The following remarks were delivered by AcademyHealth, President and CEO, Lisa Simpson, MB, BCh, M.P.H., FAAP, at AcademyHealth’s National Health Policy Conference on Monday, February 1 during the opening welcome.

Thank you, Lucy, and welcome to all of you. We are excited to be your hosts and thrilled with the program that Dr. Savitz and the planning committee helped assemble.

At AcademyHealth, our mission is to work alongside our members to improve health and the performance of the health system by supporting the production and USE of evidence to inform policy and practice. When you consider the different types of science in a continuum of health research, our field of health services research builds on the discoveries of basic and clinical science to determine how to deliver care and cures most effectively, with the highest level of quality, and in the most efficient way. That means looking at the thorny issues of health care costs, quality, access and equity with an eye toward generating applicable, relevant evidence for policymakers, health system leaders and patients.

Promoting the use of evidence takes many forms at AcademyHealth – and one way we support use is by creating space for thoughtful discussion and debate. This meeting is one of those spaces, and you are going to hear from experts representing a wide range of views, expertise, and different political ideologies throughout this meeting. We work hard to ensure a diversity of opinion, experience and perspective are represented across the agenda because we recognize that evidence-informed policy happens in an environment shaped by that other ‘p’ word – politics.

The questions and challenges you’ll discuss during this meeting also reflect the growing recognition that promoting and preserving health takes action well beyond ‘traditional’ health care. This shift to a broader, cross-sector view reflects the kinds of conversations our policymakers, and many of you, are having – discussions about the intersection of health, business, community, economics, environment, public safety, and our increasingly digitally connected world. Every policy decision has impacts – intentional or otherwise – that radiate to other sectors. Our field of health services research identifies, investigates and predicts those interactions so that policymakers from the delivery system, to states, to Capitol Hill can make informed decisions based on the outcomes they value.

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The following remarks were delivered by Former Governor of Kentucky, Steven Beshear, at AcademyHealth’s National Health Policy Conference on Monday, February 1 during the opening plenary session.

Thanks, Lisa. 

I was proud to host your visit to the Governor’s Mansion in Kentucky early in my administration, and I’m thrilled that you and the Academy have returned the favor by inviting me here to talk about the critical issue of health care.

There is no more pressing issue for our country today.

Good health is the foundation of everything from a competitive workforce to the financial security of our families, and that’s why I have a message for elected leaders and candidates both here in Washington and in our state capitols.

That message is this: 

This is not about you.

It’s not about your political ideology, or your partisan gamesmanship, or your personal aspirations.

In fact, take the politics out of it altogether.

What this issue is about … is people.

The good health of our people, and the collective health of our communities.

That – and only that – should be the basis for your decisions.

And if you can’t explain how your policy and rhetoric on health care will lead to better health outcomes … then quite simply you need to change your policies and rhetoric.

The American people are tired – in fact, they’re more than tired, they’re angry – about leaders who put ideology ahead of people.

Look, I was governor of Kentucky for eight years.

And in that time we made incredible progress toward improving the health of a very unhealthy state.

We did it because we had strategic vision … we were bold in implementing it … we relied on facts and research to set policy … and we brought to the table a wide variety of stakeholders and partners in both the public and private sectors, including our providers and our universities.

Some of those partners are here today.

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I wrote about Kevin Quinn’s insightful typologies of health care payment methods in a prior post, which you should read before this one. In it, I discussed this table:


At each point (1-8) in this hierarchy of risk, AmeriCare bears risks in changes in units at and above that point and USHC bears the risk for changes in units below that point. That’s because it’s a nesting of units: beneficiaries within time period, recipients are a subset of beneficiaries, each recipient has one or more episodes, each of which can span on or more days, etc. Another way to see this is in the figure Rick Mayes and I included in our 2012 Health Affairs paper:

financial risk

Because of the nesting of risk, if you multiply the numbers down the columns in Quinn’s table above, you get the bottom line total cost: 1 × 313 914 040 × 7.2% × 1.61 × 4.5 × $2299 × 3.54 = $1 337 939 745 325, or $1.3 trillion, which is total 2012 spending on inpatient hospitalization.

