Health care in a multi-payer system: Spillovers of health care service demand among adults under 65 on utilization and outcomes in medicare

Alternative Payment Models and Performance in Federally Qualified Health Centers

Importance

Several state Medicaid agencies have transitioned from traditional fee-for-service to a value-centric alternative payment model (APM) to reimburse federally qualified health centers (FQHCs). Little is known about the effects of this shift on FQHC performance.

Objective

To assess the association between APMs and the clinical performance, payer mix, risk profile, and financial sustainability of FQHCs.

Design, Setting, and Participants

This retrospective cohort study was performed in 684 FQHCs (representing 37 states plus the District of Columbia) that continuously operated between January 2009 and December 2021. Data on payer mix (eg, type of insurance) and risk profile (eg, proportion of patients with chronic conditions) of FQHC patients were obtained from the Uniform Data System, and clinic-level financial data (eg, revenue) were obtained from Internal Revenue Service form 990 tax documents. Data were analyzed between November 2022 and October 2023.

Exposure

Initial rollout of a value-based payment model (ie, an APM) for FQHCs, as offered by state Medicaid program, between January 2013 and December 2021.

Main Outcomes and Measures

The main outcomes were 4 audited process measures of health care quality (cervical and colorectal cancer screening and body mass index [BMI] assessment for adults and children) and 2 intermediate health outcome measures (hypertension control and diabetes control). A difference-in-differences design was used with staggered implementation comparing FQHCs before and after the initial APM rollout vs contemporaneous changes in FQHCs in states without APMs.

Results

A total of 684 FQHCs (8892 FQHC-years) that served 17 823 959 patients in 2021 (57.3% female) were included in the study. Among FQHCs in states implementing APMs, significant differential increases in 3 of the 4 process quality measures were observed compared with FQHCs in states that did not implement an APM: colorectal cancer screening (3.24 percentage points [pp]; 95% CI, 1.40-5.08 pp), adult BMI (3.19 pp; 95% CI, 0.70-5.68 pp), and child BMI (4.50 pp; 95% CI, 1.83-7.17 pp). There were also modest differential improvements in blood pressure control for individuals with hypertension (1.02 pp; 95% CI, 0.04-2.00 pp) and blood glucose control for individuals with type 2 diabetes (1.02 pp; 95% CI, 0.02-2.02 pp) compared with FQHCs in states without an APM. There was no evidence that the APM rollout was associated with clinics selecting healthier patients (-0.01 pp; 95% CI, -0.21 to 0.19 pp) or stinting on care (-0.02 visits; 95% CI, -0.08 to 0.04 visits).

Conclusions and Relevance

In this cohort study, introduction of Medicaid APM options for FQHCs was associated with modest, statistically significant increases in quality concentrated among FQHCs with APM models that explicitly incentivized quality. This finding suggests that APMs can be both a financially viable and a health-promoting model for reimbursement in the health care safety net.

Demand and Supply Drivers of Medicare and Non-Medicare Health Spending: An Analysis of U.S. States, 1991-2019

For the last four decades, policymakers have attempted to control the United States's high health care costs by reducing patients' demand for care (e.g., by imposing managed-care restrictions or high costs on patients at the time of use). Yet studies based mostly on data from the public Medicare program, which covers mostly elderly Americans, suggest that supply (e.g., number of physicians or hospital beds) rather than demand drives aggregate service use and, hence, costs. Using variation between U.S. states in per enrollee Medicare spending versus per capita spending of all other (non-Medicare) individuals, we find that greater supply boosts costs for the entire population. Furthermore, we find that factors that suppress demand in the non-Medicare population do reduce non-Medicare health care spending, but simultaneously increase Medicare spending. This suggests that for a given supply of medical resources, suppressing demand for one group of patients may produce a compensatory increase in provision of care to those whose demand has not been suppressed. Health planning to assure adequate medical resources where they are needed while preventing excess supply where it is duplicative and wasteful is likely a more effective cost control strategy than the imposition of managed-care restrictions or imposing higher costs onto patients seeking care.

Among Medicare beneficiaries, Affordable Care Act coverage expansions reduced utilization of ambulatory care, particularly among duals

We leveraged local area variation in the size of the Affordable Care Act (ACA) expansions of Medicaid and nongroup coverage and measured changes in Medicare utilization and spending from 2010 through 2018 using the universe of Medicare fee-for-service claims. We found that the ACA coverage expansions led to decreases in the share of Medicare beneficiaries receiving ambulatory care and decreases in spending per beneficiary on ambulatory care. The reductions in ambulatory care were larger among beneficiaries enrolled in both Medicare and Medicaid ("duals"). Our results suggest that coverage expansions may lead to congestion and reduced access to physicians for those who are continuously insured.

