The Payment Reform Landscape: Maternity Care Progress And Stagnation

Improvements in the delivery of health care often stem from costly medical and technological advances, but in maternity care the evidence makes a strong argument that less is more. We can intervene less and spend less money in labor and delivery care while improving the quality of care for women and their babies. Why then is there so much unnecessary intervention and why is it so persistent?

The Example of Cesarean Deliveries

In 1985, the World Health Organization (WHO) declared there was no scientific justification for cesarean births in more than 10-15 percent of pregnancies. And the evidence continues to support that there is no improvement in mortality for mothers or infants with rates exceeding 10 percent to 19 percent depending on the study.

Even though the medical literature suggests that lower rates of cesarean delivery are better for women and children, the actual rates in the United States remain persistently high. In 2014, the Center for Disease Control (CDC) reported that 32.2 percent of U.S. births were cesareans. Even among “low risk” first time mothers (full term singleton pregnancy without breech presentation), more than one in four babies is delivered by cesarean. And large variation among hospitals suggests room for improvement.

Progress

But there is evidence that strong economic incentives to reduce unwarranted intervention can work in maternity care.

Over the past several years, application of financial and other pressures has led to relatively quick reductions in the number of early elective deliveries (EEDs). Cesarean or induced vaginal deliveries before 39 weeks without a medical indication are particularly pernicious because they are performed only for the convenience of the mother, doctor, or hospital staff, and are associated with significant risk of poorer medical outcomes for mothers and babies.

In South Carolina, under the leadership of the Birth Outcomes Initiative (SCBOI), they were able to combine the work of the State Medicaid program (DHHS) along with SC’s largest payer, Blue Cross Blue Shield of South Carolina, to implement quality improvement efforts along with a nonpayment policy for non-medically necessary EEDs. The quality improvement effort included establishing a list of The American Collegeof Obstetricians and Gynecologists’ approved indications for early delivery, utilizing two modifiers on the claims forms, tracking rates of EEDs by hospital, and providing each hospital with baseline and quarterly updates. Combining the quality improvement efforts with a nonpayment policy for EEDs, which applies to the hospital and the physician, has enabled SCBOI to reduce the EED rate among South Carolina’s 44 birthing hospitals by 72 percent between the first quarter of 2011 when the Birth Outcomes Initiative was launched, and the third quarter of 2015 (from 9.62 percent to 2.70 percent). Also, 75 percent of the hospitals now boast a 0 percent rate of non-medically necessary EEDs, based on data received from the South Carolina Department of Health and Human Services. (Updated information on this and other SCBOI programs will be available in October at scdhhs.gov under SCHealthviz).

Similar trends can be seen across the country. The rate of EEDs has been declining overall — from 17 percent nationally in 2010 to 2.8 percent in 2016. However, there is still work to be done as experts agree this number should be zero and the work on EEDs hasn’t had much if any impact on the overall rate of cesarean delivery.

Stagnation

Even in the face of compelling evidence, many commercial health insurance plans have resisted realigning their payment structures in any bold way. When they have changed their approach to payment, most have added quality measures on maternity care into a larger set of measures that they use in broad pay-for-performance programs. Many have focused their efforts on educating expectant mothers and their doctors on the benefits of full-term, spontaneous vaginal births and the dangers of medically un-indicated cesarean deliveries. But these education efforts have not had substantial impact on clinical practice.

Reducing the overall number of cesareans will be more challenging than eliminating early elective deliveries, as determining when a cesarean is “necessary” is much less straightforward. Nevertheless, payment design has done little to encourage more judicious use of many interventions. Services that are associated with higher rates of spontaneous vaginal birth and less intervention, such as doula care and delivery in free-standing birth centers, are often not covered by insurance. Despite abundant evidence that care by Certified Nurse Midwives (CNMs) is associated with less intervention and equal or better outcomes, many insurers will not contract with midwives and, of those that do, many pay them at a lower rate for the same care.

In the case of hospitals, those that bring down their cesarean rates are actually penalized financially for doing so: hospitals are paid 50 percent more when delivery occurs by cesarean rather than vaginally. Recent evidence suggests that this differential payment may prevent decreases in cesarean rates: when a single delivery rate was paid regardless of birth route, cesarean rates decreased by an average of 20 percent (from 27.2-32.6 percent to 19.5-27.2 percent) among the three participating hospitals.

Potential Solutions

We don’t know for sure what provider payment or benefit design strategies will support good outcomes while reducing the level of unnecessary and potentially harmful interventions, but there are many worth trying, including:

• Encouraging health plans to pay facilities the same blended fee for vaginal or cesarean deliveries, which would take away the economic incentive for elective cesarean deliveries. Providers would be paid more than they are today for vaginal births and less for cesarean deliveries, resulting in a reduction of the frequency of cesareans and the attendant cost.
• Contracting directly with midwives, where allowed, offering the same payment as physicians, to increase access to providers known to intervene less often.
• Contracting with accredited free-standing birth centers, providing the option for low-risk women to deliver in a safe, out-of-hospital setting.
• Steering women to designated “centers of excellence” that have the processes in place to follow current medical guidelines and have shown they can lower the number of deliveries with intervention.
• Separately bundling inpatient and outpatient costs for a pregnancy, which could stimulate innovation in ambulatory prenatal care.
• Making doula care a covered benefit, allowing more women access to a service that the American College of Obstetricians and Gynecologists considers “one of the most effective tools to improve labor and delivery outcomes.”

In the world of medicine, sometimes the most persistent habits don’t change quickly, even with data-driven arguments. Nearly 170 years ago, Dr. Ignaz Semmelweis proved that washing hands was a sure-fire way for doctors to prevent maternal and infant mortality during childbirth. Still, even today fewer than half of medical providers wash their hands as often as they should. Without strong incentives from payers, could it be another century before the overuse of cesareans catches up with what medical science puts forth today as an acceptable norm?

from Health Affairs BlogHealth Affairs Blog http://ift.tt/2dsR01I

The Payment Reform Landscape: Maternity Care Progress And Stagnation

Improvements in the delivery of health care often stem from costly medical and technological advances, but in maternity care the evidence makes a strong argument that less is more. We can intervene less and spend less money in labor and delivery care while improving the quality of care for women and their babies. Why then is there so much unnecessary intervention and why is it so persistent?

The Example of Cesarean Deliveries

In 1985, the World Health Organization (WHO) declared there was no scientific justification for cesarean births in more than 10-15 percent of pregnancies. And the evidence continues to support that there is no improvement in mortality for mothers or infants with rates exceeding 10 percent to 19 percent depending on the study.

Even though the medical literature suggests that lower rates of cesarean delivery are better for women and children, the actual rates in the United States remain persistently high. In 2014, the Center for Disease Control (CDC) reported that 32.2 percent of U.S. births were cesareans. Even among "low risk" first time mothers (full term singleton pregnancy without breech presentation), more than one in four babies is delivered by cesarean. And large variation among hospitals suggests room for improvement.

Progress

But there is evidence that strong economic incentives to reduce unwarranted intervention can work in maternity care.

Over the past several years, application of financial and other pressures has led to relatively quick reductions in the number of early elective deliveries (EEDs). Cesarean or induced vaginal deliveries before 39 weeks without a medical indication are particularly pernicious because they are performed only for the convenience of the mother, doctor, or hospital staff, and are associated with significant risk of poorer medical outcomes for mothers and babies.

In South Carolina, under the leadership of the Birth Outcomes Initiative (SCBOI), they were able to combine the work of the State Medicaid program (DHHS) along with SC's largest payer, Blue Cross Blue Shield of South Carolina, to implement quality improvement efforts along with a nonpayment policy for non-medically necessary EEDs. The quality improvement effort included establishing a list of The American Collegeof Obstetricians and Gynecologists' approved indications for early delivery, utilizing two modifiers on the claims forms, tracking rates of EEDs by hospital, and providing each hospital with baseline and quarterly updates. Combining the quality improvement efforts with a nonpayment policy for EEDs, which applies to the hospital and the physician, has enabled SCBOI to reduce the EED rate among South Carolina's 44 birthing hospitals by 72 percent between the first quarter of 2011 when the Birth Outcomes Initiative was launched, and the third quarter of 2015 (from 9.62 percent to 2.70 percent). Also, 75 percent of the hospitals now boast a 0 percent rate of non-medically necessary EEDs, based on data received from the South Carolina Department of Health and Human Services. (Updated information on this and other SCBOI programs will be available in October at scdhhs.gov under SCHealthviz).