Over the decades, Medicare has changed the unit on which it pays various providers many times. The following table from Quinn’s paper documents those changes. Except for the payment method change for critical access hospitals in 1997, all changes have been to move up the hierarchy, which shifts more risk to providers and away from Medicare. The shifting of risk to providers reflects the idea that, given the right incentives, it is they, not Medicare that more accurately can assess how to provide the right care to the right patient at the right time.

medicare initiatives

In most transactions in most markets, the units are the thing that is being bought and sold. Health care is only different to the extent participants in transactions are motivated by non-pecuniary factors. Quinn writes that the fact that payment for health care services can be and has been rendered at different units reflects the notion that “the ‘product’ being purchased and delivered [] remains variable and unsettled.” It’s a deep insight baked from some rather dry ingredients.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs, an Associate Professor at Boston University’s School of Medicine and School of Public Health, and a Visiting Associate Professor with the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs, Boston University, or Harvard University.

Editor’s Note: AcademyHealth’s National Health Policy Conference (February 1-2 in Washington, DC) features several sessions on payment reform, innovations, and alternate models. Explore the agenda here.




I know a lot of physicians who like to think that getting sued is just a matter of bad luck. Or, that it’s inevitable. A new study at the NEJM has some data to shine on that belief. “Prevalence and Characteristics of Physicians Prone to Malpractice Claims“:
BACKGROUND: The distribution of malpractice claims among physicians is not well understood. If claim-prone physicians account for a substantial share of all claims, the ability to reliably identify them at an early stage could guide efforts to improve care.
METHODS: Using data from the National Practitioner Data Bank, we analyzed 66,426 claims paid against 54,099 physicians from 2005 through 2014. We calculated concentrations of claims among physicians. We used multivariable recurrent-event survival analysis to identify characteristics of physicians at high risk for recurrent claims and to quantify risk levels over time.
Although there are issues with the NPDB, it’s still of the major sources of malpractice data, especially when you want to look at paid claims. In this case, researchers looked at more than 66,000 claims against more than 54,000 doctors from 2005 through 2014. Most importantly, they looked at the concentrations of claims among physicians.
What they found is this: Most docs who were sued (84%) were only sued once. But they account for only 68% of paid claims. About a third of claims are accounted for by just 1% of doctors. 
Docs who get sued more are more likely to get sued again. Even after adjusting for other factors, physicians were more likely to get sued again as the number of paid claims increased. Compared to physicians with only one paid claim, physicians with three paid claims had a 24% chance of winding up with another paid claim in the next two years. That’s an absolute risk increase, not just a relative risk increase (which was more than three times).
A small number of doctors account for a rather large number of paid malpractice claims. You might think there might be something different about them. We should probably focus on fixing that, instead of focusing only on reforming”the system”.
P.S. This is even more reason to believe that malpractice reform won’t reduce health care spending. Defensive medicine is based on the idea that all physicians are spending more in order to avoid being sued. It assumes that reducing lawsuits would reduce the need for that spending. But if being sued is related to certain physician characteristics, not to whether they practiced “defensive medicine” then the theory of tort reform starts to fall apart.
P.P.S. I have previously written about malpractice here at the AcademyHealth blog here, here, and here.


By: Megan Collado, AcademyHealth

At AcademyHealth, we believe that the most effective health care policy is informed by objective, rigorous evidence, and we have a long history of supporting the generation of new evidence through our management of grantmaking program and initiatives. For 25 years, AcademyHealth served as the national program office for the Robert Wood Johnson Foundation’s (RWJF) Changes in Health Care Financing and Organization (HCFO) grantmaking program, and we continue to manage special topic solicitations for the Foundation covering a broad array of issues.

