We are working to gather raw data for your own analysis and to pinpoint trustworthy outside sources of data, analysis and summaries that you can use in your reporting. Below are data sources that can assist you in covering insurance.
With Need Rising, Medicaid Is at Risk for Cuts. A report from the nonpartisan Center on Budget and Policy Priorities shows that states are not generating the tax revenue that expected at the beginning of the year, creating shortfalls in state budgets because so many Americans are newly unemployed or facing steep losses in income. At the same time, the need to provide health insurance through Medicaid is growing. Among 22 states, enrollment in Medicaid has risen by 6.6 percent since February. In 15 states that have expanded Medicaid eligibility under the Affordable Care Act, enrollment in Medicaid has risen by almost 10 percent since February.
Medicaid Enrollment Increases Show Surprisingly Wide Variability Among States. In this blog post from researchers from the Center for Children and Families at the Georgetown University Health Policy Institute reported that some experts have predicted potentially large growth in Medicaid enrollment as a result of the sharp increases in unemployment since the Covid-10 pandemic began early in 2020. The average cumulative gain in Medicaid enrollment among 22 states was 5 percent and the average growth in child enrollment in 13 states was 4.0 percent, the researchers wrote.
Second-Year Results from Comprehensive Primary Care Plus Evaluation Show Supports for Practices Continuing Care Transformation. The research and consulting company Mathematica evaluated the Comprehensive Primary Care Plus (CPC ) program of the federal Centers for Medicare and Medicaid Services to improve the delivery of primary care in the United States. The evaluation of the second year of the five-year program showed that CPC practices provided care management to high-risk patients, continued integrating behavioral health care into their practices, and established formal processes with hospitals and emergency departments to improve care transitions. There were, however, few improvements in cost control, service use or and quality for Medicare fee-for-service (FFS) beneficiaries, the report said.
Medicaid: Primer on Financing Arrangements. In this report the federal Government Accountability Office (GAO) provides a primer describing the most common types of arrangements states use to finance the nonfederal share of each state's Medicaid expenditures and includes examples of how these arrangements can shift the share of expenditures to local governments, providers, and the federal government.
Changes in Health Insurance Coverage Due to the COVID-19 Recession: Preliminary Estimates Using Microsimulation. Researchers from the Urban Institute and the Robert Wood Johnson Foundation estimated that about 10.1 million people have lost employer-sponsored health insurance coverage because of a COVID-19-related job losses through September 2020. But about one-third of them have access to employer-based insurance through a family member meaning about 32 percent of 10.1 million will remain in employer-based insurance. About 28 percent will enroll in Medicaid or the Children’s Health Insurance Program, and 6 percent will choose nongroup coverage, mainly marketplace coverage with premium tax credits, the report said. Some 3.5 million people will become uninsured and about 55 percent of them are eligible for, but will not use, subsidized coverage through the marketplace or Medicaid.
Medicaid: State Views on Program Administration. In the report from the Government Accountability Office, researchers explaind the challenges that state Medicaid officials face when seeking to implement the some federal policies. For example, residents of certain mental health institutions are generally excluded from Medicaid coverage, making it difficult to offer them a full range of services. Also, Medicaid prescription drug coverage includes newer outpatient prescription drugs that cost more and don’t have proven benefits.
Report: Drug Companies Keep Raising Prices in the Midst of a Pandemic. In a report, Patients For Affordable Drugs showed that pharmaceutical companies raised the list prices of 245 drugs by an average of 23.8 percent since the first case of the novel coronavirus in the United States was reported in January and that 75 percent of those price hikes were for drugs used for treating patients infected with COVID-19 treatment or for conditions that place consumers at higher risk of infection. The report itself is here and the supporting data are here.
The Projected Economic Impact of the COVID-19 Pandemic on the US Healthcare System. On the basis of hospital procedure and revenue codes, FAIR Health estimated that the total costs for all hospitalized COVID-19 patients in the United States would range from$139 billion to $558 billion in estimated amounts that health insurers allow and from $362 billion to $1,449 trillion in charges, depending on the rate of the infection in the population. Charges are the highest amounts hospitals charge patients and allowed amounts are what insurers pay.
Cause-of-death Data From the Fetal Death File, 2015–2017. This National Vital Statistics Report from the federal Centers for Disease Control and Prevention shows that five causes accounted for 89.5% of fetal deaths, including unspecified causes; complications of placenta, cord and membranes; maternal complications of pregnancy; congenital malformations, deformations and chromosomal abnormalities; and maternal conditions that may be unrelated.
Problems Paying Medical Bills, 2018. In this data brief, the National Center for Health Statistics, a division of the federal Centers for Disease Control and Prevention, reported that in 2018, the percentage of persons in families who had problems paying medical bills decreased from 19.7% in 2011 to 14.2% in 2018. In the same year, the percentage of persons in families having problems paying medical bills was higher among females (14.7%), children (16.2%), and non-Hispanic black persons (20.6%) compared with males, adults, and other racial and ethnic groups, respectively. Among persons under age 65, those who were uninsured were more likely than those with Medicaid or private coverage to have problems paying medical bills.
The Association Between Drug Rebates and List Prices. Researchers with the USC Leonard D. Davis Center on Health Policy and Economics report that drug manufacturers’ rebates to pharmacy benefit managers may cause drug prices to rise. On average, a $1 increase in rebates was associated with a $1.17 increase in list price. Reducing or eliminating rebates could lower list prices and out-of-pocket costs, the report showed.
2019 Milliman Medical Index. In 2019, the cost of healthcare for a hypothetical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan was $28,386, according to the Milliman Medical Index (MMI). The report also showed that in 2019, health care costs were increasing at a slower rate than they had in earlier years. In the early 2000s, such expenses for a family of four rose by 10 percent annually, but Milliman estimated that costs rose by only 2.9 percent from 2017 to 2018, and by 3.8 percent from 2018 to 2019.
Rural Hospital Vulnerability Study. In this study from February 2020, the Chartis Center for Rural Health identified 453 rural hospitals that could be considered vulnerable to closure. Since 2011, more than 120 rural hospitals have closed, limiting access to care for people who are older, less healthy and less affluent than people in urban areas, the report showed.
In a report, Addressing Health Care Market Consolidation and High Prices, from the Urban Institute and the University of California Hastings College of Law, researchers outlined policy options that states could adopt to improve competition in provider markets and regulate prices. One of those options is health care price transparency.
The Texas Two-Step: Implementation of State Balance Billing Law Reveals Gaps in Consumer Protections. In a post on the Center for Health Insurance Reform blog (the CHIRblog), Rachel Schwab, a research associate, explained that while a law in Texas prohibiting balance billing is among the strongest such laws in the nation, it was almost gutted due to a loophole in the law that opponents used to undermine the provisions in the law. The blog post is useful to journalists in any state because it explains how opponents can undermine laws after they’re passed.
Model Pharmacy Benefit Manager Contract Terms. In a report, the National Academy for State Health Policy outlines efforts in some states to promote price transparency through all-payer claims databases and other means, and strengthen antitrust enforcement.
Measuring Maternal Mortality. In February 2020, researchers affiliated with the Commonwealth Fund reported on new maternal mortality data from the National Center for Health Statistics (NCHS). As a result of the new data, researchers have a more accurate picture of maternal mortality in the United States allowing comparisons among states and with other countries, the researchers explained. In previous years, not all states collected the same data in the same way.
A report from the National Center for Health Statistics showed that for 2018, the maternal mortality rate was 17.4 per 100,000 live births in the United States and that wide racial and ethnic gaps existed among non-Hispanic black (37.1 deaths per 100,000 live births), non-Hispanic white (14.7), and Hispanic (11.8) women.
CMS Drug Spending dashboards. CMS released new dashboards that list prescription drugs in their first year on the market (meaning new in 2018) when previously, it took two years for new drugs to appear. The interactive dashboards provide spending information for drugs in Medicaid and in Medicare parts B and D. They also show per-dosage average spending and changes in average spending over time.
Household Health Spending Calculator. A calculator from the Peterson Center on Health Care and Kaiser Family Foundation shows that Americans know what they spend out-of-pocket and for monthly insurance premiums but may not know that a large portion of health spending is less visible, such as state and federal income taxes for Medicare and Medicaid and Medicare payroll taxes that employers and the self-employed pay.
Assessing the Redesigned Medicare Plan Finder Tool: Room for Improvement. In this article in Health Affairs, researchers said the revised Medicare Plan Finder (MPF) emphasizes monthly plan premiums over more relevant information, such as estimated total drug and out-of-pocket costs. The MPF menu defaults to placing plans with the lowest premiums at the top of the list, rather than by total annual drug costs (as the previous version did).
Private Health Insurance. Enrollment Remains Concentrated among Few Issuers, including in Exchanges. A March 2019 report from the Government Accountability Office shows that enrollment in private health insurance plans was concentrated among a small number of insurers in 2015 and 2016. In the large group market (meaning coverage large employers offer), the small group market (coverage small employers offer), and the individual market (coverage individuals buy directly), the three largest insurers held 80 percent of the market or more in 37 of 50 states and the District of Columbia. These levels are similar to what GAO reported for 2011 through 2014.
Health deductible health plan—What’s an HDHP? This report from Insure.com includes data that explains how HDHPs work and the results of a survey of consumers who said they have high-deductible plans and have not seen lower health care costs. Forty-six percent of respondents said their costs increased and 43% said they stayed the same. A mere 11% said their costs decreased.
The Medicine Price Index 2019. In this report, researchers from Medbelle, a company in the United Kingdom, collected data on the price of 13 common pharmaceutical medications on a dollar-for-dollar basis, regardless of payer. The result is a comparative index based on data from 50 countries that reveals the price disparities for widely used medications. The results range from a high of 306.82 percent deviation in price in the United States, to negative 93.93% in Thailand, highlighting disparities in what patients pay for the same medicine across the world. Based in London, Medbelle is building the world’s first digital hospital.
Evaluation of the Accountable Care Organization Investment Model. In this analysis of two years of the federal Centers for Medicare and Medicaid Services ACO program, researchers estimated that the ACOs cut Medicare by $131.0 million in the first year of the program (2016) for a reduction of 2.8 percent from a baseline, and by $187.7 million in the second year (2017) for a 3.5 percent reduction from baseline. After CMS paid out the ACOs’ share of the savings in this shared-savings program, Medicare had net savings of $108.4 million in year one and $153.4 million in year two, the researchers reported.
The Compendium of U.S. Health Systems for 2018. In November 2019, the Agency for Healthcare Research and Quality’s (AHRQ) Comparative Health System Performance Initiative, released a report on the data it collects and tracks on health systems and tracks. It’s the most recent update since 2016 and could help journalists and policy makers understand how health systems influence cost, quality and access to care.”
Coding Variability in Genetic Testing. In this report issued in September 2019, Concert Genetics, a tech company that collets and curates data on genetic testing, provided a summary of coding and pricing variation in commercial health insurance claims. The report showed the correlation between variations in billing codes and what health insurers paid for genetic tests.
The Number of Uninsured Children is on the Rise. From 2016 through 2018, the number of uninsured children in the United States rose by more than 400,000 bringing the total number of uninsured children (meaning those under age 19) to more than 4 million uninsured children, according to a report from the Georgetown University Health Policy Institute Center for Children and Families.
What Do Americans Think About Their Health Coverage Ahead of the 2020 Election? A report from the Commonwealth Fund is based on a survey of Americans that shows just over a quarter (27%) of adults favor eliminating all private health insurance and making public insurance such as Medicare the only coverage option. But 40 percent said they do not know enough to form an opinion. More than two-thirds (68%) of adults in states that have not yet expanded Medicaid favor expanding eligibility for the program. Large majorities of insured adults are satisfied with their current coverage, and those enrolled in Medicaid and in employer plans are the most satisfied.
Competition in Health Insurance: A Comprehensive Study of U.S. Markets Competition (2019 update). A study by researchers for the American Medical Association shows that commercial in health insurance has decreased since 2014. The share of highly concentrated commercial health insurance markets increased from 71 percent to 75 percent from 2014 through 2018. An estimated 73 million Americans with commercial health insurance live in highly concentrated markets and face limited choice. In almost half of metropolitan areas, a single health insurer has 50 percent or more of the market, and patients are not benefitting from this degree of market power, the AMA said.
Medicare Advantage. In this fact sheet, researchers from the Kaiser Family Foundation show that in 2019, most of the 64 million people on Medicare are enrolled in traditional Medicare (sometimes called fee-for-service Medicare), but 34 percent are enrolled in Medicare Advantage plans. Over the past decade, the number of beneficiaries enrolled in private MA plans has nearly doubled from 11.1 million in 2010 to 22.0 million in 2019. Between 2018 and 2019, total Medicare Advantage enrollment grew by about 1.6 million beneficiaries, or 8 percent – a nearly identical rate of growth compared with the prior year.
What Is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries? In an issue brief, researchers from the Commonwealth Fund used international data to show that women in United States report the least positive experiences among the 11 countries studied. They have the greatest burden of chronic illness, highest rates of skipping needed health care because of cost, difficulty affording their health care and are least satisfied with their care. U.S. women also have the highest rate of maternal mortality and of caesarean sections.
How U.S. Health Policy Changes Have Affected Healthcare Costs Over Time. The real estate listing company Clever did this analysis because it was interested in how such financial factors as health care, health insurance, retirement planning and salaries) affect consumers' abilities to buy homes. While we the study does not make a direct like between health care and insurance costs and home buying, the three factors are connected, the company said.
Financial Eligibility Criteria and Medication Coverage for Independent Charity Patient Assistance Programs. Research into patient-assistance programs that pharmaceutical manufacturers run tend to favor patients with insurance rather than those who are uninsured and the most vulnerable. The researchers from Department of Health Policy and Management at the Bloomberg School of Public Health at Johns Hopkins University, published their results in the Journal of American Medical Association. An accompanying editorial explained that the research shows that patient assistance programs provide assistance to a narrow, insured patient population to the benefit of the pharmaceutical companies.
10 Things to Know about Medicaid Managed Care. Capitated managed care is the dominant method states ue to deliver services to Medicaid enrollees. As of July 2018, 39 states, including Washington, D.C., were contracting with comprehensive, risk-based managed care plans to provide care to at least some of their Medicaid beneficiaries.
The Future of Value-Based Care: 2019 Survey Results. A report shows from Definitive Healthcare, a consulting and data-analytics company shows that from 2011 through 2018, the number of states and territories that have implemented value-based care programs has rising from three states in 2011 to 48 in 2018. Most of the increase has been due to efforts by the federal Centers for Medicare and Medicaid Services to shift payment away from fee-for-service under the Medicare Improvements for Patients and Providers Act of 2008.
Marketwide Price Transparency Suggests Significant Opportunities For Value-Based Purchasing. In a report published in Health Affairs, researchers showed that paid health care prices for what the researchers called insurer-provider-service triads in Massachusetts revealed extensive variation in health care prices for outpatient services that were not attributable to geographic variation in the cost of doing business. They added that meaningful savings are possible from policies to reduce price variation.
Medicare Physician Services: Spending on and use of Billing Codes for Comprehensive Care Planning Services. In this federal report, researchers from the Government Accountability Office, showed that a majority of Medicare's 39 million beneficiaries in 2017 had a serious condition, such as diabetes or heart disease, requiring planning and coordination among medical specialists. Medicare has at least 58 billing codes for some aspect of care planning and 13 of which accounted for $467 million in spending in 2017.
Medicare Plan Finder. In this federal report, researchers from the Government Accountability Office found that Medicare’s health insurance plan finder for traditional Medicare and for Medicare Advantage plans had usability problems and incomplete information that made it difficult for beneficiaries to compare coverage options.
ACOs' Strategies for Transitioning to Value-Based Care. In this federal report, the HHS Office of Inspector General, makes seven recommendations, including expanding efforts to share information about strategies that reduce spending and improve quality, adopt outcome-based measures and better align measures across programs, and identify and share information about strategies that integrate physical and behavioral health services and address social determinants of health.
HRC Releases Healthcare Equality Index, Rates Record 680 Health Care Facilities on LGBTQ Inclusion. The Human Rights Campaign Foundation released its 12th annual Healthcare Equality Index (HEI) report on Aug. 12, 2019. The reports scores 680 health care facilities health care facilities on policies and practices dedicated to the equitable treatment and inclusion of LGBTQ patients, visitors and employees.
Diving into the Data: How Many Americans Die Prematurely from Treatable Causes? A report from the Commonwealth Fund shows that premature mortality is higher among people of color—and African Americans in particular who also tend to be disproportionally low income—that expanding Medicaid under the Affordable Care Act in states that have not yet done so may help reduce premature deaths. A recent analysis found a more rapid decline in mortality from “disease-driven” deaths in states that expanded Medicaid compared with those states that have not expanded Medicaid. But expanding insurance coverage is not enough. Further reductions in premature mortality will require cooperation among public health, health care and social service sectors, the report said.
Vizient Drug Price Forecast 2019. In a report, data and health care consulting firm Vizient predicted that health systems can expect a nearly 5% increase in their pharmaceutical spending in 2020.
Military Families with TRICARE Less Satisfied with Health Care Quality and Access for Children. Researchers from the PolicyLab at Children’s Hospital of Philadelphia showed that military families with health insurance through TRICARE, the health care program for uniformed service members and their families, report lower access to care and satisfaction with the quality of care than civilian families who have private or public coverage for their children. The study was published in the August issue of Health Affairs.
