Congress is in the midst of its summer recess, but the public’s attention remains fixed on what will happen when our elected officials return to Capitol Hill on September 8. And with agenda items including the Iran Nuclear Deal and a number of looming fiscal deadlines–namely the funding of the federal government–the items on Congress’s fall agenda are significant.

I recently spoke with Emily Holubowich, senior vice president at CRD Associates and director of the Coalition for Health Funding to get her insights on Congress’s agenda and what it could mean for the health research community. Here’s what she had to say:

Congress will reconvene after a roughly month-long recess next week. What can we expect to see when they return to town? 

Lawmakers have a busy fall ahead. First up, they’ll consider the Iran Nuclear deal. Shortly thereafter, they’ll need to address government funding before the fiscal year ends on September 30th since Congress failed to finalize any fiscal year 2016 spending bills before leaving for August recess. Consideration of the funding bills that support health services research and public health stopped at the committee level in both the House and Senate in June; neither chamber brought their respective bills to the floor, nor will they.

Clearly all eyes are on a government shutdown, with House Budget Committee Ranking Member Rep. Chris Van Hollen recently saying that it’s a “real danger.” How likely do you think a shutdown is at this point? 

Anything is possible, and I would never say never when it comes to a shutdown.

Congressional leadership has made it clear that they want to avoid a government shutdown. Then again, congressional leadership didn’t want a shutdown in 2013, and it happened nonetheless. In 2013, we saw the main point of contention was funding for the Affordable Care Act; this year, it’s funding for Planned Parenthood in the wake of undercover videos about the acquisition of fetal tissue for medical research.

A shutdown could occur if Republicans cannot garner enough support for a “clean” short-term, stop-gap funding bill that keeps the government (and Planned Parenthood) running at current levels. If Republicans in Congress put forward a stop-gap spending bill that defunds Planned Parenthood–as more and more conservatives insist–the president will certainly veto it. This highly-politicized, election cycle debate around whether or not to ban all federal funding for Planned Parenthood and the women’s health services it provides may prove too difficult for cooler heads to overcome.

What about sequestration? How do you think those conversations will play out this fall? 

Sequestration returns in fiscal year 2016 after a two-year, partial reprieve granted under the “Murray-Ryan” Bipartisan Budget Act of 2013. There is bipartisan agreement that sequestration is bad policy, and there is bipartisan interest in avoiding sequestration’s cuts, but the path to enacting a “Murray-Ryan 2.0″ deal is unclear.

Replacing sequestration for defense and non-defense activities, including health services research, will cost nearly $75 billion for just one year. Most of the “low-hanging fruit” to offset such an expense has already been picked to pay for other priorities like the Medicare physician payment fix, or will be needed to pay for other high-ticket priorities this fall, such as the Highway Trust Fund. The cost of avoiding these cuts may be insurmountable despite the widespread recognition that this no-growth fiscal environment is not sustainable to meet current and emerging priorities and needs.

The Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare and Medicaid Innovation (CMMI), and the Patient-Centered Outcomes Research Trust Fund were all targeted in the House and, to a lesser extent, the Senate Appropriations Committees’ spending bills for FY16. Any of these measures pose a real threat to the health research enterprise. How do you see the discussions surrounding these provisions unfolding? 

My sense is that members of Congress have been taken aback by the public outcry against the cuts and outpouring of support from our field. As a result, they are interested in making AHRQ and other health research initiatives whole in fiscal year 2016. But that will only be possible with more funding–funding that would come from sequestration relief. (*Note: Emily is also founding co-chair of NDD United, which advocates for sequestration relief.) In this regard, the fate of these agencies and their activities in the near-term is inextricably linked to Congress’s ability to pay for a “Murray-Ryan 2.0″ budget deal.

If Congress is unable to reach a deal to patch sequestration, we might expect lawmakers to enact a year-long continuing resolution, a stop-gap spending bill that will hold funding for all government agencies, programs, and activities at current levels–essentially maintaining the status quo. But even then, current funding levels for non-defense programs like health services research exceed the funding allowable under the sequestered spending caps for the next fiscal year. So, if Congress enacts a year-long continuing resolution at current levels, all non-defense programs will take a 1.5 percent spending cut.