In 2015, RWJF funded five grantees through the first round of funding from the Policy-Relevant Insurance Studies (PRIS) program. The PRIS program emphasizes quick turnaround studies examining highly policy-relevant questions related to health insurance markets. The inaugural grantees are examining current policies and/or potential policy changes and their effect on coverage issues, including considerations of Medicaid expansion and self-insurance in the small group market, among other topics. AcademyHealth is currently working with these grantees as they conduct their studies and disseminate their findings.

The Foundation recently announced the 2016 PRIS Call for Proposals (CFP), which again places priority on highly policy-relevant research questions and rapid-turnaround projects, but this time the CFP focuses on the issue of affordability of health insurance. Despite a significant reduction in the uninsured rate of the United States population after the passage of the Affordable Care Act, millions of eligible individuals remain uninsured, with concerns about affordability and high-quality health coverage. At the same time, a number of carriers are experiencing financial difficulties in these new marketplaces, while impending mergers among large carriers raise questions about the price effects of further consolidation in health care. Proposals for research that will directly inform the policy process will be prioritized during the selection process. Do you have questions about the PRIS program or CFP? Contact the project staff at Applications are due Friday, February 19, 2016 at 3:00 pm ET.

colladom_headshot(1)Megan Collado, M.P.H., is a senior manager at AcademyHealth, where she co-directs and supports a number of Robert Wood Johnson Foundation grantmaking programs and is the Project Director of an AHRQ-sponsored conference grant that convenes policy audiences to discuss the evidence and future research needs related to health care costs, financing, organization and markets. 


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By Enrique Martinez-Vidal

The third open enrollment period is coming to an end and the lack of drama may signal an opportune time for states to reassess the exchange model they are using. Certainly, eligibility determination and plan enrollment remain critical. But with many of the kinks and transitions worked out, states have an opportunity to pursue additional policy goals like improving customer service, increasing health plan competition, controlling administrative costs, and promoting delivery system transformation.

Different exchange models are more or less suited to the achievement of various goals, as outlined in a new brief written for the Robert Wood Johnson Foundation’s State Health Reform Assistance Network (State Network). As the authors Patrick Holland and Jon Kingsdale state, “Some of the 13 states (including Washington D.C.) that currently bear full responsibility for operation their own SBMs [State-based Marketplaces] may re-evaluate the relative costs and benefits of this model. And some the 11 “in-between” states that share risk and responsibility with the FFM [Federally-facilitated Marketplace] could move to full state control or exit the field altogether.”

It may be more difficult for a state currently using the FFM eligibility determination and enrollment platform to build its own SBM technology infrastructure given that federal funding to do so is no longer available. However, as more commercial firms have developed improved technologies to support exchanges, that option may become more attractive. Another brief written for the State Network explores the feasibility of a state contracting with a single firm to build and operate its marketplace.

Regardless of the technology underlying an exchange, additional health care policy goals beyond robust enrollment may be more attainable under an SBM. For example, because SBMs, for the most part, have an integrated process, Medicaid and Advanced Premium Tax Credit eligibility determination is handled more efficiently through one “front door” and with less likelihood of individuals falling through the enrollment cracks. In addition, it is easier for an SBM to work with its state department of insurance and to be operationally more flexible to actively encourage the participation and retention of health insurers to increase health plan competition than it is for other models that don’t know local markets as well.

While it may seem to be somewhat premature for these moves to be considered, the health care and political landscapes within which exchanges exist are constantly evolving. These briefs present evidence and analysis to help policymakers make considered decisions about how to best structure this important vehicle for getting insurance coverage to those who need it.


Enrique Martinez-Vidal is Vice President for State Policy and Technical Assistance at AcademyHealth. He is also the director of State Coverage Initiatives (SCI), a grant program of the Robert Wood Johnson Foundation, which provides timely, experience- and research-based information and technical assistance to state leaders in order to help them move health care reform forward at the state level. SCI is assisting in the management of the State Health Reform Assistance Network, a program of the Robert Wood Johnson Foundation, located at the Woodrow Wilson School of Public and International Affairs at Princeton University.


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In an August 2015 issue of Annals of Internal Medicine, Kevin Quinn offered one of the most insightful typologies of health care payment methods I’ve ever seen. Though they can be mixed and matched to some extent, are modified by risk adjustment in many cases, and can go by different names, he identified eight fundamental methods:

Fundamental Payment Methods

  1. Per time period—e.g., a fixed payment per year; salaried physicians amount to the same thing
  2. Per beneficiary—a payment method more common to health plans than providers, a.k.a. capitation
  3. Per recipient—though rare, this is like #2, but it’s a carve-out for a specific service a patient might receive, e.g., “a cardiologist
    accepting financial risk for treatment of [a] cardiac patient”
  4. Per episode—e.g., bundled payments or prospective, diagnosis-based payment (DRGs)
  5. Per day—a.k.a. per diem
  6. Per service—it’s not evident any entities pay according to number of services
  7. Per dollar cost—cost-based reimbursement
  8. Per dollar of charges—”charges” are “costs” marked up for profit (they’re higher); typically a payer would pay a proportion of charges, reflecting negotiated discounts or in an attempt to pay costs

It may not be obvious, but the ordering above reflects a useful nesting of financial risk. Here’s how to see that, using inpatient hospitalization and the non-institutionalized U.S. population as an example (familiarize yourself with the table and then I’ll walk you through it):


Using actual data (sources listed in the paper) for 2002 and 2012, the table shows number, proportion, or multiplier relevant to the units that relate to the eight types of payment methods, in order. These are interpretable as risk factors in the following way. Imagine there’s only one payer of health care for all Americans (call it AmeriCare). And imagine there’s just one, giant, U.S. hospital system (US Hospital Corp.). Now imagine AmeriCare and US Hospital Corp (USHC for short) are squaring off to negotiate 2012 payment rates for inpatient care. How would financial risk to AmeriCare and USHC change as the unit (risk factor or payment method) changes? Starting at the top, and with key words in bold that link to the fundamental payment methods listed above, here’s how to think about it:

  1. Obviously the time period unit is one year (2012). If AmeriCare and USHC negotiated at this unit level, AmeriCare would hand USHC a wad of money for the whole year. USHC would have to manage that wad to fund all the inpatient care for all Americans in the year, keeping any surplus as profit and going into debt for any overrun. In other words, USHC would assume all the cost risk. Good luck USHC! (Though different, because the VA is a public agency, not a private corporation, this is similar to the kind of risk VA hospitals face.)
  2. The number of “beneficiaries” (here, anyone who could use hospital care, not anyone who does use hospital care) per time period is a count of the U.S. non-institutionalized population, about 314 million in 2012. Relative to #1, negotiation at this level shifts very little risk from USHC to AmeriCare, since population size is predictable with high accuracy. Should there be a monstrous epidemic requiring substantially more hospital visits than anticipated, USHC would be in trouble.
  3. Payment per recipient of that care shifts that kind of risk from USHC to AmeriCare. In 2012, only 7.2% of the non-institutionalized population received inpatient hospital care. Per recipient payment would place the risk in the estimate of that figure with AmeriCare, since it would pay USHC a fixed amount for any, unique recipient of care, no matter how many there turned out to be.
  4. Each unique recipient of care might visit the hospital for one or several episodes of care in a year. On average, in 2012, a recipient had 1.61 inpatient hospital episodes. So, payment per episode is at a slightly finer level than payment per recipient. Under this arrangement, AmeriCare would assume risk in the number of episodes per recipient, USHC would retain the risk in cost per episode though. Here, Quinn notes that we’ve reached a dividing line in the risk hierarchy between “epidemiologic risk (prevalence of medical conditions) and performance risk (treatment of medical conditions).” Though one could argue the point slightly, by and large, neither AmeriCare nor USHC can exert much influence at the unit levels above per episode (#1, #2, #3 above), at least not at the time scale of a year; they’re mostly baked into the nature of medical conditions. However, at and below per episode (#5, #6, #7, #8 below), the organizations can more easily influence the number of units. That is, payment becomes more contingent on volume. One can even find health policy experts worried about bundled payments’ sensitivity to efforts by providers to increase episodes, for example. We’ve transitioned from concerns about stinting (USHC providing less care than necessary), which are associated with all payment methods at and above episode-based payments, to concerns about waste (USHC providing more care than necessary), which are associated with all payment methods below episode-based.
  5. An episode’s costs can be attributed to days, and each inpatient episode was about 4.5 days long in 2012. Payment per day moves length of stay risk from USHC to AmeriCare. In cases for which the daily rate is above (below) marginal cost, USHC has an incentive to increase (decrease) lengths of stay.
  6. Each day includes many services. In principle AmeriCare could pay USHC per service (without regard to what those services are). In practice, I’m not aware this has ever been done. More common would be to pay different rates for different services, but that’s getting closer to …
  7. … payment per dollar cost of service. If AmeriCare paid USHC its cost, clearly the cost risk is entirely with AmeriCare. USHC has no incentive to control costs. Traditional Medicare’s original payment system was intended to pay hospitals their costs. Perhaps that’s what many insurers attempt to do today as well but, ultimately, what they’re doing is a version of …
  8. … payment per dollar charge, meaning hospitals report their charges and insurers pay some fraction of those. In terms of cost risk and incentive for cost control, this isn’t much different than #7. Quinn reports average inpatient hospital markups over cost of 3.54 in 2012, meaning that for each dollar of cost, a hospital receives $3.54.*

