Tag Archives: healthcare

The Affordable Care Act is Good for Colorado (and Repeal is Not)

The effects of the Affordable Care Act of 2010 in each state depend on various factors, such as the number of uninsured individuals in the state and the governor’s receptiveness to the law’s provisions. In this post, I focus on the benefits of the Affordable Care Act (ACA) in Colorado, primarily from the perspective of my job as an emergency department (ED) physician, in support of my argument that the ACA must not be repealed–instead, I recommend that it be strengthened. In a prior post, I summarized estimates of the impact of the GOP’s proposed ACA repeal/replace plans on coverage and consumer costs.

Effects of the ACA on Uninsurance Rate in Colorado

In Colorado, the number of uninsured individuals declined by 25.5%, from 729,000 individuals in 2013, or 14.1% of the population, to 543,000 individuals in 2014, or 10.3% of the population. colorado-uninsurance-rate

Colorado was one of 32 states (including DC) that had expanded Medicaid as of 1/1/2017. In fiscal year 2014, annual Medicaid enrollment in Colorado increased by 26.1%. Average monthly enrollment increased 59% from 783,420 to 1,244,031 pre-ACA to post-ACA.

Drivers of Healthcare Cost and Utilization from the Emergency Department Perspective

Healthcare access and coverage–so improved under the ACA–drive a lot of what happens in the emergency department (ED). We can think of this in 3 categories:

  1. How the ACA has impacted who comes into the ED (and the hospital).
  2. How the ACA has decreased the amount of services we ED physicians provide to patients while they are in the ED (and hence the cost).
  3. How the ACA has impacted what happens at the end of the ED visit (should I stay or should I go?)

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How the ACA has impacted who comes into the ED (and the hospital)

In Colorado, the number of ED visits has declined with ACA implementation. This varies state, by state, but in Colorado, we have seen a clear decline in the rate of ED visits per insured person–a trend driven by the expansion of Medicaid insurance.

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The trend is also apparent when we restrict the analysis to children only:decline-ed-visits-children-co

(This and other data are available from the Colorado All Payer Claims Data summary tools, at Colorado Medical Price Compare, available at https://www.comedprice.org/#/reports )

The decline in population rate of ED visits among Medicaid patients did not result in a net decline in the number of ED visits–in 2014, the overall number of Medicaid ED visits went up, largely because more patients were on Medicaid. But, among those on Medicaid, during the ACA rollout, population rates of ED visits went down. As expected, the number of un-insured ED visits declined in Colorado as the number of Medicaid visits rose.

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Increasingly, patients are more likely to visit their medical home (primary care provider) because they are more likely to have one, thanks to the ACA.  When we do see patients in the ED, patients are more likely to have had started treatment before coming in (saw or called their medical home). Diverting more ED visits to the medical home is good for many reasons, not the least of which is cost. cost-ed-vs-pcp

The decline in ED visits is also a Colorado Medicaid performance metric for Colorado’s seven Regional Care Collaborative Organizations (RCCOs)–RCCOs received payment incentives if they achieved a 3% decline in ED visits per patient in their RCCO. Although most RCCOs did not achieve this decline, all achieved some decline in 2016:rcco-level-ed-visit-reduction-medicaid

How the ACA has decreased the amount of services we ED physicians provide to patients while they are in the ED (and hence the cost)

If we know a patient in the ED has no coverage (no financial access to primary care), the ED visit costs more for many reasons, including:

  • The patient is more likely to have tests done in the ED because there is no primary care provider to order tests and follow test results
  • The patient is more likely to have subspecialty consultations instead of office follow-up visits with primary care providers
  • The patient is more likely to get more conservative (more aggressive) treatment in the ED, rather than waiting a day or two to see if the patient really needs more aggressive testing/treatment, because there is no medical home to provide that testing/treatment in a day or two.

 

How the ACA has impacted what happens at the end of the ED visit

If we, as ED physicians, know a patient has financial access to primary care, we are more likely to discharge them home rather than admit them to the hospital. This is reflected in the decrease in hospital admissions relative to the rate of ED visits among all ages:

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The same trend is seen among children only:decline-ed-admit-rate-children-co

As an example of how this works, one of the most common reasons young children are admitted to the hospital in Colorado (and nationwide) is for a common lower respiratory viral syndrome called bronchiolitis. Several of my colleagues at Children’s Hospital of Colorado have performed the research (here and here) to show the circumstances under which a child is safely discharged home on home-oxygen therapy. This is cost-saving in that hospitalizations are expensive, and also result in many missed days of work for parents. The criteria for discharge to home (rather than hospital admission) in our hospital’s evidence based guideline include access (within 24 hours) to a medical home for a follow up check:

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Before the ACA permitted so many more access to a medical home, patients with common conditions like bronchiolitis were more likely to be admitted. Discharging more to home means fewer inpatient stays:

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Thus, for Colorado consumers, the ACA has helped improve coverage, thereby reducing the per-insured rate of ED visits, the per-ED-visit rate of inpatient admissions and the overall rate of inpatient admissions, both for adults and children. It has primarily done this by allowing more Coloradans to access care where they should be able to: in a medical home. By reducing these costly forms of healthcare utilization, EDs are less crowded for those who truly need ED care. By reducing the proportion of uninsured visitors to the ED and hospital, the ACA has also decreased the amount of uncompensated care, permitting more hospitals to remain in business.

What we miss when we look only at the cost of healthcare coverage

With the Republicans on the verge of dismantling the Affordable Care Act and Medicaid, much of their focus has been on how much healthcare insurance “costs”. I thought it would be timely to revisit a 2015 analysis in the American Journal of Public Health, “Considering Whether Medicaid is Worth the Cost: Revisiting the Oregon Health Study.” (full text) The investigators performed a cost-effectiveness analysis using data from the Oregon Health Study (OHS), the experiment that began in 2008 when the state randomly selected uninsured participants to apply for Medicaid coverage creating a randomized controlled trial of a social policy. They concluded that Medicaid is in fact a cost-effective program.

