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.
Study by: Gary Claxton, Matthew Rae, Cynthia Cox, and Larry Levitt
When an individual receives medical care outside of their health insurance plan’s established network of providers, they are required to pay out-of-network (OON) rates for that care. In practice this means the amount the individual pays in cost sharing is significantly higher than it would have been had they received the same service from an in-network provider. Recent research has made it clear that individuals are frequently being exposed to OON rates- often times through no fault of their own. A new study from the Kaiser Family Foundation analyzes insurance claims from almost 20 million individuals enrolled in large employer plans and shows that 17.6 percent of all inpatient admissions include a claim from an OON provider. Furthermore, the analysis shows especially high rates of OON billing for individuals receiving emergency care, surgery, or psychological and substance abuse treatment in an inpatient setting; even if they are treated at an in-network facility. The study also shows that while only 7.7 percent of all individuals receiving outpatient care are faced with OON provider claims, the rate is actually much higher for individuals receiving outpatient mental health services, emergency care, and anesthesia. The findings of this study are supported by other recent analyses of insurance claims data that also found an alarmingly high frequency of OON provider charges and highlight the importance of finding ways to protect consumers from OON charges through regulation or legislation. Full study here.
Study by: Anuj Gangopadhyaya, Emily M. Johnston, Genevieve M. Kenney, and Stephen Zuckerman
This past January, the Centers for Medicare & Medicaid Services approved Kentucky’s Section 1115 Medicaid waiver that requires Medicaid beneficiaries (with a few exceptions) to participate in work or community engagement activities for at least 80 hours a month in order to retain their coverage. A new study estimates the size of potential Medicaid coverage losses among working Kentucky enrollees who do not qualify for an exemption under this new policy. Researchers found that one-third of nondisabled, nonelderly working individuals who do not qualify for an exemption, roughly 55,000 individuals, could be at risk of losing their Medicaid coverage either because they worked fewer hours than required or did not work consistently enough throughout the year. While a goal of the work requirement program is to create incentives for individuals to obtain and maintain coverage through employer-sponsored insurance (ESI), many working enrollees are ineligible for ESI due to the part-time nature of their work, and for those who are eligible, obtaining ESI is often cost-prohibitive. The researchers concluded that the structure of Kentucky’s Medicaid waiver does not align with the reality of some working enrollees’ lives, wherein many are working more than enough hours to satisfy requirements, but just not enough in the right weeks. Full study here.
Study by: Alice J. Chen, Amy J. Graves, Matthew J. Resnick, and Michael R. Richards
The Affordable Care Act included a temporary 10 percent fee increase for primary care visits provided to Medicare beneficiaries in an attempt to encourage primary care workforce participation and improve access to care. A new study examining whether this policy adequately incentivized primary care providers (PCPs) to increase their Medicare caseload finds limited evidence of an increase in PCP visits following the fee increase. Specifically, PCPs in independent practices demonstrate, at most, a 2 percent increase in patient visits. Furthermore, there was no change in Medicare primary care caseloads for PCPs that are horizontally and vertically integrated into health systems. The researchers estimate the fee bump introduced a $1.5 billion transfer during the first three years of the programs. “These findings call into question the wisdom of public insurance programs relying on a fee-for-service mechanism and unconditional contracting to induce better health system performance. Such policy levers can be attractive due to their simplicity and political appeal but may risk inefficiencies,” write the authors. Full study here.
“Another possible factor behind the lack of impact was the temporary nature of the fee increase, which would limit investments to expand services as well as another policy goal for the fee increase, which was to make primary care more attractive by increasing its relative compensation.”
-Paul Ginsburg, PhD, Director, USC-Brookings Schaeffer Initiative for Health Policy