How do low-income enrollees in the Affordable Care Act marketplaces respond to cost-sharing?

The Affordable Care Act requires insurers to offer cost-sharing reductions (CSRs) to low-income consumers on the marketplaces. We link 2013–2015 All-Payer Claims Data to 2004–2013 administrative hospital discharge data from Utah and exploit policy-driven differences in the actuarial value of CSR plans that are solely determined by income. This allows us to examine the effect of cost-sharing on medical spending among low-income individuals. We find that enrollees facing lower levels of cost-sharing have higher levels of healthcare spending, controlling for past healthcare use. We estimate demand elasticities of total health care spending among this low-income population of approximately −0.12, suggesting that demand-side price mechanisms in health insurance design work similarly for low-income and higher-income individuals. We also find that cost-sharing subsidies substantially lower out-of-pocket medical care spending, showing that the CSR program is a key mechanism for making health care affordable to low-income individuals.     

Managed care, consolidation among health care providers, and health care: evidence from mammography

We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.     

Will employee choice and defined contribution health plans salvage the embattled managed care system?

Defined contribution or consumer-driven health approaches will shift to employees not just the risks and rewards of the managed care system, but also decisions that will determine whether that system can survive. This article reviews the current state of the employer-sponsored health care system, describes defined contribution and consumer-driven health plan concepts, and outlines the approaches and steps employers can take to implement them. The author argues that, if fully implemented, such approaches could salvage the embattled managed care system by giving employees a financial stake in controlling medical costs while educating them to wisely take control of health plan spending decisions.     

Health care spending accounts: a flexible solution for Canadian employers

Flexible benefits plans have grown more slowly in Canada than in the United States, largely because of certain legal and regulatory considerations. Health care spending accounts (HCSAs) provide a cost-effective way for Canadian employers to address the health care benefit needs of a diverse workforce. A flexible health care spending account is a versatile and cost-effective instrument that can be used by Canadian employers that wish to provide a full range of health care benefits to employees. The health care alternatives available through an HCSA can provide employees with an opportunity to customize and optimize their benefits program. Regulatory requirements that an HCSA must meet in order to qualify for available tax advantages are discussed, as are the range of health care services that may be covered.     

Community health care in developing countries

Health care systems in many developing countries have shared characteristics. Government expenditures in poor countries are low for health care. The majority of people cannot easily reach a modern health facility. Most spending is for high-cost curative medicine, e.g., hospitals. Programs are often inefficient in their use of funds. The tragedy of disease in developing countreis is that many of the most serious problems are either preventable or curable by simple, inexpensive, safe methods. About 16 million children under age 5 died in 1979 in developing countries; 5 million of these deaths could have been prevented by immunization against measles, polio, tetanus, diphtheria, whooping cough, and typhoid. Many countries are establishing community-level health care facilities that use community health workers instead of doctors. A 3-tiered program is being adopted in some areas: the community health center, the rural or urban polyclinic, and the referral hospital. The community health center seeks to provide two-thirds of the needed services, including supervision of pregnancy, midwifery, care of new-born children, treatment of endemic diseases, and emergency care for injuries. Early experience has taught that it is more important for the community health worker to have practical experience and the respect of the people he serves than formal education. Improvements in nutrition, hygiene, and sanitation are needed to reach the full health potential of most communities.     

Single-payer health care systems: the roles and responsibilities of the public and private sectors

Health care systems all over the world are experiencing some change as they look for a new balance between supply and demand. This article provides context for the U.S. health care financing debate by examining the health care systems of five other countries: Canada, the United Kingdom, Australia, China and India. The authors show that, with few exceptions, countries around the world have seen an increase in both government and private health care spending between 1998 and 2002. The authors also demonstrate that employers throughout most of the world are becoming more, rather than less, involved in the funding and delivery of health care to employees and their dependents-even among nations with so-called single-payer health systems.     

Finding a lasting cure for U.S. health care

In "Making Competition in Health Care Work" (July-August 1994), Elizabeth Olmsted Teisberg, Michael E. Porter, and Gregory B. Brown ask a question that has been absent from the national debate on health care reform: How can the United States achieve sustained cost reductions while at the same time maintaining quality of care? The authors argue that innovation driven by rigorous competition is the key to successful reform. A lasting cure for health care in the United States should include four basic elements: corrected incentives to spur productive competition, universal insurance to secure economic efficiency, relevant information to ensure meaningful choice, and innovation to guarantee dynamic improvement. In this issue's Perspectives section, eleven experts examine the current state of the health care system and offer their views on the shape that reform should take. Some excerpts: "On the road to innovation, let us not forget to develop the tools that allow physicians, payers, and patients to make better decisions." I. Steven Udvarhelyi; "Health care is not a product or service that can be standardized, packaged, marketed, or adequately judged by consumers according to quality and price." Arnold S. Relman; "Just as antitrust laws are the wise restraints that make competition free in other sectors of the economy, so the right kind of managed competition can work well in health care." Edward M. Kennedy "Biomedical research should be considered primarily an investment in the national economic well-being with additional humanitarian benefits." Elizabeth Marincola.     

The customer satisfaction factor: the value of conducting employee evaluations of managed care networks

Gathering customer satisfaction information is an idea whose time has come. Employers conducting employee evaluations of their managed care networks find the data valuable from both a strategic and a tactical standpoint. The thoughtful, intelligent use of such data can lead to more effective health care management.     