There’s more to say about this typology. I’ll continue discussion of it in a future post.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs, an Associate Professor at Boston University’s School of Medicine and School of Public Health, and a Visiting Associate Professor with the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health. He blogs about health economics and policy at The Incidental Economist and tweets at @afrakt. The views expressed in this post are that of the author and do not necessarily reflect the position of the Department of Veterans Affairs, Boston University, or Harvard University.


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One common argument from opponents of the Affordable Care Act is that an expansion of government into health care will result in “crowd out”, where private influences and coverage go down as public ones go up.

But that’s not always the case, as seen in a study just released by the NEJM (Full disclosure, I’m one of the authors of this work). “Dependent Coverage under the ACA and Medicaid Coverage for Childbirth.”

In the United States, rates of uninsurance have been historically high among young adults (19 to 26 years of age). One of the first implemented provisions of the Affordable Care Act (ACA) was a mandate that all private-insurance family policies cover dependents until 26 years of age. Estimates suggest that this provision has reduced the rate of uninsurance among young adults by approximately 10%. Childbirth, the major reason for hospitalization of young adults, has received little attention in prior literature on the mandate.

As I’ve written many times, Medicaid is a huge source of coverage for babies born in the United States. Even before the ACA, Medicaid covered all pregnant mothers who were earning less than 133% of the federal poverty level. In 2010, Medicaid financed 45% of all births in the United States. This means, of course, that relatively few births are uninsured. In 2009, only about 5% of deliveries to young adults were uninsured, more than 60% were Medicaid covered.

One of the provisions of the ACA was that young adults (YA) could stay on their insurance until they were 26 years of age. It’s possible, therefore, that this would mean that some of them would no longer need to rely on Medicaid for coverage of giving birth. We wanted to test that hypothesis. We used two different data sources. The first was the natality files from the CDC and the second was the Nationwide Inpatient Sample from AHRQ. For both, we compared mothers age 19-25 years to mothers age 27-29 years, before and after the YA provision went into effect, before 2010 and after 2011.

We found that the rates of Medicaid covered births for YA, while increasing before 2010, decreased after 2011. They were also increasing before 2010 for 27-29 year-olds, but continued to increase after 2011:

Fig 1 AH





Private coverage, on the other hand, while decreasing before 2010, showed an increase in YA after 2011. The reduction in private coverage for those age 27-29 years old seen before 2010 seemed to continue after 2011 as well:

Fig 2 AH





The results were similar in both data sources. In other words, the YA provision of the ACA seems to be associated with a significant increase in private coverage of childbirth among YA, and a significant decrease in Medicaid coverage. Granted, it’s a specific expenditure, but it’s not an uncommon one.

