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Health Care Systems and HMOs

 
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Narrow Provider Networks in New Health Plans: Balancing Affordability with Access to Quality Care (Research Report)
Sabrina Corlette, JoAnn Volk, Robert A. Berenson, Judy Feder

Consumers choosing health insurance plans inside and outside the new marketplaces may face a tradeoff: narrower provider networks may lower premiums, but they may also limit access to care or increase out-of-pocket costs. This policy brief assesses the benefits and risks of policy options open to federal and state policymakers now reviewing requirements for plans' network adequacy. The authors find that no single policy can achieve the appropriate balance between insurers' flexibility to negotiate with providers and consumers' confidence that plans will deliver on promised benefits. Accordingly, the authors call on policymakers to protect consumers with a combination of regulatory standards, up-to-date information to facilitate consumer choices, and active monitoring of plans' actual performance.

Posted to Web: May 29, 2014Publication Date: May 29, 2014

Trends in Prescription Drug Spending Leading Up to Health Reform (Article)
Fredric Blavin, Timothy Waidmann, Linda J. Blumberg, Jeremy Roth

Over the past decade, prescription drug expenditures grew faster than any other service category and comprised an increasing share of per capita health spending. Using the 2005 and 2009 Medical Expenditure Panel Surveys, this analysis identifies the sources of spending growth for prescription drugs among the nonelderly population. We find that prescription drug expenditures among the nonelderly increased by $14.9 billion (9.2%) from 2005 to 2009 and expenditures increased in 12 out of the 16 therapeutic classes. Changes in the number of users and expenditures per fill were the drivers of spending fluctuations in these categories. The main results also provide insight into generic entry, the price gap between brand and generic drugs, and from a health reform evaluation perspective, the importance of separating pre-policy secular trends in expenditures from changes attributable to specific forces, such as shifts toward generic versions of blockbuster drugs.

Posted to Web: May 19, 2014Publication Date: May 14, 2014

Evaluation of the Medicaid Health Home Option for Beneficiaries with Chronic Conditions: Final Annual Report - Base Year (Research Report)
Brenda Spillman, Barbara A. Ormond, Elizabeth Richardson

Medicaid health homes is a new optional benefit for high-need, high-cost beneficiaries with chronic physical conditions or serious mental illness, authorized in Section 2703 of the Affordable Care Act. Distinctive features of the model include the elevated importance placed on integrating physical health care with behavioral/mental health care and on linking enrollees to social services and other community supports. The Urban Institute is conducting the 5-year long-term evaluation for the DHHS Assistant Secretary of Planning and Evaluation. This initial report examines the context, design, and initial implementation challenges and successes of six programs in Missouri, Rhode Island, New York, and Oregon, the first four states with approved programs.

Posted to Web: May 19, 2014Publication Date: December 01, 2012

An Estimated $84.9 Billion In Uncompensated Care Was Provided In 2013; ACA Payment Cuts Could Challenge Providers (Article)
Teresa A. Coughlin, John Holahan, Kyle Caswell, Megan McGrath

Millions of uninsured people use health care services every year. We estimated providers' uncompensated care costs in 2013 to be between $74.9 billion and $84.9 billion. In the aggregate, at least 65 percent of providers' uncompensated care costs were offset by government payments designed to cover the costs. Medicaid and Medicare were the largest sources of such government payments, providing $13.5 billion and $8.0 billion, respectively. Anticipating fewer uninsured people and lower levels of uncompensated care, the Affordable Care Act reduces certain Medicare and Medicaid payments. Such cuts in government funding of uncompensated care could pose challenges to some providers, particularly in states that have not adopted the Medicaid expansion or where implementation of health care reform is proceeding slowly.

Posted to Web: May 07, 2014Publication Date: May 06, 2014

Placing Diagnosis Errors on the Policy Agenda (Policy Briefs/Timely Analysis of Health Policy Issues)
Robert A. Berenson, Divvy Upadhyay, Deborah R. Kaye

Between 5 and 15 percent of health care encounters result in a diagnosis error. While misdiagnoses and missed diagnoses can have devastating effects on patients and even result in death, the issue does not receive much attention from health care providers and policy leaders as the major quality and safety issue that it deserves to be. A new brief from the Urban Institute explores the different reasons for diagnosis errors, the challenges of measuring them, and fruitful approaches to reducing their prevalence and harm to patients. The brief offers recommendations for policy-makers on how they can place the issue on the policy agenda.