Either way, we should expect some level of cut for AHRQ. Obviously these cuts are not equal!

A lot of what we’re talking about here relates to the near future. What about looking beyond the short-term? What does our community need to know? 

In the long-term, our community should be very concerned with the anti-health services research language in the proposed spending bills. The threat to the health services research enterprise is real, and depending on the outcome of the 2016 election, could become a reality is the community is not vigilant in its advocacy for and promotion of health services research. AcademyHealth is developing tools to help producers and users of health services research raise awareness about our field among lawmakers, the media, and the public. Joining AcademyHealth’s Advocacy Interest Group is also a great way to stay abreast of developments in Washington and learn effective strategies for engagement.

If you would like more information about AcademyHealth’s advocacy activities or would like any additional information, please contact AcademyHealth’s advocacy staff.



Austin recently talked about how universal coverage, although a stated goal of many health care systems, is rarely fully achieved. This coincided nicely with recent news that the ACA has significantly reduced the number of uninsured in the United States.

However, many people still do remain uninsured. Who are they? The Urban Institute Health Policy Center has a new report which can help us answer that question:

As of March 2015, 1 in 10 nonelderly adults remained uninsured. As the adults most inclined to obtain health insurance coverage have likely already enrolled, there is concern that the remaining uninsured may be harder to reach and require more assistance or other targeted strategies to encourage enrollment. However, private resources and federal grants supporting outreach efforts are waning, which makes it important to understand the characteristics of the remaining uninsured and the barriers that may be keeping them from enrolling. This brief describes adults who remain uninsured in March 2015 and focuses on their potential eligibility for financial assistance for coverage under the ACA, the reasons they give for not being insured, and potential barriers to and opportunities for expanding coverage to these adults.

They used the ongoing Health Reform Monitoring Survey to gather data in March of this year. The biggest news is that more than 70% of uninsured adults are potentially eligible for financial assistance in gaining coverage under the ACA. More than 27% of uninsured adults earned less than 138% of the federal poverty line, meaning that they would be eligible for Medicaid under the expansion. Another 40% of uninsured adults earn between 138% and 400% of the poverty line, meaning that they are eligible for subsidies in the insurance exchanges.

If they’re eligible, why don’t they have insurance? Some can’t get insurance, even if they’re poor enough, because of immigration status. Almost 26% of uninsured adults who might qualify for assistance can’t get it because they are noncitizens. Others might qualify for exchange subsidies in the exchanges based on income but can’t get them because of the family glitch, where an offering of individual insurance by an employer to an employee makes other family members ineligible for subsidies.

But one of the biggest reasons many remain uninsured is that the Medicaid expansion did not occur in their state. Almost 23% of the uninsured have incomes at or below the federal poverty line, but no expanded Medicaid program to cover them.

Less than 7% of the uninsured have an income at or above 400% of the poverty line, meaning that they would receive no financial assistance in purchasing insurance. This is important because many argue that not purchasing health insurance is a “choice”. But very few of the uninsured earn 400% of the poverty line or more. This would suggest that when people earn enough to be able to afford health insurance, most choose to purchase it.

In fact, more than 60% of people who are uninsured said that affordability issues were the reason they didn’t have insurance. This was true even among 60% of those who were potentially eligible for financial assistance. Less than 17% of the uninsured said that they “didn’t want” insurance.

Depressingly (for those of us who write and talk about this for a living), more than half of those who are potentially eligible for financial assistance don’t know about it. While I know that many of them would still be frustrated by a lack of Medicaid expansion in their state, or still unaffordable premiums even with assistance, it’s just frustrating that so many still do not know about the basic benefits of the ACA.

While true universal coverage may be unattainable, there are still too many people in the United States who say they want coverage and don’t have it. Some of them still find the financial barriers to be too high, whether it be because their state has refused the Medicaid expansion or because subsidies are still not enough to offset the high cost of health insurance. But others still remain unaware that the ACA might have brought insurance into their grasp if they just knew about it. That’s simply tragic.




