Instruction: create a high quality summary of the given input

Input:
Consumer-protected crypto payments platform raises $3.5m pre-ICO
 ZUG, Switzerland - September 20, 2017 - ( Newswire.com

UTRUST is pleased to announce it has so far raised $3.5 million USD in total, for the world‘s first Bitcoin and cryptocurrency payments platform with consumer protections. To express gratitude and to show how much they appreciate the enthusiasm of their supporters, UTRUST has decided to introduce an Early Supporter Reward.

Anyone who is already registered, or who registers on the UTRUST website before the 20th of September 2017, will receive a 20% reward on the first $10,000 contributed during the ICO. For example, if a supporter contributes $1,000, they will receive $1,200 of UTRUST tokens.

UTRUST CEO Nuno Correia, and co-founder Filipe Castro, CIO also hosted a live video streaming AMA event on the 15th Sept. Nuno, Filipe, and Artur the CTO answered many questions from the community. The full recorded live stream can be viewed here.

Last week, UTRUST also announced that a new public ICO date will be shared in early October, with a more equitable public ICO structure.

About UTRUST

UTRUST has currently raised $3.5 million through private early investors and the sold-out pre-ICO, with the public ICO to be announced in early October.

UTRUST is the world’s first cryptocurrency payments platform to implement consumer protections on a mass scale. The company is building a global PayPal–like payments platform with extensive cryptocurrency support.

UTRUST’s end goal is to provide all the benefits of fast, secure, convenient, and inexpensive cryptocurrency transactions, in tandem with the world’s first cryptocurrency payment protections, which consumers need to fully embrace blockchain technology en masse.

With 2.5 billion unbanked people in Emerging Markets yet to benefit from financial inclusion, UTRUST is also planning to build the bridge to enable the unbanked worldwide to access the mainstream global financial system.

UTRUST ICO and Tokens

UTRUST’s public ICO will be set in October. The company will use the collected funds to establish key industry partnerships and to develop the world’s first PayPal-like cryptocurrency payments platform. The ERC20 compatible tokens are created over the Ethereum protocol and can be used as a means of payment on UTRUST’s payment gateway along with other cryptocurrencies.

UTRUST’s token can be used for making zero-fee payments to the thousands of merchants accepting any cryptocurrency via UTRUST, and be traded against other currencies on supported exchange platforms.

UTRUST will allocate a certain portion of the revenues to buyback and destroy the tokens in circulation. Being a deflationary currency by design, the demand for UTRUST tokens will increase with time, which combined with buyback should lead to appreciation in its market value.

To learn more about UTRUST’s ICO please go to: https://utrust.io/ico

The Team

UTRUST is backed by a highly-experienced team from various sectors including corporate management, startups, payments, cryptocurrency development, law, finance, and computer science. Some of the prominent members of the team include:

Nuno Correia, CEO

Nuno Correia is an early cryptocurrency investor who has been involved in the cryptomarkets since the beginning of 2011. Having founded multiple B2C businesses in the past, Correia has a background in Law and Marketing, and his passion lies in transforming the future of digital payments.

Filipe Castro, CIO

Filipe Castro holds a business degree from MSENG and is passionate about disruptive technologies. He has experience developing electronic payment systems and other software solutions during the early days of his career. Castro is engaged in business development and strategic development of new ventures.

Artur Goulão, CTO

Artur Goulão comes with previous experience in the payments industry. He has previously donned the role of a CTO in one of leading digital payment platform and is currently serving as the Head of Development at a Swiss-based cybersecurity company. With a background in computer science from IST and MIT, Goulão is well-acquainted with both classical and blockchain smart contract-based approach.

Roberto Machado, CPO

Founder and Product Manager at several startups prior to UTRUST, he has been leading different teams to build highly-reliable software products, with a focus on the end-user experience. Previously, he has worked together with major international companies such as AT&T, Betfair, Airtel, and Uphold, being responsible for the vision outline, goals and product strategy of solutions used by millions of users.

Other significant team members include Luis Ferreira as Head of Engineering; Laura Esteves as Head of Operations; Joao Ferreira as Head of Design; Nick Olender as Head of Sales and Partnerships; and Francisco Baila as Product Designer. UTRUST has a team of software engineers like Miguel Palhas, Gabriel Poca, Ronaldo Sousa, Fernando Mendes, Bruno Azevedo, Pedro Costa, and Joao Justo.

UTRUST’s diverse advisory team includes Francisco Maia, Francisco Cruz, Joao Paulo, Sergio Viana, Marc Howland, David Dryan, Daniel Pierce and Sascha Benz.

Learn more about UTRUST: https://utrust.io

Read the UTRUST Whitepaper: https://s3-eu-west-1.amazonaws.com/utrust/UTRUST-whitepaper-v1.0.1.pdf

Learn more about UTRUST’s ICO: https://utrust.io/ico

Follow UTRUST on Twitter: https://twitter.com/UTRUST_Official

Join UTRUST on Facebook: https://www.facebook.com/utrust.io

Join the UTRUST Slack conversation: https://utrust-official.slack.com

Join UTRUST on Telegram at: https://t.me/utrustofficial

Read UTRUST’s posts on Medium: https://medium.com/@UTRUST

Media Contact

Contact Name: Nuno Correia, UTRUST CEO

Contact Email: nuno@utrust.io

Contact Phone: +41 22 518 70 77

Location: Zug, Switzerland

Related Links

Press Release Service by Newswire.com Original Source: UTRUST Raises $3.5 Million for Blockchain Payments Platform, Public ICO in October

Output: Swiss blockchain firm UTRUST has raised $3.5m from private investors ahead of its planned initial coin offering (ICO) in October. The funds will be used to establish key industry partnerships. UTRUST is developing the first cryptocurrency payments platform to feature consumer protections. The company aims to offer "fast, secure, convenient and inexpensive cryptocurrency transactions", and also target the 2.5 billion unbanked people in emerging markets.


Instruction: create a high quality summary of the given input

Input:
Dublin's Pointy raises $6m to help retailers list their wares
 Mark Cummins and Charles Bibby. Pointy

Pointy, a Dublin startup with a device that shopkeepers can use to list their products online, has raised $6 million (£4 million) from a host of big name investors.

The Series A funding comes from Matt Mullenweg, founder of WordPress, Lars Rasmussen cofounder of Google Maps, Taavet Hinrikus cofounder of TransferWise, and Michael Birch cofounder of Bebo.

Venture capital firms Draper Associates and Frontline Ventures also participated in the round, which brings total investment in Pointy up to around $7.2 million (£5.3 million).

Founded by Mark Cummins and Charles Bibby, who met while studying their PhDs in robotics, Pointy provides local stores with a way to list all of their products online.

The company's "Pointy box" device connects to a store's barcode scanner and automatically puts scanned items on a website for the store. Pointy says that store pages are optimised for search engines, so that when local customers search for products, they find results from local stores.

The Pointy Box. Pointy

"For many local retailers, keeping up with technology can feel like too much," said Cummins in a statement. "They have full time jobs to do already, they don't have the time or expertise to create digital stores as well. But consumers increasingly expect to find everything on their smartphones.

"If someone takes out their phone to search for a product they want to buy, they're likely to see a result from Amazon, even if a local store 50 feet away has the product in stock. It's a frustrating for retailers and consumers alike. Pointy is solving that problem in a way that's effortless for retailers."

Output: Dublin start-up Pointy has raised $6m in a series A funding round led by the founders of Bebo, Google Maps, TransferWise and WordPress. The Irish firm has developed a device that links to a barcode scanner, enabling retailers to easily list their products on a website, with results optimised for search. "If someone takes out their phone to search for a product they want to buy, they're likely to see a result from Amazon, even if a local store 50 feet away has the product in stock. It's frustrating for retailers and consumers alike," said co-founder Mark Cummins.


Instruction: create a high quality summary of the given input

Input:
SoCal Confronts Hepatitis A Outbreak
 Vaccinations are urged, but the source of the outbreak is still unknown, as public health agencies in Los Angeles, Santa Cruz and San Diego counties take measures to combat the highly contagious virus.

Three counties in Southern California are dealing with a hepatitis A outbreak, with the majority of cases afflicting homeless people, drug addicts and the people who provide services for them.

“Public Health has been proactively preparing for an outbreak for some time and is working diligently to prevent spread in local communities. Our priorities are to keep all our residents both safe and well informed of the situation,” Jeffrey Gunzenhauser, MD, MPH, Interim Health Officer, Los Angeles County, said in a media release this week.

“Vaccination is the best protection against Hepatitis A. With this in mind, our outreach teams and clinics are offering free vaccine to persons who are homeless, active drug users, and those who provide services and support to those individuals,” Gunzenhauser said.

Hepatitis A outbreaks are also ongoing in San Diego and Santa Cruz counties. Officials have confirmed 10 total cases of the highly contagious virus among high-risk people in Los Angeles County. Four of the infected people had been in San Diego and one had been in Santa Cruz during their exposure period.

Three secondary cases occurred in a healthcare facility in Los Angeles County. Two most-recent cases appear to have acquired their infection locally within Los Angeles County, officials said.

Hepatitis A can be acquired through contact with an infected person’s feces through contaminated food or objects. Officials have all but ruled out contaminated food as the source of this outbreak.

The hepatitis A virus can spread when a person does not properly wash their hands after going to the bathroom or changing diapers. The virus can cause acute liver disease.

Other modes of transmission include certain sexual practices, sharing equipment related to illicit drug use, and consumption of food or water contaminated with the virus. People who are homeless are at higher risk because they face challenges to maintaining good hygiene, officials said.

Symptoms of acute hepatitis A include fever, malaise, dark urine, lack of appetite, nausea, and stomach pain, followed by jaundice. Symptoms generally last for less than two months although some persons may have prolonged or more severe illness. Infection can be prevented in close contacts of patients by vaccination or administration of immune globulin within two-weeks following exposure.

San Diego County

Public health officials in San Diego County have been grappling for several months with the outbreak of hepatitis A, which is blamed for at least eight deaths, with all of the victims weakened by underlying medical conditions.

Nick Yphantides, MD, with the San Diego County Health & Human Services Agency, said this week that “the outbreak is not from a contaminated food source. It is caused by person-to-person transmission.”

“One of the challenges of this virus is the long incubation period,” Yphantides said. “With this virus the average incubation period is 28 days, but the range of the incubation period can be anywhere from 15 to 50 days, which is quite a long incubation period.”

“Another complicating factor, medically speaking, is that individuals can be infected and can be transmitting the virus for up to two weeks prior to them having any symptoms,” he said.

Santa Cruz County

Since April, Santa Cruz County has had 69 confirmed cases of hepatitis A. They usually have 1-2 confirmed cases per year.

The county’s Public Health Division says an investigation is ongoing and challenging because of the long incubation period and the difficulty contacting people sickened with the illness who are homeless and/or illicit drug users.

With no common source of food, beverage, or other cause identified, the source of the outbreak remains undetermined, county officials said.

Output: Vaccinations are urged, but the source of the outbreak is still unknown, as public health agencies in Los Angeles, Santa Cruz and San Diego counties take measures to combat the highly contagious virus.


Instruction: create a high quality summary of the given input

Input:
California would lose $78 billion — more than any other state — under GOP health bill
 California would lose more federal funding than any other state under the latest GOP plan to repeal the Affordable Care Act, according to an analysis released Wednesday by the health policy consulting firm Avalere Health.

By 2026, California would lose $78 billion in federal money for the Medi-Cal insurance program for the poor and in federal subsidies for low-income residents who buy health insurance through Covered California, the state exchange created under the ACA. That figure represents a 13 percent drop in federal funding levels, according to the analysis, which was funded by the left-leaning think tank Center for American Progress.

Blue states like California and New York that accepted the ACA’s additional federal dollars to expand Medicaid would be hit disproportionately hard by the bill, advanced by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.). By comparison, some red states that did not expand Medicaid would see an increase in federal funding. Texas, for instance, would receive $35 billion more from the federal government in 2026, the analysis found.

“The bill reallocates funding from states that expanded Medicaid to those that did not,” said Caroline Pearson, senior vice president at Avalere Health. “So a large state like California, which has had a big Medicaid expansion under the ACA, (is) going to be worse off.”

The Graham-Cassidy bill is similar to previous GOP bills that failed to gain enough support in the Senate earlier this year. It would eliminate the ACA’s individual and employer mandate and the expansion of Medicaid — which allowed California to enroll 4 million new people. It would also phase out federal subsidies currently used by 1.3 million low-income Californians to buy health insurance through Covered California.

Cassidy and Graham released their own estimates of how the bill would impact states, finding that California would receive roughly the same amount of federal funding under their plan. However, outside analysts said this estimate understates the impact to states because it was based on a misleading comparison. Rather than comparing spending levels under the GOP bill to spending levels under the ACA for the same year, it compares spending levels under the GOP bill for 2026 to spending levels under the ACA for 2020. This comparing apples to oranges, analysts said, because health costs rise over time, regardless of changes to health policy.

The non-partisan Congressional Budget Office plans to release a partial assessment of the bill next week.

The bill proposes grouping together the two streams of federal funding — federal subsidies for those buying Covered California plans and federal funding for Medi-Cal expansion — capping it, and then decreasing the amount over time through a mechanism known as a block grant. The funding for the block grants would end altogether after 2026, though Congress would have authority to reauthorize them.

In addition, the bill would impose a cap on federal funding for the overall Medi-Cal program. Currently, Medi-Cal is an open-ended program, meaning federal contributions increase to accommodate changing health care needs among beneficiaries.

This week, a group of Republican governors, led by Wisconsin’s Scott Walker, expressed support for the bill, saying that block grants give states flexibility and control over spending — though some GOP governors, including John Kasich of Ohio and Brian Sandoval of Nevada, have said they oppose the bill.

While the state would get flexibility in deciding how to spend the block grant, the net loss in federal dollars would be so significant that state officials would likely have to cut benefits for Medi-Cal recipients or make eligibility rules stricter so fewer people would receive benefits, experts said.

“Those caps on federal funding would mean billions of lost Medi-Cal dollars in the state, and the state legislature would have to decide how to respond to that,” said Laurel Lucia, a health policy researcher at the UC Berkeley Labor Center, which released a separate analysis this week on the impact of the Graham-Cassidy bill. “They could cut eligibility, benefits. They could find money in other parts of the budget. But the cuts we’re talking about are at such a large scale it’d be difficult choices they’d face.”

The UC Berkeley analysis found that 6.7 million Californians would lose health insurance in 2027 under the bill: the 4 million enrolled in Medi-Cal expansion, 1.3 million who have subsidized coverage through Covered California, and an additional 1.4 million children, seniors and people with disabilities currently on Medi-Cal. A small percentage of these individuals may be able to buy coverage without subsidies or enroll in employer-sponsored health plans, but the vast majority would become uninsured, researchers said.

The center based its findings on data from the left-learning Center on Budget and Policy Priorities, and the assumption that California would respond to the Medi-Cal funding cap by cutting eligibility or limiting enrollment for certain groups.

Air Quality Tracker Check levels down to the neighborhood Ratings for the Bay Area and California, updated every 10 minutes

“This bill would be more severe than simply rolling back the ACA,” Lucia said. “It rolls back the ACA and makes additional cuts to Medi-Cal on top of that.”

Catherine Ho is a San Francisco Chronicle staff writer. Email: cho@sfchronicle.com Twitter: @Cat_Ho

Uncovered

The new GOP health plan would have a significant impact on Californians who get health insurance through Covered California or Medi-Cal. This chart shows how many people in each Bay Area county and in the state as a whole are projected to lose coverage by 2027 under the proposed plan.

Output: California would lose more federal funding than any other state under the latest GOP plan to repeal the Affordable Care Act, according to an analysis released Wednesday by the health policy consulting firm Avalere Health.


Instruction: create a high quality summary of the given input

Input:
CMS Innovation Center Seeks New Direction to Encourage Competition, Flexibility
 CMS has issued an informal request for information seeking input on a new direction promoting patient-centered care and market-driven reforms for the CMS Innovation Center.

In an op-ed published in The Wall Street Journal, CMS Administrator Seema Verma noted the large numbers of Americans enrolled in Medicare and Medicaid plus the fiscal concerns surrounding those problems as a reason for leading the Innovation Center in a new direction.

“We will move away from the assumption that Washington can engineer a more efficient health-care system from afar—that we should specify the processes health-care providers are required to follow,” Verma wrote.

She added that CMS was analyzing current Innovation Center models to determine which ones should continue and which ones should not. In its request for information, CMS noted the following guiding principles:

Promote competition based on quality, outcomes, and costs.

Focus on voluntary models; reduce burdensome requirements and unnecessary regulations to allow physicians and other providers to focus on providing high-quality healthcare; and give patients and providers tools to make informed decisions.

Empower patients, their families, and caregivers to take ownership of their health and provide them with information and flexibility to make choices.

Use data-driven insights to ensure cost-effective care that also improves outcomes.

Draw on partnerships and collaborations for a transparent model design and evaluation.

Test smaller scale models that can be scaled up if they meet requirements for expansion under the Affordable Care Act.

1. Advanced alternative payment models (APMs)

Under the Medicare Access and CHIP Reauthorization Act, clinicians can choose to participate in an Advanced APM. The innovation Center is seeking ways to increase opportunities for eligible clinicians to participate in Advanced APMs.

2. Consumer-directed care and market-based innovation models

Beneficiaries should be empowered as consumers to make choices among competitors in a market-driven healthcare system. CMS is considering new options to promote consumerism and transparency.

3. Physician specialty models

CMS wants to increase specialty physician models to improve quality of care and lower costs by engaging specialty physicians in APMs.

4. Prescription drug models

CMS wants to test new prescription drug payment models in Medicare Part B and Part D and state Medicaid programs. Models should engage beneficiaries as consumers and promote novel arrangements between plans, manufacturers, and stakeholders.

5. Medicare Advantage innovation models

The Medicare Advantage Value-Based Insurance Design model is one example of providing more flexibility to improve outcomes, but CMS believes this model can be modified to provide more flexibility. The agency seeks other demonstrations that incentivize plans to compete for beneficiaries.

6. State-based and local innovation

CMS wants to increase partnership with states on additional state-led models that drive reform and innovation. Models would vary based on the needs and goals of each state.

7. Mental and behavioral health models

CMS is looking for models to improve care for behavioral health, including a focus on opioids, substance use disorder, and dementia, as well as improve participation of mental health care providers in Medicare, Medicaid, and the Children’s Health Insurance Plan.

8. Program integrity

The agency is seeking ways to reduce fraud, waste, and abuse, as well as improve program integrity.

There will also be main 8 areas where the Innovation Center is interested in testing models:

“There are a lot of great ideas, and we want to hear from people on the front lines,” Verma wrote. “No government agency has all of the answers, especially in an industry as large and multifaceted as healthcare.”

The announcement of the new direction of the Innovation Center comes just days after Patrick Conway, MD, MSc, left his position in CMS as head of the Innovation Center to serve as president and CEO of Blue Cross Blue Shield of North Carolina.

The comment period will remain open through November 20, 2017, and ways to submit comments can be found here.

Output: CMS has issued an informal request for information seeking input on a new direction promoting patient-centered care and market-driven reforms for the CMS Innovation Center.


Instruction: create a high quality summary of the given input

Input:
CMS says it will change direction of CMMI, wants providers to have greater flexibility in payment model design
 The Centers for Medicare and Medicaid Services is redesigning its Innovation Center to give providers greater flexibility in payment models while encouraging greater competition among healthcare systems to drive down cost.

“This administration plans to lead the Innovation Center in a new direction,” said CMS Administrator Seema Verma in an op-ed published in The Wall Street Journal.

The Innovation Center came out of the Affordable Care Act and introduced many new models shifting payment from fee-for-service to value-based care.

But CMS is now looking for feedback on what models work and which ones don’t. It will accept comments through Nov. 20.

“Providers need the freedom to design and offer new approaches to delivering care,” Verma said. “Our goal is to increase flexibility by providing more waivers from current requirements.”

Current models have encouraged consolidation in the healthcare system, she said.

CMS wants to see more competition between providers to compete for patients in a free market system. Transparency is needed for consumers to be more cost-conscious, she said.

The Innovation Center is interested in testing models in eight focus areas including increased participation in advanced alternative payment models, consumer-directed care and market-based innovation, physician specialty models, prescription drug models, Medicare Advantage innovation models, state-based and local innovation, including Medicaid focused models, mental and behavioral health models and program integrity.

“We will move away from the assumption that Washington can engineer a more efficient healthcare system from afar -- that we should specify the processes healthcare providers are required to follow,” Verma said.

The move away from federal control to giving providers greater flexibility follows a push by the Department of Health and Human Services to do the same for states by urging state officials to apply for Section 1332 waivers to ACA requirements.

Legislation is also moving towards giving states fewer restrictions in the Section 1332 waivers established under the ACA. An estimated 23 states have begun steps towards getting a waiver. Seven have applied and two have gotten waivers.

Verma said Medicare and Medicaid are both facing a fiscal crisis, with Medicare’s trust fund projected to run out of money in 11 years and Medicaid representing the second largest budget item after education in most states.

CMMI’s new direction is to promote patient-centered care and test market-driven reforms to empower beneficiaries as consumers, provide price transparency, increase choices and competition, reduce cost and improve outcomes, CMS said.

Twitter: @SusanJMorse

Email the writer: susan.morse@himssmedia.com

Output: The Centers for Medicare and Medicaid Services is redesigning its Innovation Center to give providers greater flexibility in payment models while encouraging greater competition among healthcare systems to drive down cost.


Instruction: create a high quality summary of the given input

Input:
Obama says Republican healthcare plan would inflict 'real human suffering'
 Trump Jr. to speak privately to Senate staff on Thursday

(Richard Drew / Associated Press)

President Trump’s oldest son is expected to meet privately with a Senate committee investigating Russian interference in the 2016 presidential election, several senators said Wednesday.

Donald Trump Jr.’s appearance Thursday before the Senate Judiciary Committee would probably focus on a meeting he had with a Russian lawyer and others during the final stretches of last year’s campaign. Emails released in July show that Trump Jr. was told the session at Trump Tower in New York was part of a Russian government effort to aid his father, the Republican nominee.

Special counsel Robert Mueller is investigating that meeting, also attended by Trump’s son-in-law, Jared Kushner, and then-campaign chairman, Paul Manafort. A grand jury has heard testimony about it.

Trump Jr. has also agreed to appear in the coming weeks before the Senate Intelligence Committee, which is conducting its own investigation.

Separately, President Obama’s national security advisor, Susan Rice, was meeting on Wednesday with the House Intelligence Committee, according to a person familiar with the interview. This person wasn’t authorized to discuss the committee’s confidential work and spoke on the condition of anonymity.

That committee has subpoenaed the Justice Department and the FBI for documents related to a dossier of salacious allegations involving Trump and possible ties to Russia.

As for Donald Trump Jr., some Democratic senators said they planned to attend his session though tradition dictates that senators cannot ask questions at such interviews conducted by committee staff.

Sens. Richard J. Durbin (D-Ill.) and Richard Blumenthal (D-Conn.) said they would be there. Sen. Chris Coons (D-Del.) was considering it.

“I go in with an open mind,” Durbin said. “I want to hear his answers to questions — there are plenty of questions — about the involvement of the Trump corporation as well as the Trump campaign with the Russians and other foreigners, and I just want to hear what Mr. Trump has to say.”

Durbin said he would be “shocked” if questions weren’t asked about whether Trump Sr. knew about the Trump Tower meeting.

“The critical part of his testimony will be following the financial dealing,” Blumenthal said. He said he also wants to find out what Trump Jr. may know about potential obstruction of justice, adding there may have been conversations between the two about the firing of FBI Director James Comey and other matters.

Blumenthal and Coons said the private interview is no substitute for a public hearing, which the committee chairman, Sen. Charles E. Grassley (R-Iowa), has promised will happen.

“This meeting is far less important than his public testimony, under oath, before the American people,” Blumenthal said.

Grassley would not say on Wednesday whether he would issue a subpoena for Trump Jr. if he refuses to testify publicly.

Meanwhile, the Justice Department is reviewing subpoenas from the House intelligence committee.

In a letter Friday that was obtained by the AP, the committee wrote that it had served subpoenas on Aug. 24 to the department and the FBI for documents related to the committee’s investigation of Russian meddling. The Justice Department and FBI had missed the original Sept. 1 deadline, so the committee extended the deadline to Sept. 14.

The letter was signed by the committee chairman, Rep. Devin Nunes (R-Calif.), who stepped back from the Russia investigation this year after he was criticized for being too close to the White House. Rep. Mike Conaway (R-Texas) took over the leading role, but his name does not appear on the letter.

As chairman, Nunes retains subpoena power in the committee.

According to the letter, the original subpoenas requested any documents related to the dossier and sought information about whether the department was involved in its production.

If the documents are not produced, the committee is seeking to compel Atty. Gen. Jeff Sessions, who has withdrawn from investigations examining connections between Trump and Russia, and newly installed FBI Director Christopher Wray to testify in an open hearing. The committee issued two additional subpoenas to Sessions and Wray on late Tuesday.

“Resort to compulsory process was necessary because of DOJ’s and FBI’s insufficient responsiveness to the committee’s numerous Russia-investigation related requests over the past several months,” the letter said.

If the committee is unable to obtain documents or testimony, Nunes wrote, the committee “expressly reserves its right to proceed with any and all available legal options,” including a House vote to hold Sessions and Wray in contempt.

The Justice Department confirmed it was reviewing the subpoenas but declined further comment.

The dossier attracted public attention in January when it was revealed that then-FBI Director Comey had briefed Trump, soon before he was inaugurated as president, about claims from the documents that Russia had amassed compromising personal and financial allegations about him.

It’s unclear to what extent the allegations in the dossier have been corroborated or verified by the FBI because the bureau has not publicly discussed it.

Rep. Adam Schiff, the top Democrat on the Intelligence Committee, said Tuesday evening on MSNBC that the subpoenas were issued over the objections of Democrats. Schiff said Republicans are working harder to discredit those who compiled the dossier than to find out if the allegations in it are true. He said Republicans should be more focused on getting documents from the White House.

The subpoenas were first reported by the Washington Examiner.

