Week of October 5-9, 2015


ACA Implementation
The October issue of Health Affairs is devoted to the ACA.  Below, find selected articles.

The uninsurance rate for lesbian, gay, and bisexual (LGB) adults fell dramatically as the Affordable Care Act (ACA) was implemented and many states began recognizing same-sex marriages. LGB adults were also increasingly likely to report a usual source of care, but significant disparities in access and affordability by sexual orientation remain.
Lesbian, Gay, And Bisexual Adults Making Gains In Health Insurance And Access To Care

Experience in European health insurance exchanges indicates that even with the best risk-adjustment formulas, insurers have substantial incentives to engage in risk selection. The potentially most worrisome form of risk selection is skimping on the quality of care for underpriced high-cost patients—that is, patients for whom insurers are compensated at a rate lower than the predicted health care expenses of these patients. In this article we draw lessons for the United States from twenty years of experience with health insurance exchanges in Europe, where risk selection is a serious problem.
Risk Selection Threatens Quality Of Care For Certain Patients: Lessons From Europe’s Health Insurance Exchanges

The health insurance Marketplaces created under the Affordable Care Act have attracted nearly ten million enrollees, including many people who were previously insured by an employer-sponsored plan. The most popular Marketplace plan—the silver plan—has significantly higher cost sharing than does a typical employer-sponsored plan, which may cause patients to reduce the use of cost-saving services that are essential for managing chronic conditions.
Out-Of-Pocket Prescription Costs Under A Typical Silver Plan Are Twice As High As They Are In The Average Employer Plan,

This research study demonstrates that the county-by-county rollout of expanded public insurance coverage in California significantly increased coverage, by 7 percentage points, and significantly reduced the likelihood of any family out-of-pocket medical spending in the previous year, by 10 percentage points, among low-income adults.
California’s Early ACA Expansion Increased Coverage And Reduced Out-Of-Pocket Spending For The State’s Low-Income Population

The ACA has several provisions that could greatly improve the behavioral health of children and adolescents in the United States. To explore how the ACA and other aspects of health care reform can support innovations to improve children’s behavioral health and sustain those innovations over time, the IOM Forum on Promoting Children’s Cognitive, Affective, and Behavioral Health held a workshop in April. “Opportunities to Promote Children’s Behavioral Health: Health Care Reform and Beyond.”
Read the report from the workshop

Health Care Operations and Management
There are a variety of different ways to deliver the same evidence-based medicine to every patient, every time they interact with the health care system. Organizations differ in their tools and experience, but their aim is the same: to deliver the same level of medical care to every patient, every time. The benefits of reliable processes drive the Triple Aim: improved outcomes for a population, enhanced patient experience, and reduced costs.
Read this blog post from the Institute for Healthcare Improvement, 5 Steps for Creating Value Through Process Mapping and Observation

A new Government Accountability Office (GAO) report examines non federal efforts to overcome barriers to interoperability among electronic health record (EHR) systems. The report details 5 major challenges: Deficient technical standards, Variations in state privacy rules,Patient matching, High costs, and the Need for governance and trust among entities.  Electronic Health records-Non federal Efforts to Help Achieve Health Information Interoperability.
Read the GAO report here,

Cardiac arrest can strike a seemingly healthy individual of any age, race, ethnicity, or gender at any time in any location, often without warning. Cardiac arrest is the third leading cause of death in the United States, following cancer and heart disease. Four out of five cardiac arrests occur in the home, and more than 90 percent of individuals with cardiac arrest die before reaching the hospital. Read this report from the National Academies
Strategies to Improve Cardiac Arrest Survival: A Time to Act (2015),

Using VHA data for fiscal years 2005–13, this research from Health Affairs found that despite different incentives within the VHA and Medicare, rates of observation have increased over time for both populations.  Read the Health Affairs report, Observation Rates At Veterans’ Hospitals More Than Doubled During 2005–13, Similar To Medicare Trends,

In this discussion paper from Brookings, the researchers show that the hospitals that receive the largest tax benefits tend to be located in wealthier communities, whereas the demand for uncompensated care is highest in poorer communities. To ameliorate this geographic mismatch between the supply of charity care and the demand for charity care, they propose a floor-and-trade system whereby nonprofit hospitals would be required to meet charity-care standards, either by providing care to local patients or by purchasing credits from other hospitals.
A floor-and-trade proposal to improve the delivery of charity-care services by U.S. nonprofit hospitals, 

CMS and Medicare/Medicaid
So-called Medicare Advantage plans have boomed in recent years, bringing more urgency to questions about whether the customers in this roughly $160 billion market have adequate access to doctors and other health workers. Enrollment stands at more than 16 million people, or more than 30 percent of the elderly and disabled people covered by Medicare.
Read this report from the Commonwealth Fund, Insurer-Run Medicare Plans Pressured to Guarantee Doctor Supply, 

Four years of nation-wide testing by The Centers for Medicare and Medicaid Services (CMS) has now proven that the current shared savings payment models do not work effectively for low-cost Accountable Care Organizations (ACOs). High-cost ACOs have more room to improve and therefore more opportunity for savings.
Read this blog post from Health Affairs, “Creating The Next Generation: The Payment Model We Need From Medicare,”