Medicare beneficiaries enrolled in Medicare Advantage (MA) are probably at least a little healthier than those who enroll in traditional Medicare (TM, also known as fee-for-service or FFS Medicare). But, according to a recent paper by Michael Geruso and Timothy Layton, MA enrollees appear much sicker than they would if enrolled in FFS Medicare, due to how their illnesses are coded. Because plans are paid more for apparently sicker enrollees, this “upcoding” costs taxpayers a lot of money.

Plan payments for an enrollee are proportional to her “risk score,” which is based on demographics and diagnoses. An enrollee of average risk has a risk score of 1.0. Lower risk scores correspond to lower expected spending. Higher risk scores correspond to higher expected spending.

The following figure, from the authors’ analysis of 2011-2012 Massachusetts’ All-Payer Claims Dataset (APCD) tells you all you really need to know. (For this figure, fee-for-service Medicare enrollees were those with Medigap claims in the APCD.)

risk score pre-post Mcare

The figure shows that risk scores tend to increase as people transition to Medicare at age 65, whether to fee-for-service or Medicare Advantage. But, (a) MA enrollees are healthier than FFS enrollees and (b) MA enrollees’ risk scores increase much more than FFS enrollees. This is the signature of upcoding. These findings are upheld in the paper in several other analyses and with other sources of data.

For example, the authors’ primary analysis exploits variation in MA market penetration (the proportion of beneficiaries enrolled in the program) over time (2006-2011) and across markets. Markets in which MA penetration is higher tend to have higher average risk scores, precisely what you’d expect from upcoding. This analysis reveals that MA risk scores are 7% higher than FFS risk scores. This difference is equivalent to 7% more beneficiaries becoming paraplegic, 12% more developing Parkinson’s disease, or 43% more becoming diabetics. These findings are consistent with those of Kronick and Welch, about which I wrote previously. They are also consistent with media reports and legal allegations.

Another analysis was based on the dataset colleagues and I used to assess premiums and quality for MA plans vertically integrated with providers. The authors found that these organizations had much higher risk scores: 16% above FFS.

The authors speculate that insurers achieve greater risk scores through a variety of means:

  • They might pay physicians more for higher risk patients, which encourages providers to code more completely.
  • They might selectively contract with providers that code more aggressively.
  • They might provide electronic tools that pre-populate physicians’ notes with prior-year diagnoses.
  • They might provide training to physicians’ billing staffs that leads to more intensive or complete coding.
  • They might review claims, notes, and charts and request changes.
  • They might incentivize or require annual exams for “risk assessment,” which uncovers diagnoses that might otherwise not be observed.
  • They might proactively contact enrollees or send physicians or nurses for home visits, particularly for those expected to have high risk scores.

FFS Medicare would not engage in any of these practices.

The Centers for Medicare and Medicaid Services already deflates MA risk scores by 4.91% to adjust for upcoding. Even after this adjustment, MA upcoding costs taxpayers an additional $2 billion per year. The Government Accountability Office believes upcoding is more substantial, warranting up to a to 7% adjustment. The analysis by Michael Geruso and Timothy Layton suggests the GAO is correct.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and 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 or Boston University.


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I thank Jennifer Gilbert for her research assistance for this post. Her research summary is here.

The Affordable Care Act expanded, and is expected to continue to expand, coverage for health care. But it won’t lead to universal coverage—unauthorized immigrants and people with lower incomes are among those less likely to become insured. Even some working and well off individuals simply choose to go uninsured. In falling short of universal coverage, the U.S. is not alone. Moreover, data from various analyses suggests the term “universal coverage” is often misapplied.

As I’ve come to learn, many nations that are thought of as having universal coverage don’t. They leave a few groups out, like unauthorized immigrants and those with no ability to pay required premiums, in some cases. This sounds familiar! Granted, the excluded groups amount to a tiny percentage of the population in many countries, but that they exist at all begs the question of what “universal coverage” really means.

