Research Roundup - December 2018

Connecticut 

Lowering the Cost of Specialty Care in Medicaid Using Electronic Consultations

By Daren Anderson, et al. | Health Affairs | December 2018

Specialty care accounts for a significant and growing portion of year-over-year Medicaid cost increases. Some referrals to specialists may be avoided and managed more efficiently by using electronic consultations. A study in Health Affairs found that linking primary care providers with specialists in dermatology, endocrinology, gastroenterology and orthopedics in Connecticut, using an electronic platform, reduced the need for face-to-face visits, saving an average of $82 per patient per month. Researchers concluded that expanding the use and reimbursement of electronic consultations for Medicaid patients could result in substantial savings while improving access to and timeliness of specialty care and strengthening primary care.

Hawaii

CMS Approves 1115 Waiver Housing Services Amendment

By DJ Wilson | State of Reform | Dec. 10, 2018

CMS recently approved Hawaii’s 1115 waiver request to use Medicaid funds to help those experiencing chronic homelessness and mental health issues find housing, according to State of Reform. Services that will be covered by Medicaid include assistance with housing searches, job skills training, moving and education/training on tenant responsibilities. Officials hope to see reductions in healthcare costs for eligible individuals by addressing a prominent social determinant of health. Hawaii is one of only a few states approved to use Medicaid funds for these kinds of supportive housing services.

Oklahoma

Half of Oklahoma Counties Have No OB/GYNs, Delivery Hospitals

By Meg Wingerter | NewsOK | Dec. 16, 2018

Forty-one of Oklahoma's 77 counties are designated “maternity deserts,” meaning they lack a hospital performing deliveries or an obstetrics provider, reports NewsOK. Most of the counties are rural, and women who live there are more likely to live in poverty than the statewide average. The decline in hospitals performing deliveries is partially due to the economics of running a maternity unit – for example, they must be staffed around the clock, which isn't feasible in areas that don't have a large enough population. Ideas to expand maternity care in rural areas include: offering incentives for doctors to work in rural areas; training doctors who grew up in rural areas and are more likely to return to practice; and expanding Medicaid to increase the number of women receiving coverage for prenatal care.

Texas 

Health Suffers Deep in the Troubled Heart of Texas

By Sharon Jayson | Kaiser Health News | Dec. 17, 2018

A new analysis from the Urban Institute revealed that Texas has both the largest number and highest percentage of uninsured residents under age 65 in the country. Additionally, patients often struggle to pay their bills, according to Kaiser Health News. Part of the problem may be “entrepreneurial healthcare practices” like freestanding emergency rooms, doctor-owned hospitals and balance billing. At last count, 214 freestanding ERs, which are generally highly profitable, have popped up across the state, in addition to hundreds of urgent care clinics and surgery centers. Employers are also continuing to eliminate subsides for employee premiums and shifting to high-deductible health plans. Without policy changes, Texas’ working poor and uninsured will find it difficult to access quality care.

Virginia

Virginia Looks to Boost Medicaid Reimbursement to Attract More Doctors

By Michael Martz | Richmond-Times Dispatch | Nov. 26, 2018

The Virginia Department of Medical Assistance Services has asked the governor to include $19.1 million in his budget proposal to boost Medicaid reimbursements for primary care doctors in order to prevent a physician shortage, according to the Richmond-Times Dispatch. With Medicaid expansion set to begin on January 1, state legislators are concerned about the widening gap between reimbursement rates to doctors in Medicaid and those in Medicare and inconsistent access to care under the Medicaid program. For the current fiscal year, Medicaid reimbursement was 71 percent of the rates paid by Medicare. The state expects to enroll 360,000 people under expanded Medicaid eligibility.

Recent Reports

The Current State of Telehealth Evidence: A Rapid Review

By Erin Shigekawa, et al. | Health Affairs | December 2018

Telehealth encompasses many applications for varied conditions and populations, making it difficult to draw broad conclusions about its efficacy. A review in Health Affairs examined recent evidence about telehealth’s efficacy by clinical area and its impact on utilization. Researchers concluded that telehealth interventions are generally equivalent to in-person care, but its impact on the use of other services remains unclear. The authors recommend careful consideration of many factors when weighing the evidence of telehealth’s efficacy, including modality, evidence quality, population demographics and point-in-time measurement of outcomes.

The Use of Telehealth Services Among Underserved Populations

By Jeongyoung Park, et al. | Health Affairs | December 2018

Telehealth use increased dramatically from 2013-2016, with new modalities such as live video, live chat, texting and mobile apps gaining traction. An analysis of data from a nationally representative consumer survey revealed that underserved populations—including Medicaid, low-income and rural residents—did not use live video communication as widely as other groups did. Less restrictive state telehealth policies were not associated with increased usage overall or among underserved populations, suggesting that state efforts to remove barriers to using telehealth might not be sufficient for increasing use. New incentives for providers and consumers to adopt and use telehealth may also be needed.