How the ACA’s Medical Loss Ratio Rule Protects Consumers and Insurers Against Ongoing Uncertainty. In a report from the Commonwealth Fund, researchers show that consumer rebates under the medical loss ratio rule (MLR) of the Affordable Care Act increased in 2017 as insurers raised rates and regained profitability. At the same time, the rule’s calculation of MLRs based on a three-year rolling average allowed insurers in 2017 to recoup a portion of their losses from earlier years, the report added. As the individual market continues to experience cycles of profits and losses, the MLR rule dampens the severity of these cycles, thus protecting insurers as well as consumers, the researchers said.
Project ECHO is creating waves, employers should take notice. A report from Catalyst for Payment Reform describes how a local solution for improving access to health care in New Mexico has spread to other places in the nation. Project Extension for Community Healthcare Outcomes (ECHO), is a way to expand access to health care and improve care delivery that employers should embrace, the report says.
How Many Employers Could Be Affected by the High-Cost Plan Tax (the Cadillac Plan Tax). In a report that’s important for journalists covering health reform plans, the Kaiser Family Foundation shows that employer-based health benefits are not taxed, meaning employees get thousands of dollars of tax benefits when have employer-sponsored health insurance. The Congressional Budget Office estimates that the exclusion cost to the federal government is $300 billion in forgone revenue. Economists argue that providing this tax break encourages employers to offer more generous benefit plans than they otherwise would because employees prefer to receive additional benefits (which are not taxed) in lieu of wages (which are taxed). Employees with generous plans use more health care because they face fewer out-of-pocket costs, which economists argue contributes to the overall growth in health care spending. To address this issue, the ACA included the High-Cost Plan Tax (HCPT), sometimes referred to as the “Cadillac Plan Tax.”
Expanding Access to Outcomes-Driven Maternity Care through Value-Based Payment. A report from the Health Care Transformation Task Force (HCTTF) shows that despite evidence about what works, efforts to transform maternity care payments have remained sluggish. The report examines how fee for service payment has exacerbated the maternal health crisis and details the state of value-based payment adoption for maternity care in the United States.
Health Care Spending, Utilization, and Quality 8 Years into Global Payment. Researchers published an article in the New England Journal of Medicine about changes in spending, quality, and health care use after eight years under the Alternative Quality Contract (AQC) of Blue Cross Blue Shield (BCBS) of Massachusetts. This population-based global payment model includes financial rewards and penalties (two-sided risk) and gives health care providers a spending target for the care of a defined group of patients.
HPC DataPoints, Issue 12: Cracking Open the Black Box of Pharmacy Benefit Managers. The Massachusetts Health Policy Commission reported that in 2018, that the price of drugs from managed care organizations and pharmacy benefit managers were 95 percent higher than what the MCOs and PBMs paid to acquire those drugs and were 42 percent higher than the fee-for-service price of those drugs, leading to higher average drug prices overall. For widely prescribed generic drugs, a drop in the cost MCOs and PBMs paid to acquire these drugs (called the acquisition cost) did not translate into lower prices for managed care plans serving MassHealth, the state’s Medicaid program. From the first quarter of 2016 through the end of 2018, the average acquisition cost for buprenorphine fell by 60 percent but the price of the drug for the state’s MassHealth plans rose by 13 percent.
Upcoding: Evidence from Medicare on Squishy Risk Adjustment. In this report from the National Bureau of Economic Research, researchers reported that in most health insurance markets in the United States, health insurers have strong incentives to “upcode,” meaning to increase patients’ reported diagnoses because doing so raises the risk-adjusted payments they receive from government or other purchasers. Enrollees in private Medicare plans generate 6 percent to 16 percent higher diagnosis-based risk scores than they would under fee-for-service Medicare, where diagnoses do not affect most provider payments, the researchers wrote.
Vital Signs: Pregnancy-Related Deaths, United States, 2011–2015, and Strategies for Prevention, 13 States, 2013–2017. Researchers from the federal Centers for Disease Control and Prevention report that some 700 women die each year in the United States from pregnancy-related complications and that when the timing was known, 31.3 percent of such deaths occurred during pregnancy, 16.9 percent happened on the day of delivery, 18.6 percent have on days one to six postpartum, 21.4 percent on days seven to 42 postpartum, and 11.7 percent occurred on days 43 to 365 postpartum. Most (60 percent) pregnancy-related deaths were preventable.
Prices Paid to Hospitals by Private Health Plans Are High Relative to Medicare and Vary Widely. In a report based on findings from an employer-led price-transparency initiative, researchers from RAND showed that private health plans pay hospitals 241 percent of what Medicare would pay. An examination of hospital prices covering 25 states showed that in 2017, the prices paid to hospitals for privately insured patients in some states (such as Kentucky, Michigan, New York and Pennsylvania) had average relative prices that were 150 percent to 200 percent of what Medicare paid, while other states (such as Colorado, Indiana, Maine, Montana, Wisconsin and Wyoming) had average relative prices that were 250 percent to 300 percent of what Medicare would have paid.
Medicaid and CHIP Enrollment Decline Suggests the Child Uninsured Rate May Rise Again. A report from the Georgetown University Health Policy Institute’s Center for Children and Families shows that children are losing coverage under Medicaid and under the federal Children’s Health Insurance Program (CHIP). Overall, more than 828,000, or 2.2 percent, fewer children were enrolled in Medicaid and CHIP, combined, at the end of 2018 than were enrolled in 2017, the center reported. A drop in child enrollment is unusual, the center added.
Negotiation Over Drug Prices in Medicare. In a two-page letter to U.S. Senate Finance Committee Chair Chuck Grassley, the Congressional Budget Office answered two questions about options for allowing the Secretary of Health and Human Services to negotiate over the prices paid for drugs under the Medicare Part D benefit.
The Burden of Health Care Costs for Working Families. Researchers at Penn LDI (the Leonard Davis Institute) and the United States of Care reviewed national data on rising health care costs and different ways to measure whether health care and coverage are affordable. Then, they adapted one of those measures to provide state-level data on the cost burden working families face when they have employer-sponsored insurance. In the report, the researchers examined how this burden varies across states and how it has changed within states from 2010 to 2016.
The U.S. Healthcare Cost Crisis. A survey from West Health and Gallup reveals financial hardships and gaps between members of political parties on the quality of the U.S. health care system. The report on the West Health-Gallup survey shows how the high cost of health affects Americans’ personal finances, individual health care choices and their perceptions of the health care system in the United States.
Effect of a Workplace Wellness Program on Employee Health and Economic Outcomes: A Randomized Clinical Trial. In JAMA, researchers published results that could reduce expectations about the financial return on investment that workplace wellness programs can deliver in the short term. The 18-month study showed that among employees of a large warehouse retail company, there were no significant differences in clinical measures of health, health care spending and utilization, or employment outcomes. The program showed significantly greater rates of some positive self-reported health behaviors among employees exposed to the program compared with those who were not exposed.
Study Uncovers the Heavy Financial Toll of Untreated Maternal Mental Health Conditions. Researchers for Mathematica reported that when following mother–child pairs from pregnancy through five years postpartum, the estimated costs of maternal mental health conditions was $14.2 billion for births in 2017, or an average of $32,000 for every mother–child pair affected but not treated. In addition to national results, state-specific details are available for California, Colorado, and Washington State.
Hospital Consolidation: Trends, Impacts & Outlook. For a collection of charts and graphs, the National Institute for Health Care Management (NIHCM) Foundation collected data on the increasing rate of consolidations among hospitals and health systems.
D is for Distortion: Medicare Part D's $2 Billion Problem. In an analysis in the prices set for the top 15 generic drugs in Medicare Part D, researchers from 46brooklyn Research report that these drugs represented about one third of all Part D spending on generic drugs in 2017. The research also shows that some of the generic pricing appeared to be arbitrary in the Part D program, which is similar to what others have found in the Medicaid program, the researchers reported.
Care Coordination Toolkit for Medicare’s accountable care organizations (ACOs). This care coordination toolkit describes strategies ACOs use to ensure that Medicare beneficiaries get high-quality and efficient care by managing patients’ transitions across different settings of care. It explains how ACOs coordinate care for beneficiaries who get care in an emergency room, need treatment in a skilled nursing facility, have recently been discharged home after a hospital or ER visit, have been diagnosed with a chronic condition, or have conditions the social determinants of health affect.
Prices for and Spending on Specialty Drugs in Medicare Part D and Medicaid. In this report from the Congressional Budget Office, the CBO said spending in 2015 on brand-name specialty drugs accounted for about 30 percent of net spending on prescription drugs under Medicare Part D and Medicaid, but they accounted for only about 1 percent of all prescriptions dispensed in each program.