Hospital concentration and low-income populations: Evidence from New York State Medicaid

While a large body of evidence has examined hospital concentration, its effects on health care for low-income populations are less explored. We use comprehensive discharge data from New York State to measure the effects of changes in market concentration on hospital-level inpatient Medicaid volumes. Holding fixed hospital factors constant, a one percent increase in HHI leads to a 0.6% (s.e. = 0.28%) decrease in the number of Medicaid admissions for the average hospital. The strongest effects are on admissions for birth (-1.3%, s.e. = 0.58%). These average hospital-level decreases largely reflect redistribution of Medicaid patients across hospitals, rather than overall reductions in hospitalizations for Medicaid patients. In particular, hospital concentration leads to a redistribution of admissions from non-profit hospitals to public hospitals. We find evidence that for births, physicians serving high shares of Medicaid beneficiaries in particular experience reduced admissions as concentration increased. These reductions may reflect preferences among these physicians or reduced admitting privileges by hospitals as a means to screen out Medicaid patients.

Trends and Disparities in the Distribution of Outpatient Physicians' Annual Face Time with Patients, 1979-2018

BACKGROUND

Physician time is a valuable yet finite resource. Whether such time is apportioned equitably among population subgroups, and how the provision of that time has changed in recent decades, is unclear.

OBJECTIVE

To investigate trends and racial/ethnic disparities in the receipt of annual face time with physicians in the USA.

DESIGN

Repeated cross-sectional.

SETTING

National Ambulatory Medical Care Survey, 1979-1981, 1985, 1989-2016, 2018.

PARTICIPANTS

Office-based physicians.

MEASURES

Exposures included race/ethnicity (White, Black, and Hispanic); age (<18, 18-64, and 65+); and survey year. Our main outcome was patients' annual visit face time with a physician; secondary outcomes include annual visit rates and mean visit duration.

RESULTS

Our sample included n=1,108,835 patient visits. From 1979 to 2018, annual outpatient physician face time per capita rose from 40.0 to 60.4 min, an increase driven by a rise in mean visit length and not in the number of visits. However, since 2005, mean annual face time with a primary care physician has fallen, a decline offset by rising time with specialists. Face time provided per physician changed little given growth in the physician workforce. A racial/ethnic gap in physician visit time present at the beginning of the study period widened over time. In 2014-2018, White individuals received 70.0 min of physician face time per year, vs. 52.4 among Black and 53.0 among Hispanic individuals. This disparity was driven by differences in visit rates, not mean visit length, and in the provision of specialist but not primary care.

LIMITATION

Self-reported visit length.

CONCLUSION

Americans' annual face time with office-based physicians rose for three decades after 1979, yet is still allocated inequitably, particularly by specialists; meanwhile, time spent by Americans with primary care physicians is falling. These trends and disparities may adversely affect patient outcomes. Policy change is needed to assure better allocation of this resource.

Trading spaces: Medicare's regulatory spillovers on treatment setting for non-Medicare patients

Medicare pricing is known to indirectly influence provider prices and care provision for non-Medicare patients; however, Medicare's regulatory externalities beyond fee-setting are less well understood. We study how physicians' outpatient surgery choices for non-Medicare patients responded to Medicare removing a ban on ambulatory surgery center (ASC) use for a specific procedure. Following the rule change, surgeons began reallocating both Medicare and commercially insured patients to ASCs. Specifically, physicians became 70% more likely to use ASCs for the policy-targeted procedure among their non-Medicare patients. These novel findings demonstrate that Medicare rulemaking affects physician behavior beyond the program's statutory scope.

The effect of Medicaid expansion on Medicaid participation, payer mix, and labor supply in primary care

Evidence of increased health care utilization associated with the Medicaid expansion suggests that clinicians increased capacity to meet demand. However, little is known about the mechanism underlying this response. Using a novel source of all-payer data, we quantified clinicians' response to the Medicaid expansion - examining whether and how they changed their Medicaid participation decisions, payer mix, and overall labor supply. Primary care clinicians in expansion states provided an average of 49 additional appointments per year (a 21% relative increase) for patients insured by Medicaid, compared to clinicians in non-expansion states - with new-patient visits representing half (25 appointments) of this overall increase. Clinicians did not increase their labor supply to accommodate these additional appointments. They instead offset the 1.7 percentage point average increase in Medicaid payer mix with an equivalent reduction in commercial payer mix. However, this reduction in commercial patient share represented only a 2.8% relative decrease, with commercially insured patients still comprising the majority of the average clinician's patient panel. Subsample analyses revealed a larger increase in care for Medicaid patients among clinicians with high Medicaid participation preceding the eligibility expansion.