Similar trends can be seen across the country. The rate of EEDs has been declining overall — from 17 percent nationally in 2010 to 2.8 percent in 2016. However, there is still work to be done as experts agree this number should be zero and the work on EEDs hasn't had much if any impact on the overall rate of cesarean delivery.

Stagnation

Even in the face of compelling evidence, many commercial health insurance plans have resisted realigning their payment structures in any bold way. When they have changed their approach to payment, most have added quality measures on maternity care into a larger set of measures that they use in broad pay-for-performance programs. Many have focused their efforts on educating expectant mothers and their doctors on the benefits of full-term, spontaneous vaginal births and the dangers of medically un-indicated cesarean deliveries. But these education efforts have not had substantial impact on clinical practice.

Reducing the overall number of cesareans will be more challenging than eliminating early elective deliveries, as determining when a cesarean is "necessary" is much less straightforward. Nevertheless, payment design has done little to encourage more judicious use of many interventions. Services that are associated with higher rates of spontaneous vaginal birth and less intervention, such as doula care and delivery in free-standing birth centers, are often not covered by insurance. Despite abundant evidence that care by Certified Nurse Midwives (CNMs) is associated with less intervention and equal or better outcomes, many insurers will not contract with midwives and, of those that do, many pay them at a lower rate for the same care.

In the case of hospitals, those that bring down their cesarean rates are actually penalized financially for doing so: hospitals are paid 50 percent more when delivery occurs by cesarean rather than vaginally. Recent evidence suggests that this differential payment may prevent decreases in cesarean rates: when a single delivery rate was paid regardless of birth route, cesarean rates decreased by an average of 20 percent (from 27.2-32.6 percent to 19.5-27.2 percent) among the three participating hospitals.

Potential Solutions

We don't know for sure what provider payment or benefit design strategies will support good outcomes while reducing the level of unnecessary and potentially harmful interventions, but there are many worth trying, including:

• Encouraging health plans to pay facilities the same blended fee for vaginal or cesarean deliveries, which would take away the economic incentive for elective cesarean deliveries. Providers would be paid more than they are today for vaginal births and less for cesarean deliveries, resulting in a reduction of the frequency of cesareans and the attendant cost.
• Contracting directly with midwives, where allowed, offering the same payment as physicians, to increase access to providers known to intervene less often.
• Contracting with accredited free-standing birth centers, providing the option for low-risk women to deliver in a safe, out-of-hospital setting.
• Steering women to designated "centers of excellence" that have the processes in place to follow current medical guidelines and have shown they can lower the number of deliveries with intervention.
• Separately bundling inpatient and outpatient costs for a pregnancy, which could stimulate innovation in ambulatory prenatal care.
• Making doula care a covered benefit, allowing more women access to a service that the American College of Obstetricians and Gynecologists considers "one of the most effective tools to improve labor and delivery outcomes."

In the world of medicine, sometimes the most persistent habits don't change quickly, even with data-driven arguments. Nearly 170 years ago, Dr. Ignaz Semmelweis proved that washing hands was a sure-fire way for doctors to prevent maternal and infant mortality during childbirth. Still, even today fewer than half of medical providers wash their hands as often as they should. Without strong incentives from payers, could it be another century before the overuse of cesareans catches up with what medical science puts forth today as an acceptable norm?

from Health Affairs BlogHealth Affairs Blog http://ift.tt/2dsR01I

Paper Plate Witches

Halloween is just around the corner! Shared below is an easy tutorial for Paper Plate Witches, a cute and easy craft for Halloween.

Paper Plate Witches

This easy and fun craft is a cute decoration for kids' Halloween parties. We made some to tape to our kitchen door to celebrate fall! We used green paper plates, but of course kids could paint white paper plates green.

To make this craft you will need:

• Green paper plates
• Black and orange construction paper
• Wiggly eyes
• Black permanent marker
• Black yarn
• Tape
• White school glue

RELATED: Halloween Necklace Craft for Kids

After gathering supplies, invite children to cut 8 strands of black yarn. Tape the strands of yarn to the paper plate. If kids want their witches to have thicker hair, simply add more strands of yarn.

After taping the hair to the paper plate, use scissors to cut a witch's hat from black paper. Tape or glue the hat to the top of the witch's head. If desired, cut a small buckle for the hat from orange and yellow construction paper. Kids will also enjoy creating witch hats from colored paper or scrapbook paper.

Last, secure the wiggly eyes to the witch's face with glue. Use the black permanent marker to draw eyebrows, a nose, and a mouth.

More Witch Crafts for Kids

Paper Plate Witch's Hat

25 Witch Crafts and Recipes

The post Paper Plate Witches appeared first on Kids Activities Blog.

from Kids Activities Blog http://ift.tt/2dcSiDg

Paper Plate Witches

Halloween is just around the corner! Shared below is an easy tutorial for Paper Plate Witches, a cute and easy craft for Halloween.

Paper Plate Witches

This easy and fun craft is a cute decoration for kids’ Halloween parties. We made some to tape to our kitchen door to celebrate fall! We used green paper plates, but of course kids could paint white paper plates green.

To make this craft you will need:

• Green paper plates
• Black and orange construction paper
• Wiggly eyes
• Black permanent marker
• Black yarn
• Tape
• White school glue

RELATED: Halloween Necklace Craft for Kids

After gathering supplies, invite children to cut 8 strands of black yarn. Tape the strands of yarn to the paper plate. If kids want their witches to have thicker hair, simply add more strands of yarn.

After taping the hair to the paper plate, use scissors to cut a witch’s hat from black paper. Tape or glue the hat to the top of the witch’s head. If desired, cut a small buckle for the hat from orange and yellow construction paper. Kids will also enjoy creating witch hats from colored paper or scrapbook paper.

Last, secure the wiggly eyes to the witch’s face with glue. Use the black permanent marker to draw eyebrows, a nose, and a mouth.

More Witch Crafts for Kids

Paper Plate Witch’s Hat

25 Witch Crafts and Recipes

The post Paper Plate Witches appeared first on Kids Activities Blog.

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ACA Round-Up: Appropriations, Battles Over Reinsurance Program Collections, And More

On September 29, President Obama signed a continuing resolution appropriations bill that will fund the government through December 9, 2016, unless a 2017 appropriations bill is passed before that date. The headline is that the bill provides $1.1 billion in funding for combating the Zika virus. But the legislation otherwise continues in place funding for ACA programs at the rates at which they were funded for 2016, subject to a half percent reduction.

The continuing resolution retains riders and restrictions imposed by the 2016 appropriations legislation, including restrictions on using HHS administrative funds to fund the risk corridor program, elimination of funding for the Independent Payment Advisory Board, and various reporting requirements for ACA programs. The only new restriction on ACA funding in the bill is a rescission of $168 million in unspent ACA funds that were supposed to be available for funding health coverage in the territories.

The continuing resolution otherwise contains no new restrictions on ACA funding or implementation, however. There is no prohibition against the use of the judgment fund to settle risk corridor cases. And there is no requirement that HHS transfer funds from the reinsurance program to the Treasury, another demand of ACA critics (see below). The battle over health care reform will likely be rejoined in Congress after the elections, but the ACA has survived the latest round of congressional action largely unscathed.

GAO Sides With Republicans On Treasury Reimbursements From Reinsurance Program Collections; HHS Stands Its Ground

The temporary reinsurance program established by section 1341 of the Affordable Care Act was adopted to reinsure health insurers in the individual and small group market for high-cost claims during 2014, 2015, and 2016, the first three years of the health insurance market reforms and the marketplaces. The reinsurance program is funded by contributions collected from insurers and third party administrators of self-insured employer plans, which were supposed to amount to $10 billion for 2014, $6 billion for 2015, and $4 billion for 2016. The program has had a significant effect on individual market premiums, accounting for premium reductions of 10 to 14 percent in 2014, 6 to 11 percent in the 2015, and 4 to 6 percent for 2016, according to the American Academy of Actuaries.

The program was also, however, supposed to collect $2 billion each for 2014 and 2015 and $1 billion for 2016 to be deposited in the Treasury. These funds were intended to reimburse the Treasury for the $5 billion spent on the early retiree reinsurance program between 2010 and 2013. HHS set the contribution rate for the insurers and self-insured plans contributing to the program for the three years at a level that it believed would be sufficient to collect the amounts needed to fund the program and reimburse the Treasury, plus cover administrative costs. For 2014, however, HHS collected only $9.7 billion toward the $12.2 billion target, and in 2015 it received only $6.5 of the $8.025 billion needed. CMS had thus to decide how to allocate the funds collected toward the program's costs.

