The July issue of Health Affairs, a variety issue, covers a broad range of topics: the Affordable Care Act (ACA) coverage provisions; improvements in emergency department care; trends in health spending by different income groups; efforts by accountable care organizations (ACOs) to improve behavioral health care; and others.

US emergency department death rates reduced by 48 percent, 1997-2011

Despite a wealth of literature about the relationship between emergency care and subsequent mortality for selected conditions, little is known about overall mortality trends in the emergency department (ED). In what is believed to be the first national study of its kind, Hemal Kanzaria of the University of California, San Francisco and coauthors analyzed ED visit data from the National Hospital Ambulatory Medical Care Survey from 1997 to 2011.

The data included ED visits by adults 18 years and older across the country. The authors found that ED mortality rates decreased from 1.48 per thousand in 1997 to 0.77 per thousand US adults in 2011, a 48 percent reduction (see chart below). The authors propose several potential explanations for the lowered mortality rate, including: improvements in emergency medicine and pre-hospital care; the increasing role of palliative care, which results in patients dying outside EDs in hospice settings; and an overall decline in mortality trends in the US population during the study period due to continued public health achievements.

Kanzaria_Exhibit1

In the United States, ACA Marketplaces lack network adequacy

Improving access to affordable health insurance, and by extension, to care, is one of the main goals of the Affordable Care Act (ACA). In the price-competitive ACA Marketplaces, plans with relatively narrow provider networks have proliferated. To find out how this affected access to care, Simon Haeder of the West Virginia University and coauthors used a “secret shopper” survey of 743 primary care providers from five of California’s 19 insurance Marketplace pricing regions in 2015.

They found that inaccurate and outdated provider information and a resistance to new patients were commonplace, both inside and outside California’s Marketplace, with only about 30 percent of efforts to make an appointment with a specific primary care physician ending in success. The authors conclude that more frequent updating (California currently requires quarterly updates), potentially coupled with incentives and penalties for both providers and insurers, might be the only path to improved access for patients.

A related study about ACA coverage provisions:

Medical marijuana laws reduce Medicare prescriptions

Over the past 20 years, 24 states and the District of Columbia have adopted laws legalizing the use of marijuana for medical purposes. In one of the first studies to investigate how implementing state-level medical marijuana laws changes prescribing patterns, Ashley Bradford and W. David Bradford of the University of Georgia reviewed data on all prescriptions filled by Medicare Part D enrollees from 2010 to 2013, in nine medical condition categories where at least one drug had been already approved by the Food and Drug Administration for on-label use.

They found that in seven of the nine categories they studied, implementing an effective medical marijuana law led to a reduction of between 265 daily doses and 1,826 daily doses per physician per year and the effects of the medical marijuana law were all statistically significant. The authors estimated that in states with legal medical marijuana laws, Medicare Part D spending reductions in 2013 were $165.2 million — and recommend that these savings should be one of the factors considered when changes in marijuana policy are discussed.

Tobacco surcharges cut insurance take-up

The ACA allowed health insurers to charge different premiums to tobacco users and non-users. Abigail Friedman and coauthors, all of Yale University, used 2011-14 data from the Behavioral Risk Factor Surveillance System to examine the effect of tobacco surcharges on insurance status and smoking cessation in the first year of the health insurance exchanges’ implementation.

Focusing on adults most likely to purchase insurance on the exchanges, they found that tobacco surcharges reduced smokers’ insurance take-up relative to non-smokers, without increasing smoking cessation. In particular, high tobacco surcharges—at or above 30 percent of premiums—yielded an 11.6 percentage-point reduction in smokers’ likelihood of having insurance coverage, with an even larger response among those under age 40. Concurrently, smokers facing high surcharges showed no change in smoking cessation relative to those facing zero-surcharges.

According to the study, tobacco surcharges had the unintended consequence of reducing smokers’ insurance coverage in the first year of the ACA’s implementation, without increasing cessation, an effect running counter to the ACA’s goal of achieving universal coverage. Moreover, dissuading young smokers from taking up coverage may reduce risk-pooling on the exchanges, such that high surcharges could eventually increase costs for all enrollees.

Also of interest in the July issue, two studies about health care spending:

Increased cost sharing in European health systems

Looking at the growing use of patient cost sharing in Europe during and after the recent economic recession, Raffaele Palladino and coauthors at Imperial College London, in the United Kingdom, used data from the Survey of Health, Ageing and Retirement in Europe to identify changes from 2006–07 to 2013 in out-of-pocket expenditures among people ages 50 and older in 11 European countries. They found significant increases in the incidence and size of out-of-pocket expenditures and the share of the population facing catastrophic health expenses in several of the countries

“We found that people in poorer income quintiles were less likely to incur any out-of-pocket expenditure and reported lower mean out-of-pocket expenditure, compared to people in the highest income quintile,” the authors noted. “This suggests that better financial protection from increasing health care costs exists among vulnerable populations than among the highest-income populations.”

Also of global interest in the July issue:

Improvement in rates of treatment services for children with ADHD enrolled in Medicaid

At a time of escalating health costs, the quality of treatment services received by children diagnosed with attention deficit hyperactivity disorder (ADHD), particularly those in low-income families, has been a subject of concern to policy makers.

To better understand the issue, Kimberly Hoagwood of New York University School of Medicine and coauthors analyzed Medicaid claims data from 2001 to 2010. Their analysis revealed that during that decade, the proportion of low-income children diagnosed with ADHD rose by 83 percent — but, importantly, rates of diagnoses without any reimbursed treatment declined by 39 percent. According to the authors, more children received clinically appropriate treatment, including at 73.5 percent increase in combined treatments (both medication and psychotherapy). The authors concluded that the treatment rates they found are substantially higher than in other recent reports.

A related study about behavioral health care: