Mark Zezza

Variation in inpatient hospital prices and outpatient service quantities drive geographic differences in private spending in Texas.

OBJECTIVE To measure the contribution of market-level prices, utilization, and health risk to medical spending variation among the Blue Cross Blue Shield of Texas (BCBSTX) privately insured population and the Texas Medicare population. DATA SOURCES Claims data for all BCBSTX members and publicly available CMS data for Texas in 2011. STUDY DESIGN We used observational data and decomposed overall and service-specific spending into health status and health status adjusted utilization and input prices and input prices adjusted for the BCBSTX and Medicare populations. PRINCIPAL FINDINGS Variation in overall BCBSTX spending across HRRs appeared driven by price variation, whereas utilization variation factored more prominently in Medicare. The contribution of price to spending variation differed by service category. Price drove inpatient spending variation, while utilization drove outpatient and professional spending variation in BCBSTX. The context in which negotiations occur may help explain the patterns across services. CONCLUSIONS The conventional wisdom that Medicare does a better job of controlling prices and private plans do a better job of controlling volume is an oversimplification. BCBSTX does a good job of controlling outpatient and professional prices, but not at controlling inpatient prices. Strategies to manage the variation in spending may need to differ substantially depending on the service and payer.

Medicare Beneficiaries Less Likely to Experience Cost- and Access-Related Problems than Adults with Private Coverage

The experiences of people covered by Medicare and those with private employer insurance can help inform policy debates over the federal budget deficit, Medicares affordability, and the expansion of private health insurance under the Affordable Care Act. This article provides evidence that people with employer-sponsored coverage were more likely than Medicare beneficiaries to forgo needed care, experience access problems due to cost, encounter medical bill problems, and be less satisfied with their coverage. Within the subset of beneficiaries who are age sixty-five or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10 percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems. These results suggest that policy options to shift Medicare beneficiaries into private insurance would need to be attentive to potentially negative insurance experiences, problems obtaining needed care, and difficulties paying medical bills.

Effect of Public Reporting on MR Imaging Use for Low Back Pain

PURPOSE To determine whether magnetic resonance (MR) imaging examination rates for low back pain before conservative therapy in the Medicare and privately insured populations changed after introduction of a Centers for Medicare & Medicaid Services public reporting initiative. MATERIALS AND METHODS Institutional review board approval was obtained, with waiver of informed consent. A retrospective study was performed by using fee-for-service claims data from Medicare and a commercial carrier (Blue Cross Blue Shield of Texas [BCBSTX]) for Texas enrollees. OP-8 was calculated, which is a publicly reported measure as of 2009 of the proportion of MR imaging examinations performed for low back pain without history of conservative therapy. For 330 463 MR imaging examinations, OP-8 rates, trends, and regional variation were analyzed for 2008-2011 within different outpatient settings-outpatient hospital department (OHD) and nonhospital outpatient department (NOD)-according to payer. Largest-volume hospitals were also evaluated within the Medicare population. RESULTS No significant reduction was found in annual OP-8 values for Medicare or BCBSTX (Medicare OHD, 0.35 for 2008 vs 0.36 for 2009 [P = .01]; BCBSTX OHD, 0.42 for 2008 vs 0.44 for 2009 [P = .03]; Medicare NOD, 0.33 for 2008 vs 0.35 for 2009 [P < .0001]; and BCBSTX NOD, 0.43 for 2008 vs 0.42 for 2009[P = .23]). These changes were not sustained during subsequent years in the BCBSTX population, and there were no further changes in Medicare rates. Among hospitals with highest Medicare volumes, those with the highest OP-8 rates in 2008 were associated with the highest decrease in their measure. (The annual change rate was negative for all years, with 2008 as the reference [P < .0001 for 2009-2011].) Hospitals with the lowest OP-8 rates had increases in OP-8 rates, which persisted in following years (P = .006 for 2009, P = .037 for 2010, and P = .004 for 2011). Hospitals with baseline OP-8 rates in the 25th-75th percentile remained relatively steady over time. CONCLUSION No evidence was found that public reporting (OP-8) reduced MR imaging rates for low back pain without conservative therapy in either Medicare or commercially insured populations in hospital or nonhospital settings.

Confounding constituents: Complicated healthcare communications and the Affordable Care Act in the United States

It has been over a year since the United States committed to a landmark healthcare reform bill, now known as the Affordable Care Act (ACA). With a weakened economy and costs predicted to remain largely out of control, conflicts in messages and inadequate clarity in communication has left the public with mixed emotions – over half of the respondents to the Kaiser Family Tracking Polls remain confused about the law and do not understand how the law ultimately impacts on them. In many respects, these sentiments may be understandable. While major changes are already underway, amidst many concerns and controversy, it will take years for provisions in the law to be fully implemented. Adding to the confusion are the means by which healthcare reform is being publically debated and how specifics (or lack thereof) are shared across media outlets from politicians and healthcare stakeholders. This state of affairs is epitomized by the efforts to repeal the reform bill immediately following its passage. In fact, after an essentially symbolic repeal vote by the currently conservative-leaning House of Representatives, over one in five Americans believed that the bill was actually repealed. Additionally, the debate on how to reform the healthcare system, particularly Medicare and Medicaid, continues on, albeit now as part of federal deficit discussions. This reframing has unfortunately shifted the crux of the health reform debate from improving the way healthcare is delivered, to simply focusing on coverage reform and deficit reduction, not fully addressing true cost containment gained through efficiencies in delivery. Conflicting messages and priorities from leadership are likely impeding the timeliness and effectiveness of healthcare reform efforts. Furthermore, the longer that conflicting debates continue, the larger the risk for repeals to occur before major provisions that will truly advance coordinated care and personalized medicine are enacted. As the debates and efforts to implement reform continue, all stakeholders must commit to meaningful and specific communication on what always has had fairly strong consensus – the USA system is broken and needs to be fixed. The ACA builds, in part, on that shared sentiment and can help guide us toward a future centered on a more effective healthcare system.

Making Healthcare Reform Matter to American Patients

In October 2011, we discoursed about how conflicting messages and inadequate clarity in communications regarding the United States’ Affordable Care Act (ACA) caused major confusion among the American public and hindered progress on healthcare reform implementation. Five years since President Obama signed the ACA into law on March 23, 2010, it would still be premature to draw definitive conclusions about its overall impact as some provisions are still being phased in (e.g., payment reductions to Medicare providers) and others have yet to be implemented (e.g., the tax on the most generous health insurance plans). However, with multiple constitutional challenges of the ACA now in the rearview mirror and an impending presidential campaign that will undoubtedly influence its impact, this is an opportune time to reassess how the law is currently perceived and how healthcare communication experts can assist in improving both messaging and implementation. We have deliberately focused on a specific subset of stakeholders—i.e., the patients— seeing pivotal opportunities available for them to be drivers of change.