As people take sides over the added expense of the ACA to the nation’s public health care spending, getting YA off of Medicaid’s rolls and onto private insurance for childbirth is an interesting step in a good direction.

Read the whole article here.



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By: Mark A. Hall, Wake Forest University

Throughout the history of health care public policy, major insurance market developments have inevitably been followed by major regulatory responses. The initial growth of health insurance prompted state regulation of covered benefits. The spread of employer-sponsored health insurance yielded the Employee Retirement Income Security Act (ERISA). The managed care revolution sparked regulatory backlash against restrictive coverage. And the Affordable Care Act’s (ACA’s) creation of public health insurance exchanges carried with it a host of regulatory requirements for “qualified health plans” that participate in public exchanges.

It would be most surprising, then, if the emergence of private insurance exchanges did not prompt some significant regulatory response. The ACA has galvanized renewed attention to the long-standing idea of using insurance exchanges to implement superior forms of managed competition. In addition to the ACA’s public exchanges for individuals, similarly-structured private exchanges have emerged that offer employer-sponsored coverage from competing insurers. Although initial growth has been slower than expected, there is widespread anticipation that these private multi-carrier exchanges could soon become an established component of the health coverage landscape, creating a way for employers to facilitate more choice by workers while more firmly controlling costs.

If so, one would assume that this development, albeit welcome by many, would pose some new public policy and regulatory challenges. To the contrary, my extensive investigation, funded by the Robert Wood Johnson Foundation’s Changes in Health Care Financing and Organization (HCFO) initiative, concluded that private exchanges to date are an unusual case where regulatory forbearance is the wisest course of action. As detailed in this report (which is summarized here), none of the potential concerns that one might conjure for private exchanges appears to have materialized or to be a real threat. Currently, private exchanges are not a pathway for employers to drop or radically reduce coverage. They are not being offered as a way to circumvent or exploit other federal or state regulatory standards. And, they do not pose a threat to the public exchanges.

These findings are based on an extensive literature review and in-depth interviews with several dozen expert market participants and observers. These sources reported that private exchanges have not degraded employer sponsorship of health benefits, and informed experts believe this is not likely to happen. Instead, there is good reason to believe that private exchanges might enhance employers’ willingness to continue offering health benefits by making costs more predictable through the use of “defined contribution” vouchers. Although capping employer contributions could result in unaffordable premiums, so far this has not occurred because most employers want their workers to enroll in good coverage.

Private exchanges also do not appear to threaten the ACA’s regulatory structure. For the most part, they are not in direct competition with the small-employer component of the public exchanges (known as SHOP), and direct competition remains unlikely now that the small group market is likely to remain at 50 employees, rather than increasing to 100. Also, private exchanges are not being promoted as a way to circumvent or minimize the ACA’s various regulatory requirements, such as through inappropriate self-funding for small firms.

Rather than regulators needing to guard against potential threats of private exchanges, some observers and market participants think that regulators should consider measures that facilitate their development. Views on that point are divided, however. The dominant view is that private exchanges face no substantial regulatory barriers or uncertainties, and thus they are able to succeed in the market if they demonstrate their inherent economic value. Others, however, believe that adoption of private exchanges would accelerate if laws were to confer safe harbor to adopting employers from certain existing regulatory requirements, such as those under ERISA.

The strongest accelerant would be if tax law were changed to allow workers to use pre-tax employer contributions to purchase individual insurance. Current law makes premium contributions toward non-group coverage fully taxable, which confers a substantial financial advantage on group coverage. Acknowledging that the government has reason to prevent “double-dipping” by using pre-tax dollars to purchase subsidized insurance, some exchange advocates argue with force that, now that the individual market has been fully reformed, government should not prohibit employers from facilitating pre-tax purchase of non-group coverage outside the public exchanges, where coverage is not otherwise subsidized. Others, however, disagree, fearing that these or other measures might create new problems, possibly doing more harm than good.

