Medicare Advantage Penetration and Hospital Costs Before and After the Affordable Care Act.

BACKGROUND: Research has suggested that growth in the Medicare Advantage (MA) program indirectly benefits the entire 65+-year-old population by reducing overall expenditures and creating spillover effects of patient care practices. Medicare programs and innovations initiated by the Affordable Care Act (ACA) have encouraged practices to adopt models applying to all patient populations, which may influence the continued benefits of MA program growth. OBJECTIVE: This study investigated the relationship between MA program growth and inpatient hospital costs and utilization before and after the ACA. METHODS: Primary data sources were 2005-2014 Health Care Cost and Utilization Project hospital data and 2004-2013 Centers for Medicare & Medicaid Services enrollment data. County-year-level regression analysis with fixed effects examined the relationship between Medicare managed care penetration and hospital cost per enrollee. We decomposed results into changes in utilization, severity, and severity-adjusted inpatient resource use. Analyses were stratified by whether the admission was urgent or nonurgent. PRINCIPAL FINDINGS: A 10% increase in MA penetration was associated with a 3-percentage point decrease in inpatient cost per Medicare enrollee before the ACA. This effect was more prominent in nonurgent admissions and diminished after the ACA. CONCLUSIONS: Results suggest that MA enrollment growth is associated with diminished spillover reductions in hospital admission costs after the ACA. We did not observe a strong relationship between MA enrollment and inpatient days per enrollee. Future research should examine whether spillover effects still are observed in outpatient settings.

Medicaid Accountable Care Organizations and Childbirth Outcomes.

Some states have adopted Accountable Care Organization (ACO) models to transform their Medicaid programs, but little is known about their impact on health care outcomes and costs. Medicaid ACOs are uniquely positioned to improve childbirth outcomes because of the number of births covered by Medicaid. Using Healthcare Cost and Utilization Project hospital data, we examined the relationship between ACO adoption and (a) neonatal and maternal outcomes, and (b) cost per birth. We compared outcomes in states that have adopted ACO models in their Medicaid programs with adjacent states without ACO models. Implementation of Medicaid ACOs was associated with a moderate reduction in hospital costs per birth and decreased cesarean section rates. Results varied by state. We found no association between Medicaid ACOs and several birth outcomes, including infant inpatient mortality, low birthweight, neonatal intensive care unit utilization, and severe maternal morbidity. Improving these outcomes may require more time or targeted interventions.

Comparison of 3 Safety-Net Hospital Definitions and Association With Hospital Characteristics.

Importance: No consensus exists on how to define safety-net hospitals (SNHs) for research or policy decision-making. Identifying which types of hospitals are classified as SNHs under different definitions is key to assessing policies that affect SNH funding. Objective: To examine characteristics of SNHs as classified under 3 common definitions. Design, Setting, and Participants: This cross-sectional analysis includes noncritical-access hospitals in the Healthcare Cost and Utilization Project State Inpatient Databases from 47 US states for fiscal year 2015, linked to the Centers for Medicare & Medicaid Services Hospital Cost Reports and to the American Hospital Association Annual Survey. Data were analyzed from March 1 through September 30, 2018. Exposures: Hospital characteristics including organizational characteristics, scope of services provided, and financial attributes. Main Outcomes and Measures: Definitions of SNH based on Medicaid and Medicare Supplemental Security Income inpatient days historically used to determine Medicare Disproportionate Share Hospital (DSH) payments; Medicaid and uninsured caseload; and uncompensated care costs. For each measure, SNHs were defined as those within the top quartile for each state. Results: The 2066 hospitals in this study were distributed across the Northeast (340 [16.5%]), Midwest (587 [28.4%]), South (790 [38.2%]), and West (349 [16.9%]). Concordance between definitions was low; 269 hospitals (13.0%) or fewer were identified as SNHs under any 2 definitions. Uncompensated care captured smaller (200 of 523 [38.2%]) and more rural (65 of 523 [12.4%]) SNHs, whereas DSH index and Medicaid and uncompensated caseload identified SNHs that were larger (264 of 518 [51.0%] and 158 of 487 [32.4%], respectively) and teaching facilities (337 of 518 [65.1%] and 229 of 487 [47.0%], respectively) that provided more essential services than non-SNHs. Uncompensated care also distinguished remarkable financial differences between SNHs and non-SNHs. Under the uncompensated care definition, median (interquartile range [IQR]) bad debt ($27.1 [$15.5-$44.3] vs $12.8 [$6.7-$21.6] per $1000 of operating expenses; P < .001) and charity care ($19.9 [$9.3-$34.1] vs $9.1 [$4.0-$18.7] per $1000 of operating expenses) were twice as high and median (IQR) unreimbursed costs ($32.6 [$12.4-$55.4] vs $23.6 [$9.0-$42.7] per $1000 of operating expenses; P < .001) were 38% higher for SNHs than for non-SNHs. Safety-net hospitals defined by uncompensated care burden had lower median (IQR) total (4.7% [0%-9.9%] vs 5.8% [1.2%-11.2%]; P = .003) and operating (0.3% [-8.0% to 7.2%] vs 2.3% [-3.9% to 8.9%]; P < .001) margins than their non-SNH counterparts, whereas differences between SNH and non-SNH profit margins generally were not statistically significant under the other 2 definitions. Conclusions and Relevance: Different SNH definitions identify hospitals with different characteristics and financial conditions. The new DSH formula, which accounts for uncompensated care, may lead to redistributed payments across hospitals. Our results may inform which types of hospitals will experience funding changes as DSH payment policies evolve.