The Coverage Gap: Uninsured Poor Adults in States that Do Not Expand Medicaid. Under the Affordable Care Act, millions of Americans gained coverage through the expansion of Medicaid, but decisions in the 14 states that as of March 2019, not to expand their Medicaid program left many individuals without affordable health insurance coverage. Across the United States, some 2.5 million poor uninsured adults fell into what’s called the ‘coverage gap’ that resulted from state decisions not to expand Medicaid, the Kaiser Family Foundation reported. These individuals earn too much to qualify for Medicaid, but not enough to be eligible for premium tax credits when purchasing health insurance on the ACA Marketplace.
State Efforts to Protect Consumers from Balance Billing and surprise medical bills. In a report for the Commonwealth Fund, researchers showed that as of December 2018, 25 states had laws offering some balance-billing protection against surprise medical bills and nine of those states (California, Connecticut, Florida, Illinois, Maryland, New Hampshire, New Jersey, New York and Oregon) had laws meeting the fund’s standard for “comprehensive” protections..
The C-Section Epidemic: What’s Tort Reform Got To Do With It? In an article in the Illinois Law Review, Sabrina Safrin, a law professor at the Rutgers University School of Law, reported that a new analysis of data on births by cesarean section show that a woman is not less likely to give birth by c-section in a state that limits damages in medical malpractice cases than in states without such caps on damages. “Thus, either damage caps are insufficient to address physicians’ concerns or other explanations better account for the overuse of the [c-section] procedure,” she wrote. One of Safrin’s suggestions to reduce the c-section rate involves having health insurers pay more for vaginal deliveries because they take more time.
Hospital Mergers Improve Health? Evidence Shows the Opposite. For an article The New York Times published in the Upshot blog, Autin Frakt collecteds the data over many years to show after markets for hospitals and physician groups have become more concentrated through mergers and acquisitions, higher prices result but also health care gets worse. “Studies show that rates of mortality and of major health setbacks grow when competition falls,” he wrote.
Air Ambulance: Available Data Show Privately-Insured Patients Are at Financial Risk. Researchers from the Government Accountability Office report that in 2017, about two-thirds of air ambulance transports for patients with private insurance were out-of-network and insurers generally pay only for a portion of an out-of-network charges. A review of consumer complaints showed almost all involved balance bills over $10,000.
In a report published in EconoFact, researchers from the University of British Columbia and Harvard University reported that billing and insurance-related costs make up the largest share of administrative costs and that estimates suggest that between 15 percent and 30 percent of overall health care spending, and one-quarter of the medical labor force, are involved in costs of billing, insurance management, hospital administration and other related costs.
Researchers from Harvard Medical School, the Harvard T.H. Chan School of Public Health and Harvard Pilgrim Health Care Institute reported in the Annals of Internal Medicine that among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test and the first procedure-based treatment.
Researchers from the Integrated Benefits Institute reported that employers in the United States pay about $880 billion in health care benefits for employees and dependents annually and that illness-related lost productivity costs them an additional $530 billion per year or 60 cents for every dollar employers spend on health care benefits.
In a report from the CDC’s National Center for Health Statistics, researchers from the NHIS reported that in the first six months of 2018, 28.5 million persons of all ages (8.8 percent) were uninsured at the time of the NHIS interview, which was not significantly different from 2017, but was 20.1 million fewer persons than were insured in 2010.
Among Medicare Beneficiaries Hospitalized for Heart Failure, Acute Myocardial Infarction, and Pneumonia. Researchers reported in JAMA that among Medicare beneficiaries, the Hospital Readmissions Reduction Program (HRRP) of the federal Centers for Medicare and Medicaid Beneficiaries has been associated with a reduction in readmission rates for heart failure (HF), acute myocardial infarction (AMI), and pneumonia. But it is unclear whether the HRRP has been associated with a change in patient mortality. The program was significantly associated with an increase in 30-day post-discharge mortality after hospitalization for HF and pneumonia, but not for AMI. More research is needed to understand whether the increase in 30-day post-discharge mortality is a result of the Medicare policy.
In September, the National Committee for Quality Assurance released its 2018 Health Insurance Plan Ratings showing how health insurance plans perform in the areas of consumer satisfaction, illness prevention and treatment. In the report, NCQA studied some 1,500 health plans and rated 1,040, including 445 private or commercial plans, 418 Medicare Advantage plans, and 177 Medicaid plans. NCQA’s rating system is similar to the star ratings system that the federal Centers for Medicare and Medicaid Services uses to rate Medicare Advantage plans. For information on how NCQA calculates its ratings, see this explanation of its methodology.
Findings from a recent study suggest that reference pricing could cause patients to choose lower-cost providers and cause providers to lower their prices modestly. In this study of reference pricing for three common surgical procedures (colonoscopy, cataract surgery and some types of joint arthroscopy), researchers examined whether providers respond to a shift in consumer demand by lowering their prices. Here’s the citation for the study: Whaley CM and Brown TT. “Firm Responses to Targeted Consumer Incentives: Evidence from Reference Pricing for Surgical Services.” Journal of Health Economics, 61:111-33. July 2018.
In an issue brief, researchers at the Employee Benefit Research Institute show that spending on specialty medications is expected to account for nearly one-half of total drug spending in the commercial market by 2020 but did not find any clear relationship between the use of specialty medications and workplace absenteeism. Specialty drug use for rheumatoid arthritis was associated with 2.5 fewer days absent (when absences occurred), but for multiple sclerosis, each additional specialty drug prescription filled was associated with 0.3 more days absent, the issue brief says.
An analysis of out-of-network claims in large employer health plans
Among Americans with employer-sponsored health insurance, almost one in five inpatient admissions includes a claim from an out-of-network provider. Charts based on an analysis of insurance claims from large employer plans show how often inpatient admissions or outpatient services result in a claim from out-of-network providers.
Revealing the Truth about Healthcare Price Transparency
There is minimal evidence that making prices more transparent for consumers will drive health care value, according to this June 2018 report from the Altarum Healthcare Value Hub. The report also said that consumers don’t view health care as a commodity, that most health care services are not “shoppable,” that patients pay directly for only a small portion of total spending on shoppable services, and that consumers are ill-equipped to recognize services as being of high or low value.
Strategies for Improving the Affordability of High-Quality Health Care and Coverage
In a report published in July 2018, the National Coalition on Health Care explored the affordability crisis in the U.S. health care system and identified the factors driving up costs and outlined options to address them.
New Report on Maternity Care in the U.S. Shows Encouraging Progress Reducing Episiotomies, but None Reducing C-Sections
In this May 2018 report based on findings from the 2017 Leapfrog Hospital Survey, the Leapfrog Group and Castlight Health reported no improvement in reducing the rate of Caesarean sections. The report showed that the average rate of episiotomies (an incision made in the perineum or birth canal during childbirth) declined from 9.6 percent in 2016 to 7.8 percent in 2017, the lowest rate since Leapfrog began collecting and publicly reporting these data. Also, the use of these usually unnecessary incisions remains well above Leapfrog’s standard, determined by its Maternity Care Expert Panel, of 5 percent or less, the report said.
Medical cost trend: Behind the numbers 2019
In its latest annual look at employers’ health care cost trends, PwC's Health Research Institute projects that employers will pay 6 percent more for health care in 2019 than they did in 2018, an increase that is similar to what employers have paid in each of the past five years, when costs have risen 5.5 percent to 7 percent.
Community Health Center Chart Book
The Community Health Center Chartbook highlights data from and research findings on those health centers, including Federally-Qualified Health Centers (FQHCs) that get federal grants and their efforts to improve access to care and to improve health care quality while also reducing costs and disparities in how care is delivered.
Community Catalyst report on prescription drug prices
Community Catalyst highlights four key factors contributing to the high cost of prescription drugs in the United States: Pharmaceutical monopoly power over drug pricing, the opaque pharmaceutical supply chain that allows intermediary players to maximize profits, manipulative marketing tactics that drug manufacturers use to lure providers and consumers toward high-cost medications, and the practice by health insurers to shift costs to consumers.
In a report published in April 2018, Altarum says spending on health care is rising due to price growth and is expected to become more unsustainable in 2018.
Modernizing Medicare Plan Finder: Evaluating and Improving Medicare's Online Comparison Shopping Experience
Report from the Clear Choices Campaign finds major flaws in the Medicare Plan Finder (MPF), the federal government's online tool to help Medicare beneficiaries and others make decisions about coverage options in Medicare’s fee-for-service and Parts C and D plans
Rising to the Challenge: Community Health Centers Are Making Substance Use Disorder Treatment More Accessible Than Eve
Community Health Centers have long been at the forefront of providing high quality, cost effective care to underserved rural and urban communities across the country. As communities across America cope with a dramatic increase in the prevalence of substance use disorder, health centers are providing much needed substance use disorder services to their patients. (PDF) March 2018
Who Uses a Price Transparency Tool? Implications for Increasing Consumer Engagement
Research data published in an article shows use of an online price transparency tool was relatively low, echoing prior research findings that few people offered price transparency tools use them. Earlier research also shows that younger people are more likely to use price transparency tools and that those who used transparency tools had higher medical spending than non-users. The article was published in Inquiry: The Journal of Health Care Organization, Provision, and Financing.
The 2016 Health Care Cost and Utilization Report
The Health Care Cost Institute issued a report in January 2018 on health care spending among employed workers and their family members. The 2016 Health Care Cost and Utilization Report is based on analyses of HCCI’s data from commercial health insurers. It contains day from those employed workers who under age 65 and who have employer-sponsored insurance (ESI) in the United States. In the report, HCCI said health care spending for the ESI population grew by 4.6 percent in 2016, an increase over the lower rates observed between 2012 and 2015.
Concentration of Health Expenditures and Selected Characteristics of High Spenders, U.S. Civilian Noninstitutionalized Population, 2015
In a statistical brief published Dec. 12, 2017, the federal Agency for Healthcare Research and Quality describe the concentration of health care expenses across the U.S. civilian non-institutionalized population.
What Happens to Health care Costs When Nonprofit Hospitals Take a Financial Hit?
Contrary to conventional wisdom, nonprofit hospitals generally act like for-profit hospitals, at least following a financial crisis, researchers report. Rather than raise prices, many non-profit hospitals cut back on unprofitable services to offset losses in a financial crisis. Researchers from the Kellogg School of Management at Northwestern University discussed their work in this KelloggInsight article. Wiley published the original research in The RAND Journal of Economics.
Why Value-Based Payment Isn’t Working, and How to Fix It
In a report, Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, argues that the fee-for-service payment system and current approaches to value-based payment, including pay-for-performance, shared savings, two-sided risk, population-based payments, and narrow networks, have failed to control costs or improve the quality of care. They failed because their central focus is on how to pay providers for services or how to reduce spending for insurers, not on how to achieve good healthcare outcomes for patients at the most affordable cost for patients and insurers, the report says. Instead, this report says health insurers and other payers need to develop a patient-centered payment system that corrects the problems of fee-for-service payment while preserving its strengths.
New Medicare Incentives Encourage Accountable Care Organizations To Assume Greater Risk
A report from consultants Avalere shows that ACOs participating in the Medicare Shared Savings Program could have earned additional net payments of $886 million in 2015 if they had assumed greater financial risk under the program and had qualified for the 5 percent bonus payment available under the Quality Payment Program.
Medical cost trend: Behind the numbers 2018
The Health Research Institute at consultants PwC projects the growth of medical costs in the employer insurance market for the coming year and identifies the factors expected to affect medical costs. For 2018, HRI predicts that health care costs may be settling into what PwC calls a “new normal” of moderate fluctuations, meaning cost increases will be in the single digits. For 2018, HRI predicts medical costs will rise by 6.5 percent and that this increase will be the first in three years.
Medical cost trend: Behind the numbers 2018
PwC projects 2018 medical costs will grow at a slightly faster rate than 2017. Future reductions in cost trend will require more focus on price.
Assessing the 2017 Medicare Advantage Star ratings
For a report in which it analyzed CMS data on Medicare Advantage plans, McKinsey & Company showed that it is important for health plans to invest in their abilities to deliver quality care in order to receive a bonus under the star-ratings program.
Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors
In this issue brief, researchers from the Kaiser Family Foundation explain the three provisions included in the Affordable Care Act called risk adjustment, reinsurance, and risk corridors (sometimes known as the 3Rs). These provisions were designed to help health insurers cover the uncertainty about how to price and pay for the health insurance coverage that many newly insured Americans would receive under the act. The 3Rs were intended to promote stability in the insurance markets in years following implementation of the law on Jan. 1, 2014. Previously, insurers denied coverage to those with pre-existing conditions, some of whom were considered to be uninsurable. Given that the ACA did not allow insurers to deny coverage to anyone with a pre-existing condition, insurers were concerned that insuring these individuals would cause wide swings in premiums each year as insurers learned what these individuals needed in terms of care, how to pay for that care, and how to adjust premiums to account for those costs. To keep premiums stable from year to year, the 3Rs were expected to cover some of the insurers’ losses.
Geisinger Health System’s ProvenExperience refund program
In November 2015, the Geisinger Health System in Danville, Pa., introduced its ProvenExperience program in which the health insurer and hospital system promised refunds to members who were dissatisfied with their care. At the time, Geisinger stated that its goal was to ensure the best customer experience in health care and the best customer experience in any industry. One year later, Geisinger executives reported first-year results in an article in the Harvard Business Review. In the article, the executives reported a 23 percent increase in communication between patients and patient experience advocates. Of these, 71 percent were complaints, 24 percent were requests for assistance, and 5 percent were compliments. Among the complaints, 20 percent related to trouble patients had making outpatient appointments and accessing care, 8.7 percent related to financial issues and billing, 8.4 percent involved difficulties accessing results or medical information, and 7.7 percent were complaints about provider behavior or attitude. Each month, the health insurer gets an average of 122 refund requests, averaging $464 each, amounting to about $680,000 such requests annually, they wrote.
Medicaid expansion and marketplace premiums
In an issue brief, The Effect of Medicaid Expansion on Marketplace Premiums, researchers from the Office of the Assistant Secretary for Planning and Evaluation of the federal Department of Health and Human Services examined differences in Marketplace premiums among states that expanded Medicaid and those states that did not expand Medicaid under the Affordable Care Act. The researchers estimated that Marketplace premiums were about 7 percent lower in expansion states.
National Health Expenditure Projections, 2015–25
Economy, Prices, And Aging Expected To Shape Spending And Enrollment A report from the federal Department of Health and Human Services shows that growth in national health expenditures is projected to average 5.8 percent for the period 2015 through 25, the authors said. This rate of increase will outpace growth in the gross domestic product by 1.3 percentage points and the health share of the economy is expected to climb from 17.5 percent in 2014 to 20.1 percent in 2025. One reason for this growth is that millions of Americans gained health insurance coverage in 2014 as a result of the Affordable Care Act and health spending growth reflected this change, increasing from 2.9 percent in 2013 to 5.3 percent in 2014. The expectation for the period 2017 through 2019 is for health spending growth to accelerate somewhat (averaging 5.7 percent), in part as a result of the effect of faster growth in health care prices. The report was published in Health Affairs.
Overview: Medicare Drug Spending
In this 10-page report, the Medicare Payment Advisory Commission, which advises Congress on Medicare spending, outlines how the Medicare program pays for medications and examines spending on drugs in each of Medicare’s various payment systems (fee for service, Part B), Medicare Advantage (Part C) and private drug plans (Part D). The report provides a useful snapshot for journalists seeking to track Medicare drug spending over time. It addition, the report shows how Medicare drug spending has increased since 2004 when Medicare Part D was introduced.
Improper Medicare payments
In a report, Medicare Advantage Fundamental Improvements Needed in CMS’ Effort to Recover Substantial Amounts of Improper Payments,” the U.S. Government Accountability Office showed that the federal Centers for Medicare and Medicaid Services estimated that it improperly paid $14.1 billion in 2013 to insurers running Medicare Advantage plans. The reason for the overpayments that health insurers could not provide documentation for the diagnoses used to support higher payments. CMS pays health plans based on the severity of illness among health plan members. Under this risk-score system, the health insurers submit diagnoses to CMS for the MA members covered under their contracts. In a series of articles, called Medicare Advantage Money Grab, journalists from the Center for Public Integrity have reported that insurers often tell CMS that their members have multiple chronic and costly conditions, thus using risk-adjusted payments to get CMS to overpay them.
The Health Care Cost Institute established this health care price comparison website from health insurers’ claims data. The goal of Guroo is to give consumers insight into health care costs and quality. The site offers information on the costs of health care services based on a consumer’s location.
Data from the Health Care Pricing Project show variations in hospital inpatient prices, and how market power affects what hospitals charge patients in 188 hospital referral regions (HRRs) nationwide. In particular, see the data on hospital inpatient prices which shows that prices in most expensive region are 400 times higher than they are in the least-expensive region. Data on market power show that when a hospital has a monopoly in a market, its prices are 15.3 percent higher than they are in areas with four or more hospitals. See also the presentation slides and the pricing graphs for 118 HRRs.
National Health Interview Survey
In September 2015, the Centers for Disease Control and Prevention’s National Center for Health Statistics (pdf) reported that the uninsured rate among all Americans in the first quarter of the year dropped to 9.2 percent. This rate is estimated to be the lowest among all uninsured Americans of all ages since 1972, when the center began reporting such data from the National Health Interview Survey. The report said that among adults aged 18 to 64, the percentage uninsured droped from 16.3 percent in 2014 to 13.0 percent in the first quarter of 2015. At the same time, there was an increase in private coverage from 67.3 percent to 70.4 percent. Among children under 18 years of age, the percentage with private coverage increased from 52.6 percent in 2013 to 56.3 percent in the first quarter of 2015. This increase reversed a 14-year trend of declining rates of private coverage for children under 18.