CMS initially stated in its 2014 and 2015 Notice of Benefit and Payment Parameters that in the event of a shortfall it would allocate funds collected pro rata between the reinsurance program and reimbursing the Treasury. When it became clear, however, that there would be an actual shortfall, CMS reconsidered, concluding from its interpretation of the language of section 1341 that the primary purpose of the statute was to provide reinsurance; CMS thus decided that all funds collected up to the amounts specified for the reinsurance program should be allocated to that program rather than to repaying the Treasury. Thus, it forwarded nothing to the Treasury for 2014 and about 0.5 billion for 2015.

Congressional Republicans have taken issue with this conclusion, arguing that the statute mandates that HHS reimburse the Treasury. They asked the Government Accountability Office to weigh in on the question. On September 29, the GAO issued an opinion, siding with the Republicans.

The GAO concluded that the statute requires HHS to collect funds to reimburse the Treasury as well as to fund the reinsurance program, and that money collected for the Treasury cannot be used for the reinsurance program. It opined that HHS' reading of the wording of the statute was "unconvincing" and, moreover, contrary to HHS' initial opinion on how a shortfall should be addressed. The GAO concluded that in the face of the shortfall, CMS should have allocated the funds collected pro rata between the reinsurance program and reimbursing the Treasury, and that therefore HHS owes approximately $3 billion to the Treasury.

The decisions of the Comptroller General, the head of the GAO, are binding on executive agencies, but the Comptroller General has no enforcement authority. HHS has apparently already distributed the reinsurance amount collected for 2014 and much of the amount collected for 2015 to insurers. It is very unlikely that HHS could recover these funds without doing serious damage to insurers in the individual market or that it will do so. It is also hard to believe that HHS could attempt retroactively to demand additional contributions from insurers and third party administrators of self-insured plans for 2014 and 2015, or to pay $3 billion from some other HHS account. HHS has reportedly taken the position that its interpretation of 1341, established through notice and comment rulemaking, is legal and that it intends to stay the course.

HHS Reports Coverage Gains Under ACA

On September 29, 2016 the HHS Assistant Secretary for Evaluation and Planning (ASPE) released a report titled "Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage." ASPE reports that the level of uninsured in the United States has reached a historic low of 8.6 percent, with 20 million gaining coverage under the ACA.

The report documents reductions in the uninsured rate since the ACA was adopted at every income level, in every ethnic group, in every age group, and in both urban and rural areas. Reductions in the uninsured from 2010 to 2015 for non-elderly adults range:

• by income group from 37 percent for those with incomes between 250 and 400 percent of the poverty level to 48 percent for those with incomes between 100 and 125 percent of poverty;
• by race and ethnicity from 35 percent for Hispanic non-elderly adults (from 43 to 28 percent) to 59 percent for non-Hispanic Asians (from 19 to 8 percent);
• by age group from 36 percent for those aged 26 to 34 to 52 percent for those aged 18 to 25; and,
• by metropolitan status from 39 percent for those who do not live in metropolitan areas to 42 percent for those who do.

The report once again emphasizes that reductions have been more dramatic in states that have expanded Medicaid than in those that have not. The overall uninsured rate decreased by almost 50 percent, from 19.9 to 10 percent, between 2010 and 2015 in Medicaid expansion states and by only 32 percent, from 25.9 to 17.7 percent, in states that did not expand.

The disparity in reductions in the uninsured rate was much starker with respect to non-elderly adults with incomes below 100 percent of the federal poverty level. The uninsured rate for this population dropped by 54 percent in expansion states but only by 19 percent in non-expansion states. The uninsured rate among non-elderly adult Hispanics dropped by 43 percent in expansion states but by only 26 percent in non-expansion states, while the rate among non-Hispanic Black non-elderly adults dropped by 59 percent in expansion states, by only 37 percent in non-expansion states.

There is much that is controversial about the ACA, but I know of no serious commentator on health policy who does not recognize that the uninsured rate has dropped dramatically since the ACA was adopted. It is thus remarkable that a Kaiser Health Tracking Poll released on September 29 found that only 26 percent of respondents realized that the number of uninsured was at an all-time low. Of those polled, 21 percent believed that the number of uninsured was at an all-time high, while 46 percent believed that the level was about the same as it has been. Of those who report that they have been following the news on the issue of the uninsured "very closely," 26 percent believe that the uninsured rate is at an all-time high (compared to 32 percent of very close news followers who know that it is at an all-time low). One can only guess (or despair) at what news sources Americans are following.

A Third Round Of ACA Litigation

As the ACA becomes ever more firmly established as the framework of our health care system, the nature of ACA litigation is beginning to change. In the years immediately following the enactment of the law, a dozen or more lawsuits were filed challenging the constitutionality of the law itself. These challenges largely failed, although in 2012 the Supreme Court held in the National Federation of Independent Business v. Sebelius case that Congress could not constitutionally compel states to expand Medicaid to low-income adults, thereby leaving 3 million Americans without access to health care coverage.

A second round of cases challenged the implementation of the law. A number of these cases contended that the administration had misinterpreted the law in allowing premium tax credits to be available through the federal exchange. This challenge was rejected decisively by the Supreme Court in King v. Burwell. Most of the other implementation challenges have been dismissed as well. A district court did, however, decide in favor of the House of Representatives in House v. Burwell, which challenges the provision of cost sharing reduction payments by the administration without an annual appropriation; this case is currently pending before the District of Columbia Court of Appeals. In addition, challenges to the contraceptive mandate continue to be litigated.

We are now seeing a third round of litigation, in which insurers and other participants in ACA programs are asserting their rights under the ACA or contesting the way in which the ACA has been applied to their particular situation. This includes a number of cases filed by insurers challenging the government's failure to pay out all of the money owed to them under the risk corridor program.

On September 26, 2016, the United States District Court for the District of Minnesota dismissed Batsche v. Burwell. This case involved the temporary reinsurance program. As described above, the reinsurance program collects a fee from insurers and the third party administrators of self-insured employer plans and distributes the money to insurers in the individual and small group market with very high claims.

In the initial regulations implementing this program, HHS concluded that self-insured, self-administered group health plans (mainly collectively bargained plans) were required to pay the reinsurance fee. In 2014, HHS reconsidered, and decided that they were not subject to the fee, but HHS applied this interpretation only for 2015 and 2016. The Trustees of the Twin City Pipe Trades Welfare Fund, a self-insured, self-administered fund, sued to enjoin HHS from collecting the 2014 fee as well. There was one problem, however: the fund had already paid the $762,663.90 fee for 2014. They sued to get the money back.

The federal court dismissed the case, holding that the plaintiff was essentially suing only for money damages for losses it had suffered because of the government's action in collecting the 2014 fee, and thus the lawsuit was barred by the government's defense of sovereign immunity. The sovereign immunity doctrine protects the government from lawsuits where it has not specifically agreed to liability. The court distinguished the case from lawsuits (including arguably the risk corridor cases) where a plaintiff is suing to obtain a benefit that it is "entitled" to under the ACA, where sovereign immunity may not apply. The court also held that if the plaintiffs could argue that the government had waived sovereign immunity, the case would have to be brought in the Court of Federal Claims (where the risk corridor cases are being brought).

Assuming the ACA continues to be the law of the land, it is likely that lawsuits by insurers, providers, and beneficiaries asserting rights under the statute will become quite common, as lawsuits asserting rights under the Medicare and Medicaid programs are now common. Medicaid and Medicare cases often present complex jurisdictional and procedural issues. A number of these issues have had to be decided ultimately by the Supreme Court. ACA litigation is likely also to present such issues, as the Batshe case demonstrates.

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ACA Round-Up: Appropriations, Battles Over Reinsurance Program Collections, And More

On September 29, President Obama signed a continuing resolution appropriations bill that will fund the government through December 9, 2016, unless a 2017 appropriations bill is passed before that date. The headline is that the bill provides $1.1 billion in funding for combating the Zika virus. But the legislation otherwise continues in place funding for ACA programs at the rates at which they were funded for 2016, subject to a half percent reduction.

The continuing resolution retains riders and restrictions imposed by the 2016 appropriations legislation, including restrictions on using HHS administrative funds to fund the risk corridor program, elimination of funding for the Independent Payment Advisory Board, and various reporting requirements for ACA programs. The only new restriction on ACA funding in the bill is a rescission of $168 million in unspent ACA funds that were supposed to be available for funding health coverage in the territories.

The continuing resolution otherwise contains no new restrictions on ACA funding or implementation, however. There is no prohibition against the use of the judgment fund to settle risk corridor cases. And there is no requirement that HHS transfer funds from the reinsurance program to the Treasury, another demand of ACA critics (see below). The battle over health care reform will likely be rejoined in Congress after the elections, but the ACA has survived the latest round of congressional action largely unscathed.

GAO Sides With Republicans On Treasury Reimbursements From Reinsurance Program Collections; HHS Stands Its Ground

The temporary reinsurance program established by section 1341 of the Affordable Care Act was adopted to reinsure health insurers in the individual and small group market for high-cost claims during 2014, 2015, and 2016, the first three years of the health insurance market reforms and the marketplaces. The reinsurance program is funded by contributions collected from insurers and third party administrators of self-insured employer plans, which were supposed to amount to $10 billion for 2014, $6 billion for 2015, and $4 billion for 2016. The program has had a significant effect on individual market premiums, accounting for premium reductions of 10 to 14 percent in 2014, 6 to 11 percent in the 2015, and 4 to 6 percent for 2016, according to the American Academy of Actuaries.

The program was also, however, supposed to collect $2 billion each for 2014 and 2015 and $1 billion for 2016 to be deposited in the Treasury. These funds were intended to reimburse the Treasury for the $5 billion spent on the early retiree reinsurance program between 2010 and 2013. HHS set the contribution rate for the insurers and self-insured plans contributing to the program for the three years at a level that it believed would be sufficient to collect the amounts needed to fund the program and reimburse the Treasury, plus cover administrative costs. For 2014, however, HHS collected only $9.7 billion toward the $12.2 billion target, and in 2015 it received only $6.5 of the $8.025 billion needed. CMS had thus to decide how to allocate the funds collected toward the program’s costs.

CMS initially stated in its 2014 and 2015 Notice of Benefit and Payment Parameters that in the event of a shortfall it would allocate funds collected pro rata between the reinsurance program and reimbursing the Treasury. When it became clear, however, that there would be an actual shortfall, CMS reconsidered, concluding from its interpretation of the language of section 1341 that the primary purpose of the statute was to provide reinsurance; CMS thus decided that all funds collected up to the amounts specified for the reinsurance program should be allocated to that program rather than to repaying the Treasury. Thus, it forwarded nothing to the Treasury for 2014 and about 0.5 billion for 2015.

Congressional Republicans have taken issue with this conclusion, arguing that the statute mandates that HHS reimburse the Treasury. They asked the Government Accountability Office to weigh in on the question. On September 29, the GAO issued an opinion, siding with the Republicans.

The GAO concluded that the statute requires HHS to collect funds to reimburse the Treasury as well as to fund the reinsurance program, and that money collected for the Treasury cannot be used for the reinsurance program. It opined that HHS’ reading of the wording of the statute was “unconvincing” and, moreover, contrary to HHS’ initial opinion on how a shortfall should be addressed. The GAO concluded that in the face of the shortfall, CMS should have allocated the funds collected pro rata between the reinsurance program and reimbursing the Treasury, and that therefore HHS owes approximately $3 billion to the Treasury.

The decisions of the Comptroller General, the head of the GAO, are binding on executive agencies, but the Comptroller General has no enforcement authority. HHS has apparently already distributed the reinsurance amount collected for 2014 and much of the amount collected for 2015 to insurers. It is very unlikely that HHS could recover these funds without doing serious damage to insurers in the individual market or that it will do so. It is also hard to believe that HHS could attempt retroactively to demand additional contributions from insurers and third party administrators of self-insured plans for 2014 and 2015, or to pay $3 billion from some other HHS account. HHS has reportedly taken the position that its interpretation of 1341, established through notice and comment rulemaking, is legal and that it intends to stay the course.

HHS Reports Coverage Gains Under ACA

On September 29, 2016 the HHS Assistant Secretary for Evaluation and Planning (ASPE) released a report titled “Affordable Care Act Has Led to Historic, Widespread Increase in Health Insurance Coverage.” ASPE reports that the level of uninsured in the United States has reached a historic low of 8.6 percent, with 20 million gaining coverage under the ACA.

The report documents reductions in the uninsured rate since the ACA was adopted at every income level, in every ethnic group, in every age group, and in both urban and rural areas. Reductions in the uninsured from 2010 to 2015 for non-elderly adults range:

• by income group from 37 percent for those with incomes between 250 and 400 percent of the poverty level to 48 percent for those with incomes between 100 and 125 percent of poverty;
• by race and ethnicity from 35 percent for Hispanic non-elderly adults (from 43 to 28 percent) to 59 percent for non-Hispanic Asians (from 19 to 8 percent);
• by age group from 36 percent for those aged 26 to 34 to 52 percent for those aged 18 to 25; and,
• by metropolitan status from 39 percent for those who do not live in metropolitan areas to 42 percent for those who do.

The report once again emphasizes that reductions have been more dramatic in states that have expanded Medicaid than in those that have not. The overall uninsured rate decreased by almost 50 percent, from 19.9 to 10 percent, between 2010 and 2015 in Medicaid expansion states and by only 32 percent, from 25.9 to 17.7 percent, in states that did not expand.

The disparity in reductions in the uninsured rate was much starker with respect to non-elderly adults with incomes below 100 percent of the federal poverty level. The uninsured rate for this population dropped by 54 percent in expansion states but only by 19 percent in non-expansion states. The uninsured rate among non-elderly adult Hispanics dropped by 43 percent in expansion states but by only 26 percent in non-expansion states, while the rate among non-Hispanic Black non-elderly adults dropped by 59 percent in expansion states, by only 37 percent in non-expansion states.

There is much that is controversial about the ACA, but I know of no serious commentator on health policy who does not recognize that the uninsured rate has dropped dramatically since the ACA was adopted. It is thus remarkable that a Kaiser Health Tracking Poll released on September 29 found that only 26 percent of respondents realized that the number of uninsured was at an all-time low. Of those polled, 21 percent believed that the number of uninsured was at an all-time high, while 46 percent believed that the level was about the same as it has been. Of those who report that they have been following the news on the issue of the uninsured “very closely,” 26 percent believe that the uninsured rate is at an all-time high (compared to 32 percent of very close news followers who know that it is at an all-time low). One can only guess (or despair) at what news sources Americans are following.

A Third Round Of ACA Litigation

As the ACA becomes ever more firmly established as the framework of our health care system, the nature of ACA litigation is beginning to change. In the years immediately following the enactment of the law, a dozen or more lawsuits were filed challenging the constitutionality of the law itself. These challenges largely failed, although in 2012 the Supreme Court held in the National Federation of Independent Business v. Sebelius case that Congress could not constitutionally compel states to expand Medicaid to low-income adults, thereby leaving 3 million Americans without access to health care coverage.

A second round of cases challenged the implementation of the law. A number of these cases contended that the administration had misinterpreted the law in allowing premium tax credits to be available through the federal exchange. This challenge was rejected decisively by the Supreme Court in King v. Burwell. Most of the other implementation challenges have been dismissed as well. A district court did, however, decide in favor of the House of Representatives in House v. Burwell, which challenges the provision of cost sharing reduction payments by the administration without an annual appropriation; this case is currently pending before the District of Columbia Court of Appeals. In addition, challenges to the contraceptive mandate continue to be litigated.

We are now seeing a third round of litigation, in which insurers and other participants in ACA programs are asserting their rights under the ACA or contesting the way in which the ACA has been applied to their particular situation. This includes a number of cases filed by insurers challenging the government’s failure to pay out all of the money owed to them under the risk corridor program.

On September 26, 2016, the United States District Court for the District of Minnesota dismissed Batsche v. Burwell. This case involved the temporary reinsurance program. As described above, the reinsurance program collects a fee from insurers and the third party administrators of self-insured employer plans and distributes the money to insurers in the individual and small group market with very high claims.

In the initial regulations implementing this program, HHS concluded that self-insured, self-administered group health plans (mainly collectively bargained plans) were required to pay the reinsurance fee. In 2014, HHS reconsidered, and decided that they were not subject to the fee, but HHS applied this interpretation only for 2015 and 2016. The Trustees of the Twin City Pipe Trades Welfare Fund, a self-insured, self-administered fund, sued to enjoin HHS from collecting the 2014 fee as well. There was one problem, however: the fund had already paid the $762,663.90 fee for 2014. They sued to get the money back.

