Research Roundup: Young Adult Coverage; Alternatives To Subsidies; Critical Care Hospitals

Health Affairs: Uninsurance Among Young Adults Continues To Decline, Particularly In Medicaid Expansion States
Numerous studies have found that the provision allowing adults up to age twenty-six to remain as dependents on a parent’s private insurance plan reduced uninsurance among young adults by the end of 2011. ... In 2014 additional ACA provisions, particularly the Medicaid expansion and the availability of federal subsidies to purchase coverage in state and federal Marketplaces, increased access to affordable health insurance for other young adults. We found that the dependent coverage expansion disproportionately affected coverage among higher-income young adults. In contrast, the coverage provisions implemented in 2014 were associated with substantial reductions in uninsurance among young adults with low and moderate incomes, particularly in states that expanded Medicaid under the ACA. (McMorrow, Kenney, Long and Anderson, 4/6)

Rand Corp.: How Would Alternative Subsidy Structures Affect Stability In The ACA Individual Market?
Critics of the [federal health law's] current subsidies have advanced alternative structures .... One of the most commonly proposed subsidy alternatives is a premium support (or "voucher") approach, ... Another alternative would require enrollees to pay a fixed percentage of the total premium, with the government paying the additional amount. ... The analysis found that the alternative subsidy arrangements could cause premiums to become more sensitive to the age mix of enrollees, especially the share of young adult enrollment .... If the share of young adults decreases by 1 percentage point, premiums would rise 0.44 percent under the ACA tax credit structure. In contrast, premiums would increase by 0.61 percent in the fixed-percentage-of-premium scenario and by 0.73 percent in the premium-support scenario. (Eibner and Saltzman, 4/6)

JAMA Internal Medicine: Functional Impairment And Hospital Readmission In Medicare Seniors
Medicare currently penalizes hospitals for high readmission rates for seniors but does not account for common age-related syndromes, such as functional impairment. ... [Researchers analyzed] a nationally representative cohort of 7854 community-dwelling seniors in the Health and Retirement Study, with 22 289 Medicare hospitalizations from January 1, 2000, through December 31, 2010. ... We found a progressive increase in the adjusted risk of readmission as the degree of functional impairment increased .... Subanalysis restricted to patients admitted with conditions targeted by Medicare (ie, heart failure, myocardial infarction, and pneumonia) revealed a parallel trend with larger effects for the most impaired (16.9% readmission rate for no impairment vs 25.7% for dependency in 3 or more [activities of daily living]. (Greysen et al., 4/7)

Health Affairs: Wide Variation In Payments For Medicare Beneficiary Oncology Services Suggests Room For Practice-Level Improvement
We measured annual payments for key service categories delivered to fee-for-service Medicare beneficiaries receiving care from 1,534 medical oncology practices in 2011–12. In 2012, differences in payments per beneficiary at the seventy-fifth-percentile practice compared to the twenty-fifth-percentile practice were $3,866 for chemotherapy (including administration and supportive care drugs), $1,872 for acute medical hospitalizations, and $439 for advanced imaging. Supportive care drugs, bevacizumab, and positron-emission tomography accounted for the greatest percentage of variation. ... These differences, even when clinical guidelines exist, demonstrate the potential for quality improvement that could be accelerated through alternative payment models. (Clough et al., 4/6)

Health Affairs: Minimum-Distance Requirements Could Harm High-Performing Critical-Access Hospitals And Rural Communities
Since the inception of the Medicare Rural Hospital Flexibility Program in 1997, over 1,300 rural hospitals have converted to critical-access hospitals, which entitles them to Medicare cost-based reimbursement instead of reimbursement based on the hospital prospective payment system (PPS). Several changes to eligibility for critical-access status have recently been proposed. Most of the changes focus on mandating that hospitals be located a certain minimum distance from the nearest hospital. Our study found that critical-access hospitals located within fifteen miles of another hospital generally are larger, provide better quality, and are financially stronger compared to critical-access hospitals located farther from another hospital. Returning to the PPS would have considerable negative impacts on critical-access hospitals that are located near another hospital. (Casey et al., 4/6)

Kaiser Family Foundation: The Impact Of The Coverage Gap In States Not Expanding Medicaid By Race And Ethnicity
People of color face longstanding and persistent disparities in accessing health coverage that contribute to greater barriers to care and poorer health outcomes. The Affordable Care Act (ACA) Medicaid expansion to adults with incomes at or below 138% of the federal poverty level (FPL) makes many uninsured adults of color newly eligible for the program, which would help increase their access to care and promote greater health equity. However, in states that do not implement the ACA Medicaid expansion, poor adults fall into a coverage gap and will likely remain uninsured. This brief examines the impact of this coverage gap by race and ethnicity and finds that it disproportionately impacts poor uninsured Black adults, which may contribute to widening disparities in health and health care over time. (Artiga and Stephens, 4/3)

Manatt Health Solutions/Robert Wood Johnson Foundation: States Expanding Medicaid See Significant Budget Savings And Revenue Gains
In examining Medicaid expansion across eight states—Arkansas, Colorado, Kentucky, Michigan, New Mexico, Oregon, Washington and West Virginia—it is clear that states are realizing savings and revenue gains as a result of expansion. Savings and revenues by the end of 2015 (just 1.5 years into expansion) are expected to exceed $1.8 billion across all eight states. In Arkansas and Kentucky, savings and revenue gains are expected to offset costs of the expansion at least through SFY 2021. (Bachrach, Boozang and Glanz, 4/6)

Urban Institute/Robert Wood Johnson Foundation: The Widespread Slowdown In Health Spending Growth Implications For Future Spending Projections And The Cost Of The Affordable Care Act ACA Implementation
In October 2014, the current forecast [by the CMS Office of the Actuary] suggested that national health expenditures will be $2.5 trillion less over the 2014-2019 period than under the ACA baseline forecast from September 2010. Over the 2014-2019 period, Medicare spending is now expected to be lower by $384 billion, Medicaid by $927 billion, and private health insurance expenditures by $688 billion compared to the September 2010 ACA baseline. Clearly, not all of the spending reduction is due to the ACA .... But it is also likely that the law contributed; though how much is impossible to estimate. The ACA reduced Medicare payments, established a managed care competition framework in the marketplaces, and imposes an excise tax on high cost health plans beginning in 2018. (Holahan and McMurrow, 4/7)

The Urban Institute: The Processing And Treatment Of Mentally Ill Persons In The Criminal Justice System
An estimated 56 percent of state prisoners, 45 percent of federal prisoners, and 64 percent of jail inmates have a mental health problem. ... Despite the evidence that mental illness in the criminal justice system is a pressing concern, our comprehensive effort to identify cost-effective, evidence-based programs and policies for managing and treating mentally ill persons in the criminal justice system brought to light how limited current knowledge is on this topic. There have been only a few rigorous evaluations of criminal justice programs and policies targeted at mentally ill offenders. This limitation, in and of itself, is a notable finding, as it shows what more needs to be done to better understand how to effectively alleviate the costs and challenges of treating and processing offenders with mental illness. (Kim, Becker-Cohn and Serakos, 4/7)

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

The New York Times: Study Warns Of Diet Supplement Dangers Kept Quiet By F.D.A.
Popular weight-loss and workout supplements on sale in hundreds of vitamin shops across the nation contain a chemical nearly identical to amphetamine, the powerful stimulant, and pose dangers to the health of those who take them, according to a new study. ... The Food and Drug Administration documented two years ago that nine such supplements contained the same chemical, but never made public the names of the products or the companies that made them. (O'Connor, 4/7)

Medscape: Desire For Certainty, Litigation Fears Drive ER Overimaging
Most emergency department physicians order diagnostic imaging tests they know are unnecessary, according to the results of a national survey published online March 23 in Academic Emergency Medicine. A key driver behind these excess scans is the fear of malpractice lawsuits based on missed diagnoses, the researchers found. (Swift, 4/7)

The Philadelphia Inquirer: Considering Back Surgery? Read This First
If you're considering surgery for back pain, a new study suggests you first should try physical therapy, which is both less risky and less costly. The University of Pittsburgh study found that surgery and physical therapy were equally helpful for lumbar spinal stenosis, a common condition in older people that makes walking painful. (Burling, 4/7)

Reuters: Unrelated 'Next Of Kin' May Lead To Legal Confusion
When hospitalized patients list nonrelatives as next of kin, state laws might interfere with those patients’ wishes – and a new study suggests the situation isn’t rare. In Connecticut, where researchers looked at medical charts of nearly 110,000 hospitalized veterans, eight percent had specified someone other than a close family member as next of kin – in conflict with the state’s “default surrogate consent” laws. Default surrogate consent statutes are designed to designate a proxy for patients who can’t make their own medical decisions. In most states, spouses are given first priority, followed by adult children, parents and siblings, the authors write in a research letter in JAMA. But states are inconsistent in their recognition of other relationships, like friends, distant relatives or unmarried or same-sex partners. (Doyle, 4/7)

The Wall Street Journal: Cow’s Milk Found In Breast Milk Sold Online
About 10% of breast-milk samples purchased via Internet-sharing sites contained significant amounts of cow’s milk or formula based on it, according to a study in the journal Pediatrics. Most experts recommend waiting until a baby is at least 12 months old to introduce cow’s milk because it is too low in iron and too high in protein and minerals that are difficult for infants to digest. It also can cause allergic reactions ranging from mild distress to anaphylactic shock, according to the American Academy of Pediatrics. (Beck, 4/6)

MedPage Today: More U.S. Teens Opt For Birth Control With IUDs, Implants
The use of long-acting reversible contraception (LARC) by teens increased from 2005 to 2013 but still remained relatively low, researchers reported. The percentage of female teens, ages 15 to 19, selecting LARC, which includes subdermal implants and intrauterine devices (IUDs), at Title X National Family Planning Program sites was 7.1% in 2013, up from 0.4% in 2005 (P<0.001 for trend), according to Lisa Romero, DrPH, MPH, of the National Center for Chronic Disease Prevention and Health Promotion at the CDC in Atlanta, and colleagues. (Yurkiewicz, 4/7)