Health Affairs

Health Affairs’ May issue, released today, analyzes the recent slowing in the growth of health care expenditures and explores whether the trend will last. The issue also addresses major cost drivers in Medicare and presents proposals for putting the program on a more sustainable path. Another article tracks federal spending on mental health during severe state budget constraints throughout the recession.

As Health Affairs Founding Editor John Iglehart notes on his “From The Founding Editor” page (quoted at length below), the new thematic volume, “Tackling The Cost Conundrum,” continues the journal’s coverage of a topic that has been a “driving theme” of the journal since its inception. The May issue will be discussed at a National Press Club briefing tomorrow morning, Tuesday, May 7. The issue and briefing are supported by a grant from the Robert Wood Johnson Foundation.

Researchers writing in the new issue are cautiously optimistic that the slowdown in health care spending is here to stay. A study by Michael Chernew, Alexander Ryu, and colleagues at Harvard Medical School looks at two factors potentially contributing to the record slowdown in growth to 3.1 percent during 2007-11: job loss and benefit changes shifting costs to the insured. Analyzing National Health Expenditure Accounts and large-employer data, the authors found that benefit design changes that increased enrollees’ out-of-pocket costs were responsible for about one-fifth of the observed decrease in the rate of growth. However, the slowdown occurred even when benefit generosity at large firms was held constant. The authors suggest that other factors are largely responsible and that major events, such as health reform, shifts in payment methodology, and the transformation of the delivery system’s organization may contribute to a longer-term trend of slower spending growth.

In a related article, David Cutler and Nikhil Sahni of Harvard University conclude that fundamental changes, including less-rapid development of imaging technology and new pharmaceuticals, increased patient cost-sharing, and greater provider efficiency, led to the majority of the slowdown in health care spending growth; if this path continues for the next ten years, public-sector health care spending could wind up $770 billion under projections, they write.

In a publication released in numerous states as well as a JAMA Forum article and a recent list of ten supposed “myths” about Medicaid expansion, the Heritage Foundation repeatedly cites our paper for the proposition that “40 of 50 states are projected to see increases in costs due to the Medicaid expansion,” and that expansion would force such states “to dig deep into their already overstretched budgets.” Even in the 10 remaining states, according to Heritage, the budget gains we projected to result from expansion were speculative and uncertain, since they supposedly relied on states cutting payments for hospital uncompensated care.

These claims distort our work. We identified 10 states in which Medicaid expansion would yield net savings based on just one factor—namely, unusually generous prior Medicaid coverage, for which states could claim enhanced federal matching funds. The modest additional gains resulting from uncompensated care savings did not tip any state from the red into the black.

Medicaid Expansion Offers Budget Savings, Revenue, and Economic Gains to States

More importantly, Heritage ignored our explanation that, because we were limited to “data available for all 50 states and the District of Columbia, we were unable to estimate several potential sources of state fiscal gain;” and that if additional, state-specific factors were considered, “many more states could realize net fiscal gains.” Nor did Heritage acknowledge that all states must pay for national health reform but only those that expand Medicaid will receive large, offsetting allotments of federal Medicaid dollars, with resulting economic activity, jobs, and state revenue.

As a longtime physician, I know that having access to stable, affordable health coverage is a critical step in achieving better health outcomes.

That view is underscored in a study that appeared in today’s (May 2) New England Journal of Medicine (NEJM) on the effects of Medicaid coverage on individuals’ health and finances. Led by researchers at Harvard and MIT, the study—the Oregon Health Insurance Study—offers a good snapshot of how being insured can help low-income Americans.

Here’s the background: In 2008, Oregon officials created a lottery giving uninsured, low-income adults a chance to apply for Medicaid. Nearly 90,000 people signed up, and approximately 30,000 were selected. By randomly providing health insurance to some, but not all, Oregon effectively established both treatment and control groups, presenting a unique opportunity to analyze the effects of having public health insurance.

The study in NEJM highlighted the latest data from the experiment. It showed that enrollment in Medicaid, after about two years, profoundly increased patients’ use of needed medical services, and vastly reduced the financial strain that previously limited their care.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the association’s comprehensive guide that sets the classification, diagnosis, and treatment of mental disorders across the United States and the world. In an April 24 Health Affairs Web First analysis and commentary, Helena Hansen of New York University and coauthors argue that the revision process for the DSM-5 missed crucial population-level and social determinants of mental health disorders and their diagnoses.

Some of these include environmental factors triggering biological responses that manifest in behavior; differing cultural perceptions in defining normal and abnormal behaviors; and institutional pressures, such as insurance reimbursements, disability benefits, and pharmaceutical marketing. At stake, the authors believe, are billions of dollars in insurance payments and the accurate diagnoses and treatment of patients.