The federal court dismissed the case, holding that the plaintiff was essentially suing only for money damages for losses it had suffered because of the government’s action in collecting the 2014 fee, and thus the lawsuit was barred by the government’s defense of sovereign immunity. The sovereign immunity doctrine protects the government from lawsuits where it has not specifically agreed to liability. The court distinguished the case from lawsuits (including arguably the risk corridor cases) where a plaintiff is suing to obtain a benefit that it is “entitled” to under the ACA, where sovereign immunity may not apply. The court also held that if the plaintiffs could argue that the government had waived sovereign immunity, the case would have to be brought in the Court of Federal Claims (where the risk corridor cases are being brought).

Assuming the ACA continues to be the law of the land, it is likely that lawsuits by insurers, providers, and beneficiaries asserting rights under the statute will become quite common, as lawsuits asserting rights under the Medicare and Medicaid programs are now common. Medicaid and Medicare cases often present complex jurisdictional and procedural issues. A number of these issues have had to be decided ultimately by the Supreme Court. ACA litigation is likely also to present such issues, as the Batshe case demonstrates.

from Health Affairs BlogHealth Affairs Blog http://ift.tt/2dsraun

5 Hot Breakfast Ideas to Start Your Day!

You know what they say "breakfast is the most important meal of the day" — so why not make it a hot breakfast! Today on Family Food Live, we are sharing 5 Hot Breakfast Ideas to Start Your Day!

Family Food Live is live every Wednesday and Friday at 12 Noon CST. You can find us on the Burnt Macaroni Facebook page on Wednesdays or every Friday at 12 Noon CST on the Quirky Momma Facebook page. And that includes today! Make sure to like us now so you'll never miss an episode!

Here's what we are making today…

Apple Breakfast Crisp

This very light but delicious hot Apple Breakfast Crisp combines the yumminess of cooked apples with cinnamon and honey. This is one of my favorite hot breakfasts!

On the Go Omelet Breakfast Bites

These are the perfect make ahead breakfast for the kids as they are running out the door. Your family will love these On the Go Omelet Breakfast Bites!

Biscuits and Gravy Breakfast Casserole

Shopping List:

• 2 cans Biscuits
• 1 package ground Breakfast Sausage
• 4 tablespoons Flour
• ½ teaspoon Salt
• ½ teaspoon Black Pepper
• ½ teaspoon Garlic Powder
• 2 and ½ cups milk

Instructions:

• Preheat oven to 400° F
• Cut biscuits into quarters
• Spray 9×13 baking dish with non-stick spray. Fill the bottom with half of the quarters of biscuits.
• Bake for 10 minutes
• While the biscuits are baking, brown the sausage until cooked through
• In a mixing bowl, combine flour, salt, pepper and garlic powder. Add the flour mixture to the skillet with the browned sausage
• Add milk and stir completely until the mixture comes to a simmer
• Reduce heat and continue to simmer until the gravy thickens
• Pour gravy over bottom layer of cooked biscuits and top with remaining biscuit quarters
• Bake 15-20 minutes or until top biscuits are golden brown

Peanut Butter Banana Oatmeal

Shopping List:

• 1 3/4 cups milk
• 1 cup quick oats
• 1 large ripe banana, mashed
• 2 tablespoons peanut butter
• 1/2 teaspoon ground cinnamon
• 1/4 teaspoon pure vanilla extract
• Pinch of salt
• 1 to 3 teaspoons honey, optional
• Sliced bananas, and cinnamon, for serving

Instructions

• In a saucepan, bring milk to a boil
• Stir in oats and reduce heat to a simmer for about 2 minutes
• Remove from heat and cover for a few minutes
• Stir in mashed bananas, peanut butter, honey, cinnamon, vanilla and salt
• Top with banana slices
• Serve

Pumpkin Spice Hot Chocolate

Shopping List:

• 2 1/2 cups non-dairy milk
• 1/2 cup canned pumpkin
• 2 tablespoons cocoa powder
• 1 teaspoon pumpkin pie spice
• 1/2 teaspoon vanilla extract
• Sugar to taste

Instructions

• Combine all ingredients in blender and blend until smooth. Add sugar if needed
• Pour into a saucepan and bring to a simmer, stirring occasionally
• Serve hot

Join Family Food Live with Holly & Chris every Wednesday and Friday at Noon CST on either the Quirky Momma Facebook page or the Burnt Macaroni Facebook page!

We are also so excited to share our first Family Food Live Apron with you.  Be the first to pick one up and start cooking with us!

Here are a few of our favorite products from Family Food Live (affiliate links)

• Cuisinart Food Processor
• The I Heart Naptime Cookbook by Jamielyn Nye
• Giant Popcorn bowl
• Individual Popcorn bowls
• VillaWare Uno Classic Waffle Maker
• VillaWare Farmyard Waffle Maker
• Taco Holder
• Pyrex Baking Dishes
• Hand Blender
• Pizza Peel
• Pizza Wheel (cutter)
• Pizza Stone
• Pre-Seasoned Cast Iron Double Burner Reversible Grill/Griddle
• Cuisinart Chef's Classic Stainless 5-1/2-Quart Saute Pan with Helper Handle and Cover
• BPA free lunch containers
• Egg Rite Egg Timer
• Fit and Fresh container
• One Touch Electric Bottle Opener
• Half Pint Wide Mouth Mason Jars
• Ninja Professional Blender
• Zoku Quick Pop Maker
• Williams-Sonoma Open Kitchen Half Apron in Red or Blue
• Plano Half-Size Stowaway with Adjustable Dividers – for road trip snacks
• Curious Chef 3-Piece Nylon Knife Set
• Cuisinart 2 Quart Ice Cream Maker
• Victorinox Fibrox Straight Edge Chef's Knife, 8-Inch
• Lemon Squeezer
• Mason Jars
• Crockpot
• Apple Corer
• Popcorn Bowl
• MaxiMatic double burner hot plate
• Glass Egg carton
• Black & Decker 4 slice toaster
• Hamilton Beach Hand Mixer
• Cuisinart 8-cup Food Processor
• Meat Mallet
• Ice Cream or Cookie Scooper
• Norpro Butter Keeper
• Norpro Butter Keeper
• 3-Piece Veggie Peeler
• Garlic Press

The post 5 Hot Breakfast Ideas to Start Your Day! appeared first on Kids Activities Blog.

from Kids Activities Blog http://ift.tt/2diHksq

5 Hot Breakfast Ideas to Start Your Day!

You know what they say “breakfast is the most important meal of the day” — so why not make it a hot breakfast! Today on Family Food Live, we are sharing 5 Hot Breakfast Ideas to Start Your Day!

Family Food Live is live every Wednesday and Friday at 12 Noon CST. You can find us on the Burnt Macaroni Facebook page on Wednesdays or every Friday at 12 Noon CST on the Quirky Momma Facebook page. And that includes today! Make sure to like us now so you’ll never miss an episode!

Here’s what we are making today…

Apple Breakfast Crisp

This very light but delicious hot Apple Breakfast Crisp combines the yumminess of cooked apples with cinnamon and honey. This is one of my favorite hot breakfasts!

On the Go Omelet Breakfast Bites

These are the perfect make ahead breakfast for the kids as they are running out the door. Your family will love these On the Go Omelet Breakfast Bites!