Opioid prescribing rates from the emergency department: Down but not out.

INTRODUCTION: To examine opioid prescribing rates following emergency department (ED) discharge stratified by patient's clinical and demographic characteristics over an 11-year period. MATERIAL AND METHODS: We used 3.9 million ED visits from commercially insured enrollees and 15.2 million ED visits from Medicaid enrollees aged 12 to 64 over 2005-2016 from the IBM® MarketScan® Research Databases. We calculated rates of opioid prescribing at discharge from the ED and the average number of pills per opioid prescription filled. RESULTS: Approximately 15-20% of ED visits resulted in opioid prescriptions filled. Rates increased from 2005 into late 2009 and 2010 and then declined steadily through 2016. Prescribing rates were similar for commercially insured and Medicaid enrollees. Being aged 25-54 years was associated with the highest rates of opioid prescriptions being filled. Hydrocodone was the most commonly prescribed opioid, but rates for hydrocodone prescription filling also fell the most. Rates for oxycodone were stable, and rates for tramadol increased. The average number of pills dispensed from prescriptions filled remained steady over the study period at 18-20. DISCUSSION: Opioid prescribing rates from the ED have declined steadily since 2010 in reversal of earlier trends; however, about 15% of ED patients still received opioid prescriptions in 2016 amidst a national opioid crisis. CONCLUSIONS: Efforts to reduce opioid prescribing could consider focusing on the pain types, age groups, and regions with high prescription rates identified in this study.

Family member opioid prescriptions and opioid use disorder.

It is recognized that family members are a major source of diverted opioids. Yet it is not known how family member opioid prescriptions predict the development of an opioid use disorder (OUD).We conducted an observational study using commercial health care claims to investigate the association between a family member opioid prescription and an individual having an OUD-related claim in a large sample of patients with commercial insurance. We found that individuals had higher odds of having an OUD when a family member had an opioid prescription. This effect was magnified in spouses and employees compared with adolescents and young adult dependents. In addition, adult dependents with a pre-existing non-OUD substance use disorder had higher odds of having an OUD when a family member also had an opioid prescription. Given the high risk of opioid-related morbidity and mortality, more attention should be given to safeguard opioid diversion and to facilitate appropriate disposal of unused opioids.

Changes in hospital service demand, cost, and patient illness severity following health reform.

OBJECTIVE: To estimate the effects of the health insurance exchange and Medicaid coverage expansions on hospital inpatient and emergency department (ED) utilization rates, cost, and patient illness severity, and also to test the association between changes in outcomes and the size of the uninsured population eligible for coverage in states. DATA SOURCES: Healthcare Cost and Utilization Project State Inpatient and Emergency Department Databases, 2011-2015, Nielsen Demographic Data, and the American Community Survey. STUDY DESIGN: Retrospective study using fixed-effects regression to estimate the effects in expansion and nonexpansion states by age/sex demographic groups. FINDINGS: In Medicaid expansion states, rates of uninsured inpatient discharges and ED visits fell sharply in many demographic groups. For example, uninsured inpatient discharge rates across groups, except young females, decreased by ≥39 percent per capita on average in expansion states. In nonexpansion states, uninsured utilization rates remained unchanged or increased slightly (0-9.2 percent). Changes in all-payer and private insurance rates were more muted. Changes in inpatient costs per discharge were negative, and all-payer inpatient costs per discharge declined <6 percent in most age/sex groups. The size of the uninsured population eligible for coverage was strongly associated with changes in outcomes. For example, among males aged 35-54 years in expansion states, there was a 0.793 percent decrease in the uninsured discharge rate per unit increase in the coverage expansion ratio (the ratio of the size of the population eligible for coverage to the size of the previously covered population within an age/sex/payer/geographic group). CONCLUSIONS: Significant shifts in cost per discharge and patient severity were consistent with selective take-up of insurance. The "treatment intensity" of expansions may be useful for anticipating future effects.

Factors associated with potentially problematic opioid prescriptions among individuals with private insurance and medicaid.

If opioid analgesics are prescribed and used inappropriately, they can lead to addiction and other adverse effects. In this study, we (1) examine factors associated with potentially problematic opioid prescriptions and (2) quantify the link between potentially problematic prescriptions and the development of opioid use disorder. We found that older age; female sex; having back pain, arthritis, or migraine; hydrocodone prescription; previous pharmacotherapy for opioid use disorder; and frequent emergency department use were associated with problematic prescriptions among individuals with Medicaid and private insurance. Patients with commercial insurance and Medicaid who had potentially problematic opioid prescriptions were eight and three times more likely, respectively, to develop an opioid use disorder than patients without potentially problematic opioid prescriptions. Our findings help identify factors associated with problematic prescriptions and underscore the importance of targeted public health interventions.

Opioid Use Disorder and Prescribed Opioid Regimens: Evidence from Commercial and Medicaid Claims, 2005-2015.

INTRODUCTION: In response to the US opioid crisis, interventions are being implemented to lower opioid prescribing to reduce opioid misuse and overdose. As opioid prescribing falls, opioid misuse may shift from prescriptions to other, possibly illicit, sources. We examined how the percentage of patients with an opioid use disorder (OUD) diagnosis in a given year without a current opioid prescription changed over a decade among commercially insured enrollees and Medicaid beneficiaries. We also examined how the percentages differed by enrollee demographic factors. METHODS: We used commercial and Medicaid claims from the IBM MarketScan® databases from 2005 to 2015 to identify enrollees with and without current opioid prescriptions who have been diagnosed with OUD. We measured the percentage of enrollees with OUD without a current opioid prescription by year and demographic factors. RESULTS: We identified 99,396 enrollee-years with OUD covered by commercial insurance and 60,492 enrollee-years with OUD covered by Medicaid. Among enrollees with OUD, the percentage without a current opioid prescription increased from 37% in 2005 to 49% in 2012 before falling back to 39% in 2015 in the commercial population, and increased from 32% in 2005 to 38% in 2015 in the Medicaid population. Differences in percentages were observed by age, sex, race, and region, particularly among young people where 70 to 89% had OUD without a current prescription. CONCLUSIONS: Most enrollees with OUD in the data had current opioid prescriptions, suggesting that continuing efforts to reduce misuse of prescribed opioids among patients with prescriptions may be effective. However, a substantial percentage of enrollees with OUD may be obtaining opioids via other, likely illegitimate, channels, particularly younger people, which suggests an opportunity for targeted efforts to reduce opioid diversion.

The Effects of Medicare Accountable Organizations on Inpatient Mortality Rates.