To address future DSM revisions, the Hansen and her colleagues propose the formation of an independent, multidisciplinary task force; the commentary outlines how this task force would operate.

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

Below, Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute answers a reader query; previously, Jessie Gruman and Rachael Fleurence answered questions. Watch for a Health Affairs Facebook post tomorrow inviting questions for Benjamin Moulton of the Foundation For Informed Medical Decision Making.

Paul Gionfriddo: Ming, you’ve concluded both that we need a better system of communication between clinicians and patients with less variation in clinicians’ responses and that clinicians appear to be out of their comfort zone communicating with patients about mental health concerns. Would you argue that more universal use of screening tools like the PHQ-9, coupled with better training of primary care clinicians about how to interpret results, respond to patients, and refer (via collaboration to or integration with) behavioral health professionals would create more effective give-and-take with patients and address some of the issues you raised in your paper?

Ming Tai-Seale: Thank you, Paul, for your thoughtful question. Indeed, the United States Preventive Services Task Force (USPSTF) has recommended that screening adults for depression be done in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

The Mental Health Parity and Addictions Equity Act of 2008 (MHPAEA) prohibits group health plans that cover mental health and substance abuse treatment from imposing higher cost-sharing requirements for these benefits, as compared to cost-sharing requirements for other conditions. Rigorous studies from Oregon and the Federal Employees Health Benefits Program have not found that similar parity requirements resulted in increased costs.

A recent report from the Health Care Cost Institute (HCCI) has been widely interpreted as suggesting that the MHPAEA and an interim final rule (IFR) implementing the statute caused an increase in hospital inpatient admissions for psychiatric conditions. However, the report does not support this interpretation.

The HCCI released its report on trends in inpatient psychiatric admissions as if it evaluated the impact of the MHPAEA. But the report simply juxtaposes a longstanding trend of increasing hospitalization for psychiatric conditions between 2007 and 2011 with the observation that the MHPAEA and its Interim Final Rule (IFR) were implemented at the end of 2010 and in 2011. This tells us nothing useful about the impact of the MHPAEA. In contrast, the FEHB Program and Oregon studies, which did not find cost increases attributable to parity, analyzed time periods just prior to policy implementation and just following implementation, and they controlled for the secular trend of increasing psychiatric admissions, using a difference-in-differences analytic strategy.

There is a health crisis in this country (as well as worldwide) that adversely affects one-fifth of the US population. Consequences of this crisis manifest in a wide variety of serious disease conditions. Physically it can exhibit as cancer and/or as any number of equally severe mental illnesses. Socially the disease is, in a word, criminality. Costs are estimated at over $100 billion per year, or similar to the annual expense of the war in Afghanistan. Investment in its prevention is estimated at a nickel on every $100 in research, compared to $2 for cancer. (See Note 1)

Despite considerable attention drawn to this issue this past year — the Surgeon General termed it an “epidemic” well over a decade ago — the crisis was not discussed during the presidential campaign. It remains largely ignored by the Congress (though just prior to adjourning sine die an innocuous bill to evaluate child welfare systems was passed), was unaddressed by the Affordable Care Act, and has been ignored as well to date by the Center for Medicare and Medicaid Innovation. “The leading journal of health policy thought and research,” Health Affairs, has never published on the topic.

The health crisis is child sexual abuse, which adversely affects the health status of 50 million survivors.

The horrific massacre of 27 children and adults in Newtown, Connecticut ranks second only to Virginia Tech among U.S. mass shootings. These tragedies are part of a lengthening list of mass killings in such varied places as a shopping mall, a movie theater, a Sikh Temple, a high school, a congressional constituent meeting, and a military base. But this one was different. Not only were the death toll particularly high and the killings particularly savage; the killer’s victims were first-grade students, teachers and school staff.

Millions are deeply touched by this tragedy, but few of us can fathom the shock and grief felt by the survivors, parents, family members and friends of those who died. Our first concern must be to comfort them and support what will likely be a long and difficult recovery. But few people are prepared to stop with that. This event, unlike its predecessors, has sparked a movement to challenge the inevitability of mass shootings, not to mention the thousands of individual gun homicides that occur each year in the United States.

In response, President Obama has signaled his intention to submit legislation to the Congress by end of January. To prepare for this action, he is convening an Administrative task force, led by Vice President Biden, to craft a package of proposals. What this panel recommends, and how the public reacts over the next few weeks, could be decisive in determining what will come from this terrible tragedy.

