Research roundup: Medicare costs in nursing homes; Docs reluctant to adopt EHRs; Health law to improve access to care

May 13 2011

Shefali S. Kulkarni compiled this selection of recently released health policy studies and briefs:

Archives Of Internal Medicine: Medicare Expenditures Among Nursing Home Residents With Advanced Dementia -- Researchers followed 323 dementia patients in 22 nursing homes for up to 18 months and found that over an 18-month period, "total mean Medicare expenditures were $2303 per 90 days but were highly skewed; expenditures were less than $500 for 77.1% of the 90-day assessment periods and more than $12 000 for 5.5% of these periods. The largest proportion of Medicare expenditures were for hospitalizations (30.2%) and hospice (45.6%)." Patients who lived in a specialized care unit, did not have a feeding tube, or were under a do-not-hospitalize order had lower Medicare expenditures than others. "Strategies that promote high-quality palliative care may shift expenditures away from aggressive treatments for these patients at the end of life," the authors conclude (Goldfeld et al., 5/9).

Government Accountability Office: More Reliable Data Consistent Guidance Would Improve CMS Oversight Of State Complaint Investigations -- "CMS, the agency within HHS that manages Medicare and Medicaid, contracts with state survey agencies to investigate complaints about nursing homes from residents, family members, and others," according to this report, which adds that "[c]oncerns have been raised about the timeliness and adequacy of complaint investigations and CMS's oversight." The GAO recommends that the "CMS Administrator take several steps to strengthen oversight of complaint investigations, such as improving the reliability of its complaints database and clarifying guidance for its state performance standards to assure consistent interpretation" (Dicken et al., 4/7).

Commonwealth Fund: Risk Adjustment Under The Affordable Care Act: A Guide For Federal And State Regulators -- This brief examines methods and guidelines states and federal regulators could use to design an effective system of risk adjustments for health care insurers. Summarizing "a Commonwealth Fund-supported conference of leading risk adjustment experts," the author "suggests that regulators use diagnostic rather than only demographic risk measures, that they allow states some but limited flexibility to tailor risk adjustment methods to local circumstances, and that they phase in the use of risk transfer payments to give insurers more time to predict and understand the full effects of risk adjustment"  (Hall, 5/10).

UCLA Center For Health Policy Research: Who Can Participate In The California Health Benefit Exchange? -- This policy brief examines the characteristics of the 1.7 million nonelderly uninsured in California in 2009 who "are estimated to be eligible to participate and receive subsidies in the new California Health Benefit Exchange marketplace" under the federal health law and finds that "they are often single, young working-age adults, and are employed in small firms. Most are healthy and the prevalence rates of most chronic conditions are similar to those with employment-based insurance. However, several indicators show poorer access to care for those who are uninsured." The authors note that the exchange  "is likely to improve access to care " (Pourat, Kinane and Kominski, May 2011).

A related brief by UCLA's Center for Health Policy Research (Californians Newly Eligible For Medi-Cal Under Health Care Reform) examines the 2.13 million nonelderly Californians who will be eligible for Medicaid under the law. " Despite lack of access or inconsistent access, the newly-eligible population is not sicker than the current Medi-Cal insured population. The slightly elevated rates of being a current smoker, being overweight or having high blood pressure are amenable to low-cost medical intervention in this relatively young and working-age population. The major benefit of expanding Medi-Cal coverage will be in improving access to care." For both newly-eligible populations, the law will improve health care quality, access and not create a large expenditure in the state, the authors conclude (Pourat, Martinez and Kinane, May 2011).

National Academy For State Health Policy: What a Difference A Dollar Makes: Affordability Lessons From Children's Coverage Programs That Can Inform State Policymaking Under The Affordable Care Act -- This issue brief notes that "states have varying degrees of flexibility in implementing coverage provisions under [ACA, the federal health law] so that programs can be tailored to states' unique needs." The author concludes: "Although the law provides free and reduced-cost coverage to eligible individuals and families, this does not automatically mean that all people will have access to affordable coverage. ... State policymakers should examine and build on the lessons learned from state children's coverage programs when looking to the future and designing affordable coverage options under ACA" (Basini, April 2011).

HHS Office of the Assistant Secretary for Planning and Evaluation: The Value Of Health Insurance: Few Of The Uninsured Have Adequate Resources To Pay Potential Hospital Bills -- This issue brief looked at data from the Health Care Cost and Utilization Project and concludes that "most uninsured people have virtually no savings. ... Even uninsured families with incomes above 400% of the Federal Poverty Level (FPL) can afford to pay in full for only 37% of their hospitalizations. Hospitalizations for which the uninsured cannot pay in full account for 95% of the total amount hospitals bill the uninsured. ... Lacking health insurance poses a greater risk of financial catastrophe than lacking car insurance or homeowner's insurance. ...  And, while the bill for a single hospitalization is about the same as the loss from an average house fire, a person is ten times more likely to be hospitalized than to experience a house fire" (Chappel, May 2011).

Commonwealth Fund: Women at Risk: Why Increasing Numbers of Women Are Failing to Get the Health Care They Need and How the Affordable Care Act Will Help -- Exploring the findings of the Commonwealth Fund Biennial Health Insurance Survey of 2010, the authors of this brief examine the factors that meant nearly 27 million working-age women were uninsured "for at least part of" 2010. The authors conclude that the health law "is already bringing dramatic change for women and their families through required free coverage of preventive care services integral to women's health, coverage of young adults on family plans, preexisting condition insurance plans, small business tax credits, and insurance market reforms including bans on lifetime benefit limits" (Robertson and Collins, May 2011).

Center For Studying Health Systems Change: Physician Practices, E-Prescribing And Accessing Information To Improve Prescribing Decisions -- The authors examined 24 physician practices to see how they were implementing electronic prescribing and using electronic health records (EHR) . "Study respondents highlighted two barriers to use: 1) tools to view and import the data into patient records were cumbersome to use in some systems; and 2) the data were not always perceived as useful enough to warrant the additional time to access and review them, particularly during time-pressed patient visits." The brief concludes that while the federal financial incentives will help move physicians towards a more "robust and effective use of e-prescribing," it will take additional effort from policymakers and stakeholders to use EHRs (Grossman et al., May 2011).

U.S. Bureau of Labor Statistics: High Deductible Health Plans, A Growing Option In Private Insurance -- According to this BLS "Perspectives" brief, to "respond to higher health care costs and provide coverage for more workers, employers are offering a new type of health plan: high deductible health plans (HDHPs). In 2009, 15 percent of all private industry participants in medical care plans had coverage in an HDHP. ... In 2009 the median deductible in a high deductible health plan was $1,600, compared with $400 for traditional deductible health plans," according to this guide to HDHPs (April, 2011).