Biscuits and Gravy Breakfast Casserole

Shopping List:

• 2 cans Biscuits
• 1 package ground Breakfast Sausage
• 4 tablespoons Flour
• ½ teaspoon Salt
• ½ teaspoon Black Pepper
• ½ teaspoon Garlic Powder
• 2 and ½ cups milk

Instructions:

• Preheat oven to 400° F
• Cut biscuits into quarters
• Spray 9×13 baking dish with non-stick spray. Fill the bottom with half of the quarters of biscuits.
• Bake for 10 minutes
• While the biscuits are baking, brown the sausage until cooked through
• In a mixing bowl, combine flour, salt, pepper and garlic powder. Add the flour mixture to the skillet with the browned sausage
• Add milk and stir completely until the mixture comes to a simmer
• Reduce heat and continue to simmer until the gravy thickens
• Pour gravy over bottom layer of cooked biscuits and top with remaining biscuit quarters
• Bake 15-20 minutes or until top biscuits are golden brown

Peanut Butter Banana Oatmeal

Shopping List:

• 1 3/4 cups milk
• 1 cup quick oats
• 1 large ripe banana, mashed
• 2 tablespoons peanut butter
• 1/2 teaspoon ground cinnamon
• 1/4 teaspoon pure vanilla extract
• Pinch of salt
• 1 to 3 teaspoons honey, optional
• Sliced bananas, and cinnamon, for serving

Instructions

• In a saucepan, bring milk to a boil
• Stir in oats and reduce heat to a simmer for about 2 minutes
• Remove from heat and cover for a few minutes
• Stir in mashed bananas, peanut butter, honey, cinnamon, vanilla and salt
• Top with banana slices
• Serve

Pumpkin Spice Hot Chocolate

Shopping List:

• 2 1/2 cups non-dairy milk
• 1/2 cup canned pumpkin
• 2 tablespoons cocoa powder
• 1 teaspoon pumpkin pie spice
• 1/2 teaspoon vanilla extract
• Sugar to taste

Instructions

• Combine all ingredients in blender and blend until smooth. Add sugar if needed
• Pour into a saucepan and bring to a simmer, stirring occasionally
• Serve hot

Join Family Food Live with Holly & Chris every Wednesday and Friday at Noon CST on either the Quirky Momma Facebook page or the Burnt Macaroni Facebook page!

We are also so excited to share our first Family Food Live Apron with you.  Be the first to pick one up and start cooking with us!

Here are a few of our favorite products from Family Food Live (affiliate links)

• Cuisinart Food Processor
• The I Heart Naptime Cookbook by Jamielyn Nye
• Giant Popcorn bowl
• Individual Popcorn bowls
• VillaWare Uno Classic Waffle Maker
• VillaWare Farmyard Waffle Maker
• Taco Holder
• Pyrex Baking Dishes
• Hand Blender
• Pizza Peel
• Pizza Wheel (cutter)
• Pizza Stone
• Pre-Seasoned Cast Iron Double Burner Reversible Grill/Griddle
• Cuisinart Chef’s Classic Stainless 5-1/2-Quart Saute Pan with Helper Handle and Cover
• BPA free lunch containers
• Egg Rite Egg Timer
• Fit and Fresh container
• One Touch Electric Bottle Opener
• Half Pint Wide Mouth Mason Jars
• Ninja Professional Blender
• Zoku Quick Pop Maker
• Williams-Sonoma Open Kitchen Half Apron in Red or Blue
• Plano Half-Size Stowaway with Adjustable Dividers – for road trip snacks
• Curious Chef 3-Piece Nylon Knife Set
• Cuisinart 2 Quart Ice Cream Maker
• Victorinox Fibrox Straight Edge Chef’s Knife, 8-Inch
• Lemon Squeezer
• Mason Jars
• Crockpot
• Apple Corer
• Popcorn Bowl
• MaxiMatic double burner hot plate
• Glass Egg carton
• Black & Decker 4 slice toaster
• Hamilton Beach Hand Mixer
• Cuisinart 8-cup Food Processor
• Meat Mallet
• Ice Cream or Cookie Scooper
• Norpro Butter Keeper
• Norpro Butter Keeper
• 3-Piece Veggie Peeler
• Garlic Press

The post 5 Hot Breakfast Ideas to Start Your Day! appeared first on Kids Activities Blog.

from Kids Activities Blog http://ift.tt/2diHksq

15 Creative Play Ideas for Kids {and Moms!}

Creative Play is really important. We know it is important for kids, but have you thought about how important it is for moms as well? Kids shouldn't have ALL the fun! Today we've compiled some of the best 15 Creative Play Ideas for Kids and Moms!

Does your family ever eat out? Here's 20+ Creative Ways to Keep Preschoolers Occupied at a Restaurant.

 

15 Creative Play Ideas for Kids {and Moms!}

Creative Play Ideas for Kids

• Encourage your kid to play independently with these Good Morning Tubs…written for a classroom, but I'm so stealing these for HOME! -via The Brown Bag Teacher
• I just LOVE these 43 Quiet Time Activities for 2 Year Olds! Seriously, bookmark this page now if you have a toddler. -via How We Learn
• Building with Sticks and Playdough is such a great idea and you don't have to go out and buy anything if you make homemade playdough. -via FireFlies and Mud Pies
• Want to raise a helper? Get your kids off to a great start with these 15 Ways to Raise a Helper. -via Rhythms of Play

Supporting Your Kid's Creative Play

• You know how much we love paper plate crafts over here at Kids Activities Blog and here's 10 Creative Paper Plate Crafts to keep your kids busy all afternoon. -via Kids Activities Blog
• Your kids will have fun turning their gifts into fruit with this very creative Fruit Wrapping Paper idea! -via The House that Lars Built
• Here's a creative homemade gift idea –> a Play Dough Cupcake Factory Kit! I've never seen anything like this before. -via Plain Vanilla Mom
• Science for Kids: Make Magic Milk is a classic science experiment that is colorful too. -via Babble Dabble Do
• Make drawing SUPER FUN with these Toilet Roll Scribblers. You never thought about doing this with a toilet paper roll. -via The Craft Train
• Here's a science project a toddler can make all by themselves, a Pine Cone Bird Feeder. -via Kids Activities Blog

5 Creative Play Ideas for Moms

• Dieting is a piece of cake…and that's why there's White Chocolate and Raspberry Cheesecake. Did we mention it's no bake too? -via Neil's Healthy Meals
• My mouth is watering over this Triple Cheese and Bacon Dauphinoise. Just don't tell the kids how good it tastes. -via BBC Good Food
• Bump up your smartphone game with these 7 Photography Apps that you may not have heard of and how to use them. -via The Glitter Guide
• Check out this FREE Floral Calendar that you can download and print year after year. -via Smart School House
• These 13 Clever Melt and Pour Soaps are almost too pretty to use. -via The Perfect DIY

What are some of your Creative Play Ideas for Kids or Moms? Head over to our Facebook page to share your ideas!

The post 15 Creative Play Ideas for Kids {and Moms!} appeared first on Kids Activities Blog.

from Kids Activities Blog http://ift.tt/2dIZbuQ

15 Creative Play Ideas for Kids {and Moms!}

Creative Play is really important. We know it is important for kids, but have you thought about how important it is for moms as well? Kids shouldn’t have ALL the fun! Today we’ve compiled some of the best 15 Creative Play Ideas for Kids and Moms!

Does your family ever eat out? Here’s 20+ Creative Ways to Keep Preschoolers Occupied at a Restaurant.

 

15 Creative Play Ideas for Kids {and Moms!}

Creative Play Ideas for Kids

• Encourage your kid to play independently with these Good Morning Tubs…written for a classroom, but I’m so stealing these for HOME! -via The Brown Bag Teacher
• I just LOVE these 43 Quiet Time Activities for 2 Year Olds! Seriously, bookmark this page now if you have a toddler. -via How We Learn
• Building with Sticks and Playdough is such a great idea and you don’t have to go out and buy anything if you make homemade playdough. -via FireFlies and Mud Pies
• Want to raise a helper? Get your kids off to a great start with these 15 Ways to Raise a Helper. -via Rhythms of Play

Supporting Your Kid’s Creative Play

• You know how much we love paper plate crafts over here at Kids Activities Blog and here’s 10 Creative Paper Plate Crafts to keep your kids busy all afternoon. -via Kids Activities Blog
• Your kids will have fun turning their gifts into fruit with this very creative Fruit Wrapping Paper idea! -via The House that Lars Built
• Here’s a creative homemade gift idea –> a Play Dough Cupcake Factory Kit! I’ve never seen anything like this before. -via Plain Vanilla Mom
• Science for Kids: Make Magic Milk is a classic science experiment that is colorful too. -via Babble Dabble Do
• Make drawing SUPER FUN with these Toilet Roll Scribblers. You never thought about doing this with a toilet paper roll. -via The Craft Train
• Here’s a science project a toddler can make all by themselves, a Pine Cone Bird Feeder. -via Kids Activities Blog

5 Creative Play Ideas for Moms

• Dieting is a piece of cake…and that’s why there’s White Chocolate and Raspberry Cheesecake. Did we mention it’s no bake too? -via Neil’s Healthy Meals
• My mouth is watering over this Triple Cheese and Bacon Dauphinoise. Just don’t tell the kids how good it tastes. -via BBC Good Food
• Bump up your smartphone game with these 7 Photography Apps that you may not have heard of and how to use them. -via The Glitter Guide
• Check out this FREE Floral Calendar that you can download and print year after year. -via Smart School House
• These 13 Clever Melt and Pour Soaps are almost too pretty to use. -via The Perfect DIY

What are some of your Creative Play Ideas for Kids or Moms? Head over to our Facebook page to share your ideas!