Posted to Web: April 24, 2014Publication Date: April 24, 2014

The Urban Institute Health Policy Center's Medicaid/CHIP Eligibility Simulation Model (Methodology Report)
Jennifer M. Haley, Victoria Lynch, Genevieve M. Kenney

The Urban Institute Health Policy Center's Medicaid/CHIP Eligibility Simulation Model is a microsimulation that uses rules about Medicaid/CHIP eligibility to approximate adults' and children's eligibility for Medicaid and CHIP. It has been used to simulate eligibility in the 50 states and Washington DC for the years 2008-2012 (before the Affordable Care Act [ACA] was implemented) and 2014 (simulating the new coverage provisions of the ACA). It has also been used to simulate eligibility in Puerto Rico in 2011 and enrollment under hypothetical statehood. It relies on the American Community Survey (ACS) and the Puerto Rico Community Survey (PRCS).

Posted to Web: March 26, 2014Publication Date: March 26, 2014

Integrating Community Health Workers into a Reformed Health Care System (Research Report)
Randall R. Bovbjerg, Lauren Eyster, Barbara A. Ormond, Theresa Anderson, Elizabeth Richardson

Community health workers (CHWs) can help to achieve the goals of the Affordable Care Act—better health, better care, and lower costs. CHWs are typically laypeople whose close connections with a community enable them to win trust and improve health and health services for those they serve. However, challenges with financing structures, workforce training, and service organization can hinder the expansion of the CHW workforce. This paper highlights the roles played by CHWs, assesses evidence of their achievements, describes the increasing opportunities for them under health care reform, and considers productive next steps for growing the CHW workforce.

Posted to Web: March 26, 2014Publication Date: March 26, 2014

Opportunities for Community Health Workers in the Era of Health Reform (Research Report)
Randall R. Bovbjerg, Lauren Eyster, Barbara A. Ormond, Theresa Anderson, Elizabeth Richardson

Health reform has created a watershed moment for community health workers (CHWs). Both coverage expansions and a new focus on creating value in health care offer new opportunities for CHWs. This paper assesses existing impediments to and enablers of the expansion of CHW employment. It catalogues how the ACA and other health reform efforts affect prospects for sustainable employment for CHWs. It also looks at workforce issues, insurance enrollment needs, affordability and accessibility of services, and changes in approaches to public health and prevention. The paper concludes by highlighting particular promising opportunities for CHWs in both public and private sectors.

Posted to Web: March 26, 2014Publication Date: March 26, 2014

The Evolution, Expansion, and Effectiveness of Community Health Workers (Research Report)
Randall R. Bovbjerg, Lauren Eyster, Barbara A. Ormond, Theresa Anderson, Elizabeth Richardson

In the past decade, the community health worker (CHW) profession in the United States has increased its visibility, but its potential contributions remain underappreciated and more permanent financing is elusive. This paper describes the current state of knowledge about how and where CHWs can contribute effectively, where barriers inhibit efficient deployment of CHWs, and what business models could support change. Observations come from literature reviews, key stakeholder interviews, case studies of CHW initiatives, and a convening of practitioners, employers, advocates, policymakers, and other experts.

Posted to Web: March 26, 2014Publication Date: March 26, 2014

Promising Approaches to Integrating Community Health Workers into Health Systems: Four Case Studies (Research Report)
Lauren Eyster, Randall R. Bovbjerg

The productive roles that community health workers (CHWs) can play in health care are drawing increasing interest among US policymakers, providers, insurers, and other stakeholders. While there is a growing interest, little has been documented about the scope of practice, supervision, and human resources standards implemented by states and by employers of CHWs, or how CHWs are financed. Such dimensions of implementing CHW models are important to promoting interventions that integrate CHWs. This volume offers four case studies – in Texas, Minnesota, North Carolina, and Ohio – of interventions that illustrate the challenges and opportunities for integrating CHWs into health systems.

Posted to Web: March 26, 2014Publication Date: December 15, 2013

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