Environmental Scan on Consolidation Trends and Impacts in Health Care Markets.

The No Surprises Act (NSA) was created to help protect consumers with private insurance from surprise medical bills from out-of-network health care providers. The NSA requires the Department of Health and Human Services to prepare annual reports to Congress on the effects of the NSA's provisions. This article summarizes findings of an environmental scan on consolidation trends and impacts in health care markets. It describes the evidence on price, spending, quality of care, access, and wages in health care provider and insurance markets, as well as other market trends. The authors found strong evidence that hospital horizontal consolidation is associated with higher prices paid to providers and some evidence of the same for vertical consolidation of hospitals and physician practices. Health care spending is likely to increase in tandem with these price increases. Most studies find decreased or no change in quality of care associated with consolidation; however, findings differ by quality measures examined and setting. Horizontal consolidation of commercial insurers is associated with lower prices paid to providers as insurers gain market power in negotiations with providers, but the lower prices paid to providers do not appear to be passed onto consumers, who face higher premiums following insurer consolidation. There is insufficient evidence of the effects on patient access to care and health care wages. The few evaluations of state surprise billing laws have found heterogeneous effects on prices and have not directly examined effects on spending, quality, patient access, and wages.

Developing an Adjunct Services Approach to Identify the Use of Procedures Not Covered by Health Insurance: The Case of In Vitro Fertilization.

BACKGROUND: Health care claims have an inherent limitation in that noncovered services are unreported. This limitation is particularly problematic when researchers wish to study the effects of changes in the insurance coverage of a service. In prior work, we studied the change in the use of in vitro fertilization (IVF) after an employer added coverage. To estimate IVF use before coverage began, we developed and tested an Adjunct Services Approach that identified patterns of covered services cooccurring with IVF. METHODS: Based on clinical expertise and guidelines, we developed a list of candidate adjunct services and used claims data after IVF coverage began to assess associations of those codes with known IVF cycles and whether any additional codes were also strongly associated with IVF. The algorithm was validated by primary chart review and was then used to infer IVF in the precoverage period. RESULTS: The selected algorithm included pelvic ultrasounds and either menotropin or ganirelix, yielding a sensitivity of 93.0% and specificity of >99.9%. DISCUSSION: The Adjunct Services Approach effectively assessed the change in IVF use postinsurance coverage. Our approach can be adapted to study IVF in other settings or to study other medical services experiencing coverage changes (eg, fertility preservation, bariatric surgery, and sex confirmation surgery). Overall, we find that an Adjunct Services Approach can be useful when (1) clinical pathways exist to define services delivered adjunct to the noncovered service, (2) those pathways are followed for most patients receiving the service, and (3) similar patterns of adjunct services occur infrequently with other procedures.

The association of strained ICU capacity with hospital patient racial and ethnic composition and federal relief during the COVID-19 pandemic.

OBJECTIVE: To identify the association between strained intensive care unit (ICU) capacity during the COVID-19 pandemic and hospital racial and ethnic patient composition, federal pandemic relief, and other hospital characteristics. DATA SOURCES: We used government data on hospital capacity during the pandemic and Provider Relief Fund (PRF) allocations, Medicare claims and enrollment data, hospital cost reports, and Social Vulnerability Index data. STUDY DESIGN: We conducted cross-sectional bivariate analyses relating strained capacity and PRF award per hospital bed with hospital patient composition and other characteristics, with and without adjustment for hospital referral region (HRR). DATA COLLECTION: We linked PRF data to CMS Certification Numbers based on hospital name and location. We used measures of racial and ethnic composition generated from Medicare claims and enrollment data. Our sample period includes the weeks of September 18, 2020 through November 5, 2021, and we restricted our analysis to short-term, general hospitals with at least one intensive care unit (ICU) bed. We defined "ICU strain share" as the proportion of ICU days occurring while a given hospital had an ICU occupancy rate ≥ 90%. PRINCIPAL FINDINGS: After adjusting for HRR, hospitals in the top tercile of Black patient shares had higher ICU strain shares than did hospitals in the bottom tercile (30% vs. 22%, p < 0.05) and received greater PRF amounts per bed ($118,864 vs. $92,407, p < 0.05). Having high versus low ICU occupancy relative to pre-pandemic capacity was associated with a modest increase in PRF amounts per bed after adjusting for HRR ($107,319 vs. $96,627, p < 0.05), but there were no statistically significant differences when comparing hospitals with high versus low ICU occupancy relative to contemporaneous capacity. CONCLUSIONS: Hospitals with large Black patient shares experienced greater strain during the pandemic. Although these hospitals received more federal relief, funding was not targeted overall toward hospitals with high ICU occupancy rates.