Let’s look at the U.S. first. According to the CBO, by 2016 and beyond, 11% of the U.S. population will remain uninsured, including 3% that are unauthorized immigrants. Work by Rachel Nardin and David Himmelstein shows that even after ACA implementation, the uninsured are more likely to be found among lower-income groups. About 60% of the uninsured will have incomes below 200% of the federal poverty level, according to their analysis. You’ll find a state-by-state breakdown of the uninsured at

It’s not a surprise that the ACA won’t achieve universal coverage, because it relies on the voluntary enrollment of individuals into insurance and, in most cases, their willingness to pay for it.*

Now let’s consider some other nations. According to the OECD, “All OECD countries have universal (or quasi-universal) health coverage for a core set of health services and goods, except Mexico and the United States.” Now, “quasi-universal” is a wiggle word. And, I’ll grant that all OECD countries except Mexico and the U.S. have extremely high rates of insurance. But they’re not all at 100%.

Greece, Slovenia, and Luxembourg are OECD member nations. Yet, the European Foundation for the Improvement of Living and Working Conditions identifies some groups without coverage in those countries. In Greece, for instance, people in debt to public authorities or health insurers can be uninsured. The same is true in Slovenia. As Jennifer Gilbert explains,

In Luxembourg, health insurance is transferred from an employer to the government automatically when one loses employment, but gains public health coverage. That coverage requires a long process and initial premium payments, and is only available to residents, so illegal immigrants and people who aren’t aware of how to navigate the process are at higher risk of losing coverage.

Bradford Gray and Ewout van Ginneken thoroughly explored the size of undocumented migrants and their insurance status in the U.S. and European countries. Even wealthy countries like Denmark, Germany, and Sweden don’t guarantee access to more than emergency services to this population. That’s even true in England, which most of us probably think as the (or one of the) quintessential universal coverage exemplars. In Austria, 2% of the population is uninsured.

I do not write all this to claim that the U.S. is no worse than other wealthy nations in terms of access to coverage.* We’re clearly worse! I merely wish to make two points: First, true, universal coverage is a challenge for many countries, not just the U.S. Second, the types of populations that remain uninsured are similar across many countries, though differ in size and detail—they tend to be unauthorized immigrants and those facing financial challenges.

I’m a little disappointed in the way “universal coverage” is used. It seems that fewer countries achieve it than is claimed. Even the most densely knit safety nets have some holes, even if relatively small ones.

* Note: I am also not claiming that universal coverage is a morally necessary goal, as I’ve written.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and 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 or Boston University.


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by: Michel Boudreaux

I was thrilled to be accepted into AcademyHealth’s New Investigator Small Grant Program (NISGP). I am now more than half-way through my grant year. AcademyHealth’s NISGP in partnership with the Association for Community Affiliated Plans (ACA) and the March of Dimes (MOD) has provided an excellent opportunity to network with established experts while receiving financial support (from MOD) and building a track record of externally funded research.

My research focuses on the impact of Massachusetts’ landmark health reform initiative on infant and maternal health, two bell weathers of population health that the U.S. has historically lagged on. The many parallels between the Affordable Care Act (ACA) and the Massachusetts reform make Massachusetts an informative case study for what is currently unfolding under the ACA.

For the past several decades many have hypothesized that high levels of uninsurance contribute to poor infant and maternal health outcomes. Expansion of Medicaid in the 1980’s and 1990’s was largely predicated on the notion that if we expanded Medicaid to low-income pregnant women they would be more likely to access prenatal care and their infants would be born healthier as a result. However, a handful of important studies found that the Medicaid expansions had only moderate impacts on measures such as low birthweight. A possible explanation for that result is that many women delayed getting care until late in pregnancy because they were not eligible for coverage until after they were pregnant. Not only did eligibility rules make early prenatal care initiation difficult, but pregnancy-related eligibility did not promote pre-conception health and it did little to protect household finances from long-term medical risks.

The Massachusetts reform was fundamentally different from the Medicaid expansions of the 1980’s and 1990’s. Health insurance was expanded to all adults regardless of pregnancy status. The reform mandated that everyone obtain coverage and health insurance reached near universal levels. Health care access and use increased, adult health improved, and medical debt declined. My study is the first to examine if the Massachusetts reform had an effect on infant and maternal health.

The NISGP has been a great resource. The program has provided key financial support that lets me focus on the study. I was paired with a mentor that is a national leader in neonatology. He has been extremely generous with his time, proving guidance on research design and data issues and offering a clinical perspective that complements my health services research training. Finally, the NISGP has been a great way to get exposure and build a track record of externally funded research. That track record was essential in helping me write a successful grant application to the Health Resources and Services Administration which is supporting the purchase of additional data and the inclusion of more personnel on the study.

With the resources provided by the NISGP, I have made excellent progress at the half-way point (July 2015) of my grant year. The data are nearly finalized, and I am on track to be done with analysis by late October. The NISGP has been a great partner in my research and professional development, and I am grateful I have had the opportunity to participate.


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We’ve spent the last few years writing about changes to the health care system due to the ACA and other reforms. But most of those pieces have focused on how those changes have affected spending or care. Few have discussed how physicians feel about reform. A recent survey by The Commonwealth Fund and The Kaiser Family Foundation will change that:

In recent years, the U.S. primary care delivery system has experienced many changes in the way health care is organized, delivered, and financed. Some of these changes have been strengthened or accelerated by the Affordable Care Act (ACA). For instance, there has been an increased use of health information technology, a move toward team-based care and using nonphysician clinicians, an effort to better coordinate care through medical homes and accountable care organizations, and the introduction of financial incentives and quality metrics to determine how providers are paid.

Using data from the Commonwealth Fund/Kaiser Family Foundation 2015 National Survey of Primary Care Providers, this brief examines providers’ opinions about the changes in primary care payment and health care delivery. Between January 5 and March 30, 2015, a nationally representative sample of 1,624 primary care physicians and a separate sample of 525 midlevel clinicians (i.e., nurse practitioners and physician assistants) working in primary care practices were surveyed online and by mail.

In recent years, both patient-centered medical homes and accountable care organizations have sought to reorganize the way that care is delivered so that it’s more coordinated and, perhaps, more efficient. Twenty-nine percent of physician respondents said that they participate in an ACO. About 30% reported receiving payments or incentives for qualifying as a patient-centered medical home under the Advanced Primary Care Practice medical home demonstration provision of the ACA. Many, however, (28%) did not know whether they were part of an ACO. An additional 17% of physicians reported that their practices were bought out by a larger organization, leading to consolidation.

Changes to practice or payment were not uncommon. Feelings about these changes were mixed. About a third of physicians viewed the impact of medical homes as positive, and another quarter or so thought they had no impact. More physicians who were in medical homes (43%) thought they had a positive impact than those not in medical home settings (28%). This relationship was also seen in midlevel practitioners, 63% of whom viewed them positively if they were in one, versus 31% of those who were not.

Respondents did not like the increased use of quality metrics. Half of all physician respondents were negative about them, regardless of whether they were receiving incentive payments based on their use. Of those physicians who did receive incentive payments, 28% viewed the quality metrics positively, versus 17% of those who didn’t. Regardless, many more physicians viewed them negatively than did positively.

Physicians were also negative about the increased reliance on mid-level practitioners (41% negative versus 29% positive). Although those who had any nurse practitioners or physician assistants in their practice were more positive (25% negative versus 40% positive), they were dwarfed by the negativity of those practicing with none of them (50% negative versus 16% positive).

Physicians seemed most satisfied with payments from private insurance than with Medicare, and most unsatisfied with payments from Medicaid. When asked about the ease of administration related to reimbursements, the differences were not as striking. They were not positive on balance, though.

And, in what will likely get the most attention, almost half of primary care physicians reported that the trends discussed above are causing them to consider retiring earlier than they thought they would. As readers of my writing know, I usually take such pronouncements with a grain of salt.