From 2002 through 2012, the use complementary medicine, such as acupuncture, chiropractic care and massage therapy increased among adults who did not have health insurance for these services, according to the CDC’s National Health Interview Survey. The NHIS found no change in use of these services among Americans who had health insurance.
Health insurance coverage for individuals seeking complementary health approaches has not been widely studied. The most recent national data on this topic was released 20 years ago, the NHIS said.
Among adults who saw a chiropractor, 60 percent had some health insurance coverage. But for those getting acupuncture, only 25 percent of adults had insurance for acupuncture and for those getting massage therapy, only 15 percent had coverage such therapy. Adults received acupuncture and chiropractic care were likely to have only partial coverage, the survey showed.
The annual State of Health Care Quality Report from the National Committee for Quality Assurance focuses on quality issues health plans face in using evidence-based care. The 2015 report documents performance trends over time, tracks variation in care and recommends quality improvements based on data collected in 2014 by NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS), a health plan performance improvement tool. The report summarizes the quality and consumer satisfaction results of health plans covering more than 171 million people, or 54 percent of the U.S. population. Among the 136 quality improvement measures in the report, NCQA showed that over three to five years, health plans had statistically significant improvements in performance on 46 measures (34 percent of the total) and plans had statistically significant declines in performance on 12 measures (9 percent of the total).
Provider Utilization and Payment Data
CMS has released a data set on Provider Utilization and Payment Data: Referring Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Public Use File. It contains information on products and services provided to Medicare beneficiaries ordered by physicians and other health care professionals.
An Analysis of Popular Legal Arguments Against Price Transparency
Along with the Report Card on State Price Transparency Laws, July 2015, the Catalyst for Payment Reform (CPR) and the Health Care Incentives Improvement Institute included An Analysis of Popular Legal Arguments Against Price Transparency. This four-page analysis should be useful to journalists covering state legislation designed to improve transparency because it will allow reporters to refute the arguments that health insurers, hospitals, physicians, and other providers make when opposing price transparency laws. Insurers and providers often argue, for example, that pricing information should not be made public because it is confidential by contract (which is often true) or protected as trade secrets (which it is not). In addition, the information that would be most useful is that of the largest insurers and provider organizations and they are often the most successful in keep price information out of the public domain, the report says.
Report Card on State Price Transparency Laws, July 2015
This report from the Catalyst for Payment Reform (CPR) and the Health Care Incentives Improvement Institute shows little progress since 2014, and in some cases, states regressed. In the report, CPR and HCI3 say the report shows the need for more pricing transparency. The 2015 report is based on legislation enacted in 2014, but the researchers also say that many proposed price transparency laws never pass because of pressure from health insurers, hospitals, physician groups and others who benefit from keeping price data opaque. “That pressure often rests on spurious arguments about price as a trade secret and/or the potential for a state law on price transparency to violate contracted terms between payers, providers, and suppliers—arguments legislators and the media often accept,” the report said. In the report, CPR and HCI3 gave failing grades to 45 states. Only New Hampshire got an A; Colorado and Maine got Bs; and Vermont and Virginia got Cs.
Medical Cost Trend: Behind the Numbers 2016
In this report, researchers from PwC’s Health Research Institute predict that spending on health care in 2015 will reach $2.9 trillion but the growth in spending will be lower in 2016 than it was in 2015, but it will still outpace overall economic inflation. Despite the full implementation of the Affordable Care Act in 2014, affordable health care remains out of reach for many consumers. The researchers identified three factors that are expected to reduce the rate of growth in health care spending in 2016 and two factors that may increase spending in 2016. The first of the three factors that will reduce spending are the “Cadillac tax,” an excise tax on employers’ high-cost benefit plans that is set to go into effect in 2018 unless congress acts to eliminate the tax or slow the implementation data. This tax may cause employers to change their benefit design to avoid paying a 40 percent tax on health plan premiums over $10,200 for individuals and $27,500 for family coverage. The other two factors are virtual care such as remote monitoring and telehealth and new health advisers who help employees of large companies to use the health care system more efficiently. The two factors that could increase spending in 2016 are the high price of specialty medications and large-scale security breaches of health insurers and health care providers.
Utilization of products, services by Medicare beneficiaries
CMS has released a data set on Provider Utilization and Payment Data: Referring Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Public Use File. It contains information on products and services provided to Medicare beneficiaries ordered by physicians and other health care professionals.
Enhancing the State Health Insurance Markets: State Progress Reports
The National Health Council (NHC) created state-specific progress reports to assess the patient-centeredness of health insurance markets across states. These reports show the variability across insurance marketplaces and identify states where changes could improve access to coverage and care for patients. These reports also can identify leading states that set best practices for patient-friendly requirements.
Q4 2014 TransUnion Healthcare Report
A survey of 7,400 Americans showed that 54 percent of respondents were confused by bills from health care providers, 64 percent received surprise health care bills, and only 25 percent received a cost estimate before receiving health care services. Among respondents, 80 percent said cost estimates would be helpful.
In addition, to the survey results, the report said consumers had less credit available to pay for health care services despite an improving economy. Consumers’ ability to pay for medical procedures decreased by more than 11 percent in 2014 as health care costs rose and revolving credit became less available, said TransUnion Healthcare, a division of TransUnion, a credit-rating company. The company uses a ratio to compare consumers’ available revolving credit to select health care costs. The report showed that consumers’ available credit declined 11 percent from 2013 to 13.5 to 1 at the end of 2014. The ratio means that for every $100 in health care costs, consumers had $1,350 in revolving credit to use to make those payments in the last quarter of 2014.
Also, the report showed, the average deductible has risen steadily since the second quarter of 2013 from rose $1,055 to $1,133 by the fourth quarter of 2014 and that the average price of major joint replacement surgeries rose steadily in the same period from $2,535 in the second quarter of 2013 to $3,135 in the fourth quarter of 2014.
NCQA State of Health Care Quality Report 2014
The National Committee for Quality Assurance (NCQA) publishes the an annual report that summarizes results from its Healthcare Effectiveness Data and Information Set. HEDIS is a performance measurement tool for health plans. The State of Health Care Quality Report 2014 (pdf) shows results from calendar year 2013 that were collected from 814 HMOs and 353 PPOs nationwide. The number of Americans enrolled in health plans that report HEDIS data has doubled in 11 years to more than 171 million, or 54 percent of the U.S. population, NCQA said.
Performance remains low in many areas, NCQA reported, adding that too few Americans receive efficient, effective care or recommended tests and treatments. Performance on mental health care and addiction treatment metrics is weakest, NCQA reported. But more children with ADHD are receiving recommended treatment than ever before, a rare highlight amid many poor results on behavioral healthcare measures, the committee said.
Consumer Reports National Research Center: Survey on surprise medical bills
In March 2015, Consumers Reports National Research Center surveyed 2,200 U.S. consumers and found that in the past two years about one third of privately insured Americans received a surprise medical bill, meaning their health plan paid less than expected. In this group, nearly one out of four got a bill they did not expect. For journalists, these findings may be worthwhile when writing about how the rising cost of health care affects consumers. The Surprise Medical Bills Survey report (pdf) is available online.
In particular, the survey findings suggest that many consumers are confused about their rights when they decide to fight surprise bills. And they showed that insurers often don’t pay when consumers have payment disputes with their insurance companies over bills from out-of-network providers. These providers often do what’s called ‘balance billing’ of consumers, meaning they bill consumers for whatever amount the insurance company does not pay. These balance billing amounts can be quite high.
The survey showed that only 28 percent of privately insured Americans with billing issues were satisfied with how their issues were resolved. More than half (53 percent) of those who received surprise medical bills reported that the issue was either not resolved at all or not resolved as they would have liked. Among these consumers 57 percent paid the bill in full. Here are some of the significant findings from the survey:
Two-thirds (67 percent) of privately insured Americans who responded to the survey did not know which state entity was responsible for resolving health insurance billing issues.
Most (87 percent) of respondents didn’t know the state agency responsible for addressing health insurance complaints.
Many (72 percent) were unsure if they had a right to appeal to the state or an independent medical expert if their health plan refused coverage for medical services.
Among respondents, 1 in 7 were surprised to find a doctor, lab, or other health care facility they thought was in-network, was in fact out-of-network.
Many (63 percent) assumed that doctors working at an in-network hospital are in-network doctors. In fact, not all doctors working at in-network hospitals are in the same network.
Most (85 percent) respondents said hospitals should notify patients if a doctor or technician involved in a procedure performed at that hospital is out-of-network.
Consumers Union supports legislation in such states as California and Texas that would strengthen protections against surprise medical bills.
A report, Problems Paying Medical Bills Among Persons Under Age 65, from the federal Centers for Disease Control and Prevention shows that the percentage of persons under age 65 in families having problems paying medical bills decreased from 21.3 percent (56.5 million) in 2011 to 17.8 percent (47.7 million) in the first 6 months of 2014. Among those under age 65 struggling to pay medical bills in the first 6 months of 2014, 31.2 percent were uninsured, 24.2 percent had public coverage, and 12.4 percent had private coverage, the report showed. The data in this report is based on information collected during the first six months of 2014.
