Health Affairs’ July Issue: Medicaid’s Evolving Delivery Systems

In recognition of the Medicaid program’s 50th anniversary, the July issue of Health Affairs contains a cluster of papers focusing on how Medicaid is shaped by and has reshaped care delivery. Other subjects covered in the issue: variation in hospital childbirth costs and the nonprofit hospital tax exemption, among others.

The July issue was supported by the California HealthCare Foundation.

Several articles that examine issues pertaining to Medicaid at the state level include:

• MetroHealth Care Plus: Effects Of A Prepared Safety Net On Quality Of Care In A Medicaid Expansion Population: Randall Cebul of Case Western Reserve University and his coauthors studied the effect of a Medicaid expansion for poor uninsured patients at three prepared safety net systems in northeast Ohio and found that quality of care improved for patients with chronic conditions at costs that were 29 percent lower than expected.

• Early Medicaid Expansion In Connecticut Stemmed The Growth In Hospital Uncompensated Care: Sayeh Nikpay at the University of Michigan in Ann Arbor and her coauthors looked at data from Connecticut’s 2010 expansion of Medicaid to childless adults and found that uncompensated care was about one-third lower than it would have been without expansion.

• In California, Primary Care Continuity Was Associated With Reduced Emergency Department Use and Fewer Hospitalizations: Nadereh Pourat of University of California, Los Angeles and her coauthors found that recently insured California residents who adhered to their individual primary care provider or clinic once they gained health coverage were less likely to use emergency departments or have hospital stays.

Also of interest in the July issue:

Out-of-Pocket Spending On Contraceptives Drops Under Health Reform

Using administrative claims from a large national insurer, Nora Becker and Daniel Polsky of the University of Pennsylvania and the Leonard Davis Institute of Health Economics found that the Affordable Care Act (ACA) mandate that private insurance plans cover prescription contraceptives with no consumer cost-sharing has had an immediate financial impact for women using these products.

From June 2012 to June 2013, women saw a 20 percentage-point drop in their out-of-pocket expenses for oral contraceptives or intrauterine devices (IUD). On average, out-of-pocket expenses for the pill dropped 38 percent, and out-of-pocket expenses for the IUD declined 68 percent. The authors estimate that average out-of-pocket savings are $255 per year for the pill and $248 for the IUD. Additionally, they found decreases in spending for emergency contraception, diaphragms and cervical caps, implants, and injections.

Trend In Mean Adjusted Per Claim Out-Of-Pocket Expenses For Oral Contraceptive Pill Prescription Fills And Intrauterine Device (IUD) Insertions, 2008-13

Source: Authors analysis of data for 2008-13 from the Clinformatics Data Mart from Optum Insight.

Where Women Deliver Will Determine The Cost Of Childbirth

Xiao Xu and colleagues of the Yale School of Medicine analyzed variation in hospital costs associated with nearly 275,000 low-risk childbirths and found the average estimated hospital facility cost per maternity stay ranged from $1,189 to $11,986 among 463 hospitals across the country. Using data from the Nationwide Inpatient Sample, they found that hospitals with higher rates of caesarean delivery or serious maternal morbidity had significantly higher costs.

The authors note that the variation in costs among low-risk childbirths suggests potential large differences in hospital practices, indicating there are likely opportunities for savings — including safely reducing caesarean deliveries, increasing care coordination and emphasizing value through new payment and delivery system reforms. With nearly four million US births per year, childbirth is the country’s leading cause of hospitalization, suggesting that there are significant cost containment opportunities.

DataWatch: Provider Payments Relatively Unchanged, While Patient Obligations Rise

What is happening to physician reimbursement under the ACA? Analyzing data on more than seventeen million patient visits to nearly 15,000 health care providers in 2013 and 2014, Katherine Hempstead of the Robert Wood Johnson Foundation and coauthors from athenahealth looked at trends in payments to providers for both new and established patients, as well as patients’ payment obligations.

They found that payments to physicians for primary care visits increased most, but modestly — by 3.4 percent for established patients and 3.8 percent for new patients. Average payments for OB/GYN visits increased 2.9 percent for established patients, but decreased for new patients. Payments associated with select other specialties, including orthopedics and surgery, declined. The research also showed that patients were responsible for an increasing portion of the cost of their care — driven almost entirely by growth in insurance deductibles.