Research Roundups: Expanding Medicaid; More spending doesn't reduce mortality; Colonoscopy cost effectiveness; Kids, asthma and access to care

Aug 7 2010

Health Affairs: Little Evidence Of Correlation Between Growth In Health Care Spending And Reduced Mortality - This study examines differences in hospital mortality and cost between 2000 and 2004 for patients at 122 U.S. hospitals, with seven common medical diagnoses: acute myocardial infarction, chronic obstructive pulmonary disease, community-acquired pneumonia, congestive heart failure, cerebrovascular accident (also called ischemic stroke), sepsis, or urinary tract infection. The authors found "almost no associations between the change in cost or mortality and patients' race, sex, or income level, or hospitals' ownership, size, region, or teaching status," and conclude: "The message to be underscored once again for policy makers is that health care dollars provide inconsistent value, and future spending increases should be targeted to care that improves outcomes" (Rothberg et al., August 2010).

Health Affairs: When Budgets Are Tight, There Are Better Options Than Colonoscopies For Colorectal Cancer Screening - This paper examines the cost and effectiveness of two techniques of screening for colorectal cancer - the colonoscopy and guaiac-based fecal occult blood tests.

"Under the majority of the scenarios we analyzed, using guaiac-based fecal occult blood tests rather than colonoscopy as the screening test would result in more individuals' being screened for colorectal cancer," the authors report. "Although colonoscopy is currently emerging as the most frequently performed colorectal cancer screening test in the United States, in many instances it might not be the optimal choice, especially for programs with fixed budgets. Across a broad population, as opposed to for use in a particular individual, the Hemoccult SENSA test can result in more benefit than colonoscopy. Therefore, colonoscopy should not be automatically considered the appropriate choice" (Subramanian, Bobashev and Morris, 7/29).

Archives of Pediatrics and Adolescent Medicine: Differences In Prevalence, Treatment, And Outcomes of Asthma Among a Diverse Population Of Children With Equal Access to Care - This study examines whether similarities in access to medical care through the Military Health System (MHS) serve to minimize the racial and ethnic differences in asthma diagnoses, treatment and outcomes in children. With data from 2007 TRICARE Prime, a  voluntary health maintenance organization-type plan, the study found "evidence of racial and ethnic differences in asthma prevalence and outcomes [even] after adjusting for differences in demographic characteristics and socioeconomic status." 

"Compared with white children in the MHS, the prevalence of asthma among black and Hispanic children was significantly higher and their outcomes were often worse. Black children of all ages and Hispanic children between the ages of 5 and 10 years were significantly more likely to have any asthma [potentially avoidable hospitalization] PAH and any asthma-related [emergency department] ED visit" (Stewart et al., August 2010).

Archives of General Psychiatry: Cost-effectiveness Analysis Of A Rural Telemedicine Collaborative Care Intervention for Depression - "Compared with their urban counterparts, rural patients with mental health care needs tend to have fewer visits, enter care later in the disease progression, have more serious symptoms at entry, receive lower-quality care, and need more expensive treatment," according to this study that examines the cost-effectiveness of a rural telemedicine-based collaborative depression intervention. "In rural settings, we found that a telemedicine-based collaborative care intervention for depression was effective but expensive," the authors conclude  (Pyne et al., August 2010).

Kaiser Family Foundation/Health Management Associates: State Medicaid Agencies Prepare For Health Care Reform While Continuing To Face Challenges from the Recession - Based on interviews with 11 state Medicaid directors in May 2010, the authors of this report (.pdf) write that "even with a full implementation more than three years away in 2014, a common concern across Medicaid directors is that state funding and administrative capacity are inadequate to accomplish all of the tasks associated with federal health reform implementation." 

The authors conclude that states are "awaiting needed guidance from the federal agencies, in particular from CMS, so they can begin to prepare the specifications and requirements for the major system changes involved with Medicaid eligibility re‐design and integration with the new health insurance exchanges. These are major undertakings, and Medicaid officials are very aware of the very short amount of time they have to carry out the required work" (Smith, Gifford and Dehner, 8/2).

Health Affairs: What The Oregon Health Study Can Tell Us About Expanding Medicaid - "For a limited time in early 2008, Oregon had a reservation list (a waiting list) for enrollment in its previously closed program that expanded Medicaid coverage to low-income adults. More than 85,000 people put their names on the list, but the state did not have enough funding to cover them all. Between March and October 2008, about 30,000 names were randomly drawn from the list, and those selected were permitted to apply for coverage," according to this paper that describes an ongoing study of the population who signed up for the plan and later enrolled in the program.

The authors concluded that those who did apply "were three years older than those who did not apply, and, among survey respondents, they were more likely to report being in fair or poor health and having days impaired by poor health. Those who enrolled were older and in worse health than the general waiting list population, who in turn were older and sicker than the low-income uninsured in general. ... That so many people with income above the eligibility limit participated—and, if selected, applied for coverage—suggests that there is substantial unmet demand for health insurance among those just above the federal poverty level" (Allen et al., August 2010).

Kaiser Family Foundation's Commission on Medicaid and the Uninsured: Expanding Medicaid to Low-Income Childless Adults Under Health Reform: Key Lessons From State Experiences - "Reaching, enrolling and delivering care to childless adults will be among the key issues in implementing health reform," write the authors of this report (.pdf) that is "based on interviews with officials in seven states and the District of Columbia and national experts [and] examines lessons learned from past state experience covering childless adults through waiver and state-funded programs ... The report finds that many best practices for enrolling parents and children in Medicaid will apply to childless adults, but successful efforts will also require new strategies and messages given their historic ineligibility for Medicaid, limited connection to public programs, fluctuating incomes and language and cultural barriers."

The authors note that many low-income childless adults will have greater health needs than the average population, so will need to be connected with primary care doctors or a medical home. For example, "In Wisconsin, enrollees are required to get a physical exam within the first 12 months of enrolling or they will be disenrolled. This exam may identify untreated and unmanaged chronic conditions and establishes a medical home" (7/28).

Health Affairs/Robert Wood Johnson Foundation: Accountable Care Organizations - This brief (.pdf) examines the concept of the accountable care organization (ACO) as described in the new health law and outlines how ACOs might evolve over time. ACOs could face challenges attracting medical providers who may have a difficult time viewing "possible shared savings as enough to offset the revenue they would lose from a reduced use of services" and the fact "[s]olo practitioners and small physician groups lack the data systems and organizational structures needed to form ACOs. ... Until the full ACO program becomes operational in 2012, the law allows CMS to begin ACO contracts with the provider groups that participated in the Physician Group Practice demonstration project. CMS is having discussions with these groups and is likely to begin preparing the initial ACO contracts soon" (Merlis, 7/27).

Institute of Medicine: Transforming Clinical Research In the United States -"There are growing indications … that the current health care system and the clinical research that guides medical evidence through clinical trials in the United States is expensive and lengthy, includes a number of regulatory hurdles, and is based on limited infrastructure," according to this document that summarizes a two-day workshop held in October 2009 "to evaluate the state of clinical research" in the country and "identify strategies for improving clinical trials' efficiency and effectiveness" (English, Lebovitz and Giffin, 8/2).