Research roundup: Funding for safety-net hospitals; insurance competition

Jun 9 2014

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

Health Affairs: Disproportionate-Share Hospital Payment Reductions May Threaten The Financial Stability Of Safety-Net Hospitals
Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid .... The Affordable Care Act (ACA) anticipates that insurance expansion will increase safety-net hospitals' revenues and will reduce DSH payments accordingly. We examined the impact of the ACA's Medicaid DSH reductions on California public hospitals' financial stability .... Decreases in uncompensated care costs resulting from the ACA insurance expansion may not match the act's DSH reductions because of the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation. ... we estimate that California public hospitals' total DSH costs will increase from $2.044 billion in 2010 to $2.363–$2.503 billion in 2019, with unmet DSH costs of $1.381–$1.537 billion (Neuhausen et al., 6/2). 

Annals of Internal Medicine: The Patient-Centered Medical Home, Electronic Health Records, And Quality of Care
The patient-centered medical home (PCMH) model of primary care is being implemented widely, although its effects on quality are unclear. The PCMH typically involves electronic health records (EHRs), organizational practice change, and payment reform. [The researchers sought to] compare quality of care provided by physicians in PCMHs with that provided by physicians using paper medical records and, separately, with that provided by physicians using EHRs without the PCMH .... The PCMH group improved significantly more over time than either the paper group or the EHR group for 4 of the 10 measures (by 1 to 9 percentage points per measure): eye examinations and hemoglobin A1c testing for patients with diabetes, chlamydia screening, and colorectal cancer screening (adjusted P < 0.05 for each). The odds of overall quality improvement in the PCMH group were 7% higher than in the paper group and 6% higher than in the EHR group (Kern, 6/3).

National Bureau of Economic Research: More Insurers Lower Premiums: Evidence From Initial Pricing In The Health Insurance Marketplaces
First-year insurer participation in the Health Insurance Marketplaces (HIMs) established by the Affordable Care Act is limited in many areas of the country. ... we study the impact of competition on premiums. We exploit variation in ratings-area-level competition induced by United Healthcare's decision not to participate in any of the [federally facilitated marketplaces] FFMs. We estimate that the second-lowest-price silver premium (which is directly linked to federal subsidies) would have decreased by 5.4 percent, on average, had United participated. If all insurers active in each state's individual insurance market in 2011 had participated in all ratings areas in that state's HIM, we estimate this key premium would be 11.1 percent lower and 2014 federal subsidies would be reduced by $1.7 billion (Dafny, Gruber and Ody, 6/4).

The National Bureau of Economic Research: The ACA: Some Unpleasant Welfare Arithmetic
Under the Affordable Care Act, between six and eleven million workers would increase their disposable income by cutting their weekly work hours. About half of them would primarily do so by making themselves eligible for the ACA's federal assistance with health insurance premiums and out-of-pocket health costs, despite the fact that subsidized workers are not able to pay health premiums with pre-tax dollars. The remainder would do so primarily by relieving their employers from penalties, or the threat of penalties, pursuant to the ACA's employer mandate. Women, especially those who are not married, are more likely than men to have their short-term financial reward to full-time work eliminated by the ACA. Additional workers, beyond the six to eleven million, could increase their disposable income by using reduced hours to climb one of the "cliffs" that are part of the ACA's mapping from household income to federal assistance (Mulligan, March 2014).

Avalere Health: Analysis of Benefit Design in Silver Plan Variations
Both state-based and federally-facilitated exchanges offer financial assistance for low-income enrollees. The assistance takes two forms: advanced premium tax credits and cost-sharing reductions (CSRs). This report focuses on CSR plans, which are available to individuals and families earning between 100% of the federal poverty level (FPL) and 250% FPL; ... health insurers have broad flexibility about how to adjust cost-sharing for other services ... in fact, plans vary substantially in how they alter cost-sharing for each of the benefits examined in this analysis. ... For example, there is a trend among issuers to consistently reduce medical deductibles, while at the same time only slightly more than half of the plans alter cost-sharing for tier four prescription medications in the 94% AV CSR plans. Given the continued flexibility granted to issuers designing CSR plans and the high proportion of enrollees eligible for financial assistance, stakeholders may wish to identify trends in benefit design of CSR plans and assess consumer affordability heading into the 2015 plan year (Brantley, Bray and Pearson, June 2014).

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

The New York Times: Study May Alter Approach To Prostate Cancer
Many men with prostate cancer put off using chemotherapy as long as possible, fearing its side effects. But a new study has found that men given chemotherapy early in their treatment for advanced disease lived a median of nearly 14 months longer than those who did not get early chemotherapy. The result could upend the established treatment practice, researchers said here on Sunday [at the annual meeting of the American Society of Clinical Oncology]. ... Another study being presented on Sunday found that drugs called aromatase inhibitors might be better than the standard drug tamoxifen in preventing a recurrence of disease in premenopausal women with early breast cancer (Pollack, 6/1).

The Associated Press: Doctors Use Immune Therapy Against Cervical Cancer
Two years ago, Arrica Wallace was riddled with tumors from widely spread cervical cancer that the strongest chemotherapy and radiation could not beat back. Today, the Kansas mother shows no signs of the disease, and it was her own immune system that made it go away. The experimental approach that helped her is one of the newest frontiers in the rapidly advancing field of cancer immunotherapy, which boosts the body's natural ways of attacking tumors. At a conference in Chicago on Monday, doctors also reported extending gains recently made with immune therapies against leukemia and the skin cancer melanoma to bladder, lung and other tumor types (Marchione, 6/2). 

Reuters: Insured Young Cancer Patients Fare Better, Live Longer: Study
Young adults with cancer are far more likely to recover or live longer if they have health insurance, a new study on the potential impact of the Affordable Care Act shows. The study published on Monday reports benefits for young people who were uninsured before the act, also called Obamacare, went into effect this year (Steenhuysen, 6/2).

Reuters: In Treating Some Cancer Patients, Less Is More: U.S. Studies
Doctors can scale back treatment for certain cancer patients, based on evidence that some drugs can be used less frequently, according to new information that is clearing the way for physicians to limit the risks of care. Several studies backing up this "less-is-more" strategy, which can also lower the cost of care, were presented on Friday at the American Society of Clinical Oncology meeting in Chicago (Beasley, 5/30). 

Modern Healthcare: Move To ICD-10 Will Hurt Low-Margin Practice, Study Finds
Pediatricians and other low-margin practices could take a significant financial hit during the transition to ICD-10 procedural and diagnostic codes, according to a study in Pediatrics, the journal of the American Academy of Pediatrics. The 68,000-code ICD-10 system is scheduled to replace the 14,000-code ICD-9 system Oct. 1, 2015. Researchers at the University of Illinois at Chicago used the CMS general equivalent mappings tool, or GEMs, to "translate" ICD-9 codes to their more granular ICD-10 counterparts. They calculated that, for pediatric patient encounters, payment and clinical data may get lost in about 8% of these translations (Robeznieks, 6/2).

Reuters: Telemedicine Detects Eye Problems, Doctors Must Prepare For More Patients
Setting up a telemedicine screening option for patients in primary care clinics can catch many potential eye problems early on. But that sends more patients to eye doctors, who need to be prepared for the influx, according to a new study from the Veterans Health Administration. Researchers at the Atlanta VA Medical Center used two years of medical records to analyze what happened when retinal cameras were placed in primary care clinics to monitor for diabetes-related eye problems. Trained nurses used the specialized cameras to take pictures of the retinas of patients with diabetes, which were then sent to eye specialists or medical image readers for analysis (Doyle, 6/4).