Opportunities to Reduce Waste in U.S. Health Care System Abound
Researchers estimated the cost of waste in the U.S. health care system at between $760 billion to $935 billion per year, accounting for 25 percent of health care spending. To develop the estimate, they focused on six domains: failure of care delivery (accounting for $102.4 to $165.7 billion in waste), failure of care coordination ($27.2 billion to $78.2 billion), overtreatment or low-value care ($75.7 billion to $101.2 billion), pricing failure ($230.7 billion to $240.5 billion), fraud and abuse ($58.5 billion to $83.9 billion), and administrative complexity ($265.6 billion). The study notes the potential savings from interventions that reduce waste, excluding savings from reducing administrative complexity, range from $191 billion to $282 billion. The findings are extrapolated from data from peer-reviewed publications, government-based reports, and reports from the gray literature. William H. Shrank, Teresa L. Rogstad, and Natasha Parekh, “Waste in the U.S. Health Care System: Estimated Costs and Potential for Savings,” Journal of the American Medical Association 322, no. 15 (October 2019):1501–9.
Participation in Food Stamp Program Reduces Mortality Rate
A study examining the relationship between participation in the Supplemental Nutrition Assistance Program and premature mortality among adults found participation in the largest food assistance program in the U.S. led to a population-wide reduction of 1-to-2 percentage points in mortality from all causes and a reduction in specific causes of death among people ages 40 to 64. The authors say more research is needed to understand the impact of the program on health outcomes for conditions influenced by nutrition (e.g., hypertension, hypoglycemia, and obesity). Colleen M. Heflin, Samuel J. Ingram, and James P. Ziliak, “The Effect of the Supplemental Nutrition Assistance Program on Mortality,” Health Affairs 38, no. 11 (November 2019):1807–15.
Strategies for Tailoring Quality Improvement Efforts for High-Need Populations
The authors of this commentary in the Journal of the American Medical Association suggest that recent national initiatives to improve the quality of U.S. health care have had limited impact because they are too diffuse and fail to target the most important issues for specific groups of patients. They recommend ways of customizing quality improvement programs for three subpopulations: patients with advanced illness near the end of life, frail older adults, and nonelderly disabled patients with serious mental illness. For patients nearing the end of life, they recommend the Centers for Medicare and Medicaid Services (CMS) track the number of healthy days at home to ensure patients’ general preferences to remain at home are honored. For frail older adults, they suggest CMS concentrate on reducing potentially avoidable hospitalizations and monitor not just hospitalizations but emergency department (ED) visits and observation stays related to ambulatory care–sensitive conditions. For nonelderly disabled patients with serious mental illnesses, they suggest supporting programs that integrate primary care and mental health services and tracking excess spending related to acute care services that result from inadequate management of mental illnesses. Jose F. Figueroa, Kathryn E. Horneffer, and Ashish K. Jha, “Disappointment in the Value-Based Era: Time for a Fresh Approach,” Journal of the American Medical Association 322, no. 17 (November 2019):1649–50.
Commercial Accountable Care Organization Reduces Outpatient But Not Inpatient Spending
A study evaluating the long-term impact of a commercial accountable care organization (ACO) on health care spending, utilization, and quality outcomes among continuously enrolled members found the ACO improved outpatient process measures modestly and slowed outpatient spending growth by the fourth year of operation, but had a negligible impact on inpatient cost, use, and quality measures. The two ACO cohorts studied had increased inpatient and outpatient spending in the first two years of ACO operation. The reductions in outpatient spending in the latter two years came from reduced primary care visits and lower spending on specialists, testing, and imaging. The researchers found no differential changes in inpatient spending, utilization, and quality measures for most of the five years, and favorable results for several quality measures in preventive and diabetes care domains in at least one of the five years. Hui Zhang et al., “Five-Year Impact of a Commercial Accountable Care Organization on Health Care Spending, Utilization, and Quality of Care,” Medical Care 57, no. 11 (November 2019):845–54.
Chronic and Acute Health Care Needs Higher for Children in Food Insecure Households
Researchers found for children, household food insecurity was related to significantly worse general health, some acute and chronic health problems, and worse health care access, including forgone care and heightened emergency department (ED) use. Compared with rates in households that were not food insecure, children in food insecure households had rates of lifetime asthma diagnosis and depressive symptoms that were 19.1 percent and 27.9 percent higher, respectively; rates of forgone medical care that were 179.8 percent higher; and rates of ED use that were 25.9 percent higher. No significant differences were observed for most communicable diseases, such as ear infections or chicken pox, or conditions that may develop more gradually, including anemia and diabetes. Margaret M. C. Thomas, Daniel P. Miller, and Taryn W. Morrissey, “Food Insecurity and Child Health,” Pediatrics 144, no. 4 (October 2019):e20190397.
Lack of Access to Specialists in Rural Communities Linked to Preventable Hospitalizations and Deaths
Researchers found lack of access to specialists was associated with higher rates of mortality and preventable hospitalizations for rural Medicare beneficiaries living with complex chronic conditions. They found that rural residence was associated with a 40 percent higher preventable hospitalization rate and a 23 percent higher mortality rate while having one or more specialist visits during the previous year was associated with a 15.9 percent lower preventable hospitalization rate and a 16.6 percent lower mortality rate. The researchers found having access to specialists accounted for 55 percent and 40 percent of the rural–urban difference in preventable hospitalizations and mortality, respectively. Kenton J. Johnston, Hefei Wen, and Karen E. Joynt Maddox, “Lack of Access to Specialists Associated with Mortality and Preventable Hospitalizations of Rural Medicare Beneficiaries,” Health Affairs 38, no. 12 (Dec. 2019):1993–2002.
Rural Counties with Black or Indigenous Populations Suffer Highest Rates of Premature Death
Researchers using county-level data to measure and compare premature death rates in rural counties by each county’s majority racial/ethnic group found that premature death rates were significantly higher in rural communities with a majority of non-Hispanic black or American Indian/Alaska Native residents than in rural counties with a majority of non-Hispanic white residents. They recommend that policymakers seeking to improve rural health focus on racially diverse communities and address economic vitality to mitigate health inequities and the harmful health effects of neglecting social determinants of health. Carrie E. Henning-Smith et al., “Rural Counties with Majority Black or Indigenous Populations Suffer the Highest Rates of Premature Death in the U.S., Health Affairs 38, no. 12 (December 2019): 2019–26.
Risk of Severe Maternal Morbidity and Mortality Higher in Rural Communities
Researchers who analyzed data on severe maternal morbidity and mortality during childbirth hospitalizations among rural and urban residents found severe maternal morbidity and mortality increased among both rural and urban residents in the study period, from 109 per 10,000 childbirth hospitalizations in 2007 to 152 per 10,000 in 2015. After controlling for sociodemographic factors and clinical conditions, they found that rural residents had a 9 percent greater probability of severe maternal morbidity and mortality, compared with urban residents. They say attention to both clinical factors (workforce shortages, low patient volume, and the opioid epidemic) and social determinants of health (transportation, housing, poverty, food security, racism, violence, and trauma) are necessary to reduce maternal morbidity and mortality in rural areas. Katy Backes Kozhimannil et al., “Rural-Urban Differences in Severe Maternal Morbidity and Mortality in the U.S., 2007-15,” Health Affairs 38, no. 12 (December 2019):2077–85.
Social Needs Navigation Reduces Utilization Among Some Groups
Researchers found a telephonic social needs screening and navigation program led to significant decreases in utilization among low–socioeconomic status patients but had modest effects on the population overall. The program focused on patients who were predicted to be high utilizers of outpatient, ED, and inpatient services (the highest 1% of total utilization in a large integrated health system). They found most patients screened (53%) reported social needs but only a minority (10%) with a need were able to connect with resources to address those needs. They found total utilization visits decreased 2.2 percent in the intervention group but decreases in total utilization were greater for certain subgroups: those in low-income areas (-7%), in low-education areas (-11.5%), and those covered by Medicaid (-12.1%). Adam Schickedanz et al., “Impact of Social Needs Navigation on Utilization Among High Utilizers in a Large Integrated Health System: A Quasi-Experimental Study,” Journal of General Internal Medicine 34, no. 11 (November 2019):2382–9.
Ensuring Greater Spending on Primary Care Yields Savings
In a commentary in the Journal of the American Medical Association, the authors explore the reasons that increased spending on primary care may not yield downstream savings and recommend that policymakers consider complementary delivery system interventions to ensure savings, such as regulation to address rising prices or value-based insurance design to lower cost-sharing for preventive care. They also suggest policymakers consider enhancing the substance of primary care by equipping practices to address the social determinants of health, reducing the administrative burden on practices to create more time for patient care, and changing malpractice laws to lessen defensive medicine. Zirui Song and Suhas Gondi, “Will Increasing Primary Care Spending Alone Save Money,” Journal of the American Medical Association 322, no. 14 (October 2019):1349–50.
Assessing Medicaid Expansion’s Impact on Health
The authors of this commentary in the Journal of the American Medical Association summarize the evidence to date on whether Medicaid expansion has resulted in improved health for low-income residents. They describe studies that have documented improvements in self-reported health; some, but not all, acute and chronic disease outcomes; and mortality reductions. They say the literature is less definitive on whether Medicaid expansion increases access to care and promotes financial well-being. Going forward, they recommend researchers focus on whether low-income populations are healthier after gaining Medicaid coverage and whether Medicaid expansion is the most effective or efficient means of improving health or whether alternative investments in private insurance expansion, social services, or direct safety-net funding would be more or less effective ways of doing so. Heidi Allen and Benjamin D. Sommers, “Medicaid Expansion and Health: Assessing the Evidence After 5 Years,” Journal of the American Medical Association 322, no. 13 (October 2019):1253–54.
Medicaid Work Requirement in Arkansas Sowed Confusion, Declines in Enrollment
A survey of low-income adults in Arkansas, which imposed work requirements on Medicaid beneficiaries in 2018, found the requirement was associated with significant losses of health insurance coverage in the initial six months of the policy but no significant change in employment. The authors say lack of awareness and confusion about the reporting requirements may explain why thousands lost coverage even though 95 percent of the target population appeared to meet the requirements or qualify for an exemption. They estimate the state reduced Medicaid enrollment by 12 percentage points. Benjamin D. Sommers et al., “Medicaid Work Requirements — Results from the First Year in Arkansas,” New England Journal of Medicine 381, no. 11 (September 2019):1073–82.