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, Jean M. Abraham, William Riley
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 50, pp 47-56; https://doi.org/10.5034/inquiryjrnl_50.01.03

Abstract:
The Affordable Care Act of 2010 recommends that consumer incentives be employed to increase the use of preventive care by Medicaid beneficiaries, but few evaluative studies exist. This study evaluates a Target gift card incentive employed by a Minnesota health plan serving Medicaid beneficiaries over the period 2002–2003. Lacking a contemporaneous control group, the proximity between the child's residence and the nearest Target store was used as the intervention variable. Using alternative specifications for the intervention variable, results of the difference-in-differences equations suggest that the incentive program significantly increased the likelihood that a Medicaid beneficiary would have a well-child visit.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 50, pp 9-26; https://doi.org/10.5034/inquiryjrnl_50.01.05

Abstract:
The minimum medical loss ratio (MLR) regulations in the Affordable Care Act guarantee that a specific percentage of health insurance premiums is spent on medical care and specified activities to improve health care quality. This paper analyzes the regulations' potential unintended consequences and incentive effects, including: higher medical costs and premiums for some insurers; less innovation to align consumer, provider, and health plan incentives; less consumer choice and increased market concentration; and the risk that insurers will pay rebates if claim costs are lower than projected when premiums are established, despite the regulations' permitted “credibility adjustments.” The paper discusses modifications and alternatives to the MLR regulations to help achieve their stated goals with less potential for adverse effects.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 50, pp 27-46; https://doi.org/10.5034/inquiryjrnl_50.01.06

Abstract:
This paper examines how income levels affected the substitution of public health insurance for private health coverage under expansions of Illinois' State Children's Health Insurance Program (SCHIP). Building on a technique developed by Abadie and Gardeazabal (2003), I estimate that among children whose family incomes are between 200% and 300% of the federal poverty level (FPL), 35% of those covered by SCHIP would have retained private coverage in the absence of SCHIP. Significant substitution also appears between 300% and 400% FPL, but surprisingly I find evidence that the introduction of SCHIP caused an increase in private health insurance coverage for those with family incomes between 400% and 500% FPL.
, Frank J. Thompson, Jennifer Farnham
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 50, pp 71-84; https://doi.org/10.5034/inquiryjrnl_50.01.04

Abstract:
Medicaid insures more than 65 million low-income people, and the Affordable Care Act of 2010 gives states the option to enroll millions more. Historical trends in state Medicaid effort possess important implications for health policy going forward. Nearly all states steadily ratcheted up their Medicaid effort in the period from 1992 to 2009, holding out promise that most will sustain their programs and ultimately participate in the expansion authorized by the Affordable Care Act. But the growth in Medicaid over this period did not appreciably curtail vast geographic disparities in program benefits that threaten to undermine the goals of health reform.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 50, pp 57-70; https://doi.org/10.5034/inquiryjrnl_50.01.02

Abstract:
The presence of a large uninsured population may create incentives to providers that affect the care delivered to all individuals in a health care market. Using Current Population Survey data on uninsurance rates and hospital discharge data on Medicare beneficiaries, this study investigates the relationship between the uninsurance rate at the metropolitan statistical area (MSA) level and inpatient quality of care delivered to Medicare beneficiaries, as measured by mortality from eight procedures and conditions. The results do not indicate large or widespread negative effects of the uninsured on Medicare beneficiaries. However, some evidence suggests that the relationship between the local uninsurance rate and Medicare mortality does vary by market size.
Elise Gould, Hilary Wething
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 50, pp 85-86; https://doi.org/10.5034/inquiryjrnl_50.01.01

, , , Deborah Levison, , Agnes C. Jensen, , Joan M. Griffin
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 339-351; https://doi.org/10.5034/inquiryjrnl_49.04.01