Trends In Hospital Prices Paid By Private Health Plans Varied Substantially Across The US.

Commercial health plans pay higher prices than public payers for hospital care, which accounts for more than 5 percent of US gross domestic product. Crafting effective policy responses requires monitoring trends and identifying sources of variation. Relying on data from the Healthcare Provider Cost Reporting Information System, we describe how commercial hospital payment rates changed relative to Medicare rates during 2012-19 and how trends differed by hospital referral region (HRR). We found that average commercial-to-Medicare price ratios were relatively stable, but trends varied substantially across HRRs. Among HRRs with high price ratios in 2012, ratios increased by 38 percentage points in regions in the top quartile of growth and decreased by 38 percentage points in regions in the bottom quartile. Our findings suggest that restraining the growth rate of HRR commercial hospital price ratios to the national average during our sample period would have reduced aggregate spending by $39 billion in 2019.

A decade of experience for high-needs beneficiaries under Medicare Advantage.

OBJECTIVE: To describe the association between longitudinal enrollment in Medicare Advantage (MA) and utilization, access, quality of care, and health outcomes for beneficiaries with complex health needs. DATA SOURCES/STUDY SETTING: Beneficiary characteristics, enrollment, and outcomes data from the 2004-2016 waves of the Health and Retirement Study (HRS). STUDY DESIGN: Using the HRS panel structure, we identified beneficiaries consistently reporting high needs as well as enrollment in MA versus traditional Medicare (TM). We first evaluated a robust set of beneficiary characteristics to identify those that distinguish beneficiaries who consistently enrolled in MA versus TM. We then described adjusted differences in outcomes between high-needs beneficiaries who consistently enrolled in MA versus TM. PRINCIPAL FINDINGS: Among high-needs beneficiaries, there was a modest amount of favorable selection into MA based on health. Controlling for several characteristics, MA enrollees used less care (with a 6.6 percentage point (pp) lower probability of hospitalization, 4.7 fewer physician visits, and a 5.1 pp lower probability of using home health care), had a 4.1 pp greater probability of being unable to afford their care, and had a 5.7 pp lower probability of reporting that they were very satisfied with their care. Compared to associations between MA and outcomes for high-needs beneficiaries, for non-high-needs beneficiaries MA enrollment was associated with smaller decreases in utilization and no statistically significant difference in the inability to afford care. CONCLUSIONS: Our descriptive findings raise the possibility that high-needs beneficiaries may experience unique challenges in MA compared to their non-high-needs counterparts.

Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage.

OBJECTIVES: To document how health insurance coverage changed for White, Black, and Hispanic adults after the Affordable Care Act (ACA) went into effect. METHODS: We used data from the American Community Survey from 2008 to 2014 to examine changes in the percentage of nonelderly adults who were uninsured, covered by Medicaid, or covered by private health insurance. In addition to presenting overall trends by race/ethnicity, we stratified the analysis by income group and state Medicaid expansion status. RESULTS: In 2013, 40.5% of Hispanics and 25.8% of Blacks were uninsured, compared with 14.8% of Whites. We found a larger gap in private insurance, which was partially offset by higher rates of public coverage among Blacks and Hispanics. After the main ACA provisions went into effect in 2014, coverage disparities declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites. Coverage gains were greater in states that expanded Medicaid programs. CONCLUSIONS: The ACA has reduced racial/ethnic disparities in coverage, although substantial disparities remain. Further increases in coverage will require Medicaid expansion by more states and improved program take-up in states that have already done so.