New Brief – Medicaid Buy-in: A State Option to Expand Access to Coverage

Some states have encountered rising premiums, consolidating markets, and the flight of insurers from some counties in their insurance exchanges. In response, some states are considering developing a Medicaid-buy-in plan, which would open their Medicaid managed care programs to consumers shopping for coverage in their exchanges. Under the concept, consumers eligible for insurance exchange subsidies could use them to purchase coverage in a Medicaid managed care plan. Read more

Antibiotic prescribing down but more needs to be done

In the past seven years, per person antibiotic prescriptions have declined 9%, according to a report by the Blue Cross Blue Shield Association. The rate declined even faster for children and infants. Overuse of antibiotics is blamed for contributing to the rise of antibiotic-resistant bacteria or “superbugs”. Every year 2 million Americans become infected with bacteria that do not respond to antibiotics and 23,000 die of that illness. Public health officials have been working to bring down the rate of antibiotic prescribing, especially for conditions that do not respond to antibiotics, e.g. most colds which are caused by viruses. Antibiotic prescription rates were 16 times higher in rural areas.  States vary significantly in the rate of antibiotic prescribing, suggesting areas to target with public education campaigns.

 

In more good news, the biggest drop in prescribing was for broad spectrum antibiotics, the most likely to trigger antibiotic resistance, which declined 13% from 2010 to 2016. Unfortunately, a great deal of work remains. The study found that last year 63% of antibiotics were prescribed for conditions which might be appropriate and another 21% for conditions which were not indicated.

Antibiotic prescriptions filled per 100 people, 2016 Rank among states Percent change in antibiotic prescribing, 2010 to 2016
CT 82.7 17th highest -8%
DE 82.5 18th +3%
ME 64.4 42nd -11%
MD 72.5 32nd -9%
MA 67.1 37th -11%
NH 67.0 38th -6%
NJ 72.7 31st -13%
NY 79.2 24th -13%
PA 85.1 16th -6%
RI 81.8 19th -15%
VT 59.1 46th -5%
US 82.6   -9%

Uninsured rates continue to improve, ERC lower than other regions

Three sources of new data on the rate of uninsurance find similar results and, mostly, good news. Reports include 2016 Census coverage data, early 2017 coverage data from the CDC, and a Commonwealth Fund survey also from 2017. All find the percent of uninsured Americans continues to fall, especially in states that chose to expand Medicaid under the ACA. Across the ERC region, the number of uninsured dropped over 2.5 million from 2013 to 2016. However, the Commonwealth Fund survey found that the uninsured rate among adults in three subpopulations increased – people with incomes above the federal subsidy level (not surprising as premiums have grown substantially), but also 35 to 49 year olds, and adults in Medicaid non-expansion states. All three sources found that uninsured rates in the ERC region remain below the national average. According to the Census, as in the past Massachusetts residents were the most likely to be insured among all states last year.

Uninsured rate 2016 Difference in number of uninsured, 2013-2016 Percent covered by Medicaid, 2016
US   -17.876 million 20.9%
CT 25,551 -160,000 20.5
DE 17,784 -30,000 20.3
ME 23,257 -41,000 19.2
MD 137,592 -230,000 18.0
MA 185,578 -76,000 23.5
NH 17,946 -63,000 13.8
NJ 230,960 -455,000 17.2
NY 684,625 -887,000 26.3
PA 342,268 -514,000 19.9
RI 36,262 -75,000 22.1
VT 5,305 -22,000 26.2

State CHIP programs at risk without federal action

MACPAC estimates that, without federal extension of funding for the CHIP program, all states will run out of funds by July of next year. Three states and the District of Columbia will run out of CHIP funds by the end of this year without federal action. Created by Congress in 1997, the CHIP program has provided coverage to 3.67 million children across the US living in families with incomes just over the Medicaid limit. Like Medicaid, CHIP is jointly funded by states and the federal government, but is administered by states. Current CHIP funding expires on September 30th of this year. The program has bipartisan Congressional support but advocates are concerned that legislation to extend CHIP could serve as a vehicle to cut Medicaid or repeal parts of the Affordable Care Act.

Children ever served by CHIP through FY 2016 Month state projected to exhaust CHIP funding without federal extension
CT 25,551 February 2018
DE 17,784 February 2018
ME 23,257 June 2018
MD 137,592 April 2018
MA 185,578 February 2018
NH 17,946 April 2018
NJ 230,960 April 2018
NY 684,625 March 2018
PA 342,268 February 2018
RI 36,262 January 2018
VT 5,305 January 2018t

New data shows more employees in high deductible plans, rate varies considerably by state

Analysis of new federal data by SHADAC finds that almost half (43%) of people covered by employer-sponsored health plans were in high-deductible plans last year, up from 30% from 2013. For purposes of this study, high-deductible plans are defined as meeting the minimum deductible amount required for Health Savings Account eligibility ($1,300 for an individual and $2,600 for a family in 2016). But that rate varies considerably between states. Within the ERC region and among all states, New Hampshire was highest last year with 59.3% of employees in high deductible plans.

 

The survey found little change in the percent of employers offering coverage from 2015 to 2016. Premium growth was offset by the 10.1% ($155) growth in average deductibles. Four of the five most expensive states for single coverage premiums were in the ERC region last year – Rhode Island, New Hampshire, Massachusetts and New York.

Employees in high-deducible health plans, 2016 Rank among states Employees in high-deducible health plans, 2013 Increase 2013 to 2016
CT 59% 3rd highest 40% 19%
DE 46% 22nd 29% 17%
ME 56% 8th 47% 9%
MD 44% 27th 25% 19%
MA 39% 41st 23% 16%
NH 69% The highest 50% 19%
NJ 41% 36th 26% 15%
NY 39% 39th 22% 17%
PA 37% 42nd 25% 12%
RI 40% 37th 27% 13%
VT 44% 31st 37% 7%
US 43%   30% 13%

CMS finalizes important patient-friendly informed consent payment proposal

CMS has finalized their proposed Medicare rule (regulation) for how hospitals are paid that includes a new measure assessing the quality of hospital informed consent documents given to patients before elective procedures. (The relevant section, Potential Inclusion of the Quality of Informed Consent Documents for Hospital-Performed, Elective Procedures Measure starts here on p. 373 of the pdf file – p. 38362 of the Federal Register Rules and Regulations 82:155, 8/14/17). The rule will make an important difference in supporting patient-centered care in hospitals across the US. The current state of hospital informed consent documents is embarrassingly poor. Under this rule, the 4,700 US hospitals that treat Medicaid members will be paid, in part, based on the quality of their informed consent documents. The measure may also be included in public quality comparisons such as Hospital Compare, allowing patients to use this measure in choosing between hospitals for their care.

Survey of state legislators’ values for health reform finds strong differences by party but some encouraging overlap

Both Democratic and Republican state legislators from across the US agree on the need to control health care costs, according to a new survey published in the American Journal of Public Health. However, other top priorities between the parties differ strongly. Republicans prioritized smaller government along with reducing costs while Democrats prioritize improving health equity with cost control. Republicans were split among themselves between prioritizing improving overall health and reducing government involvement in health care. The authors suggest that this reflects a split in the party between moderates and conservatives. There was no difference between legislators based on geography or legislative chamber. The results suggest opportunities for bipartisan progress on health reform, especially on controlling costs. The survey was supported by the Commonwealth and Milbank Memorial Funds.

State policymakers hear how bioscience is generating jobs with health innovation

The growing Bioscience industry holds great potential to improve the region’s economy and health , according to speakers at “Bioscience Initiatives: Improving Health and Growing the Economy” at this week’s CSG-ERC Annual Meeting in CT. Panelists included Mostafa Analoui, PhD, Executive Director, UConn Venture Development, Mike Hyde, Vice President, External Affairs, The Jackson Laboratory, and Jon Soderstrom, Ph.D., Managing Director of the Office of Cooperative Research, Yale University. The Northeast has a unique bio-medical ecosystem with considerable capacity to spawn innovative new bioscience companies and to meet those companies’ need for talented workers. Bioscience has attracted hundreds of millions of dollars in private equity and venture capital funding to CT alone. New companies are driving research, developing new drugs and treatments, and leading cutting edge fields such as genomic medicine. UConn has created a Technology Incubation Program supporting dozens of new bioscience ventures across industries. The 88-year old nonprofit scientific research institute, Jackson Labs, has brought 320 well-paying jobs and hundreds of millions of dollars to their new CT site. Yale has created 40 new biotech companies in the Greater New Haven area and more are forming.

State health policymakers get the latest from DC and options to respond

At this week’s CSG-ERC Annual Meeting in CT, state policymakers from across the Northeast got updates from experts on the federal health care landscape, state options to adapt. CT’s Lieutenant Governor Nancy Wyman pulled it all together describing CT’s progress toward health reform. Mitchell Stein gave a detailed summary of federal activity including CHIP reauthorization (ends Sept. 30 without action), tax bills and raising the debt limit which all could impact Medicaid and/or the Affordable Care Act. He re-capped ACA repeal efforts and the status of insurance exchanges including cost-sharing reduction payments, underserved counties, premium levels and degradation of the risk pool. It’s estimated that about half of premium rates for next year are due to uncertainty about ACA implementation. He outlined what is likely to happen this fall and potential state responses including reinsurance waivers and creating a Medicaid buy-in option.