Insurance expansions and hospital utilization: Relabeling and reabling?

The 2010 Patient Protection & Affordable Care Act (ACA) significantly expanded access to private and public health insurance for low-income individuals through income-based subsidies and income-based eligibility expansions, respectively. In this paper, we use the universe of hospitals from 2009 to 2015 to characterize how these expansions affected the financing of hospital visits, along with price, utilization, and potential spillovers in the quality of care. The insurance coverage expansions generated a shift in the composition of payers and a modest increase in the utilization of hospital outpatient services. While concerns have been raised that these shifts in utilization could cause negative spillovers to the already insured population (e.g., Medicare enrollees), we find no significant change in the quality of care experienced by those already insured. The primary result of both federally funded insurance expansions was to increase the profits generated and prices charged by the hospitals providing such services.

State Medicaid Home and Community-Based Services Policies and Health Expenditures by Payer

This study examines the relationship between two state Medicaid home and community-based services (HCBS) policies - number of beneficiaries (Participation) and use per beneficiary (Intensity) - and individual health expenditures. Data include the 2008-2013 Medicare Current Beneficiary Survey and state-level Medicaid HCBS indicators. Two-part generalized linear models are estimated for health expenditures by payer and dual-eligibility status. The likelihood and level of Medicare expenditures are significantly lower in states in the top quartile of Participation and Intensity. Findings suggest that state Medicaid HCBS policies may impact health expenditures, with potential spillover effects on Medicare spending.

Relief Supply Chain Management Using Internet of Things to Address COVID-19 Outbreak

Nowadays, due to the COVID-19 outbreak, the most significant factor to be considered all over the world is to manage this pandemic and especially to address positive cases, efficiently and effectively. This can be achieved by simultaneously utilizing the present network with supply chain settings and also the Internet of Things (IoT). This consideration enables the accurate monitoring of suspected cases in real-time to optimize total service time. Hence, this paper firstly designs two sub-models to minimize distance and traffic while minimizing total response time. Our main contribution in this paper is to develop a dynamic scheme using IoT to deal with suspected cases. We also investigate the proposed methodology on a real case problem in Canada. A comprehensive analysis of the proposed methodology behavior has been conducted and the results showed the managerial decision-making process to address COVID-19 patients. The proposed approach establishes efficient strategies to identify suspicious COVID-19 cases and provide them with medical observance in a short time when utilized with IoT. The obtained results of the considered scenarios show 12% up to 15% improvement in the ambulance response time when using IoT.

Pricing Universal Health Care: How Much Would The Use Of Medical Care Rise?

The return of a Democratic administration to the White House, coupled with coronavirus disease 2019 (COVID-19) pandemic-induced contractions of job-based insurance, may reignite debate over public coverage expansion and its costs. Decades of research demonstrate that uninsured people and people with copays and deductibles use less care than people with first-dollar coverage. Hence, most economic analyses of Medicare for All proposals and other coverage expansions project increased utilization and associated costs. We review the utilization surges that such analyses have predicted and contrast them with the more modest utilization increments observed after past coverage expansions in the US and other affluent nations. The discrepancy between predicted and observed utilization changes suggests that analysts underestimate the role of supply-side constraints-for example, the finite number of physicians and hospital beds. Our review of the utilization effects of past coverage expansions suggests that a first-dollar universal coverage expansion would increase ambulatory visits by 7-10 percent and hospital use by 0-3 percent. Modest administrative savings could offset the costs of such increases.

The Effect of Large-scale Health Coverage Expansions in Wealthy Nations on Society-Wide Healthcare Utilization

Most analysts project that a reform like Medicare-for-All that lowers financial barriers to care would cause a surge in the utilization of services, raising costs despite stable or even reduced prices. However, the finite supply of physicians and hospital beds could constrain such utilization increases. We reviewed the effects of 13 universal coverage expansions in capitalist nations on physician and hospital utilization, beginning with New Zealand's 1938 Social Security Act up through the 2010 Affordable Care Act in the USA. Almost all coverage expansions had either a small (i.e., < 10%) or no effect on society-wide utilization. However, coverage expansions often redistributed care-increasing use among newly covered groups while producing small, offsetting reductions among those already covered. We conclude that in wealthy nations, large-scale coverage expansions need not cause overall utilization to surge if provider supply is controlled. However, such reforms could redirect care towards patients who most need it.