The post 15 Creative Play Ideas for Kids {and Moms!} appeared first on Kids Activities Blog.

from Kids Activities Blog http://ift.tt/2dIZbuQ

The Grey by Westland – Ultra Luxury West Point Grey Pre-Construction Residences

Epitome of Modern Elegance
The Grey is situated at the north end of Dunbar Village on West 16th Avenue, The homes in the neighbourhood are predominantly  single­-family. With this in mind, homes are designed to appeal to the luxuries and comforts of single­-family living. Designed by acclaimed IBI, the four­-storey building complements the historic neighbourhood with a composite of natural stone, metal panel, glass and concrete. The Grey is a timeless illustration of contemporary elegance.

The Grey will have a selection of two­-bedroom to three-­bedroom plus den homes, also included in the plans are penthouse ­level homes, and ground-level commercial space. Penthouses will have their own private rooftop balconies and many homes will benefit from large outdoor terraces.The Grey is located on the crest of Dunbar, north-facing homes will have amazing views of the water, North Shore mountains and Downtown Vancouver. All large homes will carry the Westland pedigree that can only be offered from an ultra ­luxury single­-family builder.

Pricing for The Grey
Details have not yet been released

Floor Plans for The Grey
All residences will consist of two or more bedrooms, including two 1,087 sq ft 2-bedroom suites, 18 2-bedroom + den homes from 1,132-1,353 sq ft, two 1,400 sq ft 3-bedroom condos, and seven penthouses from 911-3,500 sq ft.

Superior Interiors

• Two finely-crafted, custom colour palettes by Guo Interiors coordinate with your personal style
• 9’ ceilings in living and bedroom areas visually expand the scope of each room
• Wide-plank engineered hardwood flooring flows throughout the living and bedroom areas
• Side-by-side washer and dryer laundry closets
• Solid core doors in each room create additional privacy and security
• Custom-designed built-in closets allow for plenty of room for organization of your possessions
• Automated smart-home technology by Creston controls temperature and lighting through a sleek wall-mount keypad
• Additional smart-home technology available through the Westland Design Centre
• Tailor your home with our pre-selected options for customization and personalization at the Westland Design Centre

 

Connoisseur Kitchens

• Italian-imported, custom-stained oak veneer cabinets designed for the needs of the at-home chef
• Oversized kitchens with islands
• Renowned, state-of-the-art Gaggeneau appliances:
• Multi-language options
  • 36” 5-burner gas cooktop with stainless steel high CFM hood fan
  • Stand-alone 24” integrated refrigerator column
  • Stand-alone 18” integrated freezer column
  • Built-in microwave
  • Built-in, ultra-quiet speed dishwasher
  • 24” handleless, automatic door-opening wall oven
• Each home includes the option for a one-of-a kind culinary entertainment centre with an integrated pantry that features:
  • Gaggeneau coffee maker
  • Gaggeneau refrigerated wine column
  • Pull-out storage
  • Custom bar with mirrored wall and lit display shelving for your finest cognac
• Custom-designed drawer and door organizers keep kitchen essentials in their place
• Integrated soft-touch, self-close doors and drawers maintain a visually clean kitchen and minimize noise
• Kitchens offer convenient under-cabinet task LED lighting for precision work
• Easy-to-maintain solid quartz countertops with full-height quartz backsplash and marble-top island make a statement
• European-designed, arched chrome Hans Grohe faucet

Show-Stopper Bathrooms

• Italian-imported, wood veneer cabinets hover over exquisite tile floor
• Master bathroom features:
  • Opulent free-standing tub enclosed within a stunning frameless glass bathing room
  • Flush-mount, custom-stained oak, mirrored medicine cabinets with built-in lighting and electrical outlets
  • Nu-heat flooring for year-round comfort
  • Pristine white countertops are paired with Hans Grohe wall-mount or free-standing faucets and fixtures
  • Oversized 5’-wide porcelain marble slab creates a spectacular bathing experience
• Powder room features:
  • Exceptional oversized, three-sided vessel sink
  • Duravit wall-mounted lavatory
  • Sparking chrome Hans Grohe faucet

Developer Team for The Grey
Westland, a family company, was established in 2008. Since then, Westland has designed and built over 40 ultra-luxury custom homes in some of Vancouver’s most prestige neighbourhoods – Shaughnessy and Kerrisdale. Completely original, each of these custom homes have been meticulously designed to express the unique personality of the homeowner.

Expected Completion for The Grey
Sales start Fall/Winter 2016. Completion date is yet to be determined.

The post The Grey by Westland – Ultra Luxury West Point Grey Pre-Construction Residences appeared first on Vancouver New Condos.

from Buildings – Vancouver New Condos http://ift.tt/2da3LAe

The Grey by Westland – Ultra Luxury West Point Grey Pre-Construction Residences

Epitome of Modern Elegance
The Grey is situated at the north end of Dunbar Village on West 16th Avenue, The homes in the neighbourhood are predominantly  single­-family. With this in mind, homes are designed to appeal to the luxuries and comforts of single­-family living. Designed by acclaimed IBI, the four­-storey building complements the historic neighbourhood with a composite of natural stone, metal panel, glass and concrete. The Grey is a timeless illustration of contemporary elegance.

The Grey will have a selection of two­-bedroom to three-­bedroom plus den homes, also included in the plans are penthouse ­level homes, and ground-level commercial space. Penthouses will have their own private rooftop balconies and many homes will benefit from large outdoor terraces.The Grey is located on the crest of Dunbar, north-facing homes will have amazing views of the water, North Shore mountains and Downtown Vancouver. All large homes will carry the Westland pedigree that can only be offered from an ultra ­luxury single­-family builder.

Pricing for The Grey
Details have not yet been released

Floor Plans for The Grey
All residences will consist of two or more bedrooms, including two 1,087 sq ft 2-bedroom suites, 18 2-bedroom + den homes from 1,132-1,353 sq ft, two 1,400 sq ft 3-bedroom condos, and seven penthouses from 911-3,500 sq ft.

Superior Interiors

• Two finely-crafted, custom colour palettes by Guo Interiors coordinate with your personal style
• 9' ceilings in living and bedroom areas visually expand the scope of each room
• Wide-plank engineered hardwood flooring flows throughout the living and bedroom areas
• Side-by-side washer and dryer laundry closets
• Solid core doors in each room create additional privacy and security
• Custom-designed built-in closets allow for plenty of room for organization of your possessions
• Automated smart-home technology by Creston controls temperature and lighting through a sleek wall-mount keypad
• Additional smart-home technology available through the Westland Design Centre
• Tailor your home with our pre-selected options for customization and personalization at the Westland Design Centre

 

Connoisseur Kitchens

• Italian-imported, custom-stained oak veneer cabinets designed for the needs of the at-home chef
• Oversized kitchens with islands
• Renowned, state-of-the-art Gaggeneau appliances:
• Multi-language options
  • 36" 5-burner gas cooktop with stainless steel high CFM hood fan
  • Stand-alone 24" integrated refrigerator column
  • Stand-alone 18" integrated freezer column
  • Built-in microwave
  • Built-in, ultra-quiet speed dishwasher
  • 24" handleless, automatic door-opening wall oven
• Each home includes the option for a one-of-a kind culinary entertainment centre with an integrated pantry that features:
  • Gaggeneau coffee maker
  • Gaggeneau refrigerated wine column
  • Pull-out storage
  • Custom bar with mirrored wall and lit display shelving for your finest cognac
• Custom-designed drawer and door organizers keep kitchen essentials in their place
• Integrated soft-touch, self-close doors and drawers maintain a visually clean kitchen and minimize noise
• Kitchens offer convenient under-cabinet task LED lighting for precision work
• Easy-to-maintain solid quartz countertops with full-height quartz backsplash and marble-top island make a statement
• European-designed, arched chrome Hans Grohe faucet

Show-Stopper Bathrooms

• Italian-imported, wood veneer cabinets hover over exquisite tile floor
• Master bathroom features:
  • Opulent free-standing tub enclosed within a stunning frameless glass bathing room
  • Flush-mount, custom-stained oak, mirrored medicine cabinets with built-in lighting and electrical outlets
  • Nu-heat flooring for year-round comfort
  • Pristine white countertops are paired with Hans Grohe wall-mount or free-standing faucets and fixtures
  • Oversized 5'-wide porcelain marble slab creates a spectacular bathing experience
• Powder room features:
  • Exceptional oversized, three-sided vessel sink
  • Duravit wall-mounted lavatory
  • Sparking chrome Hans Grohe faucet

Developer Team for The Grey
Westland, a family company, was established in 2008. Since then, Westland has designed and built over 40 ultra-luxury custom homes in some of Vancouver's most prestige neighbourhoods – Shaughnessy and Kerrisdale. Completely original, each of these custom homes have been meticulously designed to express the unique personality of the homeowner.

Expected Completion for The Grey
Sales start Fall/Winter 2016. Completion date is yet to be determined.

The post The Grey by Westland – Ultra Luxury West Point Grey Pre-Construction Residences appeared first on Vancouver New Condos.

from Buildings – Vancouver New Condos http://ift.tt/2da3LAe

Fail To Scale: Why Great Ideas In Health Care Don’t Thrive Everywhere

In the world of fine wine, it is well known that some types of wine grapes grow only in very specific climates and ecologies. The concept borrowed from the French is “terroir” (ter-WAHR). Terroir explains why the finest champagne grapes grow only in a small district in northeastern France, characterized by rolling hills and a chalky limestone subsoil that provides a steady level of moisture and imparts a mineral note to the wine’s flavor.

Health policy advocates have sought for generations to propagate promising forms of health care organization across the country. Yet one finds repeatedly that some forms of organization that prosper in one part of the country fail to thrive in others. Is it possible that the concept of terroir also applies in health care?

The Case Of Kaiser Permanente

Kaiser Permanente’s health plans would be a great example. Kaiser has been a darling of health policy advocates such as Alain Enthoven, Paul Ellwood, and others because of its integrated structure, global risk, and salaried employment model of physician practice. Yet, despite repeated federal interventions, beginning with the Health Maintenance Organization Act of 1973, Kaiser only recently exceeded 10 million in enrollment for the first time in its 71 year history. Moreover, 82 percent of that enrollment is in two states—Oregon and California—where Kaiser originated. The percentage of Kaiser’s enrollment that derives from its origin states is basically unchanged in a decade.

What was the “terroir” that enabled Kaiser to flourish in these states? Kaiser’s growth rested on a combination of the prevalence of large scale multispecialty group practice, a tradition of prepayment for health services (as opposed to indemnity insurance), and large unionized employers tied to trade, ship building, and defense contracting after World War II. As the unionized sector of employment was displaced by growth in other economic sectors, Kaiser’s substantial presence in large Pacific Coast markets (San Francisco, Sacramento, Portland, Los Angeles, and San Diego) lowered the cost of additional enrollment.

Kaiser has presences in other markets like Denver, Hawaii, and the District of Columbia that have grown modestly. But it never achieved West Coast levels of dominance in these markets, and ambitious attempts during the 1990s to become a “national” health insurer ended in costly failure.

Independent Practice Associations

Kaiser’s dominance in Pacific Coast markets encouraged the growth of another innovation — the risk-bearing Independent Practice Association (IPA). In order to defend their franchises against Kaiser’s steady growth, state medical societies in the 1970s encouraged their members to form rival IPA networks that preserved solo practice.

Private practicing physicians using these IPAs and insurgent payers like PacifiCare and HealthNet formed broad regional alliances during the 1980s. IPAs like Hill Physicians, Brown and Toland, and Monarch accepted delegated risk from these health plans through capitated contracts. These IPAs also developed management services organizations that supported small practices and facilitated billing and documentation for these managed care contracts, enabling them to compete for business with the vast Kaiser groups. Delegating risk to physician organized care systems helped some health insurers to keep pace with Kaiser’s growth, at least for a time. Absent the Kaiser threat, it is highly unlikely that these IPAs would have attracted enough physicians willing to support them.

One of the most successful of these risk-bearing physician enterprises, HealthCare Partners (HCP), spawned its own salaried multi-specialty group practice and grew to the point where it was acquired by DaVita in 2011 for $4.4 billion. Yet even with a very successful business model, HealthCare Partners has failed to thrive outside the Los Angeles basin. In Albuquerque, Las Vegas, Philadelphia, and Florida, HealthCare Partners has struggled to achieve either market influence or profitability. Visions of scaling up the HCP model to a national brand have thus far eluded DaVita, disappointing the company’s shareholders and challenging its management. DaVita is fighting a terroir problem.

Provider-Sponsored Health Insurance

Another example of a terroir effect can be found in provider-sponsored health insurance. There have been multiple waves of provider-sponsored health plan development since the early 1970s, characterized by a high failure rate. Adverse selection (e.g., enrolling a disproportionate number of their own patients, or people who are expected to become patients), a lack of capital, a failure to achieve a critical mass of enrollment, and in-house conflicts with hospital and physician subsidiaries have been the the main autopsy findings.

However, formidable provider-sponsored health plans survived the withering market entry process, including Presbyterian in Albuquerque, Select Health for InterMountain in Utah, Geisinger in Pennsylvania, Optima for Sentara in Virginia, and Priority Health for Spectrum in Western Michigan. Many of these plans and their dominant provider systems developed in more rural areas with limited health plan choices. Humana and PacifiCare were the only provider sponsored plans to reach public markets, but only after they were corporately separated from their sponsoring hospitals.

Nationally, about 15 million people were enrolled in provider-sponsored health insurance plans in 2015, two-thirds in managed Medicaid and Medicare Advantage segments. That translates into a total market penetration of about 5 percent of the total covered population (public and private), and about 3 percent of the commercial market.

Yet in Wisconsin, provider-sponsored health insurers today account for nearly 40 percent of the covered population. The very same conditions that fostered Kaiser’s growth played a role in Wisconsin — a long history of multi-specialty practice, plus a collectivist political tradition that inhibited protectionism on the part of solo practitioners, and a strong union-driven health benefits climate plus the factor of a significant rural population with limited health plan options.

Very Little About the Health System is Actually National

Other candidates for terroir-type explanations of striking regional variation: the wide prevalence of industrial-scale Medicare fraud in certain sunbelt communities like southern California and south Florida, the inability of the investor-owned hospital sector to achieve a significant presence in the Midwest or Northeast, the incapacity of hospital managements and physician communities to work collaboratively in wide swathes of the sunbelt, the limited success of the accountable care organization (ACO) phenomenon in the Midwest or Far West, and the limited development of economic clusters in the life sciences such as are found in Cambridge, Massachusetts, Silicon Valley, and San Diego.

In our experience, there seems to be almost nothing except Medicare that is truly national about our health system. Fort Lauderdale, Florida, Hastings, Nebraska, and Seattle, Washington are actually in different countries culturally and politically. Those significant cultural and political differences have economic and historical roots, and uniquely color the traditions of medical practice and health care organization that prevail in those communities.

The existence of marked regional differences in health system organization and financing is not news to the health services research community. Starting in the 1990s, Paul Ginsburg and colleagues at the Center for Studying Health System Change documented the markedly different development paths taken by health care players in 12 urban markets.

Looking Beyond Economic Factors in Health System Change

For the past 40 years, American health policy has been dominated by economists. Their economic models presume universality in how physicians respond to incentives. These models captivate politicians and their handlers, and seem to come in waves, like memes in fashion or popular culture. Yet, over and over again, mechanistic, marginalist economic explanations of how incentives shape physician behavior play out unevenly in different regions of the country, and have resulted in a lengthening string of policy disappointments.

A failure to understand and respect the role that local culture and market conditions for health system innovation profoundly limits the effectiveness of “single bullet” policy solutions. After a while, veteran policy observers find ourselves saying (as we did with the ACO) “Wouldn’t it be great if, before mounting our trusty steeds and charging up the same box canyon, people would simply ask, ‘What happened the last three times we tried to do this?’ Why did innovations fail in some parts of the country and succeed in others? The checkered record of the CMS Innovation Center might be attributed in part to a failure to understand and respect the effects of terroir on health system innovation.

Perhaps a healthy respect for non-economic factors in health system behavior—often rooted in local and regional circumstances and in institutional culture—might be a corrective for those who see sweeping “national” solutions to complex problems. To paraphrase the famous line from the movie Cool Hand Luke “What we have here is failure to replicate.” Absent a respect for local and non-economic factors, we will continue the wasteful practice of sowing our policy seeds on barren ground.

Authors’ Note

Authors would like to acknowledge the assistance of Lauren Crowther of Navigant Healthcare in research for this article.

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