Research roundup: Moving kids onto Medicaid; competitive markets

Aug 26 2013

Each week, KHN compiles a selection of recently released health policy studies and briefs.

JAMA Surgery: Excessively Long Hospital Stays After Trauma Are Not Related To The Severity Of Illness
Reasons related to severity of illness or medical care are commonly believed to be the main causes for prolonged hospital stays. Our study shows that delays in discharge are typically not caused by medical factors. In most cases, [excessively prolonged hospitalization] was related to administrative issues, predominantly the inability to place a patient in an appropriate rehabilitation facility, as well as to operational and insurance issues. ... patients with and without [excessively prolonged hospitalization] had similar injury severity, physiological compromise, and comorbidities. The only independent predictors of [excessively prolonged hospitalization] were issues related to insurance coverage and discharge disposition (Hwabejire et al, 8/21).

JAMA Psychiatry: Geography And The Medicaid Mental Health Care Infrastructure
Medicaid is the largest payer of mental health (MH) care in the United States, and this role will increase among states that opt into the Medicaid expansion. However, owing to the dearth of MH care providers who accept Medicaid, expanded coverage may not increase access to services. ... Our results highlight extensive gaps in the community-based MH treatment infrastructure for Medicaid enrollees across many US counties. More than one-third of counties do not have any outpatient MH facilities that accept Medicaid. Furthermore, counties with a higher percentage of residents who are black, Hispanic, or living in rural communities are significantly more likely to lack geographic access to these facilities. Among states that opt into the Medicaid expansion, our results suggest that communities with a high percentage of racial/ethnic minorities may face particular constraints on their Medicaid MH safety-net system (Cummings et al, 8/21).

Georgetown University Center for Children and Families/The Kaiser Family Foundation: Aligning Eligibility for Children: Moving The Stairstep Kids To Medicaid 
A feature of the Affordable Care Act (ACA) that has not received a lot of attention requires that Medicaid cover children with incomes up to 133 percent of the federal poverty level (FPL) ($31,322 for a family of four in 2013) as of January 2014. Today, there are "stairstep" eligibility rules for children. States must cover children under the age of six in families with income of at least 133 percent of the FPL in Medicaid while older children and teens with incomes above 100 percent of the FPL may be covered in separate state Children's Health Insurance Programs (CHIP) or Medicaid at state option. While many states already cover children in Medicaid with income up to 133 percent FPL, due to the change in law, 21 states needed to transition some children from CHIP to Medicaid. ... This brief examines how the transition of children from CHIP to Medicaid will affect children and families as well as states (Prater, 8/15).

UCLA Center for Health Policy Research/The Commonwealth Fund: Undocumented And Uninsured: Barriers To Affordable Care For Immigrant Populations 
The Affordable Care Act will significantly reduce the number of U.S. residents without health insurance to ensure appropriate access to health services, but the law specifically excludes one group from all its provisions: the approximately 11 million undocumented immigrants residing in this country. ... Undocumented residents are concentrated in a small number of states. As a result, safety-net hospitals in those states will be particularly affected by the reduction in disproportionate share hospital (DSH) payments scheduled under the Affordable Care Act that have previously cushioned the impact of providing uncompensated care. Many hospitals are expected to have a lower uncompensated care burden as a result of fewer uninsured patients, but those with a large proportion of undocumented immigrants may not experience the increase in insured patients that would otherwise be expected. Despite being in working families, most undocumented immigrants are not covered by health insurance and face significant access-to-care barriers (Wallace, Torres, Nobari and Pourat, 8/15).

Annals of Internal Medicine: A Home-Based Intervention To Reduce Depressive Symptoms And Improve Quality Of Life In Older African Americans 
Effective care models for treating older African Americans with depressive symptoms are needed. ... Design: Parallel, randomized trial stratified by recruitment site. Interviewers assessing outcomes were blinded to treatment assignment.  Setting: A senior center and participants' homes from 2008 to 2010. Patients: African Americans aged 55 years or older with depressive symptoms. Intervention: A multicomponent, home-based intervention delivered by social workers or a wait-list control group that received the intervention at 4 months. ... At 4 months, participants in the intervention group showed reduced depression severity ... and improved function ... compared with wait-list participants (Gitlin et al., 8/20).

Georgetown University Health Policy Institute/The Urban Institute: Moving To High Quality, Adequate Coverage: State Implementation Of New Essential Health Benefits Requirements
Beginning January 1, 2014, insurers selling non-grandfathered individual and small group policies must ensure they include 10 categories of essential health benefits (EHB) and restrict consumers' out-of-pocket costs. Establishing a meaningful but still affordable EHB standard generated considerable debate at the federal level and in many states.... Developing health plans that comply with the ACA's 2014 market rules has been no small lift for insurers in our [five] study states, and the review and approval process has stretched the capacity of state [departments of insurance]. However, in spite of technical glitches, most companies were able to meet federal and state filing deadlines and insurance departments have implemented practical approaches to manage the significant expansion. At the same time, in a majority of our study states, consumers are unlikely to see dramatic changes in the scope of their covered benefits, in part because states had pre-ACA benefit mandates in place. However, there remain long-term questions about the extent to which individual and small-group policies will conform to the state's benchmark benefit package (Corlette, Monahan and Lucia, 8/14).

The Heritage Foundation: Competitive Markets In Health Care: The Next Revolution
Over the course of the past several decades, federal and state lawmakers have proposed a variety of initiatives to reform America's health care system and reduce costs. One idea has been to instill competition in the health care markets to enable the industry to operate more like a traditional market. ... A classic argument, made by Kenneth Arrow and others, is that health care is inherently different from other competitive industries and is therefore incapable of functioning in a similar manner. However, the evolution of the health care industry, coupled with recent academic literature, suggests that health care can and should operate like many other industries. In fact, the academic literature suggests that proper reforms to move health care in this direction would significantly increase quality of care at lower cost. This paper discusses academic research pertaining to competition in health care and earlier attempts to instill competition into health care markets by looking at managed care, a previous attempt at competition in health care (Kevin Dayaratna, 8/19).

Here is a selection of news coverage of other recent research:

NBC News: Even Republican Young Adults Want Health Insurance, Poll Finds
Obamacare may have become a partisan issue, but more Republicans than Democrats have signed up for one of its most popular provisions, according to a survey published Wednesday. The survey also pokes holes in the idea that most 20-somethings act like "Young Invincibles" who believe they don't need health insurance. A team at the Commonwealth Fund, which strongly supports healthcare reform, looked at one of the main target groups of the 2010 Affordable Care Act – young adults who have been going without health insurance (Fox, 8/21).

Reuters: Low Prices Seen Luring Young Adults To Obamacare: Study
If uninsured young Americans shun the new health plans offered under President Barack Obama's healthcare reform law, it will be because the insurance costs too much and not because they don't expect to need much medical care, according to a study released on Wednesday (Begley, 8/21).

Medscape: Primary Care Shortage: NPs And PAs May Not Be The Answer 
Relying on nurse practitioners (NPs) and physician assistants (PAs) to relieve the primary care shortage may not be the answer, as many NPs and PAs work outside of primary care, according to a Graham Center Policy One-Pager published in the August 15 issue of American Family Physician. Stephen M. Petterson, PhD, from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, and colleagues analyzed data from the National Provider Identifier file, which identifies the locations of NP and PA clinics and identifies physicians who work in the same location. NPs and PAs practicing in clinics without a primary care physician are assumed to be practicing primary care. Those data show that only about half of NPs (52.4%) and PAs (43.2%) work in primary care, with the others choosing subspecialty areas (Brown, 8/16).

MedPage Today: Survey: Autism Dx Harder In Latinos 
Screening for autism spectrum disorders in Spanish-speaking families has posed a challenge for many pediatricians, even those whose practice includes a high proportion of Latinos, a survey indicated. Only 29% of California pediatricians surveyed offered Spanish-language screening for autism and related disorders on the recommended schedule, Katharine E. Zuckerman, MD, MPH, of Oregon Health & Science University in Portland, and colleagues found. ... fewer of those physicians in Latino-heavy practices indicated difficulty in recognizing autism spectrum disorder in white children (27%), the researchers reported in the September issue of Pediatrics (Phend, 8/19).

MedPage Today: Pre-Injury State Key To Senior's Post-Fall Function
After a hip fracture or other serious fall-related injury, how much independence older adults regained depended to a large extent on how well they were doing beforehand, a study showed. Functional trajectories were tightly linked, with rapid recovery observed only in those with no or mild disability before the fall, Thomas M. Gill, MD, of Yale University, and colleagues found. Individuals with progressive disability in the year prior to their fall had only a 25% chance of a "little recovery," whereas none with preexisting severe disability recovered at all, the researchers reported online in JAMA Internal Medicine (Phend, 8/20).

The Associated Press: Health Care Provider's Eight-Year Program Involved More Than 300,000 Patients
New research suggests giving patients easier-to-take medicine and no-copay medical visits can help drive down high blood pressure, a major contributor to poor health and untimely deaths nationwide. Those efforts were part of a big health care provider's eight-year program, involving more than 300,000 patients with high blood pressure. At the beginning, less than half had brought their blood pressure under control (Tanner, 8/20).

Reuters: Patients May Need Better Info When Leaving Hospitals
Older patients may think they understand everything doctors tell them when they are released from the hospital, but a new U.S. study found several gaps in what they remember and areas where instructions could be clearer. Out of nearly 400 patients discharged from a large academic medical center, 96 percent reported knowing why they had been hospitalized, but only about 60 percent could accurately describe their diagnoses, for instance. "Patients were very positive, but when we asked them about actual facts, they could not tell us," said Dr. Leora Horwitz, the study's lead author from the Yale School of Medicine in New Haven, Connecticut (Seaman, 8/20).

Reuters: Telemedicine Improves Care For Kids Seen In Rural ERs
Telemedicine consults can help rural emergency room doctors provide better care to seriously ill or injured young patients, new research confirms. Rural hospitals and doctors' offices are increasingly using telemedicine -- essentially, videoconferencing with another doctor from a remote location -- to gain access to specialty care, Dr. James Marcin of the University of California Davis Children's Hospital in Sacramento, the senior author of the new study, told Reuters Health (Harding, 8/20).