Crise e federalismo: tendências e padrões regionais das receitas e despesas em saúde dos estados brasileiros / Crisis and federalism: trends and regional patterns of health revenues and expenditures in the brazilian states

Resumo O estudo tem como objetivo analisar as tendências e os padrões regionais das receitas e despesas em saúde dos estados brasileiros no período de 2006 a 2016. Trata-se de estudo exploratório e descritivo com base em dados secundários de abrangência nacional e indicadores selecionados. Verificou-se crescimento da receita corrente líquida per capita para o conjunto dos estados e regiões, com quedas em anos específicos associadas às crises de 2008-2009 e de 2015-2016. A despesa em saúde per capita apresentou tendência de crescimento, mesmo em momentos de crise econômica e queda da arrecadação. Observou-se diversidade de fontes e heterogeneidade de receitas e despesas em saúde, e impactos diferenciados da crise sobre os orçamentos estaduais das regiões. Os resultados sugerem o efeito protetor relacionado à vinculação constitucional da saúde, aos compromissos e prioridades de gastos, e aos mecanismos de compensação de fontes de receitas do federalismo fiscal nas despesas em saúde dos estados. Contudo, permanecem desafios para a implantação de um sistema de transferências que diminua as desigualdades e estabeleça maior cooperação entre os entes, em um contexto de austeridade e fortes restrições ao financiamento público da saúde no Brasil.

Abstract This study aims to analyze regional trends and patterns of health revenues and expenditure in the Brazilian states from 2006 to 2016. This is an exploratory and descriptive study based on secondary national data and selected indicators. Higher per capita net current revenues for all states and regions, with decreasing levels in specific years associated with the crises of 2008-2009 and 2015-2016 were observed. Per capita health expenditure showed an increasing trend, even in times of economic crisis and declining collection. Diversity of sources and heterogeneity of health revenues and expenditures, as well as different impacts of the crisis on the regional budgets, were observed. The results suggest the protective effect of constitutional health linkage, spending commitments and priorities, and compensation mechanisms of fiscal federalism revenue sources in state health expenditures. However, challenges remain for the implementation of a transfer system that reduces inequalities and establishes greater cooperation among entities, in a context of austerity and strong public health financing constraints in Brazil.

Crisis and federalism: trends and regional patterns of health revenues and expenditures in the brazilian states. / Crise e federalismo: tendências e padrões regionais das receitas e despesas em saúde dos estados brasileiros.

This study aims to analyze regional trends and patterns of health revenues and expenditure in the Brazilian states from 2006 to 2016. This is an exploratory and descriptive study based on secondary national data and selected indicators. Higher per capita net current revenues for all states and regions, with decreasing levels in specific years associated with the crises of 2008-2009 and 2015-2016 were observed. Per capita health expenditure showed an increasing trend, even in times of economic crisis and declining collection. Diversity of sources and heterogeneity of health revenues and expenditures, as well as different impacts of the crisis on the regional budgets, were observed. The results suggest the protective effect of constitutional health linkage, spending commitments and priorities, and compensation mechanisms of fiscal federalism revenue sources in state health expenditures. However, challenges remain for the implementation of a transfer system that reduces inequalities and establishes greater cooperation among entities, in a context of austerity and strong public health financing constraints in Brazil.

O estudo tem como objetivo analisar as tendências e os padrões regionais das receitas e despesas em saúde dos estados brasileiros no período de 2006 a 2016. Trata-se de estudo exploratório e descritivo com base em dados secundários de abrangência nacional e indicadores selecionados. Verificou-se crescimento da receita corrente líquida per capita para o conjunto dos estados e regiões, com quedas em anos específicos associadas às crises de 2008-2009 e de 2015-2016. A despesa em saúde per capita apresentou tendência de crescimento, mesmo em momentos de crise econômica e queda da arrecadação. Observou-se diversidade de fontes e heterogeneidade de receitas e despesas em saúde, e impactos diferenciados da crise sobre os orçamentos estaduais das regiões. Os resultados sugerem o efeito protetor relacionado à vinculação constitucional da saúde, aos compromissos e prioridades de gastos, e aos mecanismos de compensação de fontes de receitas do federalismo fiscal nas despesas em saúde dos estados. Contudo, permanecem desafios para a implantação de um sistema de transferências que diminua as desigualdades e estabeleça maior cooperação entre os entes, em um contexto de austeridade e fortes restrições ao financiamento público da saúde no Brasil.

