Len M. Nichols

The effects of medicaid reimbursement on the access to care of medicaid enrollees : A community perspective

Previous research has not found a strong association between Medicaid reimbursement levels and enrollees’ access to medical care, even though higher fees increase the acceptance of Medicaid patients by physicians. This study shows that high Medicaid acceptance rates by physicians in a community are more important than fee levels per se in affecting enrollees’ access to medical care. Although high fee levels increase the probability that individual physicians will accept Medicaid patients, high fee levels do not necessarily lead to high levels of physician Medicaid acceptance in an area. Numerous other physician practice, health system, and community characteristics also affect Medicaid acceptance. The effects of Medicaid fees on Medicaid acceptance are substantially lower in areas with high Medicaid managed care penetration and for physicians who practice in institutional settings. The results suggest that a broad range of factors need to be considered to increase access to physicians for Medicaid enrollees.

Crossroads In Quality

Expanding insurance coverage is a critical step in health reform, but we argue that to be successful, reforms must also address the underlying problems of quality and cost. We identify five fundamental building blocks for a high-performance health system and urge action to create a national center for effectiveness research, develop models of accountable health care entities capable of providing integrated and coordinated care, develop payment models to reward high-value care, develop a national strategy for performance measurement, and pursue a multistakeholder approach to improving population health.

Ebola crisis of 2014: are current strategies enough to meet the long-run challenges ahead?

The outbreak of the Ebola virus disease (EVD) in 2014 mobilized international efforts to contain a global health crisis. The emergence of the deadly virus in the United States and Europe among health care workers intensified fears of a worldwide epidemic. Market incentives for pharmaceutical firms to allocate their research and development resources toward Ebola treatments were weak because the limited number of EVD cases were previously confined to rural areas of West Africa. We discuss 3 policy recommendations to address the long-term challenges of EVD in an interconnected world.

Obesity and Health System Reform: Private vs. Public Responsibility

Obesity is a particularly vexing public health challenge, since it not only underlies much disease and health spending but also largely stems from repeated personal behavioral choices. The newly enacted comprehensive health reform law contains a number of provisions to address obesity. For example, insurance companies are required to provide coverage for preventive-health services, which include obesity screening and nutritional counseling. In addition, employers will soon be able to offer premium discounts to workers who participate in wellness programs that emphasize behavioral choices. These policies presume that government intervention to reduce obesity is necessary and justified. Some people, however, argue that individuals have a compelling interest to pursue their own health and happiness as they see fit, and therefore any government intervention in these areas is an unwarranted intrusion into privacy and ones freedom to eat, drink, and exercise as much or as little as one wants. This paper clarifies the overlapping individual, employer, and social interest in each persons health generally to avoid obesity and its myriad costs in particular. The paper also explores recent evidence on the impact of government interventions on obesity through case studies on food labeling and employer-based anti-obesity interventions. Our analysis suggests a positive role for government intervention to reduce and prevent obesity. At the same time, we discuss criteria that can be used to draw lines between government, employer, and individual responsibility for health, and to derive principles that should guide and limit government interventions on obesity as health reforms various elements (e.g., exchanges, insurance market reforms) are implemented in the coming years.

State Regulation What Have We Learned So Far

�� Of all the different health insurance venues in the United States, small group and individual markets consistently engender the most complaints. Compared to large group purchasers, small groups and individuals suffer more from administrative diseconomies of scale, difficulties in spreading risk among themselves, and the absence of bargaining power with insurers and providers alike. These conditions lead to higher and more volatile premiums for the same or less generous benefits than large group purchasers usually obtain. Volatility and the apparently inexorable upward trend of health premium costs have led to considerable interest in reform of these markets, of which the recent national debate over comprehensive reform, in retrospect, was but a brief interlude in a history of federalism that spans half of the twentieth century (Nichols and Blumberg 1998). Because of its relative size and organized interests, most of the attention of health insurance market reformers and critics has been focused on the small group market, rather than on individual markets. Over fortyfive states have passed small group reform laws since 1989, though only twenty-five states had implemented individual market reforms prior to the Health Insurance Portability and Accountability Act of 1996. This federal law compelled all states to either pass certain conforming acts or to suffer direct federal regulation of their insurance markets for the first time. Recently, empirical and case studies of the effects of small group reforms have begun to appear (Jensen and Morrisey 1996; Sloan and Conover 1998; Marsteller et al. 1998; Hall 1998). This article, along with the other essays in this issue, attempts to redress this relative imbalance by focusing exclusively on the individual market.

The CareFirst Patient-Centered Medical Home Program: Cost and Utilization Effects in Its First Three Years

BackgroundEnhanced primary care models have diffused slowly and shown uneven results. Because their structural features are costly and challenging for small practices to implement, they offer modest rewards for improved performance, and improvement takes time.ObjectiveTo test whether a patient-centered medical home (PCMH) model that significantly rewarded cost savings and accommodated small primary care practices was associated with lower spending, fewer hospital admissions, and fewer emergency room visits.DesignWe compared medical care expenditures and utilization among adults who participated in the PCMH program to adults who did not participate. We computed difference-in-difference estimates using two-part multivariate generalized linear models for expenditures and negative binomial models for utilization. Control variables included patient demographics, county, chronic condition indicators, and illness severity.ParticipantsA total of 1,433,297 adults aged 18–64 years, residing in Maryland, Virginia, and the District of Columbia, and insured by CareFirst for at least 3 consecutive months between 2010 and 2013.InterventionCareFirst implemented enhanced fee-for-service payments to the practices, offered a large retrospective bonus if annual cost and quality targets were exceeded, and provided information and care coordination support.MeasuresOutcomes were quarterly claims expenditures per member for all covered services, inpatient care, emergency care, and prescription drugs, and quarterly inpatient admissions and emergency room visits.ResultsBy the third intervention year, annual adjusted total claims payments were

Implementing Insurance Market Reforms Under The Federal Health Reform Law

109 per participating member (95 % CI: −

A New Approach to Risk-Spreading via Coverage-Expansion Subsidies

192, −

On the existence of a market for second hand physical capital: An empirical test of the Keynesian and neoclassical assumptions☆

27), or 2.8 % lower than before the program and compared to those who did not participate. Forty-two percent of the overall decline in spending was explained by lower inpatient care, emergency care, and prescription drug spending. Much of the reduction in inpatient and emergency spending was explained by lower utilization of services.ConclusionsA PCMH model that does not require practices to make infrastructure investments and that rewards cost savings can reduce spending and utilization.

Government intervention in health care markets is practical, necessary, and morally sound.

Lost in the rhetoric about the supposed government takeover of health care is an appreciation of the inherently federalist approach of the Patient Protection and Affordable Care Act. This federalist tradition, particularly with regard to health insurance, has a history that dates back at least to the 1940s. The new legislation broadens federal power and oversight considerably, but it also vests considerable new powers and responsibilities in the states. The precedents and examples it follows will guide federal and state policy makers, stakeholders, and ordinary citizens as they breathe life into the new law. The challenges ahead are formidable, and the greatest ones are likely to be political.