Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study

Objective. To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting. Kaiser Permanente–Northern California (KPNC), a prepaid integrated delivery system. Study Design. In a quasi‐experimental longitudinal study with concurrent controls, we estimated rates of ED visits, hospitalizations, ICU admissions, and deaths associated with higher ED copayments relative to no copayment, using Poisson random effects and proportional hazard models, controlling for patient characteristics. The study period began in January 1999; more than half of the population experienced an employer‐chosen increase in their ED copayment in January 2000. Data Collection/Extraction Methods. Using KPNC automated databases, the 2000 U.S. Census, and California state death certificates, we collected data on ED visits and unfavorable clinical events over a 36‐month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare insured health system members. Principal Findings. Among commercially insured subjects, ED visits decreased 12 percent with the $20–35 copayment (95 percent confidence interval [CI]: 11–13 percent), and 23 percent with the $50–100 copayment (95 percent CI: 23–24 percent) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not increase with copayments. Hospitalizations decreased 4 percent (95 percent CI: 2–6 percent) and 10 percent (95 percent CI: 7–13 percent) with ED copayments of $20–35 and $50–100, respectively, compared with no copayment. Among Medicare subjects, ED visits decreased by 4 percent (95 percent CI: 3–6 percent) with the $20–50 copayments compared with no copayment; unfavorable clinical events did not increase with copayments, e.g., hospitalizations were unchanged (95 percent CI: ?3 percent to +2 percent) with $20–50 ED copayments compared with no copayment. Conclusions. Relatively modest levels of patient cost‐sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events.     

Increasing health insurance costs and the decline in insurance coverage

OBJECTIVE: To determine the impact of rising health insurance premiums on coverage rates. DATA SOURCES & STUDY SETTING: Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989-1991 and 1998-2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. STUDY DESIGN: Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates. PRINCIPAL FINDINGS: More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9-6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1-3 percentage points, holding all else constant. CONCLUSIONS: Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.     

Effects of an electronic health record-based mobility assessment and automated referral for inpatient physical therapy on patient outcomes: A quasi-experimental study

Objective

To assess the effectiveness of a hospital physical therapy (PT) referral triggered by scores on a mobility assessment embedded in the electronic health record (EHR) and completed by nursing staff on hospital admission.

Data Sources

EHR and billing data from 12 acute care hospitals in a western Pennsylvania health system (January 2017–February 2018) and 11 acute care hospitals in a northeastern Ohio health system (August 2019–July 2021).

Study Design

We utilized a regression discontinuity design to compare patients admitted to PA hospitals with stroke who reached the mobility score threshold for an EHR-PT referral (treatment) to those who did not (control). Outcomes were hospital length of stay (LOS) and 30-day readmission or mortality. Control variables included demographics, insurance, income, and comorbidities. Hospital systems with EHR-PT referrals were also compared to those without (OH hospitals as alternative control). Subgroup analyses based on age were also conducted.

Data Extraction

We identified adult patients with a primary or secondary diagnosis of stroke and mobility assessments completed by nursing (n = 4859 in PA hospitals, n = 1749 in OH hospitals) who completed their inpatient stay.

Principal Findings

In the PA hospitals, patients with EHR-PT referrals had an 11.4 percentage-point decrease in their 30-day readmission or mortality rates (95% CI −0.57, −0.01) relative to the control. This effect was not observed in the OH hospitals for 30-day readmission (β = 0.01; 95% CI −0.25, 0.26). Adults over 60 years old with EHR-PT referrals in PA had a 26.2 percentage-point (95% CI −0.88, −0.19) decreased risk of readmission or mortality compared to those without. Unclear relationships exist between EHR-PT referrals and hospital LOS in PA.

Conclusions

Health systems should consider methodologies to facilitate early acute care hospital PT referrals informed by mobility assessments.     