Studies have linked Accountable Care Organizations (ACOs) to improved primary care, but there is little research on how ACOs affect care in other settings. We examined whether Medicare ACOs have improved hospital quality of care, specifically focusing on preventable inpatient mortality. We used 2008-2014 Healthcare Cost and Utilization Project hospital discharge data from 34 states' Medicare ACO and non-ACO hospitals in conjunction with data from the American Hospital Association Annual Survey and the Survey of Care Systems and Payment. We estimated discharge-level logistic regression models that measured the relationship between ACO affiliation and mortality following admissions for acute myocardial infarction, abdominal aortic aneurysm (AAA) repair, coronary artery bypass grafting, and pneumonia, controlling for patient demographic mix, hospital, and year. Our results suggest that, on average, Medicare ACO hospitals are not associated with improved mortality rates for the studied IQI conditions. Stakeholders may potentially consider providing ACOs with incentives or designing new programs for ACOs to target inpatient mortality reductions.

Return on Investment for a Payer-Provider Partnership to Improve Care Management of Employees and Early Retirees.

OBJECTIVE: A large employer partnered with local health care providers to pilot test an intensive nurse care manager program for employees and retirees. We evaluated its impact on health care utilization and costs. METHODS: A database was developed containing 2011 to 2015 health care enrollment and claims data for 2914 patients linked to their nurse care manager data. We used a difference-in-difference design to compare health care costs and utilization of members recruited for the pilot program and a propensity-score-matched comparison group. RESULTS: We found statistically significant reductions in doctors' office visits and prescription drug costs. A return-on-investment analysis determined that the program saved $0.83 for every dollar spent over the 2-year pilot study period. CONCLUSIONS: Employer-driven care management programs can succeed at reducing utilization, although they may not achieve cost neutrality in the short run.

Early Impact of the Affordable Care Act Coverage Expansion on Safety-Net Hospital Inpatient Payer Mix and Market Shares.

OBJECTIVE: To examine the impact of the Affordable Care Act's coverage expansion on safety-net hospitals (SNHs). STUDY SETTING: Nine Medicaid expansion states. STUDY DESIGN: Differences-in-differences (DID) models compare payer-specific pre-post changes in inpatient stays of adults aged 19-64 years at SNHs and non-SNHs. DATA COLLECTION METHODS: 2013-2014 Healthcare Cost and Utilization Project State Inpatient Databases. PRINCIPAL FINDINGS: On average per quarter postexpansion, SNHs and non-SNHs experienced similar relative decreases in uninsured stays (DID = -2.2 percent, p = .916). Non-SNHs experienced a greater percentage increase in Medicaid stays than did SNHs (DID = 13.8 percent, p = .041). For SNHs, the average decrease in uninsured stays (-146) was similar to the increase in Medicaid stays (153); privately insured stays were stable. For non-SNHs, the decrease in uninsured (-63) plus privately insured (-33) stays was similar to the increase in Medicaid stays (105). SNHs and non-SNHs experienced a similar absolute increase in Medicaid, uninsured, and privately insured stays combined (DID = -16, p = .162). CONCLUSIONS: Postexpansion, non-SNHs experienced a greater percentage increase in Medicaid stays than did SNHs, which may reflect patients choosing non-SNHs over SNHs or a crowd-out of private insurance. More research is needed to understand these trends.

Changes in Hospital Inpatient Utilization Following Health Care Reform.

OBJECTIVE: To estimate the effects of 2014 Medicaid expansions on inpatient outcomes. DATA SOURCES: Health Care Cost and Utilization Project State Inpatient Databases, 2011-2014; population and unemployment estimates. STUDY DESIGN: Retrospective study estimating effects of Medicaid expansions using difference-in-differences regression. Outcomes included total admissions, referral-sensitive surgical and preventable admissions, length of stay, cost, and patient illness severity. FINDINGS: In 2014 quarter four, compared with nonexpansion states, Medicaid admissions increased (28.5 percent, p = .006), and uninsured and private admissions decreased (-55.1 percent, p = .001, and -6.6 percent, p = .052), whereas all-payer admissions showed little change. Uninsured expansion effects were negative for preventable admissions (-24.4 percent, p = .068), length of stay (-9.3 percent, p = .039), total cost (-9.2 percent, p = .128), and illness severity (-4.5 percent, p = .397). Significant positive expansion effects were found for Medicaid referral-sensitive surgeries (11.8 percent, p = .021) and patient illness severity (2.3 percent, p = .015). Private and all-payer expansion effects for outcomes other than admission volume were small and mainly nonsignificant (p > .05). CONCLUSION: Medicaid expansions did not change all-payer admission volumes, but they were associated with increased Medicaid and decreased uninsured volumes. Results suggest those previously uninsured with greater needs for inpatient services were most likely to gain coverage. Compositional changes in uninsured and Medicaid admissions may be due to selection.