In a report in November 2014, the National Institute for Health Care Management showed in a series of charts how 1 percent of the U.S. population accounts for nearly 23 percent of overall health care spending. The data from the 2012 Medical Expenditure Panel Survey and from the federal Agency for Healthcare Research & Quality (AHRQ), also shows that 5 percent of Americans are responsible for a 50 percent of all spending. As the NIHCM report says, “Any meaningful effort to control spending growth must account for this extreme concentration.” For health care journalists these numbers are instructive in particular because the lowest-spending half of the population accounts for less than 3 percent of total spending, about $234 per person, per year. This chart show the top spenders, the factors that drive high spending, and why these patterns of spending persist over time.
In September 2014, the U.S. Government Accountability Office reported on the range of base health insurance premiums in the individual market for each county in the 50 states and the District of Columbia. These numbers were published on the HealthCare.gov Plan Finder as of January 2013 for 14 categories of consumers, GAO said. Health care reporters may find this report useful when covering how much health insurance premium rates changed after 2013 when the Affordable Care Act became effective.
Before the Affordable Care Act was implemented on Jan. 1, 2014, insurers could vary individuals’ premium rates in most states based on age, gender, health status, geographic region, and other factors. When underwriting based on health status, insurers often charged individuals with health conditions much more than they charged consumers who were relatively healthy, and they could deny coverage to individuals with pre-existing conditions. Under the ACA, insurers can no longer use gender or health status to set premiums and are restricted in how much they can vary premiums based on age and tobacco use. The 7-page GAO letter report includes a link to an interactive map of each state.
Leapfrog Group releases new safety scores for 2,500 general hospitals
The Leapfrog Group assigns A, B, C, D and F grades to hospitals based on their ability to prevent errors, injuries and infections. The data show performance on actual outcomes has lagged but hospitals have made improvements in processes and safe practices, such as instituting hand-hygiene policies and physician staffing in intensive care units. Visit Hospital Safety Score for more information or to find specific scores.
The Rise of Retail Coverage: Report shows why some employers will shift to private exchanges
A report, The Rise of Retail Health Coverage, by the consulting firm PriceWaterhouseCoopers LLP shows that about one third of employers are considering moving health insurance benefits for their active employees to a private health insurance exchange in the next three years. The growth of private health insurance exchanges will allow more employers to shift to defined-contribution plans, thus helping them control costs more effectively and move away from having a strong role in managing employee benefits, the report explains. Moving health benefits for employers to a private exchange will allow employers to shift from defined-benefit plans, in which they pay for certain health insurance benefits, to defined-contribution plans, in which they give employees cash so employees can buy health insurance benefits for themselves and their families.
In many ways, the movement to defined-contribution plans is like the shift that occurred beginning in the mid- to late-1980s when employers moved away from traditional pension plans to 401(k) plans, PwC said. Under traditional defined-benefit pension plans, employers provided lifetime payments to former workers upon retirement. Under 401(k) plans, they could give employees funds that could be used for retirement plans and could stop paying when employees retired or were otherwise no longer employed. Shifting responsibility for retirement planning and health benefits gives employers more control over rising costs, the report said.
Not all employers will shift benefits to private exchanges, the report added. Small employers may be able to shift to a public exchange without penalty, for example, and some of the largest employers will still prefer to manage their own benefits. The report was based on PwC's 2014 Touchstone Survey of more than 1,200 employers from 35 industries in the United States.
Report outlines flaws in pay for performance and CMS’ value-based purchasing program
A report (pdf) by Harold D. Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, thoroughly explains the problems inherent in such payment strategies as pay for performance (P4P), CMS’ value-based payment program (VBP), and in fee-for-service. Titled, Measuring and Assigning Accountability for Healthcare Spending, the report raises questions about CMS’ value-based purchasing program and pay for performance in general while also explaining the deep flaws in fee for service payment. The report outlines what’s wrong with how commercial and government insurers pay for health care and how their methods of payment are not designed to produce the most desirable outcome: better patient health. Miller identifies and explains the fundamental problems with current spending methods and also gives examples of payment methods that would address these flaws.
Consultants explain the factors that will drive up health care costs in 2015
In 2015, health care costs will rise by about 6.8 percent, according to a report from the Health Research Institute at PriceWaterhouseCoopers. The report also outlines some of the reasons why costs will rise. As the economy improves, for example, health care costs will increase as well, the report says. Other reasons costs will rise include the increased us of costly specialty medications and the fact that more cancer patients are getting medications in hospitals today rather than in physicians’ offices where they had received these medications in years past. Hospitals are a more expensive setting than physicians’ offices, the report says. The report, Medical cost trend: Behind the numbers 2015, is available for download, although free registration is required. See also the accompanying charts in a separate download, Medical cost trend: Behind the numbers 2015 chart pack (pdf).
Report Card on State Price Transparency Laws
All but five states received a failing grade of F (on a scale from A to F), according to the 2014 Report Card on State Price Transparency Laws (PDF), released March 25. No state earned an A grade, and there were only two Bs and three Cs, according to the report from the Catalyst for Payment Reform (CPR) and the Health Care Incentives Improvement Institute (HCI3). With a few exceptions, state efforts to collect and publish price information have failed, the report said. In addition, many of the transparency tools that states make available to consumers are not user-friendly.
Characteristics of the Population With Consumer-Driven and High-Deductible Health Plans, 2005–2013; Labor-Force Participation Rates of the Population Ages 55 and Older, 2013
In a report published in April 2014, the Employee Benefit Research Institute (EBRI) collects data on who has consumer-driven health plans. This report finds that when compared to those in traditional health plans, enrollees in consumer-driven health plans tend to have higher incomes and better education, and are in better health. Consumer-driven health plans (CDHPs) typically consist of health reimbursement arrangements (HRAs) or health savings accounts (HSAs), the report says. About 26.1 million individuals with private insurance are either in a CDHP or they are in an HSA-eligible plan, the report says. These 26.1 million individuals represent 15 percent of the health insurance market. The report includes data from EBRI surveys going back to 2005, the report examines the population with a CDHP and how it differs from the population with traditional health coverage. The report is available online from EBRI.
Private Health Insurance: The Range of Base Premiums for Individuals Age 19 and 64 in the Individual Market by State in January 2013
In a report released Feb. 4, 2014, the Government Accountability Office issued a report on the range of base premiums before health insurers conducted underwriting for individuals. The report, Private Health Insurance: The Range of Base Premiums for Individuals Age 19 and 64 in the Individual Market by State in January 2013, is available for download as a PDF. The data in the report came from the HealthCare.gov Plan Finder in January 2013 and showed the base premiums for individuals aged 19 and 64 in each of the 50 states and the District of Columbia. The base premiums reflected data submitted by insurers to the federal Department of Health and Human Services (HHS).
Health care journalists may find this report useful because the premium numbers represent the lowest amounts that would have been available to individuals in different categories. They can compare what individuals would pay in each state andwhat individuals would have paid before the Affordable Care Act became effective one year later, on Jan. 1, 2014. The numbers do not, however, represent the actual premium amounts that consumers would pay. Consumers likely would pay more after insurers completed underwriting for health conditions and other factors, the GAO said. Also, in 2013, some individuals would have been denied coverage, although such denials were outlawed under the Affordable Care Act as of Jan. 1, 2014.
Behavioral Health Barometer: United States
In December, the Substance Abuse and Mental Health Services Administration (SAMHSA) of the Department of Health and Human Services published the first Behavioral Health Barometer: United States, a publication that provides a snapshot of the state of behavioral health in the nation. Note also that SAMHSA also published a Behavioral Health Barometer for each state and for the District of Columbia. These reports present data on substance use and mental health indicators collected by SAMHSA (from its National Survey on Drug Use and Health and its National Survey of Substance Abuse Treatment Services), from the federal Centers for Disease Control and Prevention (from the CDC’s Youth Risk Behavior Survey), and from the Monitoring the Future survey by the National Institute on Drug Abuse. Also included are data from the federal Centers for Medicare & Medicaid Services on how Medicare enrollees use mental health and substance-abuse treatment services. SAMHSA intends to update these reports regularly to reflect the state of the science and incorporate new measures of interest.
The reports show trends among teens and adults regarding smoking status and the use of prescription painkillers, for example. They also include data on youth rates of the use of cigarettes, illicit drugs, marijuana, and nonmedical pain relievers; the age at first use; mental health and treatment, depression and depression treatment; and on adult rates of mental health and treatment, including thoughts of suicide, serious mental illness and treatment, alcohol dependence and abuse, illicit drug dependence and abuse, and heavy alcohol use, among other data.
