The essential scan: Top findings in health policy research

A radiologist examines X-rays of a patient at the Ambroise Pare hospital in Marseille, southern France, April 8, 2008.   REUTERS/Jean-Paul Pelissier (FRANCE) - PM1E4480UAL01

What’s the latest in health policy research? The Essential Scan, produced by the USC-Brookings Schaeffer Initiative for Health Policy, aims to help keep you informed on the latest research and what it means for policymakers. If you’d like to receive the biweekly Essential Scan by email, you can sign up here.

Opioid Prescribing Decreases After Clinician Learns of a Patient’s Fatal Overdose

Study by: Jason Doctor, Andy Nguyen, Roneet Lev, Jonathan Lucas, Tara Knight, Henu Zhao, and Michael Menchine

As the nation continues to grapple with the opioid crisis, clinicians treating patients struggling with chronic pain play a critical role. Yet, the information prescribers receive about their patients’ outcomes on opioids is often not adequate to make accurate appraisals of drug risks. A new study leverages behavioral insights and psychology to give prescribers personal experience with the risk associated with opioids. The researchers conducted a randomized trial between July 2015 and June 2016 of 861 clinicians who had prescribed to 170 patients who subsequently suffered a fatal overdose involving prescription opioids. Half the clinicians were randomly selected to receive a letter from the county medical examiner notifying them that a patient they had prescribed opioids to in the past twelve months had a fatal overdose. The researchers found that when a clinician learns that one of their patients had suffered a fatal overdose, they reduced the amount of opioids prescribed by almost 10 percent in the following three months. Furthermore, clinicians who received the letter were seven percent less likely to start a new patient on opioids and less likely to prescribe higher doses. The researchers note the results are particularly exciting given that this intervention is scalable nationwide, and that numerous, more traditional state regulations– like imposing mandated limits on opioids– have not been shown to have much impact. Full study here.

Referring Physicians Undermine Patient Shopping Behaviors for Lower-Limb MRIs

Study by: Michael Chernew, Zack Cooper, Eugene Larsen-Hallock, and Fiona Scott Morton

Many pro-competition policy interventions aimed at decreasing healthcare spending often focus on making the cost of care salient to consumers, thereby encouraging them to shop for low-cost services. However, a new study shows that consumers are unlikely to shop for lower-limb MRIs– one of the most shoppable health care services– even when it means they pay significantly more in cost-sharing. In fact, the results of the study show that less than one percent of patients used an online price transparency tool available through their insurer to shop for low-cost MRI providers and that patients’ exposure to out-of-pocket costs only explained 2.4 percent of the variance in the price of MRIs. Taken together, these findings show that patients are largely insensitive to out-of-pocket costs associated with MRIs. The researchers also find that driving distance could not explain patients’ unwillingness to price shop, since the average patient bypassed six lower-priced providers between their home and the location where they ultimately chose to receive their MRI. Ultimately, referring physicians have the greatest impact on where patients receive their MRI. The authors suspect that physicians who refer patients to MRI providers with high relative prices often do so because they are either unaware of the prices charged by the providers they are familiar with or because they are vertically integrated with high-cost MRI providers. The authors of the study conclude that healthcare funders must be aware of the importance of the suggestions made by referring physicians and take the appropriate steps to steer patients towards lower-cost options. Full study here.

“This study provides greater insight into a growing body of research findings showing the weakness of consumer price transparency as a cost containment tool.  Network strategies have been shown to be far more effective.”

Paul Ginsburg, PhD, Director, USC-Brookings Schaeffer Initiative for Health Policy

Medicaid Eligibility Expansions Linked to Increases in Prescription Fills for Diabetes Drugs

Study by: Rebecca Myerson, Tianyi Lu, Ivy Tonnu-Mihara, and Elbert S. Huang

Diabetes medications, including insulin and new medications, can be cost prohibitive for individuals who lack insurance. A new study found that filled prescriptions for diabetes medications increased in states that expanded Medicaid during the two years following the ACA’s expansion of the program, compared to states that didn’t expand Medicaid. The researchers analyzed more than 96 million prescriptions filled using Medicaid insurance between 2008 and 2015. They found that states that expanded access to Medicaid had an additional 30 diabetes prescriptions filled per 1,000 people and the increase in prescriptions grew significantly over time. Furthermore, the researchers found that prescriptions increased for a variety of diabetes medications: they documented a 39 percent increase for first-line prescriptions typically given to newly-diagnosed patients and a 40 percent increase for prescription fills for insulin. Early treatment of diabetes can significantly impact health outcomes, an important consideration for policymakers as they grapple with how to move forward with healthcare reform and the Medicaid program. Full study here.