Comparing Neighborhoods of Children With Autism Spectrum Disorder in a Medicaid Waiver Program and a State Population, 2007-2015.

OBJECTIVE: This study investigated equity in enrollment in a Medicaid waiver program for early intensive behavioral intervention for children with autism spectrum disorder (ASD). METHODS: State administrative, Medicaid, and U.S. Census data for children enrolled in the waiver program between 2007 and 2015 (N=2,111) were integrated. Multivariate and bivariate analyses were used to compare enrollees' neighborhood demographic characteristics with those of the state's general population, with controls for enrollees' age, sex, and race-ethnicity. RESULTS: Findings indicate that in general, enrollment was equitable. During the years in which there were inequities, children who lived in neighborhoods of privilege were favored. These neighborhoods had higher median incomes, lower poverty levels, and fewer female-headed households and were located in urban areas. CONCLUSIONS: As states work to provide equitable treatment to children with ASD and their families, it is important to track potential inequities between children who do and do not enroll in services and to use this information to inform outreach efforts. States may turn to South Carolina for insight on how to ensure equity.

Implementation of a Proactive Pilot Health Plan-Driven Opioid Tapering Program to Decrease Chronic Opioid Use for Conditions of the Back and Spine in a Medicaid Population.

BACKGROUND: In 2016, the Oregon Health Authority and the Health Evidence Review Commission implemented guidance for Oregon Medicaid members who were taking opioids for chronic pain related to conditions of the back and spine. This guidance required that an individualized taper plan be developed and initiated by January 1, 2017, and a discontinuation date for all chronic opioid therapy of January 1, 2018. PROGRAM DESCRIPTION: This program evaluated the effect of a proactive and voluntary health plan-driven opioid tapering program on morphine equivalent daily dose (MEDD) before the implementation of governmental guidance. Two mailings were sent to the providers of the targeted members with a variety of resources to facilitate an opioid taper. Pharmacy claims were analyzed to measure member opioid use, in the form of MEDD, after the provider outreach to be compared with their MEDDs before the outreach. OBSERVATIONS: A total of 113 members met the study inclusion criteria for the second provider outreach. Of the 19 members' providers who submitted responses via fax to the health plan in response to this outreach, 6 indicated they would initiate taper plans. Of the 6 members with taper plans, 5 had decreases in MEDD (3.6%, 4.5%, 42.9%, 45.5%, and 46.1%) after the 3-month data collection period, while the sixth member had no change in MEDD. Of the 113 members, 16 members (14.2%) had a decrease in MEDD; 23 members (20.4%) had no change in MEDD; and 72 members (63.7%) had an increase in MEDD. IMPLICATIONS: This study demonstrated that when a physician agrees to enroll patients in a health-plan driven clinical program it may result in decreased opioid use as referenced by MEDD. However, the results also showed the progressive nature of opioid use in this population. While these initial taper results were promising, a larger sample size and longer follow-up duration are needed to validate long-term adherence to an opioid tapering program and confirm that these results are attributable to the program and not other factors. DISCLOSURES: This study was sponsored by Moda Health. Patel is employed by Moda Health; Page and Saliba were employed by Moda Health during this project; and Traver was employed by Moda Health during part of this project. Page is now employed by Oregon State University (during the writing of this manuscript) to support the College of Pharmacy's contract with the Oregon Health Authority to provide professional pharmacist support for the Oregon Medicaid program. All other authors have nothing to disclose. Study concept and design were contributed by Page and Traver, who also collected the data. Data interpretation was performed by Page and Patel. The manuscript was written by Page and revised by Page, Patel, and Saliba.

State challenges to child health quality measure reporting and recommendations for improvement.