Output: The latest Republican effort to repeal the Affordable Care Act would inflict "real human suffering" on millions of Americans, former President Barack Obama said Wednesday, speaking out in public defense of his signature healthcare reform effort.


Instruction: create a high quality summary of the given input

Input:
How the Latest Obamacare Repeal Plan Would Work
 The latest Republican proposal to undo the Affordable Care Act would grant states much greater flexibility and all but guarantee much greater uncertainty for tens of millions of people.

The legislation, proposed by two Senate Republicans, Lindsey Graham of South Carolina and Bill Cassidy of Louisiana, would not only reduce the amount of federal funding for coverage over the next decade, but also give states wide latitude to determine whom to cover and how. The result is a law that would be as disruptive as many of the Republicans’ previous proposals, but whose precise impact is the hardest to predict.

The bill would initially preserve nearly all the funding currently provided to Americans through the Affordable Care Act’s state insurance marketplace subsidies and expansion of Medicaid. But starting in 2020, that funding would be reallocated to state governments as block grants. Over time, the division of money would shift among the states based on a complex formula, and the total pot would grow according to a set rate, not based on the number of people nationwide who sign up for coverage.

States could use the money to replicate the programs in President Barack Obama’s signature health law, or to pursue completely different health policy strategies. The bill lays out some standards for program goals, but gives states broad discretion to use the funds in a variety of ways. “There will be clear differences between states about how they implement,” said Deep Banerjee, an analyst with Standard & Poor’s. “It will create quite a bit of uncertainty over the next few years.”

Output: The latest Republican proposal to undo the Affordable Care Act would grant states much greater flexibility and all but guarantee much greater uncertainty for tens of millions of people.


Instruction: create a high quality summary of the given input

Input:
Republican Leaders Defy Bipartisan Opposition to Health Law Repeal
 Yet some governors, the supposed beneficiaries of that federalism, were decidedly cool to the proposal. New Hampshire’s Republican governor, Chris Sununu, had criticized the proposal on Monday. But it was the opposition of Alaska’s governor, Bill Walker, that might prove most important. He increased pressure on Senator Lisa Murkowski, Republican of Alaska, to cast what could be a deciding vote to kill the repeal effort, just as she voted against the last repeal bill in July.

Republican leaders appeared determined to thwart any alternative ahead of a possible showdown vote next week. Senator Lamar Alexander, Republican of Tennessee, announced Tuesday that he and Senator Patty Murray, Democrat of Washington, would not come forward with the “limited, bipartisan plan to stabilize 2018 premiums” in the individual health insurance market that they had been working toward.

Their bipartisan efforts, which grew out of four days of committee hearings, were overtaken by the resumption of partisan warfare on health care.

“We have worked hard and in good faith,” said Mr. Alexander, the chairman of the Senate health committee, “but have not found the necessary consensus among Republicans and Democrats.”

Ms. Murray was more blunt: “Republican leaders have decided to freeze this bipartisan approach and are trying to jam through a partisan Trumpcare bill.”

Output: Eleven governors, including five Republicans and a pivotal Alaskan independent, urged the Senate on Tuesday to reject a last-ditch push to dismantle the Affordable Care Act.


Instruction: create a high quality summary of the given input

Input:
Why Understanding Value Is Central to True Health Care Reform
 While health care reform has become synonymous with the Affordable Care Act and this summer’s battle royale on Capitol Hill, true reform of our health care system needs to reach beyond debates over individual mandates, Obamacare, Medicaid expansion and other questions of health insurance design. It needs to address health care spending.

The U.S. health care spending problem is the ubiquitous elephant in the room, making steady appearances in presidential tweets, nightly newscasts and most certainly on our bank statements. Spending on health care is increasing at its fastest clip in 10 years, with health care expenditures growing by 5.8 percent or $3.2 trillion dollars in 2015. The Centers for Medicare and Medicaid Services projects similar spending growth through 2025.

Given the daunting dollar signs, an easy trap for policymakers, as well as for anyone in the health care industry, is simply to focus on cutting spending. But to preserve and improve the standard of care, it’s important to focus not on how much to cut but instead on where we should be spending our limited resources.

The true problem is that dollars are poured into a system without any clear understanding of how worthwhile one dollar spent is, relative to another. The remedy lies in making spending and coverage decisions based on the value – not just the price tag – of health care treatments and services.

Value-based spending is a simple notion that amounts to prioritizing spending on services where the benefits outweigh cost – spend less on recognized areas of low-value care, like unnecessary tests and procedures, and more on high-value areas like vaccines.

Implementing value-based spending in practice, however, is more complicated because health care system stakeholders each have disparate, and sometimes conflicting, definitions of value.

Self-insured employers are likely to value care that allows patients to remain in the workforce, for example, whereas an insurer like Medicare may be more concerned about reducing hospital readmissions. For patients, the value of treatment is more personal – driven by side effects and how quickly they can get back to their daily lives.

Several medical societies and research organizations – the American Society of Clinical Oncology and the Institute for Clinical and Economic Review, for example – have developed value assessment frameworks, yet because these frameworks have different objectives and intended audiences, they have different results – which simply provide ammunition for the various sides of the debate.

Value assessments need to address the reality of diverse perspectives, evolving evidence bases, and differing needs on the part of decision-makers. They must be dynamic to adapt to new evidence and treatment advances, and flexible enough to be patient-centered, yet meet the needs of physicians, payers and health systems.

Fortunately, patient groups, researchers and payers are beginning to come together to define value. Last week, health plan representatives, leading researchers and patient groups gathered at the National Press Club to discuss better approaches to measuring value in treatments and services, as well as value-based reimbursement strategies.

Meanwhile, here at the Innovation and Value Initiative, we’re using feedback from the event and from other stakeholders across the health care ecosystem to build open, consensus-driven tools that will eventually help patients, providers, payers and health care systems all individually measure value in treatments and services.

It will take a consensus approach from stakeholders across the health care industry to tackle spending in a way that rewards value rather than volume. Time to get started.

Mark Linthicum is the director of scientific communications for the Innovation and Value Initiative, a collaboration between patient advocacy organizations, payers, providers and life sciences companies dedicated to improving the way value is measured and rewarded in the health care system.

Morning Consult welcomes op-ed submissions on policy, politics and business strategy in our coverage areas. Updated submission guidelines can be found here.

Output: While health care reform has become synonymous with the Affordable Care Act and this summer’s battle royale on Capitol Hill, true reform of our health care system needs to reach beyond debates over individual mandates, Obamacare, Medicaid expansion and other questions of health insurance design. It needs to address health care spending.


Instruction: create a high quality summary of the given input

Input:
Population Health in Primary Care: Cost, Quality, and Experience Impact
 ABSTRACT

Objectives: To evaluate whether a primary care practice transformation that used population health strategies and predictive modeling to match clinical resources to patient needs reduced inpatient and total spending, while maintaining or improving quality and patient experience for adult Medicaid and Medicare patients.

Study Design: Quasi-experimental analysis using an adjusted historical control.

Methods: Measures included a quality composite metric, patient experience indicators, and total cost of care, as assessed by an independent actuary.

Results: Payers saved a cumulative $15.8 million (1.7%) across a 26-month program implementation period, which was substantially larger than the approximately $3.9 million in program staffing expenses. Driven by reduced inpatient spending, the total cost of care for high-risk adults was reduced across all lines of business, ranging from —$40.88 per member per month (PMPM) to –$737.20 PMPM. Payer savings were larger for Medicare (5.5%) than for Medicaid patients (0.7%). Patient experience metrics improved during this time. Quality findings were mixed, likely confounded by the 2014 Medicaid expansion.

Conclusions: These findings suggest that risk-stratified primary care delivery models can achieve the Triple Aim and could be self-sustaining through alternative payment models that allow reinvestment of savings into program costs. These results are consistent with literature that finds that short-term return-on-investment requires carefully targeting patients at risk of hospitalization, that reducing Medicare hospitalizations may be more easily achieved than for Medicaid, and that opportunities may be greater among unmanaged fee-for-service populations. Differences in savings by payer and by year underscore the importance of all-payer approaches to program financial sustainability.

The American Journal of Accountable Care. 2017;5(3):10-20Constraining healthcare cost growth has been a focus of health policy since the enactment of Medicaid and Medicare in the 1960s.1 Despite substantial efforts, high medical inflation persists, governmental health spending continues to crowd out other priorities, and health outcomes remain poor compared with those of international peers.2-4 Post Affordable Care Act, efforts to reverse these trends have focused on patient-centered medical homes (PCMHs), complex care management, transitions of care, and accountable care organizations (ACOs). Results to date have been inconsistent, with a limited number of multifaceted programs reducing healthcare expenditures.5-8

Programs that have lowered costs and improved quality and patient experience (the Triple Aim) often share features of Wagner’s Chronic Care Model.9 Most have implemented comprehensive team-based care, enabling proactive provider-patient interactions and tailoring care models to better support the needs of high-risk patients.10-15 Clinical information systems to facilitate population health management have also been foundational, including high-risk patient identification, decision support, and clinical performance feedback.16,17

Most cost-saving initiatives have targeted Medicare or commercial populations and have achieved savings by reducing hospitalization.10,12,13,18-22 Among the few well-designed Medicaid programs, evaluations assessing costs or hospitalizations have shown mixed findings.23-25 This suggests the need to adapt successful interventions to Medicaid populations, which will likely require attending to social determinants of health.22,26,27

Finding effective Medicaid approaches takes on increased salience as Medicaid/Children’s Health Insurance Program (CHIP) enrollment has outpaced that of Medicare.28,29 To this end, the Center for Medicare & Medicaid Innovation (CMMI) funded Health Care Innovation Challenge Awards (HCIAs) to accelerate at-scale, delivery system reform.30 We describe the reach and Triple Aim outcomes of an HCIA-funded primary care practice transformation at a large urban safety-net institution. This intervention employed predictive risk modeling to segment patients according to clinical and financial criteria, and sought to target higher-risk patients for more, and more intensive, services. This evaluation tested whether a risk-stratified, enhanced primary care delivery model demonstrated savings through reduced inpatient spending, while improving quality and patient experience for Medicaid and Medicare adults.

METHODS

Setting

Denver Health (DH) is an integrated, academic safety-net delivery system and the largest provider of Medicaid and uninsured services in Colorado, serving approximately 200,000 patients annually. DH provides comprehensive outpatient and inpatient services and operates a managed care plan. This integration enables data capture across the care continuum.

Target Population

Although the program targeted both adults and children in need of primary care services, this evaluation focused on Medicaid and Medicare beneficiaries older than 19 years, specifically: DH primary care users (≥1 primary care visits in the prior 18 months); DH managed care members; or frequent users of DH’s emergency department, urgent care, or hospital services (≥3 services in a year). The target population was dynamically redefined monthly, according to a validated population attribution and risk-stratification algorithm, described briefly below and detailed elsewhere.31 Excluded were individuals who could not be risk-stratified due to no claims history or short enrollment periods.

DH adapted commercial predictive risk modeling software to assign patients to 1 of 4 tiers of care needs. The algorithm relied primarily on age, gender, diagnosis, clinical procedure, and medication history. Through a multidisciplinary process, DH-defined rules were developed and integrated into the algorithm. These rules considered additional diagnostic information, clinical registries, and utilization patterns signaling unmet social or behavioral health needs. Algorithm development for high-risk tiers focused on defining patient groups at risk of hospitalization with distinctive care support needs, not solely on high costs. As noted, the algorithm was rerun monthly to capture new patients and changes in health status.

Intervention: Tiered Population Health Approach to Primary Care

This population health intervention built on DH’s National Committee for Quality Assurance—certified PCMHs and used Wagner Chronic Care Model principles to implement team-based care for complex populations.32-36 Consistent with Wagner’s vision of health information technology—enabled, proactive, prepared teams, DH provided real-time patient risk-tier information for care planning at the point of care. We specified a graduated set of enhanced clinical and electronic services appropriate to each risk tier, with more higher-intensity services targeted to higher-tier patients. Standard work that considers both tier and individual needs guided care teams’ service provision.

All patients (tiers 1-4) were provided “usual care” medical home services, complemented by new, optional electronic messaging reminder services. DH also expanded primary care staffing to include new team members to provide disease management, care transition, and patient navigation services (tiers 2-4). This enhanced-care team included nurse care coordinators, clinical pharmacists, behavioral health consultants, and patient navigators. More comprehensive multidisciplinary care management support was available to complex patients (tiers 3-4) during and between visits.

For tier 4, separate high-intensity clinics were established for targeted subpopulations: children with special healthcare needs, medically complex adults with multiple admissions, and adults with severe mental health diagnoses. All high-risk teams sought to empower patients through multidisciplinary care planning, goal setting, and problem-solving approaches. Patients also received referrals for specialty care, substance abuse treatment, housing, and other community resources (Figure).

Process and Outcome Measures

Primary outcomes were program reach, patient experience, quality, and total cost of care. Patient reach was quantified as the number of patients receiving any face-to-face or phone-based patient interaction by the HCIA-funded enhanced-care or high-intensity teams. Usual care clinical contacts were not included, nor were low-touch services, such as phone messages, letters, and text messages. These exclusions sought to avoid overstating program reach by focusing on new, intensive HCIA services.

To assess overall quality, DH uses an internal composite quality metric comprising individual indicators largely adapted from the Health Resources and Services Administration’s Health Center Program Uniform Data System. DH used the Consumer Assessment of Healthcare Providers and Systems’ PCMH-aligned items to assess patient experience.

Assessed from the payer perspective, the total cost of care measure was calculated by aggregating medical expenditures across all inpatient, outpatient, professional, and other services, and was expressed on a per-member per-month (PMPM) basis to account for differing lengths of enrollment. DH had nearly complete data capture for its managed care members because the DH health plan pays members’ medical claims. For those enrolled in fee-for-service (FFS) programs, spending estimates for non-DH services were derived from public sources (listed in the eAppendix [eAppendices available at ajmc.com]). Savings net of program expenses were also calculated.

Program expenses included salary and benefits of HCIA-funded staff, including the enhanced-care team, information technology, and evaluation personnel. Clinical staffing associated with reimbursable clinical care for program participants was not counted, nor were program development costs. This represented DH’s annual, unreimbursed costs to continue the program post award (eAppendix).

Analytical Approach

This quasi-experimental analysis compared trends in payer spending between a baseline performance period and 2 intervention performance periods. Because DH enrolls a majority of the Denver Medicaid market and the program was implemented at scale, no concurrent DH or non-DH control population exists. Therefore, it was necessary to develop an appropriate historical comparative population to estimate what the baseline costs would have been without the intervention. Observed costs were then compared with this historical cost benchmark. CMS uses a similar methodology to assess the financial performance of Medicare ACOs.37 Consistent with CMS’ approach, population-level cost outcomes were assessed whether or not targeted individuals were reached by the intervention. In the actuarial literature, this is approach is known as quasi-experimental analysis using an adjusted historical control.38

To construct performance populations for analysis, DH used its patient attribution and tiering algorithm to identify the target population during each month of baseline and intervention performance periods, resulting in 38 cross-sections, each with different member month counts and tier distributions. These 38 cross-sections were subsequently aggregated into 3 performance periods: a 12-month baseline period, a 14-month early program period, and a 12-month mature program period. The decision to create 2 intervention periods balanced several considerations: distinguishing early and mature program effects, minimizing seasonal effects by selecting measurement periods of approximately equal length, and isolating the potentially confounding effect of the Medicaid expansion in 2014 into a separate performance period.

Changes in medical costs were calculated by subtracting observed costs during the 2 intervention periods from the historical cost benchmark. In contrast to a pre-post analysis that focuses on a single population cross-section that is reached by the intervention, we refresh the population (38 cross-sections). This addresses regression by accounting for population dynamics such as changes in health status. To the extent that high-risk patients became lower-risk, died, or left the population during the intervention periods, this phenomenon also occurred during the baseline period, enabling detection of performance improvement net of these effects.

During the intervention periods, observed member months (which differ by time period) were the denominator used to calculate PMPM costs, but were not the multiplier to calculate total costs. To ensure the intervention period costs were comparable to those of the baseline period, the PMPMs were applied to the baseline population’s tier distribution. This “tier mix” adjustment ensures that patient health status was comparable across performance periods, effectively holding tier mix constant (see eAppendix for details).

To establish the historical cost benchmark, against which the intervention period costs can be compared, we quantified payer spending for the baseline population, adjusted by a medical inflation factor to account for secular cost trends. This adjustment is necessary to enable direct comparison of costs during the baseline and intervention periods. The Medicaid trend factor was 3.7%, consistent with the trend developed during Colorado state Medicaid agency annual capitation rate setting for DH’s health plan. The 2.3% Medicare trend factor was derived from the National Health Expenditures Projections report. Baseline costs for the Medicaid expansion population were estimated according to insurance rate-setting methods for a new population (eAppendix). We stratified cost outcomes by payer to account for payer-specific reimbursement levels.

RESULTS

Population Characteristics

Table 1 compares baseline and intervention populations according to tier, gender, and age. Member months are post adjustment, reflecting the above-described tier-mix adjustment.

Program Reach Results

As intended, a greater proportion of higher-tier patients were reached by DH interventions than were lower-tier patients. More than half of adult tier 4 patients were reached by either primary care—based enhanced-care team members or visited a high-intensity clinic during the ramp-up (51.0%) and mature program periods (56.4%). Program reach was lower for lower-tier patients: for the ramp-up and mature program periods, respectively, the percentages were 24.6% and 25.6% for tier 3, 15.7% and 12.9% for tier 2, and 1.5% and 1.4% for tier 1.

