Research Roundup: Medicaid’s Hospital Readmissions; CHIP Enrollment

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Health Affairs: Medicaid Admissions And Readmissions: Understanding The Prevalence, Payment, And Most Common Diagnoses
Reducing hospital readmissions is a way to improve care and reduce avoidable costs. However, there have been few studies of readmissions in the Medicaid population. We sought to characterize acute care hospital admissions and thirty-day readmissions in the Medicaid population through a retrospective analysis in nineteen states. We found that Medicaid readmissions were both prevalent (9.4 percent of all admissions) and costly ($77 million per state) and that they represented 12.5 percent of Medicaid payments for all hospitalizations. Five diagnostic groups appeared to drive Medicaid readmissions, accounting for 57 percent of readmissions and 49 percent of hospital payments for readmissions. The most prevalent diagnostic categories were mental and behavioral disorders and diagnoses related to pregnancy, childbirth, and their complications, which together accounted for 31.2 percent of readmissions (Trudnak, 8/4).

Health Affairs: Children's Health Insurance Program Premiums Adversely Affect Enrollment, Especially Among Lower-Income Children
Both Medicaid and the Children’s Health Insurance Program (CHIP), which are run by the states and funded by federal and state dollars, offer health insurance coverage for low-income children. Thirty-three states charged premiums for children at some income ranges in CHIP or Medicaid in 2013. Using data from the 1999–2010 Medical Expenditure Panel Surveys, we show that the relationship between premiums and coverage varies considerably by income level and by parental access to employer-sponsored insurance. Among children with family incomes above 150 percent of the federal poverty level, a $10 increase in monthly premiums is associated with a 1.6-percentage-point reduction in Medicaid or CHIP coverage. ... Among children with family incomes of 101–150 percent of poverty, a $10 increase in monthly premiums is associated with a 6.7-percentage-point reduction in Medicaid or CHIP coverage and a 3.3-percentage-point increase in uninsurance (Abdu et al., 8/4).

The Urban Institute: Prison Inmates' Prerelease Application For Medicaid Take-Up Rates In Oregon
People leaving prison often return to the community lacking health insurance and thus access to appropriate health care. Many have mental illness, substance abuse, and other health issues that need treatment and compound reintegration challenges. Left untreated, they are at risk of falling into a cycle of relapse, reoffending, and reincarceration. Providing Medicaid coverage upon release has the potential to improve continuity of care that may interrupt this cycle.  This report examines whether [Oregon's pre-health law] efforts to enroll people in Medicaid prior to their release from prison are successful in generating health insurance coverage after release. ... Inmates, on average, were slightly more successful than the general population in enrolling. Only 22 percent of those who applied were denied—which was about half of the denial rate for applicants in general (Mallik-Kane, 8/5).

JAMA Internal Medicine: Use Of Medical Consultants For Hospitalized Surgical Patients
Payments around episodes of inpatient surgery vary widely among hospitals. As payers move toward bundled payments, understanding sources of variation, including use of medical consultants, is important. ... [This is a] observational retrospective cohort study of fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) between January 1, 2007, and December 31, 2010, at US acute care hospitals. ... More than half of patients undergoing colectomy (91 684) or THR (339 319) received at least 1 medical consultation while hospitalized (69% and 63%, respectively). ... Our findings of wide variation in medical consultation use—particularly among patients without complications—suggests that understanding when medical consultations provide value will be important as hospitals seek to increase their efficiency under bundled payments (Chen et al., 8/4).

JAMA Surgery: Factors Associated With General Surgery Residents' Desire To Leave Residency Programs
Despite structural changes to residency programs during the past decade, including adoption of the 80-hour and then 16-hour rules, resident attrition continues to be a problem facing general surgery programs across the country. Modern attrition rates for general surgery residents remain between 3% and 5.1% annually and total 19% during the course of a 5-year to 7-year residency program. ... This multi-institutional survey of 288 categorical general surgery residents at 13 residency programs sought to determine how often residents seriously considered leaving residency and to identify what factors were associated with this response. Overall, 58.0% of respondents seriously considered leaving their training, with a median frequency of a few times a year. ... Residents were most likely to cite sleep deprivation on a specific rotation and excessive work hours on a specific rotation, but not work hours overall, as influencing their desire to leave (Gifford et al., 7/30).