How Would State- Based Individual Mandates Affect Health Insurance Coverage and Premium Costs?

Study by: Linda J. Blumberg, Matthew Buettgens, and John Holahan

The Tax Cuts and Jobs Act of 2017 removed the tax penalty portion of the Affordable Care Act’s individual mandate, setting it to $0 in 2019. States could reinstate a similar penalty in order to encourage enrollment and stabilize the health insurance marketplaces, and in fact, some already have. A new report provides estimates of the effects of state-specific individual mandates on insurance coverage, nongroup insurance premiums, federal and state government spending, and demand for uncompensated care. Researchers found that if all states implemented individual mandates, the number of uninsured individuals would be lower by 3.9 million people in 2019, a decrease of 11.4 percent. They also estimate that marketplace premiums would be 11.8 percent lower in 2019, state mandate penalty revenues would amount to $7.4 billion and demand for uncompensated care would decrease by $11.4 billion. They concluded that states could mitigate the negative impact of the removal of the tax penalty through adopting their own, but concede that this is unlikely in several states for political or logistical reasons. Full study here.

Medicaid Expansion Did Not Erode Quality of Medicaid Managed Care Plans

Study by: Chima D. Ndumele, William L. Schpero, and Amal N. Trivedi

The Affordable Care Act (ACA) included a provision that encouraged states to expand their criteria for Medicaid eligibility to include low-income adults at or below 138 percent of the federal poverty level. This provision took effect in 2014 and has since given tens of millions of new enrollees access to Medicaid. However, some observers worried that this sudden influx of Medicaid enrollees would overwhelm existing healthcare networks and degrade the quality of care offered by Medicaid’s managed care plans. The authors of a recent study use a difference-in-differences approach to compare the publicly reported quality of care offered by managed care plans in states that chose to expand their Medicaid programs with those that did not, and find no evidence that Medicaid expansion affected the quality of care offered by managed care plans in expansion states. While the authors did observe a great deal of variation in the quality of care delivered to Medicaid managed care recipients across and within states, their main results held true regardless of whether the state expanded Medicaid. This study suggests that the Medicaid population can be increased without undermining important measures of quality of care. Full study here.

Hospitals Using Bundled Payments Report Reducing Skilled Nursing Facility Use and Improving Care Integration

Study by: Jane M. Zhu, Viren Patel, Judy A Shea, Mark D. Neuman, and Rachel M. Werner

As of 2015, approximately 20 percent of all traditional Medicare hospital admissions ended in a skilled nursing facility (SNF) stay. However, there is little evidence that increased SNF spending improves patient outcomes. Two Medicare bundled payment programs – the Bundled Payments for Care Improvement (BPCI) initiative and the Comprehensive Care for Joint Replacement (CJR) model shift financial responsibility for post-discharge care to hospitals and set incentives for stronger coordination between hospitals and post-acute care providers. A new study uses interviews with each of the 22 hospitals and health systems participating in these programs for lower extremity joint replacement episodes to understand their approaches to improving quality and controlling costs after discharge. The researchers identified two primary ways hospitals reacted to these models. The first was to reduce SNF referrals using risk stratification tools, patient education, home care supports, and linkages with home health agencies to facilitate discharges to home. The second was to enhance integration with SNFs through either sharing access to electronic health records, embedding providers across facilities, hiring or assigning dedicated care coordination staff, and creating platforms for data exchange. The researchers conceded that while some studies, like this one, have observed a decrease in SNF spending as a result of bundled payment, recent analysis of Medicare data shows persistent increases in the use of institutional post-acute care nationally, suggesting that this decrease may not be part of a larger trend. The impact of these organizational changes on patient outcomes and quality of care remains to be seen. Full study here.