Health Policy Research

Reports

• "Medicaid Analytic Extract Provider Characteristics (MAXPC) Evaluation Report, 2010." Deo Bencio, July 2013. This report describes the motivation for creating the MAXPC file and its design and content. It also examines the quality and completeness of each of the six types of provider IDs (inpatient billing provider, long-term care billing provider, other services billing and servicing provider, and prescription drug billing and prescribing providers). The analysis focuses on the 45 states that had the requisite Medicaid Statistical Information System files available for calendar year 2010 services (Idaho, Kansas, Maine, New Jersey, North Dakota, and Utah are excluded). The quality and completeness vary substantially by state and type of provider ID.
• "Potential Impact of the Affordable Care Act on the Ryan White HIV/AIDS Program." Margaret Hargreaves, Vanessa Oddo, Ann Bagchi, and Boyd Gilman, November 2012. This report assesses and identifies ways in which the Affordable Care Act (ACA) could potentially affect the Ryan White HIV/AIDS Program community. It recommends comprehensive steps to support a successful transition from current health care delivery, financing, and payment systems to changes under ACA implementation in 2014. These steps include stakeholder engagement, cross-agency collaboration, outreach, and building organizational capacity.
• "Income Measurement for the 21st Century: Updating the Current Population Survey." John L. Czajka and Gabrielle Denmead, November 2012. This report builds on previous research on income data reporting to provide additional analyses and recommendations designed to improve the collection of income data in household surveys. The study was conducted for the U.S. Census Bureau and Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services.
• "Proven Strategies for Missouri Health Care Covergage: Program Outreach and Enrollment." Sean Orzol, June 2013. This report presents findings from a study on outreach and Medicaid enrollment best practices to meet Missouri’s insurance expansions under the Affordable Care Act. The study found that mobilizing a broad network of local partners is key; new messages and partners will be needed to reach a diverse, newly eligible population. Broad enrollment access points, customer-focused assistance, and paperless eligibility determination procedures can also simplify the process. Finally, states should start developing a comprehensive approach to implementing expanded eligibility and modernizing enrollment systems today.
• "Medicaid Analytic Extract Date of Death (MAX DOD) Master File, 2009 Update." Julie Sykes and Shinu Verghese, June 2013. This report describes the creation of the MAX DOD 2009 update file and the MAX DOD 1999–2009 master file. It provides a brief synopsis of the data sources used in this process and presents quality control statistics about both files. The appendices include the file layout, data dictionary, data processing steps, and some frequently asked questions about the DOD information.
• "Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2011." Matthew Kehn, May 2013. This report, prepared for CMS, is the last in a series of annual reports on participation in the Medicaid Buy-In program. It provides updates on both national- and state-level trends in enrollment, employment, and earnings among the 35 reporting Medicaid Infrastructure Grant (MIG) states with a Buy-In program in 2011. Additionally, it addresses recent changes to state program rules and policies, and identifies factors that have affected recent Buy-In program enrollment, as reported by the states in an annual questionnaire.