Impact of Health System Affiliation on Hospital Resource Use Intensity and Quality of Care.

OBJECTIVE: To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality. DATA SOURCES: Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012. STUDY DESIGN: We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals. DATA COLLECTION: Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association. PRINCIPAL FINDINGS: Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals. CONCLUSIONS: Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations.

BACKGROUND: The American Heart Association updated its recommendations for antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in 2007, advising that AP cease for those at moderate risk of IE, but continue for those at high risk. OBJECTIVES: The authors sought to quantify any change in AP prescribing and IE incidence. METHODS: High-risk, moderate-risk, and unknown/low-risk individuals with linked prescription and Medicare or commercial health care data were identified in the Truven Health MarketScan databases from May 2003 through August 2015 (198,522,665 enrollee-years of data). AP prescribing and IE incidence were evaluated by Poisson model analysis. RESULTS: By August 2015, the 2007 recommendation change was associated with a significant 64% (95% confidence interval [CI]: 59% to 68%) estimated fall in AP prescribing for moderate-risk individuals and a 20% (95% CI: 4% to 32%) estimated fall for those at high risk. Over the same period, there was a barely significant 75% (95% CI: 3% to 200%) estimated increase in IE incidence among moderate-risk individuals and a significant 177% estimated increase (95% CI: 66% to 361%) among those at high risk. In unknown/low-risk individuals, there was a significant 52% (95% CI: 46% to 58%) estimated fall in AP prescribing, but no significant increase in IE incidence. CONCLUSIONS: AP prescribing fell among all IE risk groups, particularly those at moderate risk. Concurrently, there was a significant increase in IE incidence among high-risk individuals, a borderline significant increase in moderate-risk individuals, and no change for those at low/unknown risk. Although these data do not establish a cause-effect relationship between AP reduction and IE increase, the fall in AP prescribing in those at high risk is of concern and, coupled with the borderline increase in IE incidence among those at moderate risk, warrants further investigation.

Medicare Advantage and Traditional Medicare Hospitalization Intensity and Readmissions.

Medicare Advantage plans have incentives and tools to optimize patient care. Therefore, Medicare Advantage hospitalizations may have lower cost and higher quality than similar traditional Medicare hospitalizations. We applied a coarsened matching approach to 2013 Healthcare Cost and Utilization Project hospital discharge data from 22 states to compare hospital cost, length of stay, and readmissions for Traditional Medicare and Medicare Advantage. We found that Medicare Advantage hospitalizations were substantially less expensive and shorter for mental health stays but costlier and longer for injury and surgical stays. We found little difference in the cost and length of medical stays and in readmission rates. One explanation is that Medicare Advantage plans use outpatient settings for many patients with behavioral health conditions and for injury and surgical patients with less complex health needs. Alternatively, the observed differences in behavioral health cost and length of stay may represent skimping on appropriate care.

Insurance Financing Increased For Mental Health Conditions But Not For Substance Use Disorders, 1986-2014.

This study updates previous estimates of US spending on mental health and substance use disorders through 2014. The results reveal that the long-term trend of greater insurance financing of mental health care continued in recent years. The share of total mental health treatment expenditures financed by private insurance, Medicare, and Medicaid increased from 44 percent in 1986 to 68 percent in 2014. In contrast, the share of spending for substance use disorder treatment financed by private insurance, Medicare, and Medicaid was 45 percent in 1986 and 46 percent in 2014. From 2004 to 2013, a growing percentage of adults received mental health treatment (12.6 percent and 14.6 percent, respectively), albeit only because of the increased use of psychiatric medications. In the same period, only 1.2-1.3 percent of adults received substance use disorder treatment in inpatient, outpatient, or residential settings, although the use of medications to treat substance use disorders increased rapidly.