Fragmented Division of Labor and Healthcare Costs: Evidence from Moves Across Regions

By Leila Agha, et al. | Journal of Public Economics | January 2019

A study published in the Journal of Public Economics used Medicare claims data to analyze the effect of care fragmentation--when services are spread across many providers--on healthcare utilization and costs. Researchers found that when patients move to regions of the country with higher care fragmentation they use more specialist care and have fewer encounters with primary care physicians. In the highest fragmentation regions over $1000 per beneficiary per year more was spent compared to regions in the lowest fragmentation group. These results indicate that regional fragmentation patterns are strongly associated with regional costs of care.

Middle-Income Americans Paying More for Health Insurance

By Sara Collins and David Radley | Commonwealth Fund | Dec. 7, 2018

A report released by the Commonwealth Fund found that the cost of employer insurance is a burden for middle-income Americans. In 2017, more than half (56 percent) of people under age 65—about 152 million people—had insurance through an employer, either their own or a family member’s. In contrast, only 9 percent had a plan purchased on the individual market, including the marketplaces. The report pointed out that premium contributions and potential out-of-pocket spending for single and family policies was $7,240 in 2017. That amounts to 11.7 percent of median income—a decade ago this cost represented 7.8 percent of median income.

Nearly Half of Medicare Patients in Long-Term-Care Facilities Experienced Harm

By Tina Reed | FierceHealthcare | Dec. 4, 2018

A report issued by the Office of the Inspector General (OIG) has found that more than 20 percent of Medicare patients who received treatment in a long-term care facility experienced serious harm, with an additional 25 percent experiencing temporary harm events. In addition, the OIG found that 27 percent of Medicare patients in hospitals, 33 percent of Medicare patients in skilled nursing facilities and 29 percent of Medicare patients in rehab hospitals experienced patient harm. The report pointed out that more than half of the events were clearly or likely preventable and often related to substandard care (58 percent) or medical errors (34 percent), according to FierceHealthcare. Based on this data, the report recommends that CMS and Agency for Healthcare Research and Quality take steps to raise awareness and tailor patient safety efforts to address the needs of long-term care hospitals.

Lower Utilization Dampened Health Spending Growth in 2017

By Harris Meyer | Modern Healthcare | Dec. 6, 2018

Healthcare spending growth in the U.S. slowed between 2016 and 2017, down to 3.9 percent from 4.8 percent, according to an annual report by CMS’ Office of the Actuary featured in Modern Healthcare. This may have been driven by reduced use and intensity of hospital care, physician services and prescription drugs, although some observers raised concerns that people are forgoing needed care because of high-deductible health plans. Researchers found slower growth in the number of prescriptions dispensed and a shift to lower-cost generic products. However, hospital spending—which made up 33 percent of total spending—grew faster than the overall healthcare spending rate, up 4.6 percent in 2017.

Young People More Likely to Defer Healthcare Because of Cost

By Scott Hensley | NPR | Dec. 7, 2018

The latest NPR-IBM Watson Health Poll has revealed that 1 in 5 people have postponed, delayed or cancelled a healthcare service in the past three months due to cost. The proportion of people who said cost had deterred them from getting care varied by age, with a third of people under 35 saying it had been a problem compared with only 8 percent of people 65 and older, according to NPR. More than 40 percent of people under 35 stated that they had difficulty paying for some kind of healthcare service in the preceding three months, compared to 11 percent of people 65 and older. The cost of prescription drugs was also a bigger concern for younger people. 

High-Deductible Plans Cause Patients with Diabetes to Delay Seeking Care

By J. Frank Wharam, et al. | Annals of Internal Medicine | Nov. 20, 2018

A new study has revealed that among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease. The group studied consisted of individuals with diabetes who transitioned from a low-deductible health plan to a high-deductible one. 

Social Determinants of Health Pose Challenges for Most Americans, Survey Shows

By Jeff Lagasse | Healthcare Finance | Dec. 12, 2018

A Waystar survey found that 68 percent of Americans identified having challenges in at least one social determinant of health (SDoH) risk category, according to Healthcare Finance. These categories included financial or food insecurity, social isolation, housing insecurity, addiction, transportation access and health literacy. Addressing SDoH concerns could have a strong positive effect on a patient’s health as well as the country’s overall healthcare system by reducing healthcare costs. The Medicare and Medicaid program have a larger share of the SDoH high-stress population compared to commercial insurers. Efforts to engage patients on SDoH issues are also found to be frequently misapplied, with the majority of conversations about SDoH challenges occurring with the patients least likely to be affected by them—and less likely to accept assistance even if they are affected.

Addressing Social Determinants of Health via Medicaid Managed Care Contracts and Section 1115 Demonstrations

By Diana Crumley, et al. | Center for Health Care Strategies | December 2018

The Association for Community Affiliated Plans and the Center for Health Care Strategies have released a report on the ways in which states use Medicaid managed care contracts and state 1115 waivers to address social determinants through improved care coordination and cross-sector partnerships among community-based organizations, providers and managed care organizations.  Researchers found that there is a growing focus on social determinant of health (SDoH) in state managed Medicaid contracts, but payment incentives linked to SDoH are not yet commonplace. The report goes on to detail five policy recommendations.

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Commentary/News

Telemedicine Surging in the U.S. but Still Uncommon

By Lisa Rappaport | Washington Post | Dec. 11, 2018

Telemedicine visits have increased sharply over the last several years, but the vast majority of Americans still receive their healthcare from in-person visits versus remote technology, reports the Washington Post. The goal of telemedicine is to increase access to healthcare, especially for populations living in underserved areas of the country. As of 2016, 32 states have “parity” laws, requiring the same levels of reimbursement for in-person and remote visits, according to a new study from JAMA. As a result of these laws, telemedicine use has increased from 206 visits in 2005 to more than 202,000 in 2017. Though telemedicine is still uncommon, the lead researcher from the T.H. Chan Harvard School of Public Health notes that it is possible that telemedicine will become common practice within the decade if growth continues at this pace.

Doctors are Fed Up with Being Turned into Debt Collectors

By Blake Dodge | Bloomberg | Nov. 15, 2018

With deductibles on the rise, healthcare providers are often having to harangue patients to pay their portion of the total medial bill, according to Bloomberg. For example, Quest Diagnostics Inc., the lab-testing giant, said 20 percent of services billed to patients in the third quarter of this year went unpaid, costing the company about $80 million in lost revenue. A study found that primary care physicians lose about 15 percent of their revenue to billing activities like calling insurance companies for estimates. Due to this administrative burden, many physicians have abandoned their own practices in favor of hospitals and large physician groups. Additionally, providers are looking for ways to address the problem but often don't have real-time, fully accurate information on patient deductibles, which fluctuate based on how much has already been paid. To cope with the challenge, labs and hospitals are investing millions in programs designed to help patients understand what they owe at the point of care.

Health Insurer, Employer Groups Call on Congress to End Surprise Billing

By Shelby Livingston | Modern Healthcare | Dec. 10, 2018

Nine groups representing health insurers, employers and consumers have called for federal legislation to protect patients from surprise medical bills from out-of-network providers, according to Modern Healthcare. These groups, which include Blue Cross and Blue Shield Association, America’s Health Insurance Plans, the National Business Group on Health, and Consumers Union would like Congress to prohibit providers from billing patients for costs not covered by the health plan when an out-of-network visit is not the patient’s fault. The group said that legislation should be crafted in a way that it does not increase premiums or discourage providers from joining a health plan’s network. In response, representatives from the American Hospital Association and the Federation of American Hospitals have blamed inadequate provider networks for emergency care as one of the “root causes” of surprise medical bills.

Investigation of Generic ‘Cartel’ Expands to 300 Drugs

By Christopher Rowland | Washington Post | Dec. 9, 2018

An antitrust lawsuit brought by states over two drugs in 2016 has expanded to an investigation of alleged price-fixing involving 16 generic companies and 300 drugs, according to the Washington Post. State officials have characterized this as the largest cartel in American history, one that has overcharged consumers for common medications. Officials say they have documented price increases of up to 2,000 percent. Generic drug manufacturers have rejected the accusations.

Public Health Should Be as Reliable as Our Highways

By Karen DeSalvo and Jeffrey Levi | Roll Call | Dec. 10, 2018

To close the gap between current investments in public health and recommended levels, experts suggest creating a Public Health Infrastructure Fund in a new white paper introduced at a Bipartisan Policy Center event. Using a national study conducted by the University of Kentucky, a panel of experts brought together by the Public Health Leadership Forum found that supporting foundational public health capabilities across the country would cost an estimated $9.5 billion a year, or approximately $32 per person per year. Based on current investments by all levels of government, the University of Kentucky estimated there is a $4.5 billion gap between what is now in place and what is needed to achieve a truly nationwide public health infrastructure, according to Roll Call. The white paper also describes key principles that would guide the Public Health Infrastructure Fund.
 
 
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