The Affordable Care Act's “community first choice” option: Effect on long-term care expenditures

Objective

To empirically assess the effect of adopting Affordable Care Act's Community First Choice (CFC) option on overall state home and community-based services (HCBS) expenditures as well as distribution of HCBS expenditures across different HCBS mechanisms. We also explore the heterogeneous effect of CFC across adopting states.

Data Source

We used data from the Medicaid Long Term Services and Support (LTSS) expenditure reports prepared by Truven Analytics and Mathematica for the Centers for Medicare & Medicaid Services from 2008–2018 for all 48 states and the District of Columbia.

Study Design

An event-study difference-in-differences model was used to estimate the effect of CFC on HCBS expenditures using Medicaid LTSS expenditure reports from 2008–2018. We also employ the synthetic control method to unmask heterogeneity across CFC adopting states using data from 2008–2018.

Data Collection/Extraction Methods

Not applicable.

Principal Findings

Overall, CFC was not associated with a change in HCBS expenditures per capita or HCBS expenditures as a proportion of LTSS expenditures. However, there appears to be an increase in HCBS expenditures among states that were institutionally-oriented prior to CFC adoption. Additionally, CFC adoption was associated with an overall decrease in expenditures in alternative HCBS mechanisms (Personal Care Services State Plan Option and 1915(c) waivers), suggesting potential substitution across overlapping programs.

Conclusion

Results indicate heterogeneity across states adopting CFC. More institutionally-oriented states appear to use CFC to expand HCBS. In contrast, more HCBS-oriented states appear to employ CFC to strategically restructure their overall portfolio and processes.     

Economic Burden of Head and Neck Cancer Treatment in North India

Background: The rising cost of cancer treatment has imposed a huge financial burden on the affected households,leading to catastrophic outcomes and impoverishment. The present study was designed to estimate the economicburden incurred by households for the treatment of head and neck cancer (HNC) in India. Methods: The present studywas undertaken in a large public sector tertiary care hospital of North India. A total of 159 patients were recruitedat time of their first registration in the department of Radiation Oncology, and were followed after completion oftheir treatment. Another 288 were recruited within one month after completion of treatment. Economic burden wasassessed in terms of out of pocket (OOP) expenditure incurred, prevalence of catastrophic health expenditure anddistress financing (borrowing or selling of assets) related to different modalities of cancer treatment. Results: Theaverage OOP expenditure incurred by a patient of HNC patient was INR 37, 845 (USD 563), which varied from INR32,379 (USD 482) when a patient undergoes radiotherapy alone to INR 67,480 (USD 1,004) for surgery along withchemo-radiotherapy. Specifically, patients undergoing 2-DRT and IMRT alone had to spend INR 31,487 (USD 469) andINR 42,405 (USD 631) respectively. The prevalence of catastrophic health expenditure (CHE) and distress financing(DF) was 34% and 45% respectively. The odds of incurring both CHE and DF were found to be higher for patients inthe lowest income quartile and for those in the younger age groups. Conclusion: Cancer imposes significant economicburden on households. The existing public health system should be strengthened to reduce OOP expenditure incurredby patients. In addition, enhanced coverage of risk pooling mechanisms should be ensured.     

Mortalidad por complicaciones médicas y quirúrgicas,impacto de la crisis y gasto sanitario en España, 2002-2013

ObjectiveTo describe the evolution of mortality risks for complications due to medical care or surgery between the periods prior to (2002-2007) and after (2008-2013) the beginning of the economic crisis for Spain and by autonomous region, and to analyse the relationship between the changes in the risks of death and the socioeconomic impact of the crisis and the variation in health spending.MethodEcological study based on age-standardized mortality rates, synthetic index of vulnerability as a socioeconomic indicator and variation in health expenditure as an indicator of health expenditure. The relative risk of death between periods was estimated with Poisson regression models.ResultsThe number of deaths increased for Spain in the period studied. Although the relationship between the increase in public investment in health and the decrease in mortality due to this cause has not been clearly demonstrated, it was possible to determine that the autonomous regions with the lowest increase in health expenditure had rates higher than the rest throughout the period, and that the most vulnerable to the crisis and with the lowest increase in spending presented the greatest increase in the risk of death between the periods.ConclusionsGiven the increase in these deaths, due to avoidable failures of the system, it is necessary to continue investigating this cause of mortality.     

L’effet du non-recours aux soins médicaux et dentaires sur les dépenses de santé des personnes ayant une maladie chronique

BackgroundPeople with chronic disease often have dental (especially periodontal) disorders. Nevertheless, people with chronic disease seek dental care less often than others. We wanted to know if there is a relationship between the consumption of medical care and the consumption of dental care, and if so if the relationship is especially strong for people with chronic disease.MethodsWe conducted a longitudinal study that combined two data-sets: consumption data from the French National Health Insurance Fund and health and socioeconomic welfare data collected with a dedicated national survey. We studied healthcare expenditure and analyzed the association between healthcare consumption, health status and healthcare expenditure over a four-year period (2010–2013).ResultsPeople who did not seek medical or dental care in 2010 exhibited irregular consumer behavior thereafter. This pattern was particularly evident among those with chronic disease whose healthcare expenditures did not stabilize during the study period compared with the rest of the study population. Among people who did not seek medical care in 2010, variation in average dental care expenditure was 91% in people with chronic disease versus 42% for those without chronic disease. Lack of medical care during the first year of the study was also associated with greater expenditure-delay in people with chronic disease (77%) compared with 15% in people without chronic disease.ConclusionThe lack of medical or dental care in 2010 for people with chronic disease did not lead to an increase in medical and dental consumption in the following years. The catch-up delay was longer than four years. This highlights a problem of monitoring and identifies a marginalized population within the healthcare system.     

Evolución del gasto en servicios sanitarios antes y después del ictus isquémico: análisis de base poblacional

IntroductionDespite improved survival rates, stroke represents an increasing healthcare and socioeconomic burden. We describe the main characteristics of patients with ischaemic stroke and resource use and associated expenditure one year before and 3 years after stroke, using a population-based dataset.MethodsThe information technology systems of the Catalan Health Service were used to identify patients with ischaemic strokes occurring between January 2012 and December 2016. For each patient, information from one year before the stroke and up to 3 years thereafter was linked across databases. We describe annual and monthly resource use and healthcare expenditure per patient.ResultsWe identified 36,044 patients with ischaemic stroke (mean age, 74.7 ± 13.3 years). The survival rate at 3 years was 63%. Average expenditure per patient was €3,230 the year before stroke, €11,060 for year one after stroke, €4,104 for year 2, and €3,878 for year 3. The greatest determinants of cost in year one were hospitalisation (including initial hospitalisation), representing 45% of the difference in expenditure compared to the previous year, and convalescence and rehabilitation services, representing 33% of this difference. After year one, the increase in expenditure was mainly determined by additional hospital admissions and drug treatment.ConclusionAfter ischaemic stroke, healthcare expenditure increases primarily because of initial hospitalisation. After year one, the expenditure decreases but remains above baseline values. Information from population-based datasets is useful for improving the planning of stroke services.     

孕前超重/肥胖的妊娠期糖尿病孕妇血糖管理：基于静息能量消耗计算每日总能量消耗

目的探讨基于静息能量消耗(REE)计算每日总能量消耗(TEE)，对孕前超重/肥胖的妊娠期糖尿病(GDM)孕妇血糖管理意义。 方法选择2018年6月至2019年6月，于首都医科大学附属北京潞河医院产科"糖尿病一日门诊"就诊时，被诊断为孕前超重/肥胖的67例GDM孕妇为研究对象。按照其首次就诊时间的奇、偶周，将其分为研究组(n＝34，首次就诊时间为奇数周者)和对照组(n＝33，首次就诊时间为偶数周者)。采用成组t检验对2组孕妇年龄、孕次、孕期体重增加值、新生儿出生体重、空腹血糖、餐后2 h血糖等进行统计学分析。采用Mann-Whitney U检验对2组孕妇分娩孕龄、产次等进行统计学分析。采用χ²检验、Fisher确切概率法、连续性校正χ²检验对2组孕妇尿酮体阳性率、巨大儿发生率等进行统计学分析。本研究经首都医科大学附属北京潞河医院医学伦理委员审核批准(审批文号：2018-LHKY-027-02)，并与所有受试者签署知情同意书。 结果①2组GDM孕妇年龄、孕次、产次、分娩孕龄及孕前人体质量指数(BMI)构成比比较，差异均无统计学意义(P>0.05)。②研究组孕妇TEE为(1 532.6±301.9)kcal/d，显著低于对照组的(1 824.1±313.2) kcal/d，并且差异有统计学意义(t＝3.311、P＝0.002)；2组孕妇血糖达标情况构成比比较，差异亦有统计学意义(P＝0.040)。③研究组孕妇孕期体重增加值、糖化血红蛋白(HbA1c)水平和新生儿出生体重分别为(13.4±6.2)kg、(5.6±0.3)%和(3 287.5±577.1)g，明显低于对照组的(18.2±4.8)kg、(6.2±0.2)%和(3 632.8±490.6)g，并且差异均有统计学意义(t＝2.235、P＝0.031，t＝2.882、P＝0.047，t＝2.121、P＝0.039)。 结论基于REE估算的TEE，较通用系数法估算的TEE，更接近于孕前超重/肥胖GDM孕妇的实际能量需求。因此，基于REE估算的TEE更有利于对孕前超重/肥胖的GDM进行孕期血糖管理。