Reducing preventable and unplanned emergency department visits and hospitalizations is a major challenge in cancer care. In this review of best practices and supporting evidence, the authors identified five strategies that health systems and cancer programs can use to reduce acute care: (1) identify patients at high risk of unplanned acute care; (2) enhance access and care coordination; (3) standardize clinical pathways for symptom management; (4) develop new sites for urgent cancer care, and; (5) use early palliative care.
Surgical patients age 65 and over with Alzheimer’s disease and related dementias (ADRD) were more likely to die within 30 days of admission and to die after a complication than those without ADRD. Having better-educated nurses in the hospital improved the likelihood of good outcomes for all surgical patients, but had a much greater effect in individuals with ADRD. Specifically, a 10% increase in the proportion of nurses with a Bachelor of Science in Nursing (BSN) degree or higher was associated with 10% lower odds of death and 10% lower odds of dying after a complication for surgical patients with ADRD.
Prior Authorization Requirements for Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors Across US Private and Public Payers
A comprehensive review of prior authorization (PA) requirements for a new class of expensive cholesterol-lowering drugs known as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors has found unusually complex and burdensome demands across public and private insurance plans in the United States. These findings raise concerns that current policies may create undue barriers to care even in medically appropriate patients, particularly since requirements were just as stringent for patients with a genetic condition that creates more clear-cut eligibility for PCSK9 inhibitor treatment.
In response to regulatory changes at the federal level, states that run their own marketplaces have taken steps to stabilize their individual markets. In this comparison of state-based and federally-facilitated marketplaces from 2016-2018, we find that SBMs had slower premium increases (43% vs. 75%), and fewer carrier exits, than FFMs. The total population participating in FFMs declined by 10%, while the enrolled population in SBMs remained largely stable, increasing by 2%. We find that the performance of the ACA marketplaces varies by state and appears to cluster around marketplace types.
State Firearm Laws and Interstate Firearm Deaths From Homicide and Suicide in the United States: A Cross-Sectional Analysis of Data by County
In a cross-sectional analysis of deaths from 2010 through 2014, states with stricter gun laws had lower rates of firearm-related homicide and suicide than states with less regulation. Counties in states with less restrictive firearms laws had relatively lower rates of firearm-related homicide when they bordered states with strict gun laws. In contrast, rates of gun violence in areas with strict gun laws were unaffected by lenient laws in neighboring states. Restrictions on the sale and ownership of firearms may have measurable effects on rates of firearm deaths, with potential spillover across state lines.
The Effect of Integration of Hospitals and Post-Acute Care Providers on Medicare Payment and Patient Outcomes
Vertical integration between hospitals and skilled nursing facilities (SNFs) increases Medicare payments for the ﬁrst 60 days of care by $2,424 (17%), compared to hospital-SNF pairs that are not vertically integrated. These integrated hospital–SNF pairs also experience a decline in 30-day rates of rehospitalization or death of 5 percentage points on a base rate of 31.3%. Vertical integration between hospitals and home health agencies (HHAs) has little effect on Medicare payments and patient outcomes, nor does informal integration in either setting.
Association of Rideshare-Based Transportation Services and Missed Primary Care Appointments: A Clinical Trial
In a pragmatic trial, offering complimentary ridesharing services broadly to Medicaid patients did not reduce rates of missed primary care appointments. The uptake of free rides was low, and rates of missed appointments remained unchanged at 36%. Efforts to reduce missed appointments due to transportation barriers may require more targeted approaches.
This review examines prominent state efforts to expand health coverage to the remaining uninsured. It analyzes and compares efforts in Massachusetts, Vermont, Colorado, California, and Nevada and highlights insights and themes that emerge. It explores the context and climate for reform within the state, stakeholder involvement, political coalitions, financing, and possible opposition. As such, it serves as a case study in how different states build, or fail to build, the popular and political will towards health care coverage for all residents. This is the first in a series of reports that will monitor and analyze developments at the state level to expand coverage and improve access to care.
Association between Electronic Medical Record Implementation of Default Opioid Prescription Quantities and Prescribing Behavior in Two Emergency Departments
Setting a low quantity of opioid tablets as the default option in electronic medical record prescribing orders may “nudge” clinicians to prescribe fewer opioids. When two emergency departments implemented a 10-tablet default instead of a manual entry, the proportion of 10-tablet prescriptions written more than doubled, from 20.6% to 43.3%. Conversely, 20-tablet prescriptions decreased from 22.8% to 16.1%, and prescriptions for 11-19 tablets decreased from 33.5% to 20.1%.
Association of Patient Out-of-Pocket Costs With Prescription Abandonment and Delay in Fills of Novel Oral Anticancer Agents
High out-of-pocket (OOP) costs may limit access to novel oral cancer medications. In a retrospective study, nearly one third of patients whose OOP costs were $100 to $500 and nearly half of patients whose OOP costs were more than $2,000 failed to pick up their new prescription for an oral cancer medication, compared to 10% of patients who were required to pay less than $10 at the time of purchase. Delays in picking up prescriptions were also more frequent among patients facing higher OOP costs.
The number of clinicians specializing in nursing home care increased by 33.7% from 2012 to 2015, although nursing home specialists made up only 21% of nursing home clinicians in 2015. Most of these specialists were advanced practitioners (physician assistants and nurse practitioners) delivering post-acute care. The change in number of nursing home specialists varied significantly by geographic region.
Primary care appointment availability for new Medicaid patients declined when Medicaid fees for providers decreased after the ACA-mandated “fee bump” expired.
The prevalence of narrow provider networks on the ACA Marketplace is trending down. In 2017, 21% of plans had narrow networks, down from 25% in 2016. The largest single factor was that 70% of plans from National carriers exited the market and these plans had narrower networks than returning plans. Exits account for more than half of the decline in the prevalence of narrow networks, with the rest attributed to broadening networks among stable plans, particularly among Blues carriers. The narrow network strategy is expanding among traditional Medicaid carriers and remains steady among provider-based carriers and regional/local carriers.
This Issue Brief describes the breadth of physician networks on the ACA marketplaces in 2017. We find that the overall rate of narrow networks is 21%, which is a decline since 2014 (31%) and 2016 (25%). Narrow networks are concentrated in plans sold on state-based marketplaces, at 42%, compared to 10% of plans on federally-facilitated marketplaces. Issuers that have traditionally offered Medicaid coverage have the highest prevalence of narrow network plans at 36%, with regional/local plans and provider-based plans close behind at 27% and 30%. We also find large differences in narrow networks by state and by plan type.
Subsidized reinsurance represents a potentially important tool to help stabilize individual health insurance markets. This brief describes alternative forms of subsidized reinsurance and the mechanisms by which they spread risk and reduce premiums. It summarizes specific state initiatives and Congressional proposals that include subsidized reinsurance. It compares approaches to each other and to more direct subsidies of individual market enrollment. For a given amount of funding, a particular program’s efficacy will depend on how it affects insurers’ risk and the risk margins built into premiums, incentives for selecting or avoiding risks, incentives for coordinating and managing care, and the costs and complexity of administration. These effects warrant careful consideration by policymakers as they consider measures to achieve stability in the individual market in the long term.