Christine Buttorff

Comparing employer-sponsored and federal exchange plans: wide variations in cost sharing for prescription drugs.

Just under seven million Americans acquired private insurance through the new health insurance exchanges, or Marketplaces, in 2014. The exchange plans are required to cover essential health benefits, including prescription drugs. However, the generosity of prescription drug coverage in the plans has not been well described. Our primary objective was to examine the variability in drug coverage in the exchanges across plan types (health maintenance organization or preferred provider organization) and metal tiers (bronze, silver, gold, and platinum). Our secondary objective was to compare the exchange coverage to employer-sponsored coverage. Analyzing prescription drug benefit design data for the federally facilitated exchanges, we found wide variation in enrollees out-of-pocket costs for generic, preferred brand-name, nonpreferred brand-name, and specialty drugs, not only across metal tiers but also within those tiers across plan types. Compared to employer-sponsored plans, exchange plans generally had lower premiums but provided less generous drug coverage. However, for low-income enrollees who are eligible for cost-sharing subsidies, the exchange plans may be more comparable to employer-based coverage. Policies and programs to assist consumers in matching their prescription drug needs with a plans benefit design may improve the financial protection for the newly insured.

Policy Options To Expand Medicare’s Low-Income Provisions To Improve Access And Affordability

For fifty years Medicare has enhanced the health and financial security of seniors. Yet in 2014 an estimated 40 percent of low-income beneficiaries spent 20 percent or more of their incomes on out-of-pocket expenditures for premiums and medical care, while one-third were underinsured based on their out-of-pocket spending for medical care alone. These high burdens reflect Medicares limited benefits and restrictive income eligibility levels for supplemental Medicaid coverage. We examined the impacts of illustrative policies designed to improve beneficiaries financial protection and access to care by reducing Medicare premiums and cost sharing for covered benefits on a sliding scale for all beneficiaries with incomes up to 200 percent of the federal poverty level. We estimate that these policies could improve the affordability of health care for eleven million people. Designed to be aligned with the Affordable Care Acts subsidy approach for the population younger than age sixty-five, these policies also have the potential to smooth transitions into Medicare, reduce administrative costs, and provide a more secure and equitable foundation for Medicares future.

Implementation of Medical Homes in Federally Qualified Health Centers

BACKGROUND From 2011 through 2014, the Federally Qualified Health Center Advanced Primary Care Practice Demonstration provided care management fees and technical assistance to a nationwide sample of 503 federally qualified health centers to help them achieve the highest (level 3) medical‐home recognition by the National Committee for Quality Assurance, a designation that requires the implementation of processes to improve access, continuity, and coordination. METHODS We examined the achievement of medical‐home recognition and used Medicare claims and beneficiary surveys to measure utilization of services, quality of care, patients’ experiences, and Medicare expenditures in demonstration sites versus comparison sites. Using difference‐in‐differences analyses, we compared changes in outcomes in the two groups of sites during a 3‐year period. RESULTS Level 3 medical‐home recognition was awarded to 70% of demonstration sites and to 11% of comparison sites. Although the number of visits to federally qualified health centers decreased in the two groups, smaller reductions among demonstration sites than among comparison sites led to a relative increase of 83 visits per 1000 beneficiaries per year at demonstration sites (P<0.001). Similar trends explained the higher performance of demonstration sites with respect to annual eye examinations and nephropathy tests (P<0.001 for both comparisons); there were no significant differences with respect to three other process measures. Demonstration sites had larger increases than comparison sites in emergency department visits (30.3 more per 1000 beneficiaries per year, P<0.001), inpatient admissions (5.7 more per 1000 beneficiaries per year, P=0.02), and Medicare Part B expenditures (

Impact of Out-of-Pocket Spending Caps on Financial Burden of those with Group Health Insurance

37 more per beneficiary per year, P=0.02). Demonstration‐site participation was not associated with relative improvements in most measures of patients’ experiences. CONCLUSIONS Demonstration sites had higher rates of medical‐home recognition and smaller decreases in the number of patients’ visits to federally qualified health centers than did comparison sites, findings that may reflect better access to primary care relative to comparison sites. Demonstration sites had larger increases in emergency department visits, inpatient admissions, and Medicare Part B expenditures. (Funded by the Centers for Medicare and Medicaid Services.)