Open for business: Insurers prepare for new consumer market
A recent report, Open for business: Insurers prepare for new consumer market (PDF), from Price Waterhouse Coopers thoroughly explains the role that health insurers are playing in new government-run and new private health insurance exchanges. The new way of purchasing health insurance coverage on public and private exchanges is reshaping the health insurance industry, the report says, and these changes show that some non-traditional health insurers may benefit from using these new exchanges to enroll consumers.
HCI3 issue brief on physician quality transparency
A report, “State Report Card on Transparency of Physician Quality Information,” from the Health Care Incentives Improvement Institute (HCI3) sheds light on the problem many consumers face with trying to assess the level of quality that physicians deliver. There is very little information available publicly on the quality of physician care, yet the federal government and commercial health plans have been collecting data on quality measures for years. “There are commercial websites that provide some information on the quality of physician care, but there’s often a fee to pay for the full report, and the objectivity of the data on those sites has been questioned by many researchers,” the report says. In this new report,MinnesotaandWashingtonstate got the highest grade (an A),Californiagot a C, and all others got Ds or Fs.
Trends in Insurance Coverage, Source of Private Coverage Among Young Adults
This report shows that, since September 2010 – when adults aged 19–25 were able to obtain dependent private health insurance coverage through a provision of the ACA – the percentage of young adults with private insurance increased and the percentage without insurance decreased. The increase in the percentage with private insurance occurred at about the same time (January–June 2011) as a temporary increase in the percentage of privately insured young adults who had been uninsured at some time in the past 12 months. This suggests that those newly insured were previously uninsured or had a period of no insurance in the past year. After this spike, the percentage of young adults with a period of no insurance did not return to pre-2011 levels but rather declined to levels consistent with slightly older adults. The data comes from the National Health Interview Survey, 2008–2012.
NCQA State of Health Care Quality Report 2013
The State of Health Care Quality Report 2013 from the National Committee for Quality Assurance (NCQA) was released in October and shows trends in how managed care plans deliver care. These reports each year are a rich source of data for health care journalists. The latest report is based on 2012 data from NCQA’s Healthcare Effectiveness Data and Information Set (HEDIS), a performance improvement tool that health plans use to report quality scores to their employer clients. In 2012, NCQA collected HEDIS data from 1,151 health plans, a 9 percent increase over the 1,057 plans that participated in 2011. HEDIS scores covered a record 136 million people, or 43 percent of Americans.
The report provides information on rates of overuse and appropriateness of procedures, rates on the management of patients with chronic conditions, measures of care for children and adolescents, and measures of care for adults. The appendices report on rates of variation in plan performance, and aggregate data from HEDIS and from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey.
AHRQ report from the Medical Expenditure Panel Survey
Statistical Brief #421: Differentials in the Concentration in the Level of Health Expenditures across Population Subgroups in the U.S., 2010
Through this year, spending for health care will continue to rise slowly, according to a recent article published in Health Affairs by officials from the Office of the Actuary at the federal Centers for Medicare & Medicaid Services (CMS).
But slow growth will not continue. Starting next year and continuing until at least until 2022, costs will rise again as they did earlier, said the authors of the report, “National Health Expenditure Projections, 2012–22: Slow Growth Until Coverage Expands And Economy Improves.”
The slow growth rates through this year are a factor of a weak economy and a slow recovery, limited growth in private health insurance enrollment, and increased provisions that consumers share in the costs of care. The report includes detailed discussions about projected spending for Medicare, Medicaid, physician services, hospitals, prescription drugs, and private insurance premiums.
“For the period 2014–22, national health spending is projected to rebound to growth rates observed prior to the recession, although growth will still be slower than that experienced over the longer term,” the authors wrote. “This rebound in growth is based on improving economic conditions, coverage expansions in the Affordable Care Act, and the aging of the baby-boom generation. Expected growth for 2014 is 6.1 percent, with an average projected growth of 6.2 percent per year thereafter.”
To arrive at these projections, the authors used actuarial and econometric modeling and judgments about events and trends that influence health spending. “The projections use the economic and demographic assumptions from the 2013 Medicare Trustees Report,” the authors wrote. Included in the assumptions are estimates based on the full implementation of the Affordable Care Act and the one-year delay of the employer mandate, they added.
Of the nine authors of the report, five are economists, three are actuaries, and one is the deputy director of the National Health Statistics Group.
Employee Benefits Research Institute
The Employee Benefits Research Institute (EBRI) has published the EBRI Databook on Employee Benefits since 1990. EBRI says the databook is maintained online and updated when new data are available. The date next to each chapter link indicates when data or links were added. The databook is compiled from dozens of sources, showing all the various functions of employee benefits. It includes more than 400 tables and charts on the employee benefit system, including employer-sponsored benefits; health insurance, government programs such as Social Security, Medicare, and Medicaid; labor force and demographic trends; and retirement. Perhaps most useful for journalists are the sections showing how the population is aging, which is broken down by region, and tables on employment trends among women of childbearing age, veterans, and the disabled.
Leapfrog Group for Patient Safety
This is a group supported by large employers that contract with hospitals nationwide and thus are interested in promoting higher quality and a safer and more efficient health care system. The group collects data on safety and quality from voluntary surveys and publishes its results online. Not all hospitals participate in Leapfrog Group surveys. In 2009, 1,206 hospitals across the country completed The Leapfrog Hospital Survey.
The Leapfrog Hospital Survey assesses hospital performance based on national performance measures and practices that are of specific interest to employers, other health care purchasers, and consumers. The survey results are publicly reported, by hospital, here.
The Hospital Safety Score is used to grade hospitals on their overall performance in keeping patients safe from preventable harm and medical errors. The grades are derived from analysis of publicly available data using 26 evidence-based, national measures of hospital safety, the group says. It is the only hospital ratings methodology to be peer-reviewed and published, Leapfrog claims. Journalists should note, however, that Hospital Safety Scores cannot be republished without written permission from The Leapfrog Group.
Payment Reform Scorecard
Health insurers recognize that the fee-for-service (FFS) payment system is deeply flawed. FFS drives up spending because it provides an incentive for physicians and other providers to deliver more care whether more care is needed or not. Critics charge that under FFS, providers get paid for doing more and not necessarily for providing appropriate care.
Recognizing the inherent flaws in FFS, four organizations in 2013 called for an end to fee-for-service payment and instead move the health care system shifts from volume to value. The Report of the National Commission on Physician Payment Reform from the Society of General Internal Medicine (SGIM) said FFS payment is at the heart of what’s wrong. SGIM called for adopting new payment methods over five years (from 2013 through 2017) and eliminating FFS by 2023.
The forms of payment that will replace FFS include bundled payment but these other forms of payment represent only about 11 percent of all forms of pay to providers, according the National Scorecard on Payment Reform, a report issued by Catalyst for Payment Reform (CPR) in San Francisco. “Almost 90% of payments remain in traditional fee for service, paying providers for every test and procedure they perform regardless of necessity or outcome,” CPR said.
CPR says its scorecard provides a baseline against which health plans and employers can measure future progress toward payment reform. In 2010, for example, CPR reported that only about 3 percent of payments reflected provider performance, meaning 97 percent of spending was not used as payment for value. CPR has predicted that, by 2020, 20 percent of commercial payment would be related to value.
EBRI report tracks health insurance coverage from 1995 through March 2012
The Employee Benefit Resource Institute published a report, “Tracking Health Insurance Coverage by Month: Trends in Employment-Based Coverage Among Workers, and Access to Coverage Among Uninsured Workers, 1995–2012,” in July 2013. Available as a PDF for download, the 24-page report examines employment-based, health-benefit-coverage rates each month from December 1995 to March 2012. The data allow for identification of changes in trends and shows the effects of recessions and unemployment on changes in coverage.
Commonwealth Fund report outlines how the health system works for low-income Americans
A report published by The Commonwealth Fund in September 2013 evaluates how well state health care systems are working for low-income Americans and finds wide disparities in access to care and health care quality. The stark differences in health care access, quality, and outcomes in the report result in a substantial loss of lives and missed opportunities to improve health and quality of care. If all states reached the benchmarks set by the leading states, 30 million more low-income adults and children would have health insurance coverage, reducing the number of uninsured by more than half, the report shows.
Lower-income Americans in top performing states would be better off than higher-income people in lagging states, and millions of Americans would have better care and healthier lives if all states could do as well as the top performers, the report shows.
For health care journalists seeking information on women’s health insurance coverage and women’s health in general, the Office on Women’s Health from the federal Department of Health and Human Services provides an interactive system for searching for health data called Quick Health Data Online. The system is useful for anyone seeking health data. Free training is available on how to use the interactive system on certain dates in October, November, and December 2013. The last schedule training date is Dec. 19, 2013.
The system provides state- and county-level data on women’s health issues, including health insurance for all 50 states, the District of Columbia, and United States territories and possessions. The health insurance information includes data on access to insurance for children and adults, and statistics on the number of percentage of children below poverty.