A review of the evidence shows that bundled payments for surgical procedures can generate savings without adversely affecting patient outcomes. Less is known about the effect of bundled payments for chronic medical conditions, but early evidence suggests that cost and quality improvements may be small or non-existent. There is little evidence that bundles reduce access and equity, but continued monitoring is required.
In response to regulatory changes at the federal level, states that run their own marketplaces have taken steps to stabilize their individual markets. In this comparison of state-based and federally-facilitated marketplaces from 2016-2018, we find that SBMs had slower premium increases (43% vs. 75%), and fewer carrier exits, than FFMs. The total population participating in FFMs declined by 10%, while the enrolled population in SBMs remained largely stable, increasing by 2%. We find that the performance of the ACA marketplaces varies by state and appears to cluster around marketplace types.
In the current debate in Congress over the Affordable Care Act (ACA), the issue of provider access is a major concern. Fortunately, our 10-state audit study published in JAMA Internal Medicine finds that primary care appointment availability for new patients with Medicaid increased 5.4 percentage points between 2012 and 2016 and remained stable for patients with private coverage. Over the same period, both Medicaid patients and the privately insured experienced a one-day increase in median wait times. Higher appointment availability for Medicaid patients is a surprising result given the increase in demand for care from millions of new Medicaid enrollees. In this Issue Brief, we summarize our study’s findings, expand on possible explanations, and extend the analysis by examining the relationship between appointment availability and state-level Medicaid expansions. We find that access to primary care increased for Medicaid patients only in states that extended Medicaid eligibility to low-income, nonelderly adults. Combined, these results suggest coverage provisions in the ACA have not overwhelmed primary care capacity.
In a review of the evidence, the authors find that the ACA had minimal effect on employment, hours of work, and compensation. This brief provides critical perspective on the effects of reforms on labor markets for federal and state policymakers as they consider changing or repealing the law.
Subsidized reinsurance represents a potentially important tool to help stabilize individual health insurance markets. This brief describes alternative forms of subsidized reinsurance and the mechanisms by which they spread risk and reduce premiums. It summarizes specific state initiatives and Congressional proposals that include subsidized reinsurance. It compares approaches to each other and to more direct subsidies of individual market enrollment. For a given amount of funding, a particular program’s efficacy will depend on how it affects insurers' risk and the risk margins built into premiums, incentives for selecting or avoiding risks, incentives for coordinating and managing care, and the costs and complexity of administration. These effects warrant careful consideration by policymakers as they consider measures to achieve stability in the individual market in the long term.
Identifying and paying for value has become a recurrent theme of health care reforms. Its corollary, reducing the prevalence of, and resources directed to, ineffective or marginally effective care, has received far less attention. In July 2016, the University of Pennsylvania’s Leonard Davis Institute of Health Economics (LDI) convened a diverse set of national leaders and stakeholders representing industry, think-tanks, provider and patient groups, and academic experts to tackle how health systems, payers, and providers can spur the ‘de-adoption’ of medical practices and technologies no longer considered valuable.While the roundtable of experts unanimously supports the need for de-adoption and current efforts to curb the use of low-value practices or technologies, they identified four specific polarities at the heart of the debate about how best to build the momentum around deadoption, and move it forward. They are: 1) value (targeting ineffective, even harmful, care or expanding efforts to address care of limited value); 2) resource allocation (spending less or redirecting spending); 3) quality improvement (a subset of QI or a distinct process); 4) level of intervention (policy, payment, provider, or organization). In addition to these polarities, several key questions emerged that form practical next steps for advancing de-adoption activities. With an eye toward advancing de-adoption, this brief summarizes the polarities and questions that suggest priorities for a future research agenda and policy-relevant action steps.
This brief reviews the evidence on how key ACA provisions have affected the growth of health care costs. Coverage expansions produced a predictable jump in health care spending, amidst a slowdown that began a decade ago. Although we have not returned to the double-digit increases of the past, the authors find little evidence that ACA cost containment provisions producedchanges necessary to "bend the cost curve." Cost control will likely play a prominent role in the next round of health reform and will be critical to sustaining coverage gains in the long term.
The prevalence of narrow provider networks on the ACA Marketplace is trending down. In 2017, 21% of plans had narrow networks, down from 25% in 2016. The largest single factor was that 70% of plans from National carriers exited the market and these plans had narrower networks than returning plans. Exits account for more than half of the decline in the prevalence of narrow networks, with the rest attributed to broadening networks among stable plans, particularly among Blues carriers. The narrow network strategy is expanding among traditional Medicaid carriers and remains steady among provider-based carriers and regional/local carriers.
This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrownetworks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-basedmarketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaidcoverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at27% and 30%. We also find large differences in narrow networks by state and by plan type.
This brief summarizes evidence of nursing's effects on NICU outcomes and recommends policies to bolster and support nursing practice in NICUs. Adequate staffing and a supportive work environment are associated with better outcomes for very low birth weight infants.
This brief details changes in insurance coverage and access to care under the Affordable Care Act. About 20 million individuals gained coverage under the law and access to care improved. Despite these gains, more than 27 million individuals are still uninsured, and many others face barriers in accessing care. As a result of the 2016 elections, the future of the ACA is uncertain. As the next Administration and policymakers debate further health system reforms, they should consider the scope of the ACA’s effects on their constituents.
Journal of Policy Analysis and ManagementVolume 35, Issue 2 p. 490-492 Point/Counterpoint HEALTHY REGULATION Donald S Kenkel, Donald S KenkelSearch for more papers by this author Donald S Kenkel, Donald S KenkelSearch for more papers by this author First published: 05 February 2016 https://doi.org/10.1002/pam.21897Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume35, Issue2Spring 2016Pages 490-492 RelatedInformation
Journal of Policy Analysis and ManagementVolume 35, Issue 2 p. 492-495 Point/Counterpoint COMPREHENSIVE E-CIGARETTE REGULATION AS A STEP TOWARD HARM REDUCTION Kurt M. Ribisl, Kurt M. RibislSearch for more papers by this authorAndrew B. Seidenberg, Andrew B. SeidenbergSearch for more papers by this authorElizabeth N. Orlan, Elizabeth N. OrlanSearch for more papers by this author Kurt M. Ribisl, Kurt M. RibislSearch for more papers by this authorAndrew B. Seidenberg, Andrew B. SeidenbergSearch for more papers by this authorElizabeth N. Orlan, Elizabeth N. OrlanSearch for more papers by this author First published: 05 February 2016 https://doi.org/10.1002/pam.21899Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume35, Issue2Spring 2016Pages 492-495 RelatedInformation
The first three years of the Affordable Care Act’s Health Insurance Marketplaces have been tumultuous ones, with rapid entry and exit of insurers and recent spikes in premiums. As concerns mount about the stability and viability of the Marketplaces, this brief provides some insight into the forces behind the headlines and presents six options for policymakers to consider.
Despite national guidelines and proven health benefits, vaccination rates for the human papillomavirus (HPV) remain far below those of other vaccines recommended for adolescents. HPV is the most common sexually transmitted infection in the U.S; it is responsible for about 25,000 new cancers each year. A series of three shots is recommended for all girls and boys at age 11-12, but significant barriers exist to starting and finishing this series. This Issue Brief examines some of the barriers and summarizes a successful, multipronged clinical intervention to improve vaccination rates.
Concerns about the pharmaceutical industry's influence in academic medical centers and on medical education have led many medical schools and teaching hospitals to adopt conflict-of-interest (COI) policies. Although the restrictiveness of these policies differs, the goal is the same: to shield physicians-in-training from the persuasive aspects of pharmaceutical promotion. But do these policies work? This Issue Brief examines how COI policies affect the prescribing patterns of antidepressants, one of the most heavily promoted drug classes in the past decade. As such, it provides the first empirical evidence of the effects of COI policies in residency on the subsequent prescribing patterns of practicing physicians.
Community-based participatory research (CBPR) is a collaborative process between community-based organizations and academic investigators. It has the potential to make research more responsive to existing needs and to enhance a community's ability to address important health issues. But CBPR is often unfamiliar territory to academic investigators and community organizations alike. We interviewed CBPR investigators at Penn and community leaders to ascertain best practices in CBPR and to compare academic and community perspectives. A number of models of community-academic partnerships emerged, each with its own advantages and disadvantages. The perspectives of the investigators sometimes matched those of the community leaders, but diverged in important ways.
New technologies have given us the ability to detect genomic variation at resolutions 50-100 times greater than earlier tests. The good news is that we can now detect variations that help explain developmental delays, autism, or multiple congenital anomalies in up to 20% of children. The bad news is that we can also detect small missing or extra pieces of chromosomes that remain unexplained: that is, we don't know whether they have any clinical significance at all. The rapid pace of technological change may have outpaced the lab's ability to interpret, providers' abilities to explain, and patients' abilities to understand the test results. This Issue Brief summarizes a series of studies examining the uncertainties revolving around chromosomal microarray testing, which has become the new standard of practice in genetic testing of children with unexplained anomalies.
The nursing workforce plays a central role in our present health care system, and will likely have an even greater role in the future. Nurses already provide the vast majority of care to patients in hospitals, and so it should come as no surprise that the quality of nursing care affects patient outcomes. Over the past decade, studies have linked certain nursing characteristics--such as staffing levels, education, job satisfaction, and work environment--with better outcomes in hospitals. This Issue Brief adds to that evidence with a longitudinal study that links changes in nurse education with improvements in surgical patients' survival. It also discusses how a more educated nurse workforce could fill a range of new roles in primary care, prevention, and care coordination as health reform is implemented.
Children and adults with autism spectrum disorders (ASDs) have needs that challenge our systems of care. A new study estimates ASDs cost more than $126 billion each year in the U.S.--an amount that reflects both the costs of providing educational and medical services as well as the costs of not intervening early and effectively enough to prevent lifelong disability. This Issue Brief summarizes the implications of childhood autism for parental employment and earnings, and analyzes whether community-based services can reduce costly, psychiatric hospitalizations of children with ASDs.