State policies limiting premium surcharges for tobacco and their impact on health insurance enrollment

ObjectiveThe Affordable Care Act allows insurers to charge up to 50% higher premiums to tobacco users, making tobacco use the only behavioral factor that can be used to rate premiums in the nongroup insurance market. Some states have set more restrictive limits on rating for tobacco use, and several states have outlawed tobacco premium surcharges altogether. We examined the impact of state level tobacco surcharge policy on health insurance enrollment decisions among smokers.Study DesignWe compared insurance enrollment in states that did and did not allow tobacco surcharges, using a difference‐in‐difference approach to compare the policy effects among smokers and nonsmokers. We also used geographic variation in tobacco surcharges to examine how the size of the surcharge affects insurance coverage, again comparing smokers to nonsmokers.Data CollectionWe linked data from two components of the Current Population Survey—the 2015 and 2019 Annual Social and Economic Supplement and the Tobacco Use Supplement, which we combined with data on marketplace plan premiums. We also collected qualitative data from a survey of smokers who did not have insurance through an employer or public program.Principal FindingsAllowing a tobacco surcharge reduced insurance enrollment among smokers by 4.0 percentage points (P = .01). Further, smokers without insurance through an employer or public program were 9.0 percentage points less likely (P < .01) to enroll in a nongroup plan if they were subject to a tobacco surcharge. In states with surcharges, enrollment among smokers was 3.4 percentage points lower (P < .01) for every 10 percentage point increase in the tobacco surcharge.ConclusionsTobacco use is the largest cause of preventable illness in the United States. State tobacco surcharge policy may have a substantial impact on whether tobacco users choose to remain insured and consequently their ability to receive care critical for preventing and treating tobacco‐related disease.     

Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage

South Korea introduced mandatory social health insurance forindustrial workers in large corporations in 1977, and extendedit incrementally to the self-employed until it covered the entirepopulation in 1989. Thirty years of national health insurancein Korea can provide valuable lessons on key issues in healthcare financing policy which now face many low- and middle-incomecountries aiming to achieve universal health care coverage,such as: tax versus social health insurance; population andbenefit coverage; single scheme versus multiple schemes; purchasingand provider payment method; and the role of politics and politicalcommitment. National health insurance in Korea has been successfulin mobilizing resources for health care, rapidly extending populationcoverage, effectively pooling public and private resources topurchase health care for the entire population, and containinghealth care expenditure. However, there are also challengesposed by the dominance of private providers paid by fee-for-service,the rapid aging of the population, and the public-private mixrelated to private health insurance.     

Effects of health insurance coverage on risky behaviors

Prior to implementation of the Patient Protection and Affordable Care Act, dependent health insurance coverage was typically available only for young adults under the age of 19. As of September 2010, the Affordable Care Act extended dependent health insurance coverage to include young adults up to the age of 26. I use the National Health Interview Survey for the sample period from 2011 to 2013 to analyze the causal relationship between the expansion of dependent coverage and risky behaviors including smoking and drinking as well as preventive care. I employ a regression discontinuity design to estimate the causal effect of health insurance coverage and overcome the endogeneity problem between insurance status and risky behaviors. When young adults become 26 years old, they are 7 to 10 percentage points more likely to lose health insurance than young adults under the age of 26. Although young adults over the age of 26 are generally aged out of insurance coverage, presence or absence of health insurance does not affect their smoking and drinking behaviors and their access to preventive care.     

Estimating health care delivery system value for each US state and testing key associations