The authors’ cost-effectiveness analysis found that the observed benefit of providing Medicaid was $62,000 per quality-adjusted life-year (QALY) gained. As a reference point, placing smoke detectors in homes provides a benefit of $210,000 per QALY.

The study reminds us that health benefits are best understood broadly and over the long term, rather than through a narrow focus on one year’s “cost” in the cost-effectiveness balance.

2016 Presidential Candidates’ Positions on Child Health Issues

In September, the Pediatric Policy Council (PPC)—a nonpartisan collaboration of the Academic Pediatric Association, the American Pediatric Society, the Association of Medical School Pediatric Department Chairs, and the Society for Pediatric Research dedicated to promoting public policies to advance child health and well-being—developed four general questions related to child health to be sent to the campaigns of the two major party candidates for President of the United States, Donald J. Trump and Hillary Clinton, with the goal of better understanding where both candidates stand for children.

In early October, the campaigns of both presidential candidates submitted their responses, which are as follows.

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Paid Sick Leave Lowers Costs

An Upshot column “The High Costs of Not Offering Paid Sick Leave” argues that employees and their co-workers may be better off with an incentive to take time off when sick. About 45 percent of the American work force does not have paid sick leave; that’s about 50 million workers. Families with less ability to afford unpaid time off are more likely to lack paid sick leave. According to a study in Health Affairs, 65 percent of families with incomes below $35,000 had no paid sick leave, while the same was true of only 25 percent of families with annual incomes above $100,000. Those without sick leave were farm ore likely to go to work sick (“presenteeism”), as well as to forgo seeking medical care for themselves or for an ill family member. Although expanding health insurance helps people pay for health care, it does nothing to help them afford to take time off to get it.

Another study in Health Services Research by a Cornell economist supports the theory that paid sick leave could reduce the spread of contagion. This study found that each week, up to 3 million U.S. employees go to work sick. Females, low-income earners, and those aged 25 to 34 years have a significantly elevated risk of presenteeism behavior.

The Upshot column presents the benefits of paid sick leave for one illness, flu, although morbidity and mortality from other contagious conditions would also be reduced:

Paid sick leave slows the spread of disease. Cities and states that require employers to offer paid sick leave — Washington, D.C.; Seattle; New York City; and Philadelphia, as well as Connecticut, California, Massachusetts and Oregon — have fewer cases of seasonal flu than other comparable cities and states. Flu rates would fall 5 percent if paid sick leave were universal. According to one estimate, an additional seven million people contracted the H1N1 flu virus in 2009 because employees came to work while infected. The illnesses led to 1,500 additional deaths.

Beyond reducing flu deaths, paid sick leave is associated with

Though a few cities and states mentioned above mandate employers provide paid sick leave, the Family and Medical Leave Act requires only unpaid sick leave be provided by employers with more than 50 workers. A new Obama administration rule is extending paid sick leave to ~300,000 private-sector employees working on government contracts starting on Jan. 1.  Policy makers should consider the potential public health implications of their decisions when contemplating guaranteed sick leave benefits.

Obamacare Succeeds in Expanding Insurance Coverage

Amidst news of the increasing premiums and decreasing choice of plans in some healthcare markets, the New York TimesUpshot column brings us this visual display of the impressive and varied impact of Obamacare on insurance coverage rates from 2013-2016. States that decided to expand their Medicaid programs saw much larger declines in their uninsured rates compared with those that didn’t. The proposed mechanisms for this effect were that Medicaid expansion

  • provided a new coverage option for childless adults below or near the poverty line
  • helped spur many people who were already eligible for the program to sign up
  • boosted enrollment in Obamacare’s marketplace plans.

The column analyzed the difference in insurance coverage expansion between states that did and did not take the Medicaid expansion:

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Two most common pediatric migraine medications no more effective than placebo

Neither of the two drugs used most frequently to prevent migraines in children–amitriptyline and topiramate–is more effective than a placebo, according to results of the Childhood and Adolescent Migraine Prevention (CHAMP) trial published this week in The New England Journal of Medicine. The investigators found no significant differences in reduction in headache frequency or headache-related disability in childhood and adolescent migraine with amitriptyline, topiramate, or placebo over a period of 24 weeks.

The active drugs were associated with higher rates of adverse events. One child on topiramate attempted suicide. Three taking amitriptyline had mood changes; one told his mother he wanted to hurt himself, while another wrote suicide notes at school and was hospitalized.screen-shot-2016-10-28-at-4-01-47-pm

Migraine headaches are common in children. Up to 11 percent of 7- to 11-year-olds and 23 percent of 15-year-olds have migraines.

The Experts Were Wrong About the Best Places for Better and Cheaper Health Care

A post in the New York Times’ Upshot column today focuses on a study that overturns the conventional wisdom that regions with low Medicare spending per capita have low overall healthcare spending. The study found that places that spend less on Medicare do not necessarily spend less on health care over all.

Based on findings of regional variation in Medicare spending, the Affordable Care Act encourages mergers among hospitals. The resulting larger, integrated hospital systems can often spend less money in Medicare, by avoiding duplicative treatments. But such systems also reduce local competition, and thus can set higher prices in private markets.

The regional variation in prices insurance companies pay for medical care are a major determinant of whether regional costs are higher or lower for private insurance.

The post also shows relative Medicare and private insurance spending in your location. Atul Gawande also covered this study in the New Yorker.