Abstract:
U.S. military service members have sustained severe injuries since the start of the wars in Iraq and Afghanistan. This paper aims to determine the factors associated with financial strain of their caregivers and establish whether recent federal legislation targets caregivers experiencing financial strain. In our national survey, 62.3% of caregivers depleted assets and/or accumulated debt, and 41% of working caregivers left the labor force. If a severely injured veteran needed intensive help, the primary caregiver faced odds 4.63 times higher of leaving the labor force, and used $27,576 more in assets and/or accumulated debt compared to caregivers of veterans needing little or no assistance.
, Susan H. Busch
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 352-361; https://doi.org/10.5034/inquiryjrnl_49.04.02

Abstract:
Health insurance plans that include coverage for out-of-network providers are common and have the potential to reduce health care costs and even improve quality. Yet, consumers may be exposed to significant unexpected and unreasonable out-of-pocket costs due to lack of accurate information on network participation, nontransparent out-of-pocket costs, inadequate provider networks, involuntary use of out-of-network emergency care, and use of out-of-network providers at in-network hospitals. Although the Affordable Care Act and some states provide some consumer protections, these may not be adequate.
, Karen Stockley, Kate Willrich Nordahl
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 303-316; https://doi.org/10.5034/inquiryjrnl_49.04.03

Abstract:
While the impacts of the Affordable Care Act will vary across the states given their different circumstances, Massachusetts' 2006 reform initiative, the template for national reform, provides a preview of the potential gains in insurance coverage, access to and use of care, and health care affordability for the rest of the nation. Under reform, uninsurance in Massachusetts dropped by more than 50%, due, in part, to an increase in employer-sponsored coverage. Gains in health care access and affordability were widespread, including a 28% decline in unmet need for doctor care and a 38% decline in high out-of-pocket costs.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 317-326; https://doi.org/10.5034/inquiryjrnl_49.04.05

Abstract:
The 2006 Massachusetts health care reform expanded insurance coverage in the state to near-universal levels. As the uninsured gained coverage, their out-of-pocket costs of medical care fell, inducing them to seek more care. This paper analyzes the effect of the reform on reported health care utilization and outcomes by both synthesizing the existing research on the Massachusetts health care reform and providing new evidence using the National Health Interview Survey. The results show evidence that the Massachusetts reform increased residents' use of health care services including primary and preventive care, reduced reliance on the hospital emergency room as a usual source of care, and improved self-reported health.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 327-338; https://doi.org/10.5034/inquiryjrnl_49.04.04

Abstract:
The Massachusetts health care reform provides preliminary evidence on the function of health insurance exchanges and individual insurance markets. This paper describes the type of products consumers choose and the dynamics of consumer choice. Evidence shows that choice architecture, including product standardization and the use of heuristics (rules of thumb), affects choice. In addition, while consumers often choose less generous plans in the exchange than in traditional employer-sponsored insurance, there is considerable heterogeneity in consumer demand, as well as some evidence of adverse selection. We examine the role of imperfect competition between insurers, and document the impact of pricing and product regulation on the level and distribution of premiums. Given our extensive choice data, we synthesize the evidence of the Massachusetts exchange to inform the design and regulation on other exchanges.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 364-365; https://doi.org/10.5034/inquiryjrnl_49.04.10

John Koster, Myles P Lash, Wayne M Lerner
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 197-201; https://doi.org/10.5034/inquiryjrnl_49.03.06

, Soeren Mattke, Michael Greenberg
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 268-277; https://doi.org/10.5034/inquiryjrnl_49.03.03

Abstract:
Incentives to participate in wellness programs or reach health-related targets are becoming popular, but might expose employers and insurers to litigation risk because incentives might violate state and federal insurance, anti-discrimination, or privacy laws. This paper reviews relevant state and federal law, as well as case law and secondary literature. Findings suggest that convergence of state and federal law and recent court decisions have clarified the range of permissible incentives so that litigation risk under bona fide wellness programs seems limited.
, H. Joanna Jiang, Claudia A. Steiner, John Bott
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 202-213; https://doi.org/10.5034/inquiryjrnl_49.03.01