Journal Articles

• "State Costs of Excessive Alcohol Consumption, 2006." Jeffrey J. Sacks, Jim Roeber, Ellen E. Bouchery, Katherine Gonzales, Frank J. Chaloupka, and Robert D. Brewer. American Journal of Preventive Medicine, October 2013. A new study finds excessive alcohol use causes a large economic burden to states and the District of Columbia. The study found that excessive alcohol use cost states and the District a median of $2.9 billion in 2006, ranging from $420 million in North Dakota to $32 billion in California. This means the median cost per state for each alcoholic drink consumed was almost $2.
• "Association Between Outpatient Visits Following Hospital Discharge and Readmissions Among Medicare Beneficiaries with Atrial Fibrillation and Other Chronic Conditions." Mai Hubbard, Sloane Frost, Kimberly Siu, Nicole Quon, and Dominick Esposito. American Journal of Medical Quality, July 2013 (subscription required). A retrospective analysis of Medicare claims data examined the relationship between outpatient visits within 14 days after hospital discharge and readmission for beneficiaries with atrial fibrillation or other chronic conditions. About half of those beneficiaries with a hospitalization had an outpatient visit within 14 days of discharge. Readmission rates were 11 to 24 percent lower for beneficiaries with an outpatient visit than for those without one. These findings suggest that follow-up care shortly after discharge may lower readmissions for patients with atrial fibrillation or other chronic conditions.
• "Medication Discontinuation and Reinitiation Among Medicare Part D Beneficiaries Taking Costly Medications." Margaret S. Colby, Dominick Esposito, Seth Goldfarb, Daniel E. Ball, Vivian Herrera, Leslie J. Conwell, Susan B. Garavaglia, Eric S. Meadows, and Martin D. Marciniak. American Journal of Pharmacy Benefits, May/June 2013. This study looked at the impact of Medicare Part D coverage gaps by examining drug discontinuation and reinitiation among Medicare beneficiaries using medications for cancer or rheumatoid arthritis. The study found that patients in the arthritis or cancer groups—28 and 21 percent, respectively—discontinued medications for these conditions in 2006; about three-fourths reinitiated therapy in the first 90 days of 2007. Although medication discontinuation is often temporary, the effect is complex. Some patients might discontinue before reaching the coverage gap to avoid out-of-pocket costs. For those who spend into or through the coverage gap before discontinuing, cumulative out-of-pocket expenditures might be too high to resume treatment the following year.
• "Some Hospitals are Falling Behind in Meeting 'Meaningful Use' Criteria and Could be Vuleralbe to Penalties in 2015." Catherine M. DesRoches, Chantal Worzala, and Scott Bates. Health Affairs, August 2013. This article cite progress on the adoption of health information technology (HIT) that meets Medicare’s criteria for “meaningful use.” Through an analysis of Medicare data, the study found a substantial increase in the percentage of hospitals receiving electronic health record incentive payments between 2011 (17.4 percent) and 2012 (36.8 percent). However, critical-access, smaller, and publicly owned or nonprofit hospitals appeared to be at risk of failing to meet the criteria.
• "Medication Continuity Among Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder." Jonathan D. Brown, Allison Barrett, Emily Caffery, Kerianne Hourihan, and Henry T. Ireys. Psychiatric Services in Advance, June 2013. This study examines whether medication continuity among Medicaid beneficiaries with schizophrenia and bipolar disorder was associated with medication utilization management practices (prior authorization, copayment amounts, and refill and pill quantity limits); managed care enrollment; and other state and beneficiary characteristics. The study found that prior-authorization requirements and copayments for medications can present barriers to refilling medications for Medicaid beneficiaries with schizophrenia or bipolar disorder.
• "The Healthy Weight Collaborative: Using Learning Collaboratives to Enhance Community-Based Prevention Initiatives Addressing Childhood Obesity." Margaret B. Hargreaves, Todd Honeycutt, Cara Orfield, Michaela Vine, Charlotte Cabili, Michaella Morzuch, Sylvia K. Fisher, and Ronette Briefel. Jounal of Health Care for the Poor and Underserved, May 2013. This report from the field describes the design, implementation, and early evaluation results of the Healthy Weight Collaborative, a federally supported learning collaborative to develop, test, and disseminate an integrated change package of six promising, evidence-based clinical and community-based strategies to prevent and treat obesity for children and families.
• "Patterns of Older Americans' Health Care Utilization Over Time." Richard J. Manski, John F. Moeller, Haiyan Chen, Jody Schimmel, Patricia A. St. Clair, and John V. Pepper. American Journal of Public Health, July 2013. This study examined the use of physician, inpatient hospital, home health, and outpatient surgery for Americans more than 50 years of age. The study found that overall health and changes in health are more strongly correlated with seeking and using health care over time than financial status or changes to one’s financial status.
• "Adoption of Electronic Health Records Grows Rapidly, But Fewer Than Half of US Hosptials had at Least a Basic System in 2012." Catherine M. DesRoches, Dustin Charles, Michael F. Furukawa, Maulik S. Joshi, Peter Kralovec, Farzad Mostashari, Chantal Worzala and Ashish K. Jha. Health Affairs, July 2013 (subscription required). This article measured current hospital use of electronic health record (EHR) systems using data from the 2012 health IT supplement to the American Hospital Association’s annual survey. According to the data, 44 percent of hospitals report having at least a basic EHR system, a 17 percent increase from 2011 and a near-tripling of the 2010 adoption rate. Also, large urban hospitals continued to outpace rural and nonteaching hospitals. Although 42.2 percent of all hospitals met all the stage 1 meaningful-use criteria, only 5.1 percent had advanced to stage 2. While considerable progress has been made, findings suggest a need for a focus on hospitals still trailing behind, notably small and rural institutions. This focus is especially important as stage 2 meaningful-use criteria become the rule, and positive incentives are replaced by penalties for noncompliance.
• "Meeting Meaningful Use Criteria and Managing Patient Populations: A National Survey of Practicing Physicians." Catherine M. DesRoches, Anne-Marie Audet, Michale Painter, and Karen Donelan. Annals of Internal Medicine, June 2013 (subscription required). More than 40 percent of the nation’s physicians have access to a basic electronic health record (EHR) system; however, implementation of advanced functions for patient management and care coordination is not widespread, according to a study led by Mathematica and the Mongan Institute for Health Policy at Massachusetts General Hospital. Furthermore, when these tools are available, physicians report they are complicated and difficult to use. Many EHR functions, such as electronic data exchange, will be required for physicians to meet the meaningful use criteria of the Centers for Medicare & Medicaid Services (CMS) for EHRs. CMS established these criteria to ensure that physicians use EHRs to improve patient care; physicians participating in the meaningful use program receive financial incentives when they meet the criteria.
• "Paying the Doctor: Evidence-Based Decisions at the Point-of-Care and the Role of Fee-for-Service Incentives." Eugene C. Rich, Timothy K. Lake, Christal Stone Valenzano, and Myles M. Maxfield. Journal of Comparative Effectiveness Research, May 2013. This article dvelops a framework for understanding how financial and nonfinancial incentives can complicate point-of-care decision making by physicians, leading to the over- or under-use of health care services. The analysis highlights contributing factors that promote and impede evidence-based decision making, using examples from the “Choosing Wisely” program. The authors discuss how the existing fee-for-service payment system can contribute to the problems of over- and under-testing, diagnosis, and treatment.
• "Paying More Wisely: Effects of Payment Reforms on Evidence-Based Clinical Decision-Making." Timothy K. Lake, Eugene C. Rich, Christal Stone Valenzano, and Myles M. Maxfield. Journal of Comparative Effectiveness Research, May 2013. This article reviews the recent research, policy, and conceptual literature on the effects of payment policy reforms on evidence-based clinical decision making by physicians at the point of care. Payment reforms include recalibration of existing fee structures in fee-for-service, pay-for-quality, episode-based bundled payments and global payments. The authors review the advantages and disadvantages of these reforms in terms of their effects on physicians’ and patients’ use of evidence in clinical decisions related to the diagnosis, testing, treatment, and management of disease. They conclude with a recommended pathway for improving payment incentives to better support evidence-based decision making.
• "Perspectives of Physicians and Nurse Practitioners on Primary Care Practice." Karen Donelan, Catherine M. DesRoches, Robert S. Dittus, and Peter Buerhaus. The New England Journal of Medicine, May 2013 (subscription required). A study finds that, although primary care physicians and nurse practitioners mostly agree that nurse practitioners should be able to practice to the full extent of their education and training, they strongly disagree about proposed changes to the scope of nurse practitioners' responsibilities. The survey—led by investigators from Massachusetts General Hospital, the Institute for Medicine and Public Health at Vanderbilt University Medical Center, and Mathematica—revealed points of disagreement on appropriate leadership roles for nurse practitioners, reimbursement levels, and overall quality of services.
• "National and State Trends in Enrollment and Spending for Dual Eligibles Under Age 65 in Medicaid Managed Care." Jenna Libersky, Allison Hedley Dodd, and Shinu Verghese. Disability and Health Journal, April 2013 (subscription required). This article uses 2005 and 2008 Medicaid Analytic eXtract (MAX) data to present spending and enrollment trends for adults with disabilities who are dually eligible for Medicare and Medicaid. Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs), particularly behavioral health PHPs, driving the increase. Although overall use of managed care has increased, there has been little expansion in the use of comprehensive managed care among adult dual eligible beneficiaries, particularly when compared with their Medicaid-only disabled adult peers. This imbalance suggests room to remove barriers preventing dually eligible adults, from enrolling in comprehensive, integrated managed care.