But there was one finding that surprised me above all others. I’ve written many times about physicians’ dismal view of health information technology. The survey asked primary care providers about the impact of HIT on quality of care for patients, and half of them responded that they thought it had a positive impact, versus 28% who said it had a negative impact. This is one of the most pro-HIT responses that I’ve seen in any surveys of physicians, and I look forward to seeing if that trend holds.

Although I encourage you to review the full report, the gist is this: primary care providers’ views of many changes to the ways we organize and reimburse care are more negative than positive, with the exception of health information technology. It may be that these changes lead to improved outcomes or reduced national health care spending. In that care, they may be worth it, even if they don’t make physicians happy. But if they don’t, then it will be hard to justify their continued use.



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I’ve long been concerned about implementing public health policy without really studying it. Sometimes, it’s because I worry the policy won’t work. Sometimes, it’s because I think the policy will cost a lot of money, and it won’t be worth the results. And – sometimes – it’s because I worry that the policy might backfire. A good example of this last concern was illustrated in a recent study in the American Journal of Public Health. “The Unintended Consequences of Changes in Beverage Options and the Removal of Bottled Water on a University Campus“:

Objectives. We investigated how the removal of bottled water along with a minimum healthy beverage requirement affected the purchasing behavior, healthiness of beverage choices, and consumption of calories and added sugars of university campus consumers.

Methods. With shipment data as a proxy, we estimated bottled beverage consumption over 3 consecutive semesters: baseline (spring 2012), when a 30% healthy beverage ratio was enacted (fall 2012), and when bottled water was removed (spring 2013) at the University of Vermont. We assessed changes in number and type of beverages and per capita calories, total sugars, and added sugars shipped.

As the article states, American use about 50 billion plastic bottles each year, almost 80% of which end up in landfills. There are environmental consequences to this fact. Plastic bottles, especially those intended for single-use, don’t degrade easily, consume a lot of resources, and take up a lot of waste disposal resources.

In response to this, many colleges and universities have banned the sale of bottled water. On its face value, this seems like a reasonable response if your goal is to reduce the amount of plastic waste your campus is producing. But there’s a catch. One of the reasons that bottled water was becoming more popular was because people were turning to water as a beverage choice instead of drinks with calories, like soda, juice, or milk. That was also a good thing, as beverages with sugar are thought to be one of the causes of the obesity epidemic.

This study was an attempt to see how a ban on bottled water might affect people’s choice of beverages in general. Researchers looked at shipments of beverages to the University of Vermont before, during, and after the ban went into effect. The outcomes of interest were number and types of beverages consumed, the number of calories per person consumed, and total and added sugars shipped.

After the ban, the number of bottled beverages shopped overall went up. Concerningly, though, so did the number of calories (3249 to 3958 kcal), total sugars (714 to 864 g), and added sugars (528 to 638 g). The overall nutritional value of beverages shipped went down significantly. Here’s the chart you need to see:


Yes, the percent of sugar-free beverages increased. But so did the percent of sugar-sweetened beverages. It appears that people want portable beverages that they can drink. If they can get bottled water, they will drink that. But if they can’t, they will choose other beverages rather than start to bring their own water. That may be good for the environment, but it’s not clear that’s good for health.

So was this policy bad? I don’t know the answer. It’s possible that the environmental gains of banning bottled water outweigh the harms of drinking more sugar-sweetened beverages. But I’m not sure. What I do know is that many, if not most of the discussions I see about colleges taking action like this focus only on the potential harms of plastic, though. I see too few thinking about the unintended consequences for health. A balanced discussion would consider both. Without research, that discussion can’t take place. We need both when we consider and implement policy.



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A recent study by Amelia Haviland and colleagues found that consumer-directed health plans (CDHPs) offered by employers are associated with reductions in health care spending over three years. CDHPs are high deductible plans coupled with tax-advantaged personal medical spending accounts.

The study, published as an NBER working paper, examined changes in health spending for individuals at firms that began offering CDHPs, compared to those at firms that didn’t offer CDHPs. It’s an intent-to-treat design, as it considers individuals in the “treatment” group if they worked at a CDHP-offering firm, whether they enrolled in one or not. (The study also employed a second analysis using an instrumental variables design that I’m not covering in this post.)