ObjectiveTo estimate health care systems'' value in treating major illnesses for each US state and identify system characteristics associated with value.Data sourcesAnnual condition‐specific death and incidence estimates for each US state from the Global Burden Disease 2019 Study and annual health care spending per person for each state from the National Health Expenditure Accounts.Study designUsing non‐linear meta‐stochastic frontier analysis, mortality incidence ratios for 136 major treatable illnesses were regressed separately on per capita health care spending and key covariates such as age, obesity, smoking, and educational attainment. State‐ and year‐specific inefficiency estimates were extracted for each health condition and combined to create a single estimate of health care delivery system value for each US state for each year, 1991–2014. The association between changes in health care value and changes in 23 key health care system characteristics and state policies was measured.Data collection/extraction methodsNot applicable.Principal findingsUS state with relatively high spending per person or relatively poor health‐outcomes were shown to have low health care delivery system value. New Jersey, Maryland, Florida, Arizona, and New York attained the highest value scores in 2014 (81 [95% uncertainty interval 72‐88], 80 [72‐87], 80 [71‐86], 77 [69‐84], and 77 [66‐85], respectively), after controlling for health care spending, age, obesity, smoking, physical activity, race, and educational attainment. Greater market concentration of hospitals and of insurers were associated with worse health care value (p‐value ranging from <0.01 to 0.02). Higher hospital geographic density and use were also associated with worse health care value (p‐value ranging from 0.03 to 0.05). Enrollment in Medicare Advantage HMOs was associated with better value, as was more generous Medicaid income eligibility (p‐value 0.04 and 0.01).ConclusionsSubstantial variation in the value of health care exists across states. Key health system characteristics such as market concentration and provider density were associated with value.     

医保政策对社区卫生服务利用的影响研究

通过分析2005年以来浙江省医疗保险参保人员对社区卫生服务的利用情况，并结合随机偶遇调查，分析参保人员择医行为的主要影响因素，发现：构建社区卫生服务体系的核心是要提高其医疗水平。为此建议：要科学系统地制定社区卫生服务体系构建的规划，进一步建立健全全科医生制度及其培训制度，多方引导参保人员适时调整择医行为，引导参保人员前往社区卫生服务机构就诊。     

The Effect of Parity on Expenditures for Individuals with Severe Mental Illness

Objective

To determine whether comprehensive behavioral health parity leads to changes in expenditures for individuals with severe mental illness (SMI), who are likely to be in greatest need for services that could be outside of health plans'' traditional limitations on behavioral health care.

Data Sources/Study Setting

We studied the effects of a comprehensive parity law enacted by Oregon in 2007. Using claims data, we compared expenditures for individuals in four Oregon commercial plans from 2005 through 2008 to a group of commercially insured individuals in Oregon who were exempt from parity.

Study Design

We used difference-in-differences and difference-in-difference-in-differences analyses to estimate changes in spending, and quantile regression methods to assess changes in the distribution of expenditures associated with parity.

Principal Findings

Among 2,195 individuals with SMI, parity was associated with increased expenditures for behavioral health services of $333 (95 percent CI $67, $615), without corresponding increases in out-of-pocket spending. The increase in expenditures was primarily attributable to shifts in the right tail of the distribution.

Conclusions

Oregon''s parity law led to higher average expenditures for individuals with SMI. Parity may allow individuals with high mental health needs to receive services that may have been limited without parity regulations.     

Applying DALY to assessing national health insurance performance: the relationship between the national health insurance expenditures and the burden of disease measures in Iran

The Iranian government has considered using DALYs as an indicator to prioritize health service expenditures to reduce the burden of disease for the public. A cross-sectional study was designed to compare several measures of the burden of disease with the actual amounts of national health insurance (NHI) expenditures, in one province of Iran (Semnan) for a period of 2 months (September 2000 and February 2001). Furthermore, on the basis of the research findings, a questionnaire was designed and distributed to stakeholders at local and national levels to explore their ideas about the gap between the expenditures of the diseases group and their burden. A semi-structured interview was conducted to elicit participants' views on the research findings. The results of this study have revealed that, currently, there is no strong relation between the NHI expenditures and DALY (r = 0.41, p = 0.09), but that there are stronger relationships between the amounts of NHI reimbursements with YLL (r = 0.52, p < 0.05), mortality (r = 0.67, p < 0.01) and hospital days (r = 0.90, p < 0.01). Comparing each group of disorders' DALY with the resources allocated to them (cost per DALY) it was shown that diabetes mellitus, musculoskeletal diseases, maternal conditions, sense organ disorders received considerably generous funding; and, perinatal conditions, congenital abnormalities, nutritional deficiencies were relatively under-funded. The qualitative research results showed that the majority of respondents agreed that the differences presently existing between disorders' burden and NHI expenditures cannot be justified; and, further, that reducing the overall burden of disease must be one of the most important objectives for the NHI.