Issue Briefs

• "The HCBS Taxonomy: A New Language for Classifying Home- and Community-Based Services." MAX Medicaid Policy Brief #19. Victoria Peebles and Alex Bohl, August 2013. This brief describes the home and community-based services (HCBS) taxonomy—a uniform classification system composed of 18 categories and more than 60 services—and presents findings on expenditures and users for the 28 states whose MAX data files were approved by June 1, 2013.
• "Perspectives on HeA PA from Certified Application Assistants." Health-E-App Public Access: A New Online Path to Children's Health Care Coverage in California, Research Brief #4. Adam Dunn, Dana Petersen, and Leslie Foster, July 2013. This brief presents the views of certified application assistants on barriers to the use of California's Health-e-App Public Access, a self-service online enrollment system for Healthy Families and Medicaid, and the potential role they could play in raising awareness of the system.
• "Findings from an Analysis of Publicly Available Reports on Medicaid and CHIP Performance Measures." Brenda Natzke, Maggie Colby, and Erin Taylor, April 2013. This brief presents an analysis of the Database of Publicly Available Medicaid and CHIP Performance Measure Reports. It provides background on the database; highlights the types of documents and reports available; and discusses which measure domains are typically represented, including examples of reported measures in each domain. The brief also discusses the types of stratification used by states in their analyses, such as beneficiary, provider, or health plan, and the frequency with which measures are reported.
• "Translating Modified Adjusted Gross Income (MAGI) to Current Monthly Income." SHARE Brief #3. John L. Czajka, May 2013. This brief considers the process by which modified adjusted gross income—an annual measure of income specified by the ACA for use in determining both Medicaid and subsidy eligibility—can be converted to a measure of current monthly income for the purpose of Medicaid eligibility determination.
• "Income Eligibility for Assistance Under the ACA: The Question of Monthly vs. Annual Income." SHARE Brief #2. John L. Czajka, May 2013. This brief examines the practical coverage continuity issues raised by determining Medicaid eligibility on a monthly basis while determining subsidy eligibility on an annual basis.
• "Implications of State Methods for Offering Personal Assistance Services." MAX Medicaid Policy Brief #18. Laura Ruttner and Carol V. Irvin, June 2013. This brief examines the differences in the use and cost of personal assistance services in states that do and do not provide these services through their state plans. States that offer these services through their state plans appear to provide them to a greater number of beneficiaries at a lower cost per beneficiary than states that do not. The states that offer services also have long-term care systems that are more balanced toward home- and community-based rather than institutional long-term care services.
• "Medicare Advantage 2013 Spotlight: Enrollment Market Update." Issue Brief. Marsha Gold, Gretchen Jacobson, Anthony Damico, and Tricia Neuman, June 2013. This data spotlight, prepared by Mathematica and Kaiser Family Foundation health experts, provides an overview of Medicare Advantage enrollment patterns in March 2013 and examines variations by plan type, state, and firm. It also analyzes trends in premiums paid by beneficiaries enrolled in Medicare Advantage plans, including variations by plan type, and describes the out-of-pocket limits and prescription drug coverage in the Part D "donut hole."
• "How are States and Evaluators Measuring Medical Homeness in the CHIPRA Quality Demonstration Grant Program?" The National Evaluation of the CHIPRA Quality Demonstration Grant Program, Evaluation Highlight No. 2. Stacey McMorrow, Anna Christensen, Brenda Natzke, Kelly Devers, and Rebecca Peters, May 2013. This Highlight examines the measurement of medical homeness in selected demonstration projects. It also describes the development of the Medical Home Index: Revised Short Form, an adaptation of the Medical Home Index, for use in evaluating the demonstration projects. Supplement to Evaluation Highlight No. 2.
• "Outreach to Low-Income Families During the First Year of HeA PA." Health-E-App Public Access: A New Online Path to Children's Health Care Coverage in California, Research Brief #3. Maggie Colby, May 2013. This is the third brief in a series about the first year of California’s Health-e-App Public Access (HeA PA) enrollment system, introduced in December 2010. Available in English and Spanish, HeA PA was a self-service online application for the Healthy Families Program and a screening tool for Medi-Cal for families. This brief describes the ways that California made families aware of HeA PA, including a formal outreach campaign during the second half of 2011, and evaluates the outreach strategies’ effectiveness in attracting eligible applicants.
• "Analysis of the Variation in Efficiency of Medicare Advantage Plans." Research Brief. Marsha Gold and Maria Cupples Hudson, April 2013. The Affordable Care Act has altered payment policy for private Medicare Advantage (MA) plans, with the goal of lowering costs to bring them closer to the costs of traditional Medicare. Using new information on 2009 MA costs, an issue brief compares plans’ estimates of per capita costs for providing Parts A and B benefits to their enrollees, on a risk-adjusted basis, against government data on the same costs for traditional Medicare program beneficiaries in the same county. On average, risk-adjusted MA plan costs were 4 percent higher than traditional Medicare costs (104 percent). Among plan types, only HMOs had lower average costs than traditional Medicare. The wide variation in costs for MA plans relative to those for traditional Medicare suggests room for greater efficiency in care delivery.