“Because early identification is a key to every prevention activity, every child in America should be screened for mental illness as a part of well-child examinations,” former Connecticut state legislator Paul Gionfriddo writes in “What Funders Can Do in the Aftermath of the Tragedy in Sandy Hook, Connecticut.” Gionfriddo’s post was published yesterday on GrantWatch Blog, the sister site of Health Affairs Blog.

Gionfriddo also stresses that most violence is committed by those who are not mentally ill, and is often directed at those who are. “Now more than ever, we need anti-stigma campaigns to disassociate mental illness from violence in the minds of so many people,” he states.

Editor’s note: In addition to Stephen Shortell (photo and linked bio above), this post is coauthored by Sarah Weinberger, a graduate student at UC Berkeley; Matt Chayt, an associate at Nossaman LLP; and Ann Marie Marciarille, a visiting assistant professor at the University of California Hastings School of Law.

As defined by the Affordable Care Act and subsequent rulemaking, Accountable Care Organizations (ACOs) are accountable for the cost and quality of care for a defined group of patients. In return, ACOs are able to share in savings that may result from providing cost-effective care, and they sometimes bear risk for excessive spending as well. While originally intended for Medicare beneficiaries, public-sector ACOs have drawn considerable attention from many states as a vehicle for potentially providing more accountable, cost-effective care, to Medicaid and uninsured populations. At least ten states have already launched or are scheduled to launch Medicaid ACO initiatives.

The final ACO rules published by the Centers for Medicare and Medicaid Services specify that federally qualified health centers (FQHCs) and rural health centers are eligible for participation. This change in the original rules and regulations makes it potentially easier for these safety net providers to combine Medicaid and Medicare accountable care initiatives targeted to the dually eligible population in addition to serving the uninsured and Medicaid populations.

But in addition to these opportunities, safety net providers also face particular challenges in providing accountable care. With the aid of a survey administered to safety net providers in two California counties, this post examines those challenges and offers some policy responses.

Since the Supreme Court’s verdict on NFIB v. Sebelius in late June, considerable national attention has converged around the question of whether or not states will opt to expand Medicaid coverage for adults with incomes below 138 percent of the federal poverty level (FPL).  The argument for states to move forward – or not –... Read the rest of this entry »

More doctors who aren’t psychiatrists are offering antidepressants to patients, making these drugs the third most commonly prescribed group of medications in the United States, according to a study in the August issue of Health Affairs. A look at twelve-year trends shows that the percentage of visits in which antidepressants were prescribed to patients by... Read the rest of this entry »

On Monday, the federal government and the nation marked Post-Traumatic Stress Disorder (PTSD) Awareness Day. In a statement noting the occasion, Health And Human Services Secretary Kathleen Sebelius said: “We have a responsibility to help Americans who have lived through trauma, especially our nation’s service men and women who may be dealing with PTSD.  We... Read the rest of this entry »

We may never know the motivations behind the horrific acts in Tucson and whether they could have been prevented. Mental illness, however, has been tentatively identified as a “suspect” in the shootings.   If we are to learn anything from this tragedy, we must look at mental health as a public health issue and give it... Read the rest of this entry »

The busy daytime schedules of office-based primary care doctors, coupled with limited access to primary care services, have led a large number of Americans to seek care in hospital emergency departments, even when the problem may not be an emergency.  According to a new study in the September issue of Health Affairs, more than a quarter... Read the rest of this entry »

As the nation continues to wage war in Iraq, Afghanistan, and elsewhere, post-traumatic stress disorder (PTSD) looms as an ever-more pressing issue. Earlier this week, the Obama administration made it easier for veterans to obtain disability benefits and treatment for PTSD by eliminating the requirement that they document a specific attack or other incident that... Read the rest of this entry »

The Senate Finance Committee is scheduled to vote today on the nomination of Sherry Glied to be the Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services. The President nominated Glied, a professor and chair of the department of Health Policy and Management at Columbia University’s Mailman School of Public... Read the rest of this entry »

Many more people are using mental health services and U.S. mental health spending rose 65 percent in the past decade, but there is still a disturbingly large gap between access to care and quality of mental health care received. These are some of the findings discussed in the May/June issue of Health Affairs — Mental... Read the rest of this entry »

Last year Congress passed legislation prohibiting group health plans that provide mental health coverage from imposing stricter limits on mental health treatment than for other medical or surgical care. This marked a historical milestone for mental health care, burying the unscientific distinction between “mental” and “physical” illness. But although progress has been made in mental... Read the rest of this entry »

It’s been nearly five years since the President’s New Freedom Commission on Mental Health issued its final report. The report affirmed the possibility of recovery and the effectiveness of available treatments for many conditions. But it also warned that many patients never find their way to care and that providers are often unaware of therapies... Read the rest of this entry »