Abstract:
This study tests whether the likelihood of hospital readmission within 30 days of discharge is different for enrollees in Medicare Advantage plans versus the standard fee-for-service program. A key requirement is to control for self-selection into Advantage plans. The study uses statewide inpatient databases maintained by the Agency for Healthcare Research and Quality for five states in 2006. The type of Medicare coverage is known, along with an encrypted patient identifier. We identify eligible first discharges and the first readmission within 30 days. We use selected area characteristics as instrumental variables for enrollment in Advantage plans and apply a bivariate probit analysis. Descriptively, there is a slightly lower likelihood of readmission for Advantage plan enrollees. However, the Advantage plan patients are younger and less severely ill. After risk adjustment and control for self-selection, the enrollees in Advantage plans have a substantially higher likelihood of readmission. Recognizing caveats and limitations, the study supports informing Medicare beneficiaries about the rates of readmission for Advantage plans in their area. Analytical methods to adjust for self-selection into particular plans or plan types should be considered when possible.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 254-267; https://doi.org/10.5034/inquiryjrnl_49.03.02

Abstract:
This study examines the association between hospital uncompensated care and reductions in Medicaid Disproportionate Share Hospital (DSH) payments resulting from the 1997 Balanced Budget Act. We used data on California hospitals from 1996 to 2003 and employed two-stage least squares with a first-differencing model to control for potential feedback effects. Our findings suggest that nonprofit hospitals did reduce provision of uncompensated care in response to reductions in Medicaid DSH, but the response was inelastic in value. Policymakers need to continue to monitor uncompensated care as sources of support for indigent care change with the Patient Protection and Affordable Care Act (ACA).
, Amy J. Davidoff, Bruce Stuart, Ilene H. Zuckerman, Eberechukwu Onukwugha, Christopher Powers
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 214-230; https://doi.org/10.5034/inquiryjrnl_49.03.04

Abstract:
There is concern about poor take-up of the Medicare Part D Low-Income Subsidy (LIS), but uncertainty in published estimates. The Medicare Current Beneficiary Survey (MCBS), which contains Medicare LIS enrollment records and extensive survey data on individual beneficiary characteristics, would appear an ideal resource for evaluating LIS take-up. However, use of the MCBS to identify eligible beneficiaries is limited due to underreporting of income and lack of asset information in the published MCBS releases. We evaluate LIS eligibility and participation by enhancing the reliability of MCBS financial information using unpublished survey data on income and assets together with an income imputation procedure.
, Victoria Lynch, Jennifer Haley, Michael Huntress
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 231-253; https://doi.org/10.5034/inquiryjrnl_49.03.08

Abstract:
Steep declines in the uninsured population under the Affordable Care Act (ACA) will depend on high enrollment among newly Medicaid-eligible adults. We use the 2009 American Community Survey to model pre-ACA eligibility for comprehensive Medicaid coverage among nonelderly adults. We identify 4.5 million eligible but uninsured adults. We find a Medicaid participation rate of 67% for adults; the rate is 17 percentage points lower than the national Medicaid participation rate for children, and it varies substantially across socioeconomic and demographic subgroups and across states. Achieving substantial increases in coverage under the ACA will require sharp increases in Medicaid participation among adults in some states.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 127-140; https://doi.org/10.5034/inquiryjrnl_49.02.08

Abstract:
Risk adjustment has broad general application and is a key part of the Patient Protection and Affordable Care Act (ACA). Yet, little has been written on how data required to support risk adjustment should be collected. This paper offers analytical support for a distributed approach, in which insurers retain possession of claims but pass on summary statistics to the risk adjustment authority as needed. It shows that distributed approaches function as well as or better than centralized ones—where insurers submit raw claims data to the risk adjustment authority—in terms of the goals of risk adjustment. In particular, it shows how distributed data analysis can be used to calibrate risk adjustment models and calculate payments, both in theory and in practice—drawing on the experience of distributed models in other contexts. In addition, it explains how distributed methods support other goals of the ACA, and can support projects requiring data aggregation more generally. It concludes that states should seriously consider distributed methods to implement their risk adjustment programs.
, Anthony T. Lo Sasso
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 164-175; https://doi.org/10.5034/inquiryjrnl_49.02.02

Abstract:
Using data from the Joint Commission's ORYX initiative and the Medicare Provider Analysis and Review file from 2003 to 2006, this study employed a fixed-effects approach to examine the relationship between hospital market competition, evidence-based performance measures, and short-term mortality at seven days, 30 days, 90 days, and one year for patients with chronic heart failure. We found that, on average, higher adherence with most of the Joint Commission's heart failure performance measures was not associated with lower mortality; the level of market competition also was not associated with any differences in mortality. However, higher adherence with the discharge instructions and left ventricular function assessment indicators at the 80th and 90th percentiles of the mortality distribution was associated with incrementally lower mortality rates. These findings suggest that targeting evidence-based processes of care might have a stronger impact in improving patient outcomes.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 101-115; https://doi.org/10.5034/inquiryjrnl_49.02.07

Abstract:
The employment-based health benefits system established its roots many years ago. It was during World War II that many more employers began to offer health benefits. Recently, however, both the percentage of workers with employment-based health benefits and the comprehensiveness of such coverage have been declining. This paper examines recent trends in employment-based health benefits. It also considers the likely future of this important workplace benefit in light of shifts from defined benefit to defined contribution models of employee benefits and with regard to the implementation of health reform.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 180-180; https://doi.org/10.5034/inquiryjrnl_49.02.03

INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 90-100; https://doi.org/10.5034/inquiryjrnl_49.02.06

Abstract:
Health care rationing has been a source of contentious debate in the United States for nearly 30 years. Because rationing is bewildering to many Americans, persistent myths about “death panels” and critical health care decisions to be made by faceless bureaucrats abound, instilling fear about health care reform and cost containment measures aimed at slowing spending growth. This paper retrospectively reviews the policy literature on health care rationing over the past quarter century, examines alternative definitions and classification schemes, traces the evolution of the debate, and explores ways in which rationing may be made more rational, transparent, and equitable in the future allocation of scarce health care resources.
, David C. Stapleton
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 141-163; https://doi.org/10.5034/inquiryjrnl_49.02.04

Abstract:
This analysis used propensity score matching to construct a comparison sample that is observationally similar at baseline interview to older workers who later experience the onset of a medical condition that limits their ability to work. Using these matched onset and comparison samples, we studied trajectories in earnings and income around onset of the work limitation. Earnings two years after onset for the work-limitation group were 50% lower and poverty rates were nearly double. Income from unemployment insurance, workers' compensation, and retirement and disability benefits offset only a small amount of the earnings declines, resulting in decreased overall household income after onset of the work-limiting condition.
, Matthew Buettgens, Judith Feder, John Holahan
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 116-126; https://doi.org/10.5034/inquiryjrnl_49.02.05

Abstract:
The Congressional Budget Office, the Rand Corporation, and the Urban Institute have estimated that the Patient Protection and Affordable Care Act (ACA) will leave employer-sponsored coverage largely intact; in contrast, some economists and benefit consultants argue that the ACA encourages employers to drop coverage, thereby making both their workers and their firms better off (a “win-win” situation). This analysis shows that no such “win-win” situation exists and that employer-sponsored insurance will remain the primary source of coverage for most workers. Analysis of three issues—the terms of the ACA, worker characteristics, and the fundamental economics of competitive markets—supports this conclusion.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 78-79; https://doi.org/10.5034/inquiryjrnl_49.01.01

, Deborah Taira Juarez, John Berthiaume, Paul Sibley, Richard S. Chung
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 65-74; https://doi.org/10.5034/inquiryjrnl_49.01.06

Abstract:
One of the leading questions of our time is whether high-quality care leads to lower health care costs. Using data from Hawaii hospitals, this paper addresses the relationship of overall cost per case to a composite measure of the quality of inpatient care and a 30-day readmission rate. We found that low-cost hospitals tend to have the highest quality but the worst readmission performance. Change in quality and change in cost were also negatively correlated, but not statistically significant. We conclude that high-quality hospital care does not have to cost more, but that the dynamics of the readmission rate differ substantially from other quality dimensions.
Kenneth Ackerman, Uglas Clark, Michael Cascone, William Kreykes, Bruce McPherson
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 9-14; https://doi.org/10.5034/inquiryjrnl_49.01.02

, E. Kathleen Adams,
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 52-64; https://doi.org/10.5034/inquiryjrnl_49.01.04

Abstract:
The Patient Protection and Affordable Care Act (ACA) will substantially increase public health insurance eligibility and alter the costs of insurance coverage. Using Current Population Survey (CPS) data from the period 2000-2008, we examine the effects of public and private health insurance premiums on the insurance status of low-income childless adults, a population substantially affected by the ACA. Results show higher public premiums to be associated with a decrease in the probability of having public insurance and an increase in the probability of being uninsured, while increased private premiums decrease the probability of having private insurance. Eligibility for premium assistance programs and increased subsidy levels are associated with lower rates of uninsurance. The magnitudes of the effects are quite modest and provide important implications for insurance expansions for childless adults under the ACA.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 37-51; https://doi.org/10.5034/inquiryjrnl_49.01.05

Abstract:
To understand the effects of insurance regulation on the labor market and insurance coverage, this study uses a difference-in-difference-in-differences analysis to compare five states that passed minimum maternity length-of-stay laws with states that waited until after a federal law was passed. On average, we do not find statistically significant effects on labor market outcomes such as hours of work and wages. However, we find that employees of small firms in states with maternity length-of-stay mandates experienced a 6.2-percentage-point decline in the likelihood of having employer-sponsored insurance. Implementation of federal health reform that requires minimum benefit standards should consider the implications for firms of differing sizes.
, , Roger Feldman
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 49, pp 15-36; https://doi.org/10.5034/inquiryjrnl_49.01.03

Abstract:
Private insurance firms participating in Medicare can offer up to three principal plan types: coordinated care plans (CCPs), prescription drug plans (PDPs), and private fee-for-service (PFFS) plans. Firms can make entry and marketing decisions separately across plan types and geographic regions. In this study, we estimate firm-level models of Medicare private plan entry using data from the years 2007 to 2009. Our models include a measure of market structure and separately identify CCP, PDP, and PFFS entry. We find evidence that entry barriers associated with CCP market concentration affect all three product types. We also find evidence of cross-product competition and common cost or demand factors that make entry with certain product combinations more likely. We predict that the market presence of CCPs and PFFS plans will decrease and that of PDPs will increase in response to payment reductions included in the new health reform law.
, Gloria N. Eldridge
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 48, pp 277-287; https://doi.org/10.5034/inquiryjrnl_48.04.01

Abstract:
The Patient Protection and Affordable Care Act encourages use of payment methods and incentives to promote integrated care delivery models including patient-centered medical homes, accountable care organizations, and primary care and behavioral health integration. These models rely on interdisciplinary provider teams to coordinate patient care; health information and other technologies to assure, monitor, and assess quality; and payment and financial incentives such as bundling, pay-for-performance, and gain-sharing to encourage value-based health care. In this paper, we review evidence about integrated care delivery, payment methods, and financial incentives to improve value in health care purchasing, and address how these approaches can be used to advance health system change.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 48, pp 304-312; https://doi.org/10.5034/inquiryjrnl_48.04.04

Abstract:
This paper examines how different strategies for implementing computerized prescriber order entry (CPOE) impact hospitals' productivity. We used the American Hospital Association's Annual Survey to construct hospital-level measures for 1,812 facilities and analyzed the productivity indices against CPOE use rates. The relationship between CPOE use rates and indices for “technical efficiency change” and “total factor productivity” was significant. Hospitals introducing CPOE facilitywide in a one-year period (where usage went from zero to more than 50%) experienced declines in both productivity indices. One implication is that hospitals achieving the goals of the “meaningful use program promoted by the Centers for Medicare and Medicaid Services may do so at the expense of productivity.
INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 48, pp 343-343; https://doi.org/10.5034/inquiryjrnl_48.04.07

INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 48, pp 344-345; https://doi.org/10.5034/inquiryjrnl_48.04.10

INQUIRY: The Journal of Health Care Organization, Provision, and Financing, Volume 48, pp 273-276; https://doi.org/10.5034/inquiryjrnl_48.04.09

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