This new report from the KFF presents findings from an analysis of the Medicare Part D marketplace in 2015 and changes in features of the drug benefit offered by Part D plans since 2006. Key findings are summarized. Medicare Part D at Ten Years: The 2015 Marketplace and Key Trends, 2006-2015.
Read the report here,

Medicare Advantage payment regulations include risk-adjusted capitated reimbursement, which was implemented to discourage favorable risk selection and encourage the retention of members who incur high costs. However, the extent to which risk-adjusted capitation has succeeded is not clear, especially for members using high-cost services not previously considered in assessments of risk selection.
Read this research report from Health Affairs, “High-Cost Patients Had Substantial Rates Of Leaving Medicare Advantage And Joining Traditional Medicare

The Centers for Medicare and Medicaid Services just  issued a final rule for Medicare and Medicaid’s incentive programs for using electronic health records, along with a final rule for certification of health information technology. The final rule released on solidifies revised meaningful use requirements for providers from 2015 to 2017 and signals that “finalized” Stage 3 regulations are not set in stone. Read the CMS release, Fact Sheet: Electronic Health Record Incentive Program and Health IT Certification Program Final Rule

Population Health
Workplace wellness is a $6 billion dollar industry in the United States. Employers offer the programs to improve the health and well-being of their employees, increase their productivity, reduce their risk of costly chronic diseases, and improve control of chronic conditions.  The recently published RAND Wellness Programs Study, which included almost 600,000 employees at seven employers, showed that wellness programs are having little if any immediate effects on the amount employers spend on health care.
Read this RAND research report, “Do Workplace Wellness Programs Save Employers Money?

The authors of this research report from Health Affairs investigated the progress of Latin American countries towards UHC.  They found that no country has achieved a perfect universal health coverage score, but some countries (including those with more integrated health systems) fare better than others. All countries except one improved in overall universal health coverage over the time period analyzed.
Read the report,
 Assessing Latin America’s Progress Toward Achieving Universal Health Coverage,

Health Care Finance and the Market
This research from Health Affairs found that physician practice concentration and prices were significantly associated for twelve of the fifteen procedures we studied. For these procedures, counties with the highest average physician concentrations had prices 8–26 percent higher than prices in the lowest counties. Less Physician Practice Competition Is Associated with Higher Prices Paid for Common Procedures,

This research from Health Affairs examined the revenue side of Ambulatory Surgery Centers (ASC) growth by using a large national claims database that contains information on actual prices paid. For six common outpatient surgical procedures, prices paid to ASCs on the whole grew in line with general medical care prices, while overall prices paid to hospital outpatient departments for the same procedures climbed sharply.
Price Increases Were Much Lower In Ambulatory Surgery Centers Than Hospital Outpatient Departments In 2007–12,

During the debate over the ACA, many proponents argued that hospitals made up for losses by charging other patients more, resulting in higher insurance premiums and co-pays. Each newly uninsured person leads to nearly $900 in uncompensated care costs, of which hospitals absorb approximately two thirds as lost profits. In this report from the National Bureau of Economic Research, the authors calculate that hospitals pass along only one third of those costs by raising rates. As a result, they predict, the impact of the ACA on insurance premiums will be considerably less than anticipated.
Hospitals as Insurers of Last Resort,

According to data from ACAView, an ongoing project from the athenaResearch team and the Robert Wood Johnson Foundation, physician practice collections have increased both in states that expanded Medicaid eligibility and in those that did not, although collections growth was higher in non-expansion states, particularly for surgery.
Read the research brief, Physician Practice Economics Under Coverage Expansion,

Despite spending far more on health care than other high-income countries in 2013, Americans had comparatively poor health outcomes, including shorter life expectancy and higher rates of chronic conditions. Researcher from the Commonwealth Fund found that higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions.
Read the report, High U.S. Health Spending Likely a Result of More Technology, Higher Prices, New Analysis Finds, 

AARP Starts $40 Million Venture Fund for Technology for Seniors.  (Bloomberg) 
The Job of the Future Is … Home Health Care. (Bloomberg)
The Harvard Contest That’s Trying to Improve Health Care Delivery.  (Harvard Business Review
Congress and Obama Administration Seek Ways to Limit Increase in Medicare Premiums.  (New York Times)
Price Hikes — Even Beyond Inflation — Drive Drug Revenue.  (KHN article /WSJ) 
Better Healing from Better Hospital Design  (Harvard Business Review
Florida Hospital District Agrees to Pay United States $69.5 Million to Settle False Claims Act Allegations.(Department of Justice, U.S. Attorney’s Office Southern District of Florida
Hillary Clinton’s Health Care Proposals, Focused on Cost, Go Well Beyond Obama’s.  (New York Times) 
Can Mass. do health care better, cheaper, and more efficiently? (Boston Globe)
US cancer doctors drop pricey drugs with little or no effect.  (Reuters)
Share Your Doctor-Why joint medical appointments could be better for patients than one-on-one sessions.  (The Atlantic) 
New York City to offer low-cost healthcare to uninsured immigrants.  (Reuters) 



Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s