Quality and Patient Experience Results

The DH composite quality metric measured 77% at baseline. It increased to 82% during the intervention ramp-up, declined to 72% in 2014, and rebounded to 81% by mid-2015. Four of 6 patient experience metrics improved or remained constant during intervention ramp-up, and improved relative to baseline in 2014 and 2015 (Table 2).

Total Cost of Care Results

Reductions in total costs were observed for the majority of periods and payer populations, except for Medicaid managed care during the ramp-up period and Medicare managed care in the mature program period (Table 3). DH achieved a cumulative $10.9 million reduction in the total cost of care for its Medicaid and Medicare FFS populations across the 2 program implementation periods. These savings largely accrued to the state and federal governments. The largest share of this FFS cost avoidance ($8.2 million) was attributable to Medicare FFS. An additional $5.0 million reduction in the total cost of care was estimated for DH’s capitated managed care during this same timeframe. The annualized personnel cost of the adult program totaled $1.8 million.

During both the ramp-up and the mature program periods, reductions in the total cost of care for tier 4 adults were observed across all managed care and FFS payers, ranging from —$40.88 PMPM to –$737.20 PMPM. Reduced tier 4 spending was concentrated in inpatient reductions. For lower-risk populations (tiers 1-3), changes in claims costs varied by payer and by year. In aggregate, the analysis shows small cost reductions for tiers 1 and 3 (totaling $1 million across years and payers).

Tier 2 costs consistently exceeded the benchmark, totaling $4.8 million for Medicaid and $2.6 million for Medicare. For both Medicare and Medicaid, this higher-than-expected tier 2 spending offset, but did not eliminate, overall cost reductions.

We conducted a subanalysis on DH’s Medicaid and Medicare managed care populations to further explore the changes in tier 4 inpatient costs. We chose these populations due to the more complete data capture. Table 4 reveals that reductions in inpatient costs are not consistently observed in lower-risk tiers, suggesting that tier 4 inpatient cost reductions are not due to a broader secular trend affecting all DH populations. Consistent with prior research, Table 4 reveals that tier 4 inpatient savings are offset by increased spending in other areas, possibly reflecting program-driven referrals that resulted in additional service provisions.12,24,20

DISCUSSION

This study provides an important contribution to the literature as one of the first cost analyses of a major CMMI/HCIA initiative. Compared with an inflation-adjusted baseline period, net reductions in PMPM spending were observed in 5 out of 6 payers during 2 subsequent intervention periods. Patient satisfaction measures also improved during this same timeframe, suggesting that cost reductions were not achieved at the expense of patient experience. Overall quality improved in 2013 and 2015 over baseline performance. Reduced performance during 2014 may be partially explained by pent-up demand during the Medicaid expansion.

As hypothesized, reduced inpatient spending among high-risk adults drove the overall reduction in the total cost of care. High-risk (tier 4) adults with multiple chronic conditions and repeated hospitalizations were targeted for multiple interventions, and more than half were reached. The program reached fewer lower-tier patients and concomitant changes in associated payer spending were less pronounced, and even increased in some cases. This latter finding suggests that team-based care for lower-risk patients may need to be more targeted or evaluated over a longer time horizon.

Although we observed year-to-year fluctuations in performance, average cost reductions for Medicare exceeded Medicaid performance and FFS reductions were generally larger than those for managed care members. These results are consistent with literature that finds that short-term return on investment requires carefully targeting patients at risk of hospitalization, reducing Medicare inpatient costs may be easier than for Medicaid inpatient costs, and opportunities may be greater among unmanaged FFS populations. Differences in cost-avoidance by payer and by year underscore the importance of all-payer approaches to overall financial sustainability.

Gross cost reductions of nearly $16 million over the entire 26-month intervention period are substantially larger than the approximately $3.9 million in staffing expenses, supporting the self-sustaining potential of risk-stratified primary care delivery models. However, neither FFS nor experience-based capitation permits ongoing reinvestment of savings into program costs. Cost reductions accrue to at least 3 separate payers: the federal and state government for FFS Medicare and Medicaid patients, and the DH health plan for its managed care members. Since DH owns and operates its own health plan—an unusual arrangement among safety net institutions—there is a direct means to “capture” a portion of the payer savings. Combined Medicaid and Medicare managed care cost avoidance was estimated at $2.3 million (annualized) compared with the $1.8 million in annual program costs. However, because capitation rates are based on historical claims costs, funds for program reinvestment will decline over time as capitation payments are rebased to reflect lower levels of medical expenditures.

Thus, current payment models—even capitated managed care—do not align incentives. Although both Medicare and Medicaid have implemented new FFS care coordination, care transitions, and integrated care reimbursement opportunities, requirements are often highly prescriptive, process-oriented, and not consistent across payers. As a result, staffing models and clinical work flows that meet Medicare rules do not necessarily satisfy those of Medicaid, and vice versa. However, multipayer approaches are necessary to ensure sufficient funds and to smooth out year-to-year variations, especially for high-volume Medicaid providers. This underlines the need to accelerate implementation of advance payment models that better align financial incentives.

Recognizing that current payment models do not adequately incentivize population health approaches, CMS has set a goal to have 90% of Medicare non-FFS arrangements by 2018.39 This evaluation offers both programmatic and financing insights relevant to alternative payment model development, such as those being developed under the Medicare Access and CHIP Replacement Act.

Limitations

First, although we applied a tier-mix adjustment and stratified by payer to ensure equivalence between the baseline and intervention populations, some differences in population characteristics remain that could partially account for the findings. Second, incomplete data capture is a concern. Although we estimated service use at non-DH facilities among FFS populations, we did not attempt to estimate cross-sector impacts to the criminal justice or social service systems. Third, there is no widely accepted best practice for trend assumptions to establish the cost benchmark. Because DH accounts for approximately 57% of the Denver Medicaid primary care market, we cannot use actual trend. We therefore selected trend assumptions that were based either on state rate-setting practices (3.7% for Medicaid) or national health spending trends (2.3% for Medicare). These trends are equivalent or lower than a recent CMS actuaries’ analysis that found that US health spending growth was “historically low” between 2009 and 2013, averaging 3.7%.3 Our trends are also lower than a touted Oregon Medicaid program analysis, assuming a 5.4% trend on a 2011 baseline.31,40 Although our approach does not exclude the possibility that savings result from a broader, secular phenomenon of lower inpatient spending, reductions were concentrated in tier 4 where program reach was greatest. Generalized inpatient reductions across all tiers were not observed. Finally, the program was implemented at a single institution; findings may not be generalizable.

CONCLUSIONS

Recent leveling-off of costs is often attributed to the aggregate effect of readmission reduction programs nationally, most of which have been launched without formal research designs. Although at-scale implementation complicates efforts to identify unexposed, concurrent comparison groups, from an institutional perspective, improvements over past performance are relevant even while the broader sector also improves.34 This analysis demonstrates that a large, multifaceted program may be evaluated by benchmarking against historical costs, using well-accepted actuarial methods to address regression to the mean.41 We conclude that risk-stratified, enhanced primary care delivery models hold Triple Aim promise, assuming supportive payment models.

Acknowledgments

The authors would like to acknowledge the project team responsible for designing and implementing the intervention, including the core management team, clinical teams, information technology team, and evaluation team, as well as Ambulatory Care Services and Executive Leadership (past and present).

This study was conducted for quality improvement/quality assurance purposes. Colorado Multiple Institutional Review Board (COMIRB) determined this project to be “not human subjects” research. Results are not generalizable.Author Affiliations: Denver Health and Hospital Authority (TLJ, CIO, DB, RE, PG, SJH, HB), Denver, CO; Milliman (MvdH, SD), Denver, CO; Colorado School of Public Health (AA), Denver, CO.

Source of Funding: The intervention described herein was supported by Grant Number 1C1CMS331064 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies. Findings might or might not be consistent with or confirmed by the findings of the independent evaluation contractor.

Author Disclosures: Several of the authors are or were employed by Denver Health and Hospital Authority (TLJ, CIO, DB, RE, PG, SJH, HB). Dr Johnson was co-principal investigator, Director of Evaluation, and reports that earlier versions of this analysis were presented at 2 academic conferences. Dr Hambidge has presented data from this project at 4 national academic and policy conferences. The remaining authors report no other relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (TLJ, PG, SJH, AA, HB); acquisition of data (TLJ, DB, RE, SJH, AA); analysis and interpretation of data (TLJ, MvdH, SD, CIO, DB, RE, PG, SJH, AA, HB); drafting of the manuscript (TLJ, CIO, PG, AA); critical revision of the manuscript for important intellectual content (TLJ, MvdH, SD, CIO, RE, PG, SJH, AA, HB); statistical analysis (MvdH, SD, RE); provision of study materials or patients (SJH); obtaining funding (TLJ, PG); administrative, technical, or logistic support (TLJ, DB, RE, SJH, HB); and supervision (TLJ, RE, SJH).