Working Papers

• "The ACA, Health Care Costs, and Disparities in Employer-Sponsored Health Insurance." Nan L. Maxwell, March 2013. This working paper examines the potential changes in the disparities in employer-sponsored health insurance (ESI) and other benefits between low- and high-wage workers under health reform. The analysis suggests that potential changes firms make in compensation could decrease disparities between low- and high-skilled workers in the quality of ESI and increase the disparities in the offering of benefits other than ESI, if the legislation does not slow rising health care costs.
• "Perceptions of Electronic Health Records and Their Effect on the Quality of Care: Results from a Survey of Patients in Four States." Jelena Zurovac, Stacy Dale, and Martha Kovac, November 2012. Using data from patients surveyed after primary care provider visits, this working paper found patients had favorable perceptions of electronic health records (EHRs). Patients believed that EHRs improved the quality of care, and most were not concerned with confidentiality of records. Adopters' patients rated the quality of care higher than nonadopters' patients did. There was also no detrimental effect of EHR use on patient–provider communication and no relationship between the way in which physicians interacted with the computer and patients' perceptions of care.
• "Paying Wisely: Reforming Incentives to Promote Evidence-Based Decisions at the Point of Care." Eugene C. Rich, Tim Lake, and Christal Stone Valenzano, October 2012. This white paper describes how current financial incentives in the fee-for-service (FFS) system can lead to the over- and underuse of services at the point of care by physicians and other clinicians. It explores prominent payment reform models and concludes that no single approach consistently rewards evidence-based care. The paper also suggests that more targeted use of these models—grounded in recalibrated FFS—might be the most effective way to neutralize incentives and facilitate evidence-based decision making at the point of care.
• "Rewarding Physicians for Their Patients' Health Outcomes: What Can Medicare Learn from Education's Value-Added Models?" Greg Peterson and Eric Schone, June 2012. This working paper examines how value-added models of performance measurement used in education can apply to health care when measuring and rewarding physician performance, particularly in the Medicare system. The paper finds that value-added models used to measure teacher effects on student test scores may have useful applications in Medicare because the models provide opportunities to identify impacts on outcomes while controlling for factors that are beyond physicians' control, such as severity of illness or adherence to a treatment plan. The working paper also identifies limitations and challenges associated with value-added measures and discusses potential approaches to address these challenges.
• "RDD Unplugged: Findings from a Household Survey Using a Cell Overlap Design." John Hall, Barbara Lepidus Carlson, and Karen CyBulski, December 2011. This working paper presents methodological findings from the latest round of the Health Tracking Household Survey, which added a cell phone sample to the existing landline sample of random telephone numbers to increase the coverage of the U.S. population.
• "An Assessment of the Effectiveness of Anti-Poverty Programs in the United States." Yonatan Ben-Shalom, Robert A. Moffitt, and John Karl Scholz, May 2011. This paper assesses the effectiveness of means-tested and social insurance programs in the United States. The U.S. benefit system has a major impact on poverty rates, reducing the percentage of the poor in 2004 from 29 to 13.5 percent. The system reduces poverty the most for persons with disabilities and the elderly and least for several groups among the nonelderly and nondisabled. While there are significant behavioral side effects of many programs, their aggregate impact is very small and does not affect the magnitude of the aggregate poverty impact of the system.

Other

• Book Examines Health Reform and Employer-Based Insurance
  "The Health and Wealth of a Nation: Employer-Based Health Insurance and the Affordable Care Act," a new monograph by senior researcher Nan L. Maxwell, examines how firms behaved with respect to employment-based health insurance before Affordable Care Act deliberations and uses that behavior to predict the changes that might occur when the legislative requirements become fully implemented.