• 6 Things That Happened in Health Policy This Week

    6 Things That Happened in Health Policy This Week was created by Zoe Lyon and Garret Johnson. Find them on twitter @zoemarklyon and @garretjohnson22.

    This newsletter is produced each week by a mix of research assistants from the Healthcare Quality & Outcomes (HQO) Initiative at the Harvard T.H. Chan School of Public Health. In each edition we feature a variety of news articles, reports, and studies focused on U.S. health policy and health services research.

    Research on Aging: Medicare Advantage Enrollment Associated with Significantly Reduced Odds of Dying in the Hospital

    • Using 2008 and 2010 waves of data from the Health and Retirement Study (N=1030 people who completed the 2008 interview but had died by the time of the 2010 exit interview), the authors examined whether continuous enrollment in Medicare Advantage was associated with a decrease in odds of dying in a hospital compared to continuous enrollment in Medicare fee-for-service.
      • The strength of this study is that it captures data not available in Medicare claims which may impact site of death, such as the presence of advance directives, self-reported health, “social capital” (presence of a spouse and number of people in household) and death expected by proxy.
      • Hospice benefits are “carved out,” of Medicare Advantage; the moment that an MA enrollee switches to hospice, his/her palliative care is covered by the Medicare FFS hospice benefit program. As such, MA plans have a strong incentive to enroll patients in hospice care rather than continue to pursue curative treatment in a hospital.
    • Major limitations:
      • Observational
      • Cannot determine a patient’s state/city (these variables are masked in HRS data); it may be that areas of high MA enrollment also have higher hospice supply and this contributes to some of the difference.
      • There is actually no MA variable in the HRS data; the authors used a self-reported variable about HMO enrollment as a proxy for MA enrollment status.
    • Findings:
      • Compared to those continuously enrolled in Medicare FFS, those continuously enrolled in MA were 43% less likely to die in a hospital (OR 0.57; P≤0.05).
      • The authors used the subset of patients (N=213) who died from cancer, a disease with a more predictable prognosis and higher rates of hospice enrollment in general, to perform the same analysis.
        • The effect was even larger; continuous MA enrollees were 79% less likely to die in the hospital than continuous FFS enrollees (OR 0.21; P≤0.05).
      • Implication: MA may be associated with reduced odds of dying in a hospital due to incentives built into the program (i.e. capitated payments and hospice “carve-out”). Because most patients do not wish to die in a hospital, this may be a virtuous, if unintended, consequence of the MA program.

    KHN: Supreme Court sends health law birth control case back to lower courts

    • On Monday, the Supreme Court sent a series of cases surrounding the issue of religious rights vs. no-cost contraception back down to federal appeals courts.
    • Over the past few years, the government has made numerous changes to the requirement that under the ACA most employer health plans must provide no-cost contraception for women in order to accommodate religiously affiliated employers.
    • However, dozens of religious nonprofit employers sued on the grounds that even alerting the government to their objections (and hence triggering a series of steps so that the government can provide coverage) is a violation of their religious freedom.
    • The Court’s opinion erased all of the lower appeals rulings (all but one of which sided with the government), which at first appeared to jeopardize coverage for contraceptives for tens of thousands of employees of the organizations filing suit.
    • The Court did clarify, however, by saying that the notice of objections from employers enough for the government to “facilitate…full contraceptive coverage going forward”.
    • People on both sides of the argument are considering this a victory:
      • A lawyer for the group representing the suing organizations said “The government can find ways to give out contraception without hassling nuns”.
      • The ACLU, on the other hand, said “the opinion states clearly the need for women to receive full and equal coverage”.
      • Justices Sonia Sotomayor and Ruth Bader Ginsburg stressed that the decision should not be read as approving coverage strategies that make it harder for women to the get the benefits.
    • It isn’t yet clear what the decision the lower courts might reach, but the justices seem to want both sides to outline potential compromises.

    CQ Roll Call & Becker’s Hospital Review: Federal Judge Rejects FTC Effort to Stop Hospital Merger

    • A federal judge denied the FTC’s request for a preliminary injunