political environments. As will be the case 

with a review of national government activities, the panel 

will look at the state level involvement of stakeholder 

groups, political leadership, and messaging strategies. 

Four individuals have agreed to participate in the 

panel discussion. (One more may be added) All have 

been deeply involved in the reform process in one way 

or another. All are unquestioned experts in the both the 

policy and politics of health reform. All have written 

extensively on the subject, as researchers and policy 

analysts. All are continuing that involvement and that 

research.

Moderator Walter Zelman is Chair of the 

Department of Health Science , California State 

University 

MollyAnn Brodie is Director of Public Opinion and 

Survey Research at the Kaiser Family Foundation. 

Her focus on the panel will be on matters of public 

opinion 

Len Nichols is the Director of the Center for Health 

Policy Research and Ethics at George Mason 

University. He will focus on national developments, 

especially Congressional activity around health 

reform opposition or support 

Alan Weil is Executive Director of the National 

Academy for State Health Policy. Alan will provide 

particular insight into the efforts of states to 

establish the infrastructure for health reform and 

the politics of those efforts. 

The proposed panel will be a roundtable discussion in 

which the moderator will pose questions to panelists. 

Initial questions will be asked of individuals, drawing out 

their views on the particular expertise they bring to the 

subject. Additional questions will be intended inspire 

interaction among the panelists. Panelists will be able to 

use slides in answering the questions. Panelists will be 

given most of the questions in advance so that they may 

prepare background information that will be available, 

via slides, for sharing with the audience. Audience 

participation will be encouraged. 

Walter Zelman has moderated several similar panels 

at recent ARM conferences. They used similar formats 

of roundtable discussion and panel interaction to explore 

political themes and issues in health reform. According 

to ARM reports and feedback these discussions were 

very well received. 

Achieving Better Population Health, Better Patient 

Experience, and Reducing Cost: Learning from 

Variations in Health and Healthcare 

Organizer/Moderator: David Radley 

Monday, June 13 * 3:00 p.m.–4:30 p.m. 

Panelists: Michael Chernew, Ph.D., Harvard Medical 

School; Elliott Fisher, M.D., M.P.H., Dartmouth Medical 

School; David Kindig, M.D., Ph.D., University of 

Wisconsin, Madison; Cathy Schoen, Ph.D.; The 

Commonwealth Fund 

Roundtable Summary: A robust body of evidence 

describes unwarranted variations in the healthcare 

individuals receive—identifying duplication of services 

and the receipt of inappropriate or unsafe care that drive 

up costs and put patients at risk. These findings highlight 

an important chasm between healthcare spending and 

consistent receipt of high-quality healthcare. Other 

research points out wide variations in the underlying 

health of local populations and calls attention to the 

importance of social and environmental determinants of 

health. Rising health care costs stress household, 

business and public budgets. Efforts to slow cost growth 

while improving health outcomes have risen to the top of 

the national and local health policy agenda. 

Variation in health and healthcare motivates 

quality improvement initiatives locally and systematic 

reform efforts at regional, state, and national levels. 

Such efforts have, to date, focused primarily on cost 

control and healthcare quality, often targeting narrowly 

defined patient populations or specific processes of care. 

With rare exception, improvement efforts generally lack 

the explicit goal of improving population health. 

Recognizing that health system improvement 

efforts require a multidimensional approach, the Institute 

for Healthcare Improvement (IHI) developed the Triple 

Aim initiative. Its goal is to encourage new system 

designs that simultaneously improve the health of the 

population, enhance the patient experience when 

healthcare services are used (including access, quality, 

and reliability), and to reduce—or control—the per capita 

cost of healthcare. By pursuing these three objectives in 

concert, healthcare systems can identify and more easily 

address problems that impede care coordination, lead to 

overuse and inefficiency, and direct resources to 

activities that have the greatest impact on health. 

Without balancing the three objectives of the Triple Aim, 

improvement and reform efforts may enhance quality, 

but at the expense of cost, or conversely, reduce cost 

while alienating patients. 

The ability to accurately and effectively measure 

each dimension of IHI’s Triple Aim is fundamental to the 

success of efforts to improve health system 

performance. This roundtable will discuss regional 

variations across each of the Triple Aim’s three 

dimensions. Special attention will be given to 

measurement considerations including the definition of 

system-level metrics, the availability of data that allows 

local comparisons against standardized inter-regional 

benchmarks, and the practical action-oriented use of 

data by local improvement integrators. In addition to 

metrics, roundtable panelists will discuss efforts to 

improve performance and the potential of approaches 

that focus on the triple aim of improving population 

health, care experiences and slowing cost growth. 

This roundtable discussion will be facilitated by 

Cathy Schoen, Senior Vice President for Policy, 

Research and Evaluation at The Commonwealth Fund, 

and one of the nation’s foremost experts in health policy 

appraisal. The panelists will launch an interactive 

discussion with the audience by each offering a short 

presentation drawing from their own knowledge and 

experience, using evidence from scientific studies, and 

current reform initiatives. The roundtable will begin with 

three of the panelists each sharing their perspective and 

measurement expertise in one dimension of the IHI’s 

Triple Aim—cost, the patient experience, and population 

health; the fourth panelist will discuss the action-oriented 

use of locally representative data to evaluate ongoing 

improvement initiatives. Audience members will then be 

engaged and asked to share their experience and the 

challenges they’ve faced measuring the impact of 

improvement in their own work, with the panel providing 

direct response to audience questions.

COST: Panelist Michael Chernew, PhD, from 

the Harvard Medical School will summarize his research 

on differing mechanisms to control healthcare spending 

growth while maintaining quality of care. Specifically, Dr. 

Chernew will highlight the challenges in collecting and 

standardizing cost data, discuss consumer incentives 

and value-based insurance design, and discuss how 

alternative payment models may align with the goals of 

IHI’s Triple Aim initiative. 

PATIENT EXPERIENCE: Panelist Elliott Fisher, 

MD from The Dartmouth Institute for Health Policy and 

Clinical Practice will briefly summarize the many lessons 

learned from three decades of variation research on 

patient outcomes and the patient experience. Dr. Fisher 

will give special attention to his landmark findings 

illustrating the disconnect between utilization volume and 

patient outcomes and the implications of unwarranted 

variations for patient safety and quality of care. He will 

conclude by discussing the potential of newly proposed 

initiatives to stimulate and support accountable delivery 

systems. 

POPULATION HEALTH: Panelist David Kindig, 

MD, PhD from the University of Wisconsin School of 

Medicine and Public Health will draw on his experience 

as co-director of CountyHealthRankings.ORG and the 

Mobilizing Action Toward Community Health (MATCH) 

project to discuss measurement of the social and 

environmental determents of health and their interaction 

with the healthcare system when quantifying the health 

of a population. He will also discuss the synergies and 

conflicts between conceptualizations of population health 

in the Triple Aim and MATCH models. 

PERFORMANCE MEASUREMENT: Panelist 

David Radley, PhD, is a measurement expert at the 

Institute for Healthcare Improvement and The 

Commonwealth Fund. Dr. Radley will draw on real-world 

examples (based on IHI collaborations with 

organizations currently pursuing improvement activities 

around the Triple Aim concepts) to discuss the unique 

challenges of simultaneously measuring performance 

across the three dimensions of the Triple Aim. He will 

describe his experience creating locally representative 

health system performance scorecards and will discuss 

the collection and use of systematically defined ‘local’ 

data to measure health system performance and 

motivate improvement. 

Healthcare system design and re-design should 

simultaneously aim to improve population health, 

enhance the patient experience, and reduce per capita 

healthcare spending. Proposed and legislated 

healthcare reforms can go a long way to achieving better 

performance on each of these dimensions. However, 

success also requires the development of data systems 

and carefully defined metrics that are accessible to 

evaluators, a recognition of and commitment to 

addressing the community-based determinants of 

population health, a common purpose and the adoption 

of mechanisms to control per capita cost, and most 

importantly, engagement from motivated local entities 

that are willing and able to support a defined population 

and ensure the existence of systems that align 

healthcare services with individual’s needs. 

Reducing Readmissions: Practice, Payment, or Pot 

of Coffee 

Organizer/Moderator: Amy Boutwell 


Panelists: Arnold Epstein, M.D., M.A., Harvard 

University; Jane Brock, M.D., M.P.H., Colorado 

Foundation for Medical Care; John Young, Centers for 

Medicaid and Medicare Services 

Roundtable Summary: Hospital readmissions are of 

major policy interest because they occur frequently, vary 

across settings, and offer the potential to simultaneously 

reduce spending and improve patient outcomes. In 

recent years clinical leaders and policy makers have 

tried many approaches to reducing readmissions. Some 

of these efforts are directed at quality of care during and 

after discharge and focus on improving discharge 

planning, assuring timely follow up and providing better 

transitional care. Other efforts focus more generally on 

ambulatory care and seek to provide better disease 

management and improved coordination of care. More 

recently there has been interest in changing the 

underlying incentives for using hospital services. The 

Center for Medicare and Medicaid Services is planning 

to initiate programs to "bundle" payment for all the 

services around a hospitalization, and to provide shared 

savings for accountable care organizations. This Policy 

Roundtable will bring together policy makers, clinical 

leaders and researchers to describe and discuss 

ongoing and future efforts to reduce unnecessary 

readmissions. The four speakers and the topics that they 

will cover are described below. 

Arnold M. Epstein, Chair, Department of Health 

Policy and Management, Harvard School of Public 

Health. Dr Epstein will describe recent research 

examining the variation in rates of readmission across 

different Hospital Referral Regions (HRRs) as identified 

in the Dartmouth Atlas and the factors that explain this 

variation. Dr. Epstein and his collaborators found that 

rates of readmission within 30 days after index 

hospitalization for congestive heart failure or pneumonia 

vary more than three fold from 11% to 35%. The most 

important factor explaining readmissions is the 

propensity to hospitalize as measured by the population 

based all-cause admission rate in the HRR which 

explained roughly 35% of the variance in 30, 60 and 90 

day readmissions. Bed supply was also important. 

Comorbidity (the 29 co-morbidities in the Elixhauser 

schema), measures of discharge planning (as 

ascertained by the hospital version of the Consumer 

Assessment of Health Plans Survey (H-CAHPS) data) 

and other supply side factors (number of primary care 

physicians, and number of specialists in cardiovascular 

or pulmonary medicine per 100,000 persons in each 

HRR) explain little of the regional variation. 

These findings underscore the importance of 

general propensity to hospitalize patients and the 

number of beds available. Policy initiatives designed to 

lower the propensity to use hospital services may be

even more successful in reducing readmissions than 

many of the delivery system programs initiated to date. 

Amy E. Boutwell, Director of Health Policy 

Strategy, Institute for Healthcare Improvement. Dr. 

Boutwell will describe the STAAR (STate Action on 

Avoidable Rehospitalizations) initiative, a 

Commonwealth Fund supported project of the Institute 

for Healthcare Improvement. The aim of the STAAR 

initiative is to reduce rehospitalizations, and identifies the 

state as the unit of intervention. 

Dr. Boutwell will discuss the two-part, parallel 

strategy of the STAAR initiative: to support front-line 

process improvements in transitions of care and to 

leverage state-level multi-stakeholder leadership 

engagement to accelerate improvement at a regional 

level. STAAR provides technical assistance and 

strategic guidance to state-level steering committees 

which are tackling state-wide measurement issues, 

optimizing provider engagement in complementary 

payer-based initiatives, and initiating community-specific 

efforts to address pressing social challenges which 

contribute to hospital utilization. 

In addition, Dr Boutwell will discuss a unique 

element of the STAAR initiative: the cross-continuum 

team. Partnering hospital teams with community-based 

providers and non-clinical support services has been 

one of the most readily adopted recommendations in the 

program. Working as a cross-continuum team in a 

voluntary quality improvement initiative create a 

foundation for organizations in communities to take the 

“first steps” in the transitional phase between today’s 

practice and payment realities and the proposed models 

of a future state. 

Jane Brock, Medical Officer, Colorado 

Foundation for Medical Care and Clinical Lead, 

Transitions of Care Program Sub-national Theme. Dr 

Brock will describe the results and lessons to date 

resulting from the CMS QIO sub-national theme on 

Transitions of Care, a three-year project to improve care 

transitions and reduce rehospitalizations among 

Medicare beneficiaries in 14 geographically-defined 

communities throughout the US, covering approximately 

1.25 million beneficiaries. The Care Transitions Project 

is unique in adopting a geographically defined patient 

population as the unit of interest. Dr Brock will describe 

the common and unique models of care that are being 

implemented in the 14 communities, and what the 

project is learning about successful strategies. In some 

cases, the most successful strategy to improve care 

transitions in a community was “providing a box of 

doughnuts and a pot of coffee!” 

Dr. Brock will share the midterm results of the 

project, including Medicare utilization savings as a result 

of averted hospitalizations of $100 million. Key 

measurement issues will be described, including the 

rationale behind abandoning the original measure was % 

of all discharges that were readmitted in favor of a 

readmission incidence measure. Implementation and 

sustainability issues from the field will be described. 

John Young, Senior Advisor to the Acting 

Director, Center for Medicare & Medicaid Innovation 

(CMMI), Office of the Administrator (OA), Center for 

Medicare & Medicaid Services (CMS). Mr Young is 

responsible for advising the Center for Medicare & 

Medicaid Innovation (CMMI) acting director on creating 

national coherency across the identification, evaluation, 

and diffusion of care redesign and bundled payment 

approaches through Accountable Care Organizations 

(ACO) and Medical Homes for Medicare and Medicaid 

beneficiaries. Mr Young will describe bundled payment 

approaches as conceptualized by CMS, and will relate 

the findings of Dr Epstein’s research and Drs Boutwell 

and Brocks’ implementation experiences to the system 

redesign goals intended by payment policy reforms. 

Constitutional Challenges to Health Care Reform 

Organizer/Moderator: Mark Hall 


Panelists: Ken Wing, University of Washington; 

Timothy Stoltzfus Jost, J.D., Washington and Lee 

University; Mark Hall, J.D., Wake Forest University 

Roundtable Summary: Lawsuits challenging the 

constitutionality of the Affordable Care Act (ACA) 

threaten to overturn health insurance reform. Almost half 

the states have filed suit, in addition to a dozen or more 

suits by private individuals, provider groups, or public 

interest organizations. To date, two federal judges have 

upheld the ACA, one has struck down the individual 

mandate, and another has expressed considerable 

skepticism about the mandate’s constitutional validity. 

These, and other decisions that will likely be issued by 

the time of the conference, will be appealed to various 

circuit courts of appeal, and eventually to the Supreme 

Court. 

If some or all of the Affordable Care Act is 

declared unconstitutional, this obviously will have 

seismic impact on health policy. If the individual 

mandate, which is the main target, is stricken in 

isolation, the remaining insurance regulations could 

wreak market havoc, due to adverse selection. For that 

and other reasons, finding this major provision 

unconstitutional might sink much or all of the law, if a 

court were to invalidate all related provisions. Moreover, 

states challenge the constitutionality of requirements to 

expand Medicaid and to implement insurance 

exchanges. 

Also critical is to understand how long it will take 

courts to resolve these issues. Although the ACA’s major 

provisions do not take effect until 2014, litigation often 

takes several years, and looming uncertainty could be 

very disruptive to state and federal implementation 

efforts, and to anticipatory measures by market 

participants. 

This roundtable panel will explain the major 

components of this litigation, the likely procedural stages 

and timing, and the bases on which courts can be 

expected to rule. This will provide the audience a more 

informed foundation from which to interpret and 

anticipate unfolding legal events and their policy 

impacts. The presenters and their topics will be:

Timothy Jost, J.D., Washington and Lee 

University, will provide an overview of the various suits, 

their basic claims, and their likely progress through the 

courts. 

Mark A. Hall, J.D., Wake Forest University, will 

address the Commerce Clause challenges to the 

individual mandate, and the market consequences if the 

mandate is declared invalid. 

Ken Wing, J.D., Seattle Univ. and Univ. of 

Washington, emeritus, will address the political 

implications of these challenges, as well as constitutional 

arguments regarding individual rights. 

Also invited will be the Washington State 

Attorney General or a representative from his office, 

which is one of the suing states, to discuss claims that 

the ACA violates states’ sovereign rights. 

Implementing Electronic Health Records 

Organizer/Moderator: Melinda Beeuwkes Buntin 

Tuesday, June 14 * 8:00 a.m.–9:30 a.m. 

Panelists: Peggy Evans, Ph.D, Washington & Idaho 

Regional Extension Center for Health Information 

Technology; Eric Jamoom, National Center for Health 

Statistics; Vaishali Patel, Office of the National 

Coordinator for Health Information Technology; Mary 

Rubino, Health Affairs 

Roundtable Summary: By June 2011, thousands of 

providers will have received Medicare or Medicaid 

incentive payments for the “meaningful use” of electronic 

health records (EHRs). Many more will still be deciding 

whether or not to purchase an EHR or working to 

implement and use their EHR. In order to realize the 

goal of a health care system powered by information 

technology set out in the Health Information Technology 

for Economic and Clinical Health (HITECH) Act in 2009, 

providers will need information and assistance in 

choosing, implementing, and fully using an EHR. Only 

when a critical mass of providers have successfully 

implemented EHRs can the vision of a health care 

system in which data follows patients and seamlessly 

informs clinical decision-making be realized. Participants 

in this Policy Roundtable will discuss the latest data on 

EHR adoption, including success stories and areas that 

require policy attention, policies and strategies to boost 

EHR adoption and improve implementation, real-world 

examples of EHR implementations, and gaps in our 

understanding of the challenges of EHR implementation, 

from the viewpoint of multiple stakeholders. Vaishali 

Patel PhD, senior researcher at ONC, will provide an 

overview of what is known about the current status of 

electronic health records adoption. She will highlight 

areas of success, including the recent jump in adoption 

among primary care physicians, and groups which are 

lagging such as rural and critical access hospitals. Her 

comments will draw on the latest data from national 

surveys of physicians and hospitals and from new data 

available to ONC on electronic prescribing patterns. Dr. 

Patel has published extensively on consumer attitudes 

towards electronic health records and health information 

exchange and will also comment on how these factors 

affect the climate for adoption. David Blumenthal MD 

MPP, the National Coordinator for HIT, will provide an 

overview of federal strategies to promote the meaningful 

use of electronic health records. These include both the 

Medicare and Medicaid incentive programs and ONC’s 

own grant programs. ONC’s Regional Extension Center 

Program offers providers hands-on technical assistance, 

guidance and information on best practices to support 

and accelerate health care providers’ efforts to become 

meaningful users of Electronic Health Records (EHRs). 

The extension centers are focusing efforts on primary 

care providers in smaller and safety-net practices and on 

critical access hospitals. The Beacon Community 

Grantees aim to demonstrate the vision of a future 

where hospitals, clinicians, and patients are meaningful 

users of health IT, and together the community achieves 

measurable improvements in health care quality, safety, 

efficiency, and population health. State Health 

Information Exchange Cooperative Agreement Program 

supports States or State Designated Entities (SDEs) in 

establishing health information exchange capability 

among healthcare providers and hospitals in their 

jurisdictions. ONC also supports a comprehensive 

workforce program including a Community College 

Consortia to educate Health Information Technology 

professionals, university-based training, curriculum 

development, and competency testing. Dr. Blumenthal 

will discuss the principles that guided the development of 

the meaningful use criteria and ONC’s constellation of 

grant programs. He will also report on the progress 

made by grantees and the challenges they are facing. 

Peggy Evans, PhD, CPHIT, Director of the Washington 

& Idaho Regional Extension Center (WIREC) for 

Health Information Technology, will provide insights from 

her perspective on the ground assisting providers in the 

northwest with successfully adopting electronic health 

records (EHRs) and reaching meaningful use. Dr. Evans 

will describe the strategies being used by WIREC to 

provide education, outreach, and direct assistance. Dr. 

Evans has testified before the House Energy and 

Commerce Committee on the implementation and use of 

EHRs and is an executive with Qualis Health, a private, 

not-for-profit healthcare consulting and quality 

improvement organization based in Washington State. 

Eric Jamoom PhD, a fellow at the National Center for 

Health Statistics will discuss the new national physician 

survey related to EHR implementation that will be 

entering the field in summer 2011. The new Physician 

Workflow Study represents a data collection initiative by 

ONC and NCHS to better understand physician 

experiences with EHR adoption and use. The study will 

follow 3 cohorts of physicians from the 2011 EMR Mail 

Supplement to the National Ambulatory Medical Care 

Survey (NAMCS) at various levels of EHR adoption over 

a 3 year period from 2011 to 2013. The main purpose of 

the study is to obtain information related to the costs, 

benefits, and barriers related to the use of electronic 

health records at various stages of adoption. This 

information will help ONC target and refine the strategies 

of its grantees, understand and communicate the

experiences of adopters, measure progress towards 

HITECH program goals, and develop policies for the 

second stage of meaningful use criteria effective in 

2013. Susan Dentzer is the Editor-in-Chief of Health 

Affairs, the nation's leading journal of health policy, and 

an on-air analyst on health issues with The NewsHour 

with Jim Lehrer on the Public Broadcasting Service 

(PBS). Ms. Dentzer will round out the panel by 

discussing the key questions she hears about electronic 

health records from policymakers, providers, and other 

stakeholders and the role that she sees digitalized health 

information playing in a reformed health delivery system. 

The panel will be chaired by Melinda Beeuwkes Buntin 

PhD, Director of the Office of Economic Analysis and 

Modeling within the Office of the National Coordinator for 

Health Information Technology (ONC) at HHS. She will 

introduce the panelists, give them each 10 minutes to 

deliver introductory remarks, and then ask them a series 

of questions including: • What is the biggest challenge 

providers face when deciding whether or not to adopt an 

EHR What additional policies might help them address 

that challenge • If you could go back and add one 

provision to the HITECH Act what would it be and why 

What might it cost • Research on health information 

technology is expanding rapidly. What is the most useful 

finding you’ve seen from the research community this 

year What would you like to know more about 

Geographic Equity in Medicare Payment Policy: 

Geographic Adjustment Factors and Value-Based 

Health Care 

Organizer/Moderator: Margo Edmunds 


Panelists: Jon Christianson, Ph.D., University of 

Minnesota School of Public Health; Stuart Guterman, 

M.A., The Commonwealth Fund; Carlos Jaen, M.D., 

Ph.D., University of Texas Health Science Center at San 

Antonio; Marilyn Moon, Ph.D., American Institutes for 

Research; Thomas Ricketts, Ph.D., University of North 

Carolina, Chapel Hill 

Roundtable Summary: Medicare payments to 

physicians and hospitals are adjusted by geographic 

location, recognizing that some costs beyond the 

providers’ control vary in urban and rural areas and 

different parts of the country. Geographic adjustment is 

intended and designed to create a fee structure that 

compensates providers at the same real rate across the 

country. Before the Patient Protection and Affordable 

Care Act was passed, several members of Congress, 

policy experts, and clinical practitioners actively debated 

the need for an adjustment and the equity of the 

geographic adjustments for urban and rural areas and 

the data and methods used to calculate them. 

By Medicare statute, geographic adjustments 

must be budget-neutral, which forces a zero-sum game 

in which any adjustment upward for one provider or 

group of providers must be paid for by a downward 

adjustment to one or more other providers. Because 

there is no consensus in the provider community or 

among policy-makers on how to best adjust payments 

based on geographic location, The Secretary of Health 

and Human Services (HHS) and Congress sought 

advice from the Institute of Medicine (IOM) on how best 

to address stakeholders’ concerns as the new health 

care reform legislation is being implemented. 

The IOM study was commissioned to evaluate 

the accuracy of the adjustment factors and the 

methodology used to determine them, including the 

timeliness and accuracy of the sources of data used and 

their representativeness of operational costs of 

providers. The IOM was also asked to assess the effect 

of the adjustment factors on the level and distribution of 

the healthcare workforce and providers’ ability to provide 

high-value care, and the resulting impact on Medicare 

beneficiaries’ access to care. 

The participants in this policy roundtable will 

discuss the technical approach, findings, and 

recommendations of the IOM study’s first report to 

Congress and the Secretary of HHS, which will be 

released in May 2011. The participants include the 

study director and five members of the expert committee 

convened by the IOM to conduct the study. Their areas 

of expertise include health economics, health policy 

analysis, primary care, rural healthcare, geographic 

variation, healthcare workforce, and policy development 

and implementation. 

The study director, Margo Edmunds, PhD, will 

serve as moderator. Dr. Edmunds is a health policy 

analyst with a clinical background in disease 

management. She will provide a brief background on 

the scope and methods of the study and will introduce 

the IOM committee members who will serve as 

panelists. 

Marilyn Moon, PhD, is a health economist, 

Senior Vice President and Director, Health at the 

American Institutes for Research, and former Trustee for 

the Medicare trust fund. Dr. Moon will provide 

background on the Medicare payment structure for 

physicians and hospitals and describe the committee’s 

approach to evaluating data accuracy for the Hospital 

Wage Index. 

Stuart Guterman, MA, is Vice President, 

Payment and System Reform, and Executive Director for 

the Commission on a High Performance Health System 

at The Commonwealth Fund, and is a health economist 

with extensive experience in health care financing and 

payment systems. He will describe the committee’s 

recommendations about geographic payment localities 

and labor markets and their implications for urban and 

rural payment equity. 

Jon Christianson, PhD, Professor and James A. 

Hamilton Chair in Health Policy and Management at the 

University of Minnesota School of Public Health, is a 

health economist with expertise in health insurance, 

healthcare markets, and tracking change in healthcare 

markets. Dr. Christianson will describe the committee’s 

approach to impact analysis and the study’s implications 

for value-based healthcare delivery. 

Carlos Jaen, MD, PhD, is Professor of 

Epidemiology and Biostatistics, Co-Director of the

Center for Research in Family Medicine and Primary 

Care, and a practicing family physician at the University 

of Texas Health Science Center at San Antonio. Dr. 

Jaen will discuss the impact of the committee’s 

recommended changes in physician payment policies on 

primary care. 

Thomas Ricketts, PhD, is Professor of Health 

Policy and Management at the University of North 

Carolina Gillings School of Global Public Health. In 

October 2010, Dr. Ricketts was appointed to the 

National Health Care Workforce Commission created by 

the Patient Protection and Affordable Care Act. An 

expert in rural hospitals and health care access, Dr. 

Ricketts will discuss the implications of the committee’s 

recommendations for workforce distribution in rural and 

urban areas. 

The format for the roundtable will be interactive 

and will allow ample time for questions from members of 

the audience. Each presenter will offer a 5-7 minute 

statement summarizing key components of the study 

and recommendations from their perspective and area of 

expertise. Individual presentations will be followed by a 

Q and A led by the moderator and highlighting how the 

committee addressed conflicting stakeholder 

perspectives, such as whether the true costs of health 

care are recognized in high-cost urban areas and lowcost 

rural areas; whether the contributions of rural 

providers are undervalued or overvalued compared to 

those in urban areas; whether the occupational mix of 

clinical staff used for geographic adjustment is 

comparable in urban and rural areas; and whether socalled 

policy adjustments such as Graduate Medical 

Education or Health Professional Shortage Areas are 

accurate and fair. 

Health Information Exchange: Federal, State, and 

Local Perspective 

Organizer/Moderator: Ashish Jha 


Panelists: David Blumenthal, M.D., M.P.P., 

Department of Health and Human Services; Rachel 

Block, New York State Department of Health; Richard 

Rubin, OneHealthPort; Julia Adler-Milstein, Harvard 

University 

Roundtable Summary: Health information exchange 

(HIE) is a central component of Meaningful Use of 

Electronic Health Records (EHRs), the criteria used by 

the U.S. government to pay incentives to providers and 

hospitals under the Health Information Technology for 

Economic and Clinical Health (HITECH) Act. Several 

models suggest that broad-based HIE could result in 

large financial savings and these projections have 

served to promote HIE alongside EHR adoption. Under 

the Bush administration, funding was made available to 

support local and regional HIE efforts. However, 

enabling the flow of key clinical data, both among 

providers and among providers and other stakeholders, 

was fraught with challenges. While some efforts were 

successful in facilitating clinical data exchange, few 

supported comprehensive exchange among all 

stakeholders in the region. In addition, many efforts 

were unable to find sustainable business models, 

address legal and regulatory barriers, or negotiate 

complex technical solutions, and as a result, they 

ultimately failed. 

HITECH reignited momentum behind HIE with 

both a clear business case in the form of incentives to 

doctors and hospitals to engage in exchange, and a new 

infusion of financial support to the entities facilitating 

exchange of data. Under the State HIE Cooperative 

Agreement Program administered by the Office of the 

National Coordinator for Health IT (ONC), funding is 

being awarded to states and state-designated entities to 

build out HIE capabilities. A total of $548 million in 

funding will be given to 56 states, eligible territories, and 

qualified State Designated Entities (SDE), and awardees 

are responsible for increasing the level of 

interoperability, enabling patient-centric information flow 

in order to improve the quality and efficiency of care. 

This requires that states put in place governance, 

policies, technical services, business operations, and 

financing mechanisms for HIE over the four-year 

performance period. 

While the goals of the program are clear, states 

still have substantial latitude in deciding how to fulfill 

them. States can therefore choose to have no direct role 

in the provision of HIE, or, on the other extreme, be the 

only provider of HIE services, directly connecting to all 

the relevant stakeholders. The benefit of a state-centric 

approach is greater flexibility in designing an HIE 

strategy that can take into account state-specific 

differences in the legal/regulatory environment, the 

structure of the health care delivery market and any 

existing efforts to establish HIE. However, many of the 

same challenges faced by local and regional HIE efforts 

are likely to be encountered by states, and so it remains 

to be seen how successful states will be in increasing 

the flow of clinical data between health care 

stakeholders. 

Our policy roundtable will provide a multi-level 

perspective on the current approach to achieving 

nationwide HIE. The moderator, Dr. Ashish Jha, an 

associate professor at the Harvard School of Public 

Health and national expert on health IT and HIE, will 

open with the background and motivation for the panel. 

Next, Dr. David Blumenthal, the National Coordinator for 

Health IT, will provide an overview of the current federal 

approach. We will then have representatives from two 

states, Rachel Block of New York and Rick Rubin of 

Washington, present their plans. This will be followed by 

Julia Adler-Milstein who will present recent survey data 

on the progress of local and regional HIE efforts across 

the U.S. We will conclude with a discussion of key 

challenges that lie ahead, facilitated by Dr. Jha. We 

describe the individual topics covered by each panelist 

below. 

David Blumenthal: In his role as National 

Coordinator for Health IT, Dr. Blumenthal was a principal 

contributor to developing the State HIE Cooperative 

Agreement Program. He will describe the goals,

structure, and evaluation of the program in detail as well 

as how the program fits with the broader goals of 

HITECH. He will also discuss the key policy and 

implementation challenges to successfully achieving 

nationwide HIE. 

Rachel Block: As the HIT Coordinator for the 

state of New York, Rachel is one of the leaders working 

to formulate the HIE plan under the State Cooperative 

Agreement Program. New York has a long HIE history 

and devoted substantial funding to support HIE prior to 

HITECH. As a result, they have more than 10 

operational exchanges covering all counties in the state. 

They have therefore chosen to pursue a statewide 

approach, called SHIN-NY, based on a set of agreed 

upon protocols, standards, and policies which, when 

adopted by regional and local exchanges and other 

entities, will allow clinical data exchange across their 

systems. As a state on the forefront of HIE capabilities, 

Rachel will discuss the New York experience as well as 

offer insights into the key challenges they encountered 

and how they were addressed. 

Rick Rubin: Rick is the CEO of OneHealthPort, 

the private sector partner selected by the state of 

Washington to serve as the lead HIE organization. In 

this capacity, OneHealthPort will implement the primary 

HIE infrastructure and related services. Known as “the 

Hub”, the Washington state model is making available a 

service for routing messages containing clinical 

information between providers and other health care 

stakeholders who register to send and receive 

messages (“trading partners”). Rick will provide more 

details about the model, share the rationale for pursuing 

this approach, and discuss the key challenges they face. 

He will also discuss how this approach works in parallel 

with existing HIE efforts as well as other HITECH 

initiatives such as the Beacon Community. 

Julia Adler-Milstein: Julia Adler-Milstein is a 

national expert on local and regional HIE efforts. She 

has conducted three national surveys tracking the 

progress of these organizations as well as studied key 

facilitators of, and barriers to, their success. She will 

present her most recent survey data on the status of 

local and regional efforts, and describe the role of these 

efforts in state plans. She will also discuss key 

challenges faced by local HIE efforts and potential 

strategies that can be used by states to engage 

providers and other stakeholders in HIE. 

The Affordable Care Act and Long-Term Care: 

Meaningful Reform or Just Tinkering Around the 

Edges 

Organizer/Moderator: Edward Miller 


Panelists: Terence Ng, J.D., University of California 

San Francisco; Charles Phillips, Ph.D., M.P.H., Texas 

A&M University System Health Science Center; Robyn 

Stone, Ph.D., LeadingAge; William Weissert, Ph.D., 

Florida State University; Joshua 

Roundtable Summary: Widespread recognition of 

prevailing challenges has led to growing consensus that 

the way long-term care (LTC) is delivered, regulated, 

and financed needs to be reformed. Although receiving 

little notice in light of efforts to expand access to basic 

health insurance coverage, the Patient Protection and 

Affordable Care Act (PPACA) includes a number of 

provisions meant to address extant deficiencies in the 

LTC sector. The most prominent is the Community 

Living Assistance Services and Supports (CLASS) Act, a 

national voluntary LTC insurance program administered 

by the Federal government. Other pertinent provisions 

include a number of research and demonstration 

projects, a grab bag of nursing home quality reforms, 

and additional incentives and options for expanding 

Medicaid home- and community-based services (HCBS). 

In including these provisions it was the sense of the 

Senate that “Congress should address long-term 

services and supports in a comprehensive way that 

guarantees elderly and disabled individuals the care they 

need.” But just how effective is the PPACA likely to be in 

addressing the problems plaguing LTC Will it result in 

meaningful reform or will it just tinker around the edges 

This policy roundtable will seek to answer this question 

by drawing on the expertise of the following eminent 

scholars and analysts: Terence Ng (UCSF); Charles 

Phillips (Texas A&M); Robyn Stone (LeadingAge); 

William Weissert (Florida State), and Joshua Wiener 

(RTI).The panel will be moderated by Edward Alan Miller 

(UMASS-Boston, Brown University). Drs. Wiener and 

Weissert will focus on LTC financing. Dr. Wiener 

believes that over the long run the CLASS Act has the 

potential to radically change LTC financing. Like much of 

the PPACA, the CLASS Act gives the Secretary of the 

U.S. Department of Health and Human Services 

considerable discretion to shape the program. This 

suggests that the Act’s ultimate effectiveness will 

depend on choices the government makes during the 

course of implementation. How can adverse selection be 

prevented What should actuaries assume in setting 

premiums What disability levels should trigger benefits 

How will eligibility for benefits be determined How much 

will benefits be and what can they be used for What will 

the relationship be between the CLASS Act and private 

insurance Decisions such as these will largely 

determine whether the general working population can 

be educated to recognize their risk of needing LTC as 

they age, whether they believe that the CLASS Act can 

help to meet future LTC needs— i.e., offers value for its 

cost, and whether they can afford the premiums. Dr. 

Weissert argues that the CLASS Act gives the 

impression that it will finance the Baby Boom’s nursing 

home care needs–a financial burden crushing families 

and bankrupting the states. But alas, the CLASS Act is 

designed to pay for HCBS. Its average $50 a day cash 

payment is not nearly enough to pay for $150 to $200 a 

day in a nursing home. Furthermore, LTC insurance– 

already a tough sell–will become tougher because 

companies will no longer be able to offer home care 

coverage as a sweetener to entice purchase of 

institutional care coverage. And worse: Congress, 

thinking it has dealt with LTC financing, will be unlikely to

evisit the topic for at least a decade, maybe two or 

three. Meanwhile, Baby Boomers will be able access 

home care more readily, but for the real catastrophe, 

nursing home care costs, they will still be waiting for an 

answer. And so will state Medicaid budgets. Dr. Ng will 

focus on HCBS. He observes that over the past two 

decades state Medicaid programs have greatly 

expanded HCBS although considerable interstate 

variation in access to services remains. The PPACA has 

three important provisions to expand HCBS. First, the 

Community First Choice Option allows states to provide 

attendant care services with enhanced federal matching 

assistance. Second, HCBS can be offered as an optional 

benefit instead of a waiver at a financial eligibility level of 

300% of SSI. Third, the State Balancing Incentive 

Payments Program provides five years of enhanced 

federal matching to eligible states to increase HCBS. 

Although these provisions are valuable, the law does not 

set minimum standards for HCBS benefits. Moreover, 

the new incentives may not be sufficient to encourage 

major changes in light of ongoing state budget 

difficulties. Wide variations in access to HCBS can be 

expected to continue while HCBS competes with 

mandated institutional care for funding. Dr. Stone will 

focus on the LTC workers. She argues that the PPACA 

will impact the development and sustainability of the LTC 

workforce in several ways. Specific programs designed 

to support and strengthen the elder care workforce 

include financial incentives to encourage individuals to 

pursue geriatric careers across professions, the 

expansion of the Geriatric Education Centers program, 

and the development of core competencies and curricula 

for direct care workers. Indirectly, the PPACA will 

influence the LTC workforce through provisions 

designed to shift LTC from a primarily institutional to 

HCBS system. Promulgation of new payment 

methodologies designed to improve quality and 

efficiency in Medicare and an array of demonstration and 

pilot projects designed to promote person-centered care 

will further impact its size and structure. Ultimately, the 

type of education and training and practice patterns 

required will need to be altered to successfully achieve 

the goals inherent in these provisions. Dr. Phillips will 

focus on the provision of nursing home care. He argues 

that those portions of the PPACA most likely to have 

direct effects on nursing home quality are the Nursing 

Home Transparency Act and the Elder Justice Act. 

Potential advantages of these programs include an 

emphasis on quality assurance, performance 

improvements, abuse prevention, standardization of 

complaint processes, and strengthening enforcement 

remedies. By contrast, it is likely that the PPACA’s 

emphasis on shifting LTC services from nursing homes 

to HCBS will have indirect effects on nursing home 

quality. This is because successful implementation of 

such a shift will depend heavily on significant institutional 

restructuring; increases in human capital in the LTC 

sector; and the identification of funding sources for the 

provision of high quality care, both in the community and 

in nursing homes. 

Evaluating Short-Run Effects of PPACA on U.S. 

Health Insurance Markets: Data, Measurement, and 

Research Opportunities 

Organizer/Moderator: Jean Abraham 

Tuesday, June 14 * 11:30 a.m.–1:00 p.m. 

Panelists: Richard Kronick, Ph.D., U.S. Department of 

Health and Human Services; Brad Herring, Ph.D., 

Johns Hopkins University; Jeff Lemieux, Ph.D., 

America's Health Insurance Plans; Eric Nordman, 

National Association of Insurance Commissioners 

Roundtable Summary: A central focus of the Patient 

Protection and Affordable Care Act (PPACA) of 2010 is 

to improve the functioning of the individual and small 

employer group markets for health insurance through 

increased regulation. In the first two years following 

passage of the legislation, several new regulations will 

be implemented that will affect insurers, consumers, and 

employers. Five key provisions include: 

1) Establishing minimum medical loss ratios of 85 

percent for the fully-insured large group market and 

80 percent for the small group (2-100 workers) and 

individual markets. 

2) Having states conduct annual reviews of 

“unreasonable increases in premiums” for nongrandfathered 

health plans. 

3) Prohibiting lifetime limits on the dollar value of 

coverage for individual and group health plans. 

4) Prohibiting insurers from denying children coverage 

based on pre-existing medical conditions or from 

including pre-existing condition exclusions for 

children in policies. 

5) Requiring new health plans to provide coverage 

without cost-sharing for certain preventive services. 

The purpose of this policy roundtable is to have a 

engaging discussion among key stakeholders and 

audience members relating to what is currently known 

about health insurance market functioning, as well as the 

types of research questions and data infrastructure that 

will be needed to effectively evaluate the short-run 

effects of PPACA on the individual market, the small 

employer group market, and large employer group 

market (fully-insured and self-insured) for health 

insurance. 

The roundtable discussion will be strengthened by 

having a diversity of stakeholder perspectives 

represented, including: U.S. Department of Health and 

Human Services (DHHS): Given administrative 

rulemaking responsibilities, a representative from HHS 

can provide valuable insights regarding specific gaps in 

knowledge that would be of high value to policymakers 

for measuring and understanding the intended and 

unintended consequences of these regulatory changes 

on insurance market outcomes reflecting both the 

supply-side (e.g., entry and exit, plan offerings, benefit 

designs, etc) and the demand-side (e.g., consumer 

access, affordability, choice). 

National Association of Insurance 

Commissioners: The NAIC is the organization of state

insurance regulators for all 50 of the United States, 

Washington D.C., and five U.S. territories. The NAIC 

has played a key role in the implementation process of 

the aforementioned PPACA provisions. The vast 

majority of insurers within the United States provide 

annual data on operations and financial performance 

that may be useful for evaluating these provisions. The 

NAIC panelist can provide important technical insights 

regarding the pros and cons of these data for research 

applications and can discuss key changes that may be 

made in data collection following passage of federal 

reform. 

America’s Health Insurance Plans (AHIP): The 

panel will include a member from AHIP, which is the 

national association for health insurers. The proposed 

panelist heads AHIP’s Center for Policy and Research, 

which conducts innovative research and proposes policy 

solutions on the interrelated issues of health care quality, 

cost and access, and insurance markets. 

Academic Research Community: Also included 

on the panel is a health economist who maintains an 

active research agenda investigating the market for 

health insurance. This person can provide insights on 

what is currently known and what gaps exist in our 

understanding of the individual and employer-based 

markets. 

Potential Discussion Questions: 

(1) What do we currently know about research on 

health insurance market structure and performance 

across the three segments 

(2) What is the current “state of the world” in terms of 

data sources and measures available to evaluate 

U.S. health insurance market structure and 

performance 

(3) What are the strengths and weaknesses of existing 

data sources with respect to studying each of the 

market segments Consider issues of variables 

collected, timeliness, and granularity 

(4) What are the key outcomes and research questions 

that policymakers want and need to know, given 

the introduction of these new regulations 

(5) What types of data infrastructure investments may 

be needed for ensuring that rigorous and 

generalizable research can be conducted 

(6) How should we think about longer-run evaluation 

(e.g., once 2014 happens and state exchanges are 

in place) Will there be a way to obtain the “big 

picture” or will researchers have 50 different data 

sources to try to track

Policy Roundtable Abstracts - AcademyHealth

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