On balance, regulatory forbearance appears to be the wisest course of action for private exchanges, at the present time. No potential public policy concerns have materialized as a real threat. Instead, private exchanges appear to hold real promise for improving choice and competition in the group insurance markets. Although lawmakers might consider facilitative measures, the more prudent stance would simply be “watchful waiting” – standing back to see how private exchanges develop within existing market conditions and regulatory pathways.

For more details on this work, please join me on an upcoming webinar
Hall HeadshotMark Hall, J.D., is one of the nation’s leading scholars in the areas of health care law, public policy, and bioethics. The author or editor of 20 books, including Making Medical Spending Decisions (Oxford University Press), and Health Care Law and Ethics (Aspen), he is currently engaged in research in the areas of health care reform, access to care by the uninsured, and insurance regulation. Professor Hall has published scholarship in the law reviews at Berkeley, Chicago, Duke, Michigan, Pennsylvania, and Stanford, and his articles have been reprinted in a dozen casebooks and anthologies. He also teaches in the University’s Graduate Programs for Bioethics and its M.B.A. program, and he is on the research faculty at the Medical School. Professor Hall regularly consults with government officials, foundations and think tanks about health care public policy issues.


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Although the main thrust of the Affordable Care Act was to get more people health insurance, access is about more than just being uninsured. You still need to be able to see the doctors you need. One of the concerns expressed most often by consumers and experts alike involves the adequacy of networks in the plans offered in the exchanges.

Insurance companies can often reduce the cost of premiums by making deals with limited networks of physicians for reduced rates. By steering more patients into those networks, physicians can make up in volume what they might give up in per-patient reimbursement. Regulations mandate that all plans include “reasonable access” to “a sufficient number and type of providers”, but the devil is in the details. Research can inform us as to the adequacy of networks in exchange plans.

In a recent study in JAMA (Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act), researchers looked at physician networks in 34 states that used the federal exchange during open enrollment in 2015. In each state, they focused on the most populous county, and the silver plans with the lowest premium, the second lowest premium, the median premium, and the most expensive premium. In all, they examined 135 plans.

For each, they used online directories to look for specialists in-network in Ob/Gyn, dermatology, cardiology, psychiatry, oncology, neurology, endocrinology, rheumatology, and pulmonology. They looked for in-network specialists within two radii: up to 100 miles and about half of that. The main outcome of interest was whether a specialist could be found in that radius. They repeated their analysis at two points one month apart, and called plans that seemed deficient to confirm that status. The costs of needing to go out-of-network for specialists was also assessed.

Using the narrow radius, about 14% of plans were deemed specialist-deficient. Even using the broad radius, 13% of plans were deficient. The specialties most likely to be lacking were endocrinology, rheumatology, and psychiatry. Almost a quarter of states had at least one plan that was specialist deficient, and 12 insurers had at least one plan that was specialist-deficient. However, when they reassessed, a third of 19 originally deficient plans had added specialists. But still, that left 13 plans without any physicians in some specialties in-network.

Going out of netw0rk would cost patients, too. One-quarter of the deficient plans offered no coverage for out-of-network services. More than half of plans set cost-sharing for out-of-network care at 50% or more. Almost half of these plans would not cover any drugs that were prescribed by out-of-network physicians, even if patients used in-network pharmacies to fill their prescriptions.

In multiple states, and in multiple plans, patients would not be able to find in-network physicians for at least one specialty. If they were forced to go out-of-network, they’d face significant costs. Further, plans had high turnover, meaning that people thought they were adequately covered when they weren’t.

It is entirely reasonable for the administration and those who support the ACA to celebrate the reduction of uninsurance in the United States. The percent of people who lack insurance in the U.S. right now is the lowest that it has been, ever. But we have to acknowledge that the point of health care reform was to get more people health care. If insurance doesn’t actually offer access to needed health care, then it’s not really “insurance”.



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