The design eliminates selection bias at the individual level that could arise, for example, from healthier individuals opting into CDHPs. The authors also argue that it reduces firm-level selection bias because “offering a CDHP alongside other plans is a moderate step relative to full replacement with a CDHP.” That is, perhaps firms that institute a full switch to a CDHP are systematically different from firms that do not. Arguably, firms that offer CDHPs alongside other plans are more similar to firms that do not offer one at all.

The data are from 54 large U.S. employers, span 2003-2007, and include about five million and eight million person-years of data from CDHP-offering and non-offering firms, respectively.

The investigators found that firms that offered CDHPs experienced 6.6%, 4.3%, and 3.4% lower annual spending in the first three years after offer, respectively, and relative to non-offering firms.* The spending reductions were concentrated in outpatient care and prescription drugs, not inpatient care or the ED.

Relative to non-offering firms, annualized spending growth on pharmaceuticals is 5 to 9.5 percentage points lower in the three years after firms offer CDHPs (p < 0.01) and spending growth on outpatient care is 3.0 to 6.8 percentage points lower in the first three years though the estimate loses statistical significance in the third year (p < 0.05 in first two years). In contrast, for inpatient cost growth, we have only marginally statistically significant evidence of lower spending relative to non-offering firms in the first two years of CDHP offer (p < 0.10) while the third year estimate is non-significant and very close to zero. Finally, we do not detect any differences in cost growth for emergency department (ED) care in any of the first three years of CDHP offer although, due to high variance in ED spending, estimates are imprecise.

The findings are consistent with some prior work, including that of Paul Fronstin, Christopher Roebuck, and Martín Sepúlveda. They examined one, large, midwestern manufacturer that fully replaced its PPO with a CDHP. Like the Haviland study, this one also found sustained reductions in health care spending concentrated in outpatient care and prescription drugs. Also like the Haviland et al. study, Fronstin and Roebuck found lower savings over time.

One can speculate why CDHP savings might erode over time. My own hypothesis is that perhaps early on, CDHP enrollees try relatively hard to forgo care, saving their money under the deductible for only things that seem urgent. This may also have the effect of putting off some care they needed, to the extent that people can’t easily distinguish between necessary and unnecessary care. In turn, perhaps in subsequent years there was a relief of this self-imposed, if accidental, pent-up demand.

Because the study focused on workers for large employers, findings may not generalize to other insurance markets (like individual market exchange plans) or other populations (like non-working, Medicaid enrollees).

* When restricting to firms in the sample for all three years, savings also decrease over time, but the differences are not statistically significant. Thus, we can’t completely rule out the possibility that compositional changes explain reduced savings over time.

Austin B. Frakt, PhD, is a health economist with the Department of Veterans Affairs and an associate professor at Boston University’s School of Medicine and 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 or Boston University.


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I have written many times, here and elsewhere, about malpractice in the United States. Recently, I wrote over at The Upshot about how a significant body of evidence points to the fact that if doctors were likely better at communication, their risk of being sued would go down.

A recent study published at JAMA Internal Medicine makes the case that we aren’t headed in that direction soon, though. It looks at nondisclosure agreements, specifically in a large academic health care system, something I hadn’t considered before:

Importance  Honesty and transparency are essential aspects of health care, including in physicians’ and hospitals’ responses to medical error. Biases and habits associated with medical malpractice litigation, however, may work at cross-purposes with compassion in clinical care and with efforts to improve patient safety.

Objective  To determine the frequency of nondisclosure agreements in medical malpractice settlements and the extent to which the restrictions in these agreements seem incompatible with good patient care.

Design, Setting, and Participants  We performed a retrospective review of medical malpractice claim files, including settlement agreements, for claims closed before (fiscal year 2001-2002), during (fiscal year 2006-2007), and after (fiscal years 2009-2012) the implementation of tort reform in Texas. We studied The University of Texas System, which self-insures malpractice claims that involve 6000 physicians at 6 medical campuses in 5 cities.

Main Outcomes and Measures  Nondisclosure provisions in medical malpractice settlements.

Transparency and good communication aren’t just good for avoiding malpractice suits; they’re also good for patient care. However, when settling a malpractice case, an institution might seek a nondisclosure agreement from a patient. This would prevent anyone from discussing the details of the case. For the purposes of this study, researchers looked at malpractice cases, including settlement agreements, that took in the University of Texas health system in three time periods: 2001-2, 2006-7, and 2009-12. These three periods are important, because they occurred before, during, and after Texas implemented pretty comprehensive tort reform.

What they found is interesting. Over the study period, there were a total of 715 closed malpractice claims and 150 settlement payments. Some of those 150 were excluded because they involved only defendants not from The University of Texas making payments, and some because they involved only minor dental injuries.

Of the 124 analyzed, the median payment was $100,000, with a range of $500 to $1.25 million. The average payment was just over $185,000.

The vast majority of these (89%) involved nondisclosure provisions. All of them prevented anyone from disclosing the settlement terms or the amount of any payments. More than half (56%) prohibited disclosing a settlement had been reached at all, 46% prevented discussion of the facts of the claim. More than a quarter prevented involved parties from reporting anything to regulatory agencies, and 9% not only prevented any disclosures from the claimants, they also prevented disclosures from physicians or hospitals.

The disclosure agreements that were signed in the last period, after tort reform, had stricter provisions than those signed before. They were more likely to prevent disclosure of the settlement event, the facts of the case, or the reporting to regulatory bodies.

There are legitimate reasons that the system might want to keep claimants from discussing the terms of cases. Settling is sometimes a financial decision (ie when it’s cheaper to settle than to fight a claim in court). When that is the case, discussing settling could look like an admission of guilt when it’s really not. Some people also worry that if the terms (and sometimes large dollar values) of settlements got out, it could spur others to take a chance and see if they could get some money out of the malpractice system.

But part of the reason malpractice cases are important is to identify areas where errors occurred, and then to make sure that they don’t occur again. Nondisclosure agreements run against that purpose by preventing open dialogue about what happened, and how we can prevent it from happening again. It’s also telling that after tort reform, when there would have been less of an incentive to sue, restrictions became stricter.

It’s especially concerning that some of the settlements prevented any disclosures to regulatory bodies. It’s unclear if this is even legal in many states, and to the system’s credit, the paper reports that the health system stopped doing this when the findings of this analysis were brought to light. It makes you wonder how many other systems might still be doing this, though.

Our health care system will become better and safer through honesty, transparency, and a commitment to improvement. It’s unclear how nondisclosure agreements help that at all.



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AcademyHealth prides itself on being a non-partisan resource for congressional staff, members of Congress, and other federal, state, and local policymakers who wish to connect with some of the best and brightest health policy researchers when implementing evidence-based policy. Thanks to our members’ deep and broad expertise, we are able to serve as a one-stop-shop and trusted knowledge broker for those working across all areas of health policy and research.

On June 17, the U.S. House of Representatives passed the bipartisan “Strengthening Medicare Advantage through Innovation and Transparency for Seniors Act of 2015” (H.R. 2570), and AcademyHealth had a role in linking some of our member experts to the policymakers behind the initial legislation.

The legislation, originally introduced as the VBID for Better Care Act by Reps. Diane Black (R-TN) and Earl Blumenauer (D-OR), establishes a demonstration project in which eligible Medicare Advantage plans would implement value-based insurance design (VBID). As described by the University of Michigan, VBID “aligns patients’ out-of-pocket costs, such as copayments, with the value–not the cost–of health care services” by reducing cost-sharing for high-value health care. Over the years, VBID has gained increasing attention from employers, insurers, and policy experts as a tool to improve health care quality while lowering financial barriers to essential medications and care.

Prior to the bill’s release among congressional offices, AcademyHealth was contacted by a staffer in Rep. Black’s office, who in consultation with Rep. Blumenauer and his staff, was drafting the legislation. Dr. Lisa Simpson, president and CEO of AcademyHealth, acted as a convener [click to continue…]


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