OBJECTIVE: The Children's Health Insurance Program (CHIP) was re-authorized in 2009, ushering in an unprecedented focus on children's health care quality one of which includes identifying a core set of performance measures for voluntary reporting by states' Medicaid/CHIP programs. However, there is a wide variation in the quantity and quality of measures states chose to report to the Center's for Medicare & Medicaid Services (CMS). The objective of this study is to assess reporting barriers and to identify potential opportunities for improvement. METHODS: From 2013 to 2014 a questionnaire developed in coordination with CMS and the Agency for Healthcare Research and Quality (AHRQ) was sent to state Medicaid and CHIP officials to assess barriers to child health quality reporting for Federal Fiscal Year 2012. States were categorized as high, medium, or low reporting for comparative analysis. RESULTS: Twenty-five of the 50 states and the District of Columbia agreed to participate in the study and completed the questionnaire. States placed a high priority on children's health care quality reporting (4.2 of 5 point Likert Scale, SD 0.99) and 96% plan to use measurement results to further improve their quality initiatives. However, low reporting states believed they had inadequate staffing and that data collection and extraction was too time-consuming than high reporting states. CONCLUSION: Based on state responses, possible solutions to improve reporting includes funding and staff support, refining the technical assistance provided, and creating venues for state-to-state interaction. Realistic and tangible improvements are within reach and opportunities for CMS and states to collaborate to improve child health care quality.

The Impact of Commercial Health Plan Prior Authorization Programs on the Utilization of Services for Low Back Pain.

STUDY DESIGN: An observational study. OBJECTIVE: The aim of this study was to evaluate the impact of a health plan's prior authorization (PA) programs for low back pain (LBP) in a non-Medicare population by assessing changes in pre-surgical nonoperative care; lumbar fusion trends; and overall back surgery rates compared with another health plan with a similar program and national benchmarks. The PA programs require mandatory physiatrist consultation before surgical evaluation, with subsequent additional LBP surgery PA. SUMMARY OF BACKGROUND DATA: LBP is prevalent and concern exists that spinal fusion is overutilized for LBP. METHODS: Annual rates of lumbar fusion trended over 6 years, and analysis of changes in standardized costs for LBP-related services among a 501-member subset who underwent lumbar fusion before and after program implementations, during the period January 1, 2008, through December 31, 2013, among commercial members aged 18 and 65 years enrolled in a health maintenance organization with commercial membership averaging >500,000 annually. RESULTS: After initiation of the physiatrist PA in December 2010, lumbar fusions decreased from 76.27/100,000 in 2010 to 62.63/100,000 in 2011 with subsequent increases to 64.24/100,000 and 73.84/100,000 in years 2012 and 2013. For members who had lumbar fusion, per-member, pre-surgical costs increased by $2,233 with the physiatrist PA and an additional $1,370 with implementation of the LBP surgery PA (March 2013). Spinal injections and inpatient admissions were the greatest contributors to the overall increase in costs. The physiatrist and LBP surgery PA programs were also associated with lengthening of LBP episodes ending in surgery by 309 and 198 days. CONCLUSION: Mandatory referral to a physiatrist before surgical evaluation did not result in persistent reduction in lumbar fusions. Instead, these programs were associated with the unintended consequence of increased costs from more nonoperative care for only a transitory change in the lumbar fusion rate, likely from delays due to the introduction of both PA programs. LEVEL OF EVIDENCE: 3.

State trends in the cost of employer health insurance coverage, 2003-2013.

From 2010 to 2013--the years following the implementation of the Affordable Care Act--there has been a marked slowdown in premium growth in 31 states and the District of Columbia. Yet, the costs employees and their families pay out-of-pocket for deductibles and their share of premiums continued to rise, consuming a greater share of incomes across the country. In all but a handful of states, average deductibles more than doubled over the past decade for employees working in large and small firms. Workers are paying more but getting less protective benefits. Costs are particularly high, compared with median income, in Southern and South Central states, where incomes are below the national average. Based on recent forecasts that predict an uptick in private insurance growth rates starting in 2015, securing slow cost growth for workers, families, and employers will likely require action to address rising costs of medical care services.

The effect of the Statewide Sharing variance on geographic disparity in kidney transplantation in the United States.

BACKGROUND AND OBJECTIVES: The Statewide Sharing variance to the national kidney allocation policy allocates kidneys not used within the procuring donor service area (DSA), first within the state, before the kidneys are offered regionally and nationally. Tennessee and Florida implemented this variance. Known geographic differences exist between the 58 DSAs, in direct violation of the Final Rule stipulated by the US Department of Health and Human Services. This study examined the effect of Statewide Sharing on geographic allocation disparity over time between DSAs within Tennessee and Florida and compared them with geographic disparity between the DSAs within a state for all states with more than one DSA (California, New York, North Carolina, Ohio, Pennsylvania, Texas, and Wisconsin). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A retrospective analysis from 1987 to 2009 was conducted using Organ Procurement and Transplant Network data. Five previously used indicators for geographic allocation disparity were applied: deceased-donor kidney transplant rates, waiting time to transplantation, cumulative dialysis time at transplantation, 5-year graft survival, and cold ischemic time. RESULTS: Transplant rates, waiting time, dialysis time, and graft survival varied greatly between deceased-donor kidney recipients in DSAs in all states in 1987. After implementation of Statewide Sharing in 1992, disparity indicators decreased by 41%, 36%, 31%, and 9%, respectively, in Tennessee and by 28%, 62%, 34%, and 19%, respectively in Florida, such that the geographic allocation disparity in Tennessee and Florida almost completely disappeared. Statewide kidney allocations incurred 7.5 and 5 fewer hours of cold ischemic time in Tennessee and Florida, respectively. Geographic disparity between DSAs in all the other states worsened or improved to a lesser degree. CONCLUSIONS: As sweeping changes to the kidney allocation system are being discussed to alleviate geographic disparity--changes that are untested run the risk of unintended consequences--more limited changes, such as Statewide Sharing, should be further studied and considered.

Moving for medicaid? Recent eligibility expansions did not induce migration from other states.

Starting in 2014, many low-income adult residents of states that forgo the Affordable Care Act's expansion of Medicaid would be eligible for that program if they moved to a state that had chosen to expand its coverage. Some of these people may migrate to receive coverage, thereby increasing costs for states that have expanded the program. This is known as the "welfare magnet" hypothesis, a claim that geographic variation in social programs induces the migration of welfare recipients to places with more generous benefits or eligibility. To investigate whether such spillover effects are likely, we used data from the Current Population Survey to examine the migration patterns of low-income people before and after recent expansions of public insurance in Arizona, Maine, Massachusetts, and New York. Using difference-in-differences analysis of migration in expansion and control states, we found no evidence of significant migration effects. Our preferred estimate was precise enough to rule out net migration effects of larger than 1,600 people per year in an expansion state. These results suggest that migration will not be a common way for people to obtain Medicaid coverage under the current expansion and that interstate migration is not likely to be a significant source of costs for states choosing to expand their programs.

How states are expanding Medicaid to low-income adults through Section 1115 waiver demonstrations.

In the wake of the Supreme Court's 2012 decision making state expansion of Medicaid to more adults optional under the Affordable Care Act, several states have received approval to combine such expansion with broader Medicaid reforms. They are doing so under Section 1115 of the Social Security Act, which authorizes Medicaid demonstrations that further program objectives. State demonstrations approved so far combine expanded adult coverage with changes in that coverage and in how the states deliver and pay for health care. These states have focused especially on expanding the use of private health insurance, requiring beneficiaries to pay premiums, and incentivizing them to choose cost-effective care. By enabling states to link wider program reforms to the adult expansion, Section 1115 has allowed them to better align Medicaid with local political conditions while extending insurance to more than 1 million adults who would otherwise lack a pathway to coverage.

Implementing the Affordable Care Act: state approaches to premium rate reforms in the individual health insurance market.

The Affordable Care Act protects people from being charged more for insurance based on factors like medical history or gender and establishes new limits on how insurers can adjust premiums for age, tobacco use, and geography. This brief examines how states have implemented these federal reforms in their individual health insurance markets. We identify state rating standards for the first year of full implementation of reform and explore critical considerations weighed by policymakers as they determined how to adopt the law's requirements. Most states took the opportunity to customize at least some aspect of their rating standards. Interviews with state regulators reveal that many states pursued implementation strategies intended primarily to minimize market disruption and premium shock and therefore established standards as consistent as possible with existing rules or market practice. Meanwhile, some states used the transition period to strengthen consumer protections, particularly with respect to tobacco rating.