The Heritage Foundation: How The Affordable Care Act Fuels Health Care Market Consolidation
The growth of monopoly power among health care providers bears much responsibility for driving up the cost of health care over recent years. By mandating that general hospitals provide uncompensated care, state and federal legislators have given them cause to insist on regulations and discriminatory subsidies to protect them from cheaper competitors. Instead of freeing these markets to allow the provision of care by the most efficient organizations, the Affordable Care Act endorses these anti-competitive arrangements. It extends the premium paid for treatment in general hospitals, employs the purchasing power of the Medicare program to encourage the consolidation of medical practices, and reforms insurance law to eliminate many of the margins for competition between carriers (Christopher Pope, 8/1).

Avalere Health: Few Medicare Beneficiaries Receive Comprehensive Medication Management Services
A new analysis from Avalere Health finds that less than half of all Medicare prescription drug (Part D) enrollees eligible for medication therapy management (MTM) programs receive these services. Under Medicare rules, the Centers for Medicare & Medicaid Services (CMS) requires all Part D plans to provide MTM services to beneficiaries who meet certain criteria and have high drug utilization. MTM services involve providing high-utilizing beneficiaries with a complete review of their medication regimens by a clinical pharmacist in order to provide education, improve adherence, and detect adverse drug events or inappropriate medication use. Specifically, CMS estimates that 25 percent of beneficiaries are eligible for MTM (2010 Medicare Part D MTM Programs Fact Sheet). Yet, only 11 percent of all Part D enrollees were part of a MTM program in 2012 (Pearson, 8/7).

Here is a selection of news coverage of other recent research:

Reuters: Paying To Lose: Cost Effectiveness Of Weight Loss Programs
As weight loss becomes more about health than vanity, insurers might increasingly be footing the bill for non-surgical reducing methods, researchers say. And they'll want to know which ones are the best investment. In a new analysis, the popular Weight Watchers program and the drug Qsymia were the most cost-effective strategies to lose weight. ... Insurers and employers are under increasing pressure to cover weight loss strategies for their customers and employees, Finkelstein said. "As such, they care both about the costs and potential benefits," he said. "To date, no study has been conducted that compares all programs against each other" (Seaman, 8/5).

Reuters: About Half Of Heart Procedure Patients Make End-Of-Life Plans
Less than half of the patients who underwent a risky heart surgery at one medical center completed advanced directives to guide their care in the event they could no longer articulate their wishes, according to a new study. In addition to ensuring patients receive care that's in line with their wishes, the study’s senior author said advanced directives reduce the burden on family members who would otherwise make those decisions (Seaman, 8/5).

WBUR: 'Cowboy' Doctors Could Be A Half-A-Trillion-Dollar American Problem
When Dartmouth economics professor Jonathan Skinner was speaking recently at the University of Texas about the “cowboy doctor” problem, an audience member objected: “You have a problem with cowboys?” Well, actually, we all have a problem with cowboys — when they’re doctors. Including the Texans. New research written up in a National Bureau of Economic Research paper finds that “cowboy” doctors — who deviate from professional guidelines, often providing more aggressive care than is recommended — are responsible for a surprisingly big portion of America’s skyrocketing health costs. The paper concludes that “36 percent of end-of-life spending, and 17 percent of U.S. health care spending, are associated with physician beliefs unsupported by clinical evidence”  (Goldberg, 8/1).

The Washington Post: Promising New Approach Helps Curb Early Schizophrenia In Teens, Young Adults
The program involves an intensive two-year course of socialization, family therapy, job and school assistance, and, in some cases, antipsychotic medication. What makes the treatment unique is that it focuses deeply on family relationships, and occurs early in the disease, often before a diagnosis. So far, the results have been striking: In Portland, Maine, where the treatment was pioneered, the rate of hospitalizations for first psychotic episodes fell by 34 percent over a six-year period, according to a March study (Somashekhar, 8/6).

NPR: House Calls Keep People Out Of Nursing Homes And Save Money
In a study conducted by MedStar Washington Hospital Center in Washington, D.C., 722 such patients were provided with home-based health care delivered by a team: a physician, a nurse practitioner, licensed practical nurses and social workers. The visits were frequent, and there was someone on call for urgent situations 24/7 (Jaffe, 8/7).