Delisting eye examinations from public health insurance: Empirical evidence from Canada regarding impacts on patients and providers

This paper examines the impacts of delisting routine eye exam services on patient eye care utilization and on providers' labour market outcomes in a public healthcare system. Provincial governments in Canada started to de-insure routine eye examinations from the basket of publicly insured healthcare services in the early 1990s. We explore these policy changes across Canadian provinces to estimate the impacts of delisting from the supply- and demand-sides. Demand side analysis suggests that, on average, for the working age population delisting decreased the probability of using eye care. However, the number of visits among those who continued to use eye care services did not change. Additionally, the delisting may have had unintended consequences by causing a large negative impact among low-income individuals, and there is suggestive evidence of a positive spillover on utilization by publicly-funded patients over age 64. On the supply side, using Canadian census data we find that delisting eye exams decreased optometrists' weekly work hours, raised their annual work weeks and had little effect on their income.

Coverage Expansions and Utilization of Physician Care: Evidence From the 2014 Affordable Care Act and 1966 Medicare/Medicaid Expansions

Objectives. To evaluate the effects of the 2 major coverage expansions in US history-Medicare/Medicaid in 1966 and the Affordable Care Act (ACA) in 2014-on the utilization of physician care.Methods. Using the National Health Interview Survey (1963-1969; 2011-2016), we analyzed trends in utilization of physician services society-wide and by targeted subgroups.Results. Following Medicare/Medicaid's implementation, society-wide utilization remained unchanged. While visits by low-income persons increased 6.2% (P < .01) and surgical procedures among the elderly increased 14.7% (P < .01), decreases among nontargeted groups offset these increases. After the ACA, society-wide utilization again remained unchanged. Increased utilization among targeted low-income groups (e.g., a 3.5-percentage-point increase in the proportion of persons earning less than or equal to 138% of the federal poverty level with at least 1 office visit [P < .001]) was offset by small, nonsignificant reductions among the nontargeted population.Conclusions. Past coverage expansions in the United States have redistributed physician care, but have not increased society-wide utilization in the short term, possibly because of the limited supply of physicians.Public Health Implications. These findings suggest that future expansions may not cause unaffordable surges in utilization.

The Effects on Hospital Utilization of the 1966 and 2014 Health Insurance Coverage Expansions in the United States

BACKGROUND

Persons with comprehensive health insurance use more hospital care than those who are uninsured or have high-deductible plans. Consequently, analysts generally assume that expanding coverage will increase society-wide use of inpatient services. However, a limited supply of beds might constrain this growth.

OBJECTIVE

To determine how the implementations of Medicare and Medicaid (1966) and the Patient Protection and Affordable Care Act (ACA) (2014) affected hospital use.

DESIGN

Repeated cross-sectional study.

SETTING

Nationally representative surveys.

PARTICIPANTS

Respondents to the National Health Interview Survey (1962 to 1970) and Medical Expenditure Panel Survey (2008 to 2015).

MEASUREMENTS

Mean hospital discharges and days were measured, both society-wide and among subgroups defined by income, age, and health status. Changes between preexpansion and postexpansion periods were analyzed using multivariable negative binomial regression.

RESULTS

Overall hospital discharges averaged 12.8 per 100 persons in the 3 years before implementation of Medicare and Medicaid and 12.7 per 100 persons in the 4 years after (adjusted difference, 0.2 discharges [95% CI, -0.1 to 0.4 discharges] per 100 persons; P = 0.26). Hospital days did not change in the first 2 years after implementation but increased later. Effects differed by subpopulation: Adjusted discharges increased by 2.4 (CI, 1.7 to 3.1) per 100 persons among elderly compared with nonelderly persons (P < 0.001) and also increased among those with low incomes compared with high-income populations. For younger and higher-income persons, use decreased. Similarly, after the ACA's implementation, overall hospital use did not change: Society-wide rates of discharge were 9.4 per 100 persons before the ACA and 9.0 per 100 persons after the ACA (adjusted difference, -0.6 discharges [CI, -1.3 to 0.2 discharges] per 100 persons; P = 0.133), and hospital days were also stable. Trends differed for some subgroups, and rates decreased significantly in unadjusted (but not adjusted) analyses among persons reporting good or better health status and increased nonsignificantly among those in worse health.

LIMITATION

Data sources relied on participant recall, surveys excluded institutionalized persons, and follow-up after the ACA was limited.

CONCLUSION

Past coverage expansions were associated with little or no change in society-wide hospital use; increases in groups who gained coverage were offset by reductions among others, suggesting that bed supply limited increases in use. Reducing coverage may merely shift care toward wealthier and healthier persons. Conversely, universal coverage is unlikely to cause a surge in hospital use if growth in hospital capacity is carefully constrained.

PRIMARY FUNDING SOURCE

None.