Preparing for Medicaid managed care

As Medicaid enrollment continues to rise, hospitals and health systems could benefit from contracting with Medicaid managed care plans. Providers need to establish a Medicaid managed care strategy before beginning the contracting process. Revenue cycle leaders need to ensure that their front-end processes related to patient access, billing, and denials management are compatible with Medicaid managed care.     

Editorial

This article uses international comparisons to demonstrate the UK's relatively low spending on health care services and considers why extra money is being raised from National Insurance Contributions rather than from other sources of tax revenue. It outlines various options for measuring the UK-EU health spending gap and finds that they yield substantively different estimates of the size of the spending gap to be filled. It explains why closure of that gap may be aided by enlargement of the EU. It concludes that closure of the spending gap may be as much or more the result of accident than of design.     

Financing Higher NHS Spending from Increased National Insurance

This article uses international comparisons to demonstrate the UK's relatively low spending on health care services and considers why extra money is being raised from National Insurance Contributions rather than from other sources of tax revenue. It outlines various options for measuring the UK–EU health spending gap and finds that they yield substantively different estimates of the size of the spending gap to be filled. It explains why closure of that gap may be aided by enlargement of the EU. It concludes that closure of the spending gap may be as much or more the result of accident than of design.     

New post‐ACA insurance data highlights health insurer spending on health care quality

Following the Patient Protection and Affordable Care Act (ACA), annual financial reports by commercial health insurers include more detailed information on a Supplemental Health Care Exhibit. In this new exhibit, insurers illustrate spending on the provision of medical services and associated expenses. These expenses, which were commonly reported as “claims adjustment” and “general administrative” expenses, can now be allocated to several new categories of expenses associated with combatting fraud and improving patient health care quality. This article illustrates that quality improvement expenses have increased significantly in the individual, small group, and large group markets following implementation of the ACA. Of the five types of quality expenses reported, the greatest proportion of spending has been toward the improvement of health outcomes and the most pronounced increase from 2011 to 2017 has been spending toward increased wellness and health promotion activities, which include activities such as wellness assessments and coaching programs for patients with chronic diseases. Given that the ACA was designed not only to broaden access to health insurance but also to improve health, analysis of the allocations to various types of quality improvement activities highlights the private market's contribution to improving the health of the US population.     

Employers' liability risk for managed care injuries

Concerns about employer liability are a major public policy barrier to expanding tort liability for managed health care organizations. To evaluate the extent of these legal concerns, interviews were conducted with key informants, selected to represent a range of legal and demographic characteristics nationwide. These subjects reported a low level of existing concern about liability arising from managed health care, and few indicated that an increase in this threat would likely cause them to drop health benefits. Instead, most said employers would take a wait-and-see approach to theoretical liability threats and would consider responses short of dropping coverage, such as switching to fully insured health benefits, or from defined benefits to defined contributions.     

The history of employment-based health insurance: the role of managed care

The author describes the history of how the employment-based health benefits system has evolved. Specifically, he examines how we got where we are today, the success of managed care, the shortcomings of the managed care system and challenges that the managed care system will face in the future. He concludes that, despite substantial improvements in the quality of medical services provided, employers have a long way to go before they are truly purchasing the highest quality health care at the most efficient prices.     

Ethical considerations in health care benefits administration

Defining the scope of coverage and limitations in various health plans has become an increasingly difficult and confusing issue. The historical shift to managed care has fundamentally altered the limitations on health care benefits. Because of the existence of "benefits exclusions," confusing issues have emerged in managed care situations. Fundamental fear of health care rationing has raised the awareness of the general public to the ethics of this issue. This article discusses the definitions and examples of certain types of health benefit exclusions and the ethical considerations related to such exclusions.     

Does competition under Medicare Prospective Payment selectively reduce expenditures on high-cost patients?

Competition and prospective payment have been widely used to control health care costs but may together provide incentives to selectively reduce expenditures on high-cost relative to low-cost patients. We use patient discharge and hospital financial data from California to examine the effects of competition on costs for high- and low-cost admissions in the 12 largest Diagnosis-Related Groups before and after the Medicare Prospective Payment System (PPS). We find that competition increased costs before PPS, but that this effect decreased afterward, especially inpatients with the highest costs.We conclude that competition and PPS selectively reduced spending among the most expensive patients and that careful assessment of these patients' outcomes is important.     

Hospital managed care diversification and reinsurance strategies

As increasing numbers of patients enroll in managed care plans, health care providers are faced with new operational and financial challenges. This article, the fourth in a series on the financial perils of managed care contracting, addresses issues related to diversification of risk and reinsurance.     

Leaving an unethical managed care plan: an exploratory look at doctors' intentions

To address the problems of unnecessary care and limited resources, managed care health insurance programs have become commonplace. With managed care programs, however, physicians are facing increasing pressures. This article briefly considers four ethical situations that doctors face under managed care systems. The article surveys a national random sample of general practitioners and surgeons to determine how doctors would respond to these dilemmas and the extent to which exposure to such situations influences them to leave a managed care plan.     

Managed care: why is it "better"

Of the health care "solutions" available today, only managed care is capable of earning health care a competitive role in the nation's consumer-driven marketplace.