Send Correspondence to: Tracy L. Johnson, PhD, MA, Denver Health, Ambulatory Care Services, 777 Bannock St, MC 6551, Denver, CO 80204. E-mail: Tracy.Johnson@dhha.org.REFERENCES

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37. National Academies of Sciences, Engineering, and Medicine. Accounting for social risk factors in Medicare payment: criteria, factors, and methods. National Academies website. http://www.nationalacademies.org/hmd/Reports/2016/accounting-for-social-risk-factors-in-medicare-payment-3.aspx. Published July 13, 2016. Accessed October 27, 2016.

38. Duncan I. Part 2: actuarial issues in care management interventions. paper 6: an actuarial method for evaluating disease management savings outcomes. Society of Actuaries website. https://www.soa.org/Files/Research/Projects/Paper6-Actuarial-Methodology-for-Evaluating-DM.pdf. Published March 29, 2005. Accessed July 9, 2016.

39. Better care. smarter spending. healthier people: paying providers for value, not volume. CMS website. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html. Published January 26, 2015. Accessed July 9, 2016.

40. Stecker EC. The Oregon ACO experiment—bold design, challenging execution. N Engl J Med. 2013;368(11):982-985. doi: 10.1056/NEJMp1214141.

41. Johnson TL, Rinehart DJ, Durfee J, et al. For many patients who use large amounts of health care services, the need is intense yet temporary. Health Aff (Millwood). 2015;34(8):1312-1319. doi: 10.1377/hlthaff.2014.1186.

Output: An evaluation of the use of predictive modeling for primary care resource allocation demonstrated reduced spending and improved quality and patient experience for publicly insured adults.


Instruction: create a high quality summary of the given input

Input:
Does Medicare make sense for seniors with employer health coverage?
 Editor’s Note: Journalist Philip Moeller is here to provide the answers you need on aging and retirement. His weekly column, “Ask Phil,” aims to help older Americans and their families by answering their health care and financial questions. Phil is the author of the new book, “Get What’s Yours for Medicare,” and co-author of “Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security.” Send your questions to Phil.

More and more employers are adopting high-deductible health plans, which usually include a health savings account. In 2016, between 20 and 23 million employees and family members had HSAs, according to the Employee Benefit Research Institute. These plans can make Medicare more popular to employees aged 65 and older, even if they have the option of staying on their employer plans.

Ask Phil readers already are familiar with a major pitfall of HSA plans for employees who are receiving Social Security. In order to receive any type of Social Security payment, beneficiaries aged 65 and older must, by law, also sign up for Part A of Medicare.

Part A charges no premiums to people who have enough work experience to qualify for Social Security benefits. It can come in handy as supplement insurance to help pay for hospital and other institutional health care expenses that are covered by Part A but either not covered by their employer plan or not fully paid for by that plan.

This is usually a nice supplemental insurance benefit to have. However, Part A comes at a heavy price for HSA participants: Having Part A qualifies as being on Medicare, and Medicare recipients are prevented under IRS rules from making new pre-tax contributions to an HSA. They may use funds already in an HSA account, but cannot add new funds. If their employers don’t also offer a non-HSA health plan, the employees could be on the hook for sharply higher health insurance expenses.

READ MORE: Standard Medigap plans are learning some new tricks

This downside, when added to the burden of high and often rising annual plan deductibles, can make getting Medicare more attractive for employees with group health plans. In the past, I usually told employees turning 65 that they did not have to get Medicare and could simply keep their employer plans.

My thinking has changed.

The rise of high-deductible plans should trigger a serious study by people about the merits of Medicare – either in addition to employer plans or in place of them.

The rise of high-deductible plans should trigger a serious study by people about the merits of Medicare – either in addition to employer plans or in place of them.

The current monthly premium for Part B of Medicare is $134 a month. Part B covers expenses for doctors, care at non-hospital facilities, and durable medical equipment. This works out to a bit more than $1,600 a year. There also is a $183 annual deductible that people must pay for Part B expenses before their insurance coverage begins. Here’s a summary of Part A and Part B costs.

For people keeping their high-deductible employer plans, laying out $2,000 for Part B premiums and deductibles could well be money well spent. This is because Medicare can be a secondary insurer and can pay a big hunk of covered plan expenses before the plan’s annual deductible is reached.

I regularly receive questions from Ask Phil readers about whether Medicare can help pay these employer plan deductibles, and how this process works. Casey Schwartz, a benefits expert at the Medicare Rights Center, provided this explanation:

“Medicare pays secondary to other insurance (including paying in the deductible) in situations where the other insurance is primary to Medicare. There are some restrictions — it has to be a Medicare covered service, and the total amount paid must be equal to or less than the Medicare approved amount.”

If the care costs more than the Medicare-approved amount, she explained, Medicare coverage will cover up to that amount, and the employee would pay the difference if they wanted the care.

Schwartz noted that there is an online Medicare manual explaining rules of how Medicare works as a secondary payer of covered claims. Here is a section that gets to the heart of how it can work with employer group health insurance (GHP):

“Where a GHP is primary payer, but does not pay in full for the services, secondary Medicare benefits may be paid, to supplement the amount it paid for the Medicare covered service. If a GHP denies payment for services because they are not covered by the plan as a plan benefit bought for all covered individuals, primary Medicare benefits may be paid if the services are covered by Medicare. Primary Medicare benefits may not be paid if the plan denies payment because the plan does not cover the service for primary payment when provided to Medicare beneficiaries. “A GHP’s decision to pay or deny a claim because the services are or are not medically necessary is not binding on Medicare. Contractors must evaluate claims under existing guidelines derived from the law and regulations to assure that services are covered by the program regardless of any employer plan involvement.”

If you spend a lot on prescription drugs, you would want to explore getting a Medicare Part D drug plan. You usually need Part B to qualify for Part D. But this is not required if your employer plan’s drug coverage is inferior to a typical Part D plan. This is known as the drug coverage “credibility” test.

If you must pay thousands of dollars out of pocket for your drugs prior to reaching your health plan’s annual deductible, there is a good chance the drug coverage provided by your employer plan would not be considered credible. Employers are legally required under Medicare rules to issue annual statements about the credibility of their drug coverage. It might be possible for you to avoid getting and paying for Part B in this situation, but I’d only recommend this approach if you are comfortable that the bulk of your uninsured health expenses will be for prescription drugs.

It may well be that having employer insurance plus Medicare is not as attractive as simply dropping the employer plan and relying solely on Medicare as your primary insurer. This decision depends on how much your employer subsidizes your health care and on your maximum out-of-pocket expenses in a high-deductible employer plan. Also, if you drop an employer plan, it might not admit you back if you change your mind. These possibilities should be explored with your employer’s benefits experts.

Here are this week’s reader questions:

Roger – Ariz.: Am I not permitted to decline Medicare Part A when applying to receive Social Security benefits? I’m 66, employed, and on my employer’s group health plan (PPO). My employer has said it may move its insurance to a high-deductible health plan, with a health savings account. If I have Part A, am I automatically ineligible for the HSA and employer insurance? If so, would I be eligible for COBRA?

Phil Moeller: You cannot receive any type of Social Security benefit if you are 65 or older without also being enrolled in Part A. For better or worse, it’s the law.

In that event, you would not be able to make contributions to an HSA. Of course, I don’t know if your employer would also offer a non-HSA health plan. If not, it probably would make sense for you to get Medicare rather than signing up for a temporary COBRA extension of your employer plan.

Solomon – Wash.: I cannot understand why dental care is excluded from Medicare. This is something that older Americans need, and we need to begin this conversation NOW!

Phil Moeller: I agree that this is a discussion that we should have, and that it should include hearing and vision insurance as well. Many Medicare Advantage plans offer insurance for these things, but I’m guessing that what you would like is more comprehensive coverage that would allow people to take proper care of themselves and thus avoid many later-life health issues that can be directly traced to their earlier inability to afford needed care.

While the need is great, robust dental coverage for older people is not very attractive from an insurance perspective. When the population skews to people who are older, the need for dental care becomes much greater. For this population, you’re really not talking about a stand-alone insurance product so much as including specified care needs as one of the services that Medicare would cover.

READ MORE: Medicare’s lack of dental, hearing and vision coverage can put seniors in a bind

I’d be willing to pay a bit more for my Part B if it covered dental care. But I bet a lot of consumer groups would argue that the government should foot this bill or that wealthier people should pay higher Medicare rates to subsidize dental care for others. If Medicare did cover dental care, you could expect the dental lobby to push hard for favorable reimbursement rates. From where I sit, this is where the battle would be joined.

Ann: I just turned 65; my spouse is 61. Both of us are currently not working and we purchase insurance on our state exchange. My husband has accepted a job offer and will be eligible for group health insurance next month. Prior to the job offer, I had planned to get Medicare but have not actually signed up. When I went to the Social Security office, they signed me up for Part B of Medicare, even though I was not then 65. What should I do about the month-long gap between me turning 65 and being covered on his new employer plan?

Phil Moeller: You can terminate enrollment in Part B and should do so immediately to avoid being charged a premium. You can get this money back, but it can be a time-consuming process.

Few people know this, but you (and your husband) can keep your exchange plan even after you turn 65. In that event, you would lose any income-related subsidies, but in your case this would be a minor concern because you’re only talking about staying on for another month.

When you eventually do need Medicare, you should have a special enrollment period. At that time, your husband’s employer will need to complete this form, which attests that you have had employer health insurance and thus are qualified for the special enrollment period and will face no adverse consequences when you do enroll in Medicare and related Medicare policies.

Vicky: My parents are 84 and 85. They want to move to Germany where my sister and I can be of more help. My question is, can they tap into their Medicare from there? My dad had Parkinson’s but is still mobile. Is this move feasible?

READ MORE: I’m retiring abroad. What Medicare plan should I get?

Phil Moeller: Unfortunately, basic Medicare will not cover any of their medical expenses in Germany. Some Medicare Advantage and Medigap supplement plans do cover emergency overseas medical expenses, but this coverage is designed for travelers and not permanent overseas residents. If your parents wish to keep their Medicare, they could only use it if they returned to the U.S. for care. Unless they are planning to do so, they probably should drop their Medicare plans. I always advise people to confirm this with their Medicare insurers. Here’s a primer on Medicare for people living outside the U.S. Sorry I don’t have better news.

Output: More and more employers are adopting high-deductible health plans, which usually include a health savings account. In 2016, between 20 and 23 million employees and family members had HSAs, according to the Employee Benefit Research Institute. These plans can make Medicare more popular to employees aged 65 and older, even if they have the option of staying on their employer plans.


Instruction: create a high quality summary of the given input

Input:
Hybrid lithium anodes create more durable, rechargeable batteries
 Novel lithium electrodes coated with indium could be the basis for more powerful, longer-lasting, rechargeable batteries. The coating hinders undesirable side-reactions between the electrode and electrolyte, provide a more uniform deposition of lithium when charging, and augments storage in the lithium anode via alloying reactions between lithium and indium, as reported by American scientists in the journal Angewandte Chemie. Their success stems from the good diffusion of lithium ions along the interfacial layer.

Modern lithium ion batteries usually have graphite anodes that store lithium when the batteries are charged. An interesting alternative is presented by batteries with metallic anodes, such as lithium metal, which promise significantly higher storage capacity. However, a significant hurdle barring their successful implementation has been the uneven deposition of the metal during the charging process, which leads to formation of dendrites. After longer uses of the battery, these dendrites can grow so extensive that they short-circuit the battery. In addition, there are undesirable side-reactions between the reactive metal electrodes and the electrolyte, which significantly reduces the lifetime of the batteries. The formation of a stable, passivating layer that prevents further contact would be an ideal solution; however, it isn't possible because of the constant expansion and contraction of the electrode upon charging and discharging. This destroys the layer and exposes the metal to the electrolyte for more reactions. Other approaches include artificial films or physical barriers.

Researchers working with Ravishankar Sundararaman at Rensselaer Polytechnic Institute (Troy, USA) and Lynden A. Archer at Cornell University have now introduced a novel alternative. By using straightforward electroless ion-exchange chemistry, they produced indium coatings on lithium. Simple immersion in a special indium salt solution is all it takes. Some of the indium is deposited on the surface of the lithium electrode as metal and the lithium ion concentration in the electrolyte simultaneously increases.

The indium layer is uniform and self-healing when the electrode is in use, if small amounts of the indium salt are added to the electrolyte. It remains intact during charge/discharge cycles, its chemical composition remains unchanged, and side-reactions are prevented. Dendrites are also eliminated, leaving the surface smooth and compact.

By using computer modeling, the researchers were able to show why their method is so successful: lithium ions are very loosely bound to the indium coating. They form an alloy with the indium, which allows them to move very rapidly over the surface before they cross it and are deposited on the underlying lithium electrode. In complete cells with commercial cathodes, these new indium–lithium hybrid electrodes were stable over more than 250 cycles, retaining about 90 % of their capacity.

Provided by Wiley

Output: Scientists at Ravishankar Sundararaman at Rensselaer Polytechnic Institute and Lynden A Archer at Cornell University have developed a simple coating that prevents side-reactions between the electrode and electrolyte in rechargeable batteries, according to an article in the journal Angewandte Chemie. The researchers immersed the electrode in an indium salt solution, creating a protective layer that eliminated dendrites and remained smooth and stable over more than 250 cycles. It is hoped the development will lead to more powerful, longer-lasting, rechargeable batteries.


Instruction: create a high quality summary of the given input

Input:
Snapchat adds 14 companies to its creative partners to drive ROI
 Snapchat has added 14 companies to its roster of creative partners, with the aim of helping brands drive ROI when a user ‘swipes up’ on a vertical ad.

The Venice Beach-based company is forging ties with over a dozen new companies in order to enhance the 'post-swipe' ad experienc

The firm has forged ties with the likes of Whalar which matches advertisers with creators to produce scalable content, and Slyce which allows brands to create custom coupons and track redemption.

The Venice Beach-based company is forging ties with over a dozen new companies in order to enhance the 'post-swipe' ad experience; or in other words ensuring users remain engaged with what is on their screen after they take action on a clickable, vertical ad.

Other partners with specialists in custom games, interactive videos, haptics and gyroscope, and lead generation include: Flyr; Ceros; Undertone; Famous; Wirewax; Entrypoint; Adludio; TreSensa; GameCommerce; CrossInstall; Jebbit and Popwallet.

With the new deals, Snap is focusing on the impact of ads that load in its internal browser. This is something it has already been experimenting with through gamification and interactive experiences, including the recent unveiling of an exclusive Adidas game last week, which let viewers partake in a competitive touchscreen kick-up tournament. In June, the Economist also trialed Snapchat's Attachment format, which facilitates external links and video.

During Snap's most recent earnings call its chief strategy officer Imran Khan claimed that the average cost per-lead on the campaign was £10.28 compared to the £62 norm on other display channels.

The messaging app launched its official partner program last year when it was seriously bulking up its ad offering. Previously creative partners like Vidsy and Celtra have been tasked with producing the visuals people see when Snap Ads are served between Stories or in Discover, but today's announcement marks in a shift in focus in favor of technology that fuels post-swipe experiences.

Snap Inc's most recent financial results fell short of Wall Street forecasts with the company pulling in $182m between March and June of this year. However, in the face of growing competition from the likes of Facebook and Instagram the upstart has remained optimistic about its ad products.

Output: Snapchat has partnered with 14 creative companies to focus on the impact of ads that load in its internal browser and help brands boost its ROI. To enhance user engagement in the 'post-swipe' ad experience the firm has linked with Whalar, which matches advertisers with creators to produce scalable content, and Slyce which allows brands to create custom coupons and track redemptions. Other partners that specialise in custom games, interactive videos, haptics and gyroscope, and lead generation include: Flyr; Ceros; Undertone; Famous; Wirewax; Entrypoint; Adludio; TreSensa; GameCommerce; CrossInstall; Jebbit and Popwallet.


Instruction: create a high quality summary of the given input

Input:
Amazon said to be exploring move into US drug supply chain
 Amazon is ramping up conversations with a group of drug middlemen known as pharmacy benefits managers or PBMs, according to analysts from Leerink Partners. PBMs are a critical part of the drug supply chain, as they negotiate prices with drug manufacturers on one end, and manage pharmacy benefits for insurers on the other.

The report, which was previously spotted by Axios, also outlines the "disruptive" potential posed by Amazon across the multibillion dollar pharmacy benefits and pharmacy arena.

Citing an anonymous analyst, the report states that Amazon may "indeed be in conversations with some middle-market PBMs now, in an effort to get into various contract arrangements."

That suggests that Amazon is a "bigger threat" than many expect, but that it won't be right away. Leerink estimates that it will take about 18 to 24 months for Amazon to get pharmacy licenses in all 50 states.

CNBC reported in May that Amazon was looking to hire a general manager to lead its pharmacy business. And that it had already hired Mark Lyons from Premera Blue Cross, a local insurer, who was tasked with building an internal PBM.

In the ensuing months, analysts and investors asked players across the supply chain were asked about the Amazon threats. Some described Amazon has a potential partner, while others were skeptical that the e-commerce company would move into a highly-regulated space.

-- CNBC's Michael Bloom contributed to this report.

Output: Amazon is expanding its talks with pharmacy benefits managers (PBMs) – the middlemen in the drug industry, according to a report by analysts from Leerink Partners. A move by Amazon to pick up contracts in the sector could pose a significant risk to many of the players across the entire drug supply chain. The report stated that Amazon is a "bigger threat" than many realise; however, it estimated it will take at least 18 to 24 months for Amazon to gain pharmacy licences in all 50 US states. PBMs negotiate drug prices with manufacturers while also managing pharmacy benefits for insurers.