 

Policymakers then heard from Chris Koller, President of the Milbank Memorial Fund, on the big picture and states’ capacity to address the quickly changing environment. He reminded policymakers about the importance of social services in health outcomes and America’s poor performing health system that costs more and delivers less than other countries. He outlined concerns about slow economic growth’s impact on the health of poorer populations and government’s ability to address that stress, rising health disparities, and political changes. Probably his most popular slide described the results of a Milbank survey of state legislators finding that Democrats and Republicans have very different goals and values for health reform. Republicans are most interested in reducing costs while Democrats prioritize improving health and equity. The federal government is delegating more health policymaking to states, while Medicaid costs rise, crowding out other priorities. In good news, he highlighted Georgia’s progress in reducing infant mortality, and Delaware’s success in addressing chronic illnesses, with lessons learned. He emphasized that states need to get creative in building state health policy capacity and shared a roadmap to get there.

 

Lieutenant Governor Nancy Wyman ended the meeting by recapping what we heard and describing CT’s long history of success in reforming health care and expanding access. She outlined work creating AccessHealthCT, outreach efforts that cut CT’s uninsured rate in half, Medicaid reforms, and support for primary care and prevention with the state employee plan’s Health Enhancement Program.

 

This was followed by a lively question and answer discussion touching on the relationship between health care industries and jobs, state options to create a reinsurance program and/or require all individual coverage be sold on the insurance exchange, the role of 1332 waivers, the role of family caregivers, end of life care costs, and comparisons with the Canadian system.

 

More information on state reinsurance programs and Medicaid buy-in options will be coming.

The Future of Medicine in the Human Genome Genomics — Making a difference in patients’ lives / By Mary Branham

From CSG-ERC’s Annual Meeting in Connecticut

Mapping the first human genome in 2000 cost about $4 billion; today, it costs about $1,000.

The cost has come down because of investment, and because of the important role genomics is playing in medicine today, according to Dr. Murat Gunel, a professor of neurosurgery, genetics and neuroscience at Yale University, who spoke during Sunday’s luncheon plenary, “Genomics and Precision Medicine: Investing in the Future of Health Care.”

“We have all recognized the power of genomics,” Gunel said. “This is clinical. This is making a difference in our patients’ lives everyday.”

Plus, he said, “this is the new Internet race.” Various nations are investing in the research, recognizing the main race now is learning how to decode the genomic makeup of people to understand their diseases. It is one of four areas in which China is making multi-billion dollar investments. The U.S. also has made significant investments in the area, starting with the 2000 investment in mapping the first genome.

“You can imagine the impact it will have on our health care system if you can predict a disease before it starts,” he said.

Now, for the most part, while the ability to diagnose disease is evolving, treatments are often a best guess based on effectiveness over a general population. Genomic testing will allow for precision—also referred to as individualized—medicine to treat patients based on many factors.

But, Gunel cautioned, “genomics in isolation does not mean much.”

He said that information must be combined with what is known about the quality of the air or water in a person’s environment or about how much they exercise, for example.

Having that information for individuals can help them tailor their lifestyles to improve their health. Even so, Gunel said a bigger purpose would be to use that information in population health. Precision medicine has already seen some success, such as addressing newborn diseases, prenatal diagnosis, pharmacogenomics and individualized treatment for cancer, he said.

That’s because genomic testing has increased the number of genes that can be tested. Gunel said cancer patients are looked at with regard to their genomic makeup. That ability has helped bring a 30 percent cure rate for metastatic melanoma, he said.

It’s changing the way diseases are treated. For instance, now everyone diagnosed with lung cancer is given the same treatment, according to Gunel. With genomic testing, physicians are able to understand the baseline risks individuals have and make specific lifestyle recommendations to help prevent the diseases. Then, if the disease occurs, “we could diagnose it faster and give more effective and more individualized treatments.”

While precision medicine will have major impacts on health care, Gunel said it could also bring $1 trillion in economic growth. That could impact the development of things like new medicines and the creation of new fields to fill such roles as genetic counseling and computational biology—the people who can run the artificial intelligence (AI) in the data center.

“We think the number of people we are going to need in that field is going to ramp up tremendously,” said Rich Lisitano, vice president at Yale-New Haven Hospital.