Examining the Implementation of the Medicaid Primary Care Payment Increase

ABSTRACTBACKGROUNDThe Affordable Care Act (ACA) mandates that all private health insurance include out-of-pocket spending caps. Insurance purchased through the ACA’s Health Insurance Marketplace may qualify for income-based caps, whereas group insurance will not have income-based caps. Little is known about how out-of-pocket caps impact individuals’ health care financial burden.OBJECTIVEWe aimed to estimate what proportion of non-elderly individuals with group insurance will benefit from out-of-pocket caps, and the effect that various cap levels would have on their financial burden.DESIGNWe applied the expected uniform spending caps, hypothetical reduced uniform spending caps (reduced by one-third), and hypothetical income-based spending caps (similar to the caps on Health Insurance Marketplace plans) to nationally representative data from the Medical Expenditure Panel Survey (MEPS).PARTICIPANTSParticipants were non-elderly individuals (aged < 65 years) with private group health insurance in the 2011 and 2012 MEPS surveys (n =26,666).MAIN MEASURES(1) The percentage of individuals with reduced family out-of-pocket spending as a result of the various caps; and (2) the percentage of individuals experiencing health care services financial burden (family out-of-pocket spending on health care, not including premiums, greater than 10xa0% of total family income) under each scenario.KEY RESULTSWith the uniform caps, 1.2xa0% of individuals had lower out-of-pocket spending, compared with 3.8xa0% with reduced uniform caps and 2.1xa0% with income-based caps. Uniform caps led to a small reduction in percentage of individuals experiencing financial burden (from 3.3xa0% to 3.1xa0%), with a modestly larger reduction as a result of reduced uniform caps (2.9xa0%) and income-based caps (2.8xa0%).CONCLUSIONSMandated uniform out-of-pocket caps for those with group insurance will benefit very few individuals, and will not result in substantial reductions in financial burden.

Evaluation of CMS's Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration: Final Report

For the years 2013 and 2014, the Affordable Care Act authorized enhanced payments for qualifying providers of primary care services participating in the Medicaid program that would be funded entirely by federal dollars. RAND researchers conducted a nine-state independent case study into stakeholder experiences planning for, implementing, and evaluating the impact of the policy to inform the design of similar, future payment policies.

Evaluating consumer preferences for healthy eating from community kitchens in low-income urban areas : a discrete choice experiment of comedores populares in Peru

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The impact of practice guidelines on opioid utilization for injured workers

Many low-income individuals from around the world rely on local food vendors for daily sustenance. These small vendors quickly provide convenient, low-priced, tasty foods, however, they may be low in nutritional value. These vendors serve as an opportunity to use established delivery channels to explore the introduction of healthier products, e.g. fresh salad and fruits, to low-income populations. We sought to understand preferences for items prepared in Comedores Populares (CP), government-supported food vendors serving low-income Peruvians, to determine whether it would be feasible to introduce healthier items, specifically fruits and vegetables. We used a best-worst discrete choice experiment (DCE) that allowed participants to select their favorite and least favorite option from a series of three hypothetical menus. The characteristics were derived from a series of formative qualitative interviews conducted previously in the CPs. We examined preferences for six characteristics: price, salad, soup, sides, meat and fruit. A total of 432 individuals, from two districts in Lima, Peru responded to a discrete choice experiment and demographic survey in 2012. For the DCE, price contributed the most to individuals utility relative to the other attributes, with salad and soup following closely. Sides (e.g. rice and beans) were the least important. The willingness to pay for a meal with a large main course and salad was 2.6 Nuevos Soles, roughly a 1 Nuevo Sol increase from the average menu price, or USD

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans

0.32 dollars. The willingness to pay for a meal with fruit was 1.6 Nuevo Soles. Overall, the perceived quality of service and food served in the CPs is high. The willingness to pay indicates that healthier additions to meals are feasible. Understanding consumer preferences can help policy makers design healthier meals in an organization with the potential to scale up to reach a considerable number of low-income families.

Patient-Centered Medical Home Implementation in Indian Health Service Direct Service Facilities

BACKGROUNDnOpioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury.nnnOBJECTIVEnThis study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patients treatment protocol.nnnRESEARCH DESIGNnThis study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses.nnnRESULTSnFollowing the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending.nnnCONCLUSIONSnCounseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use.nnnPERSPECTIVEnWhile the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed.