Health Affairs December Issue: Affordability, Access, Models Of Care

The December issue of Health Affairs, a variety issue, covers a range of topics: the impact of competition in the Affordable Care Act (ACA) Marketplaces, life expectancy determinants, managing complex care in the United States and elsewhere, and others.

DataWatch: The Growing Divide Between Public And Private Inpatient Payment Rates

While geographic variations in US hospital payment rates have been well documented, there is limited evidence about how payment rates for privately insured patients compare with those for Medicare and Medicaid beneficiaries. Thomas M. Selden of the Agency for Healthcare Research and Quality (AHRQ) and coauthors used data from the Medicare Expenditure Panel Survey (MEPS) for the years 1996–2012, examining amounts paid per inpatient hospital stay.

They found that the payment rates for privately insured patients were higher than rates in Medicare and Medicaid throughout the entire period, but the difference widened dramatically from about 10 percent in 1996–2001 to 75 percent in 2012 (see graph below). Evidence on the payment differential highlights several policy questions, said authors of the study. Among these questions are whether the difference between private and public reimbursements affects the quality of care for patients with public insurance, and why the public-private differential has grown so markedly over the last decade.


Federal Marketplace Competition: More Insurers Associated With Lower Premiums

Research about the impact of competition in the federally run Marketplaces suggests that the presence of more insurers tends to result in lower premiums; however, previous work did not investigate how those effects change with the number of competitors. To answer that question, Paul D. Jacobs of the Agency for Healthcare Research and Quality and coauthors examined data on insurer participation and premiums during the first two years of the Marketplaces (2014 and 2015), analyzing how changes in county-level premiums were associated with changes in the number of competitors in each county during this period.

Based on data for federally run exchanges, the authors found that one additional insurer was associated with a 3.5 percent reduction in the premium for the second-lowest-cost silver plan and a 1.2 percent reduction in the average silver plan premium. The study’s models also suggest that competitive effects dissipate after two or three additional entrants. The authors conclude that the strong effect on premiums for the second-lowest-cost silver plans will likely have meaningful effects on federal spending for premium subsidies, an important consideration for policymakers when considering future legislative or regulatory changes to the Marketplaces.

A related study in the December issue: In The Second Year Of Marketplaces, New Entrants, ACA ‘Co-Ops,’ And Medicaid Plans Restrain Average Premium Growth Rates; Jon R. Gabel of NORC at the University of Chicago and coauthors.

Global Health: Caring For Patients With Complex Needs In Ten Industrialized Countries

As more residents of industrialized countries live longer, often with multiple chronic health conditions, primary care physicians play an increasingly important role. Robin Osborn of The Commonwealth Fund and coauthors analyzed the results from the Fund’s annual international survey of primary care doctors in the United States and nine other industrialized countries. The study examined different aspects of primary care practice for patients with complex needs, including coordination of care, arrangements for after-hours care, and the use of secure e-mail as a means of expanding access to primary care.

According to the study, the percentage of doctors who feel that their practice is well prepared to manage patients with complex needs ranged from 66 percent in Sweden to 88 percent in the Netherlands and Germany. While the authors note some bright spots for the United States, such as significant progress in the adoption of electronic medical records, American primary care physicians stand out as being the most critical of their health care system (only 16 percent felt the system works well) and as having high levels of stress (43 percent) and dissatisfaction (34 percent) practicing medicine.

Another study comparing the US and a European health system: US Children And Adolescents Had Fewer Annual Doctor And Dentist Contacts Than Their Dutch Counterparts; Dougal S. Hargreaves of the Institute of Child Health, University College (UK), and coauthors.

Also of interest in the December issue:

US Life Expectancy And Educational Attainment

Recent evidence suggests life expectancy has been declining dramatically for socioeconomically disadvantaged subgroups of the US population. Using Census Bureau data, John Bound of the University of Michigan and coauthors examined the validity of earlier findings that categorized education in terms of high school graduation, even though each year those not completing high school are a shrinking and increasingly vulnerable segment of the population.

By examining a relative (lowest quartile) instead of absolute (failure to complete high school) measure of education, the authors concluded that widely publicized estimates of worsening mortality rates among non-Hispanic whites with low socioeconomic positions are exaggerated. However, the authors found a robust trend toward increasing inequality in life expectancy—with important policy implications for retirement, public health, and health care—that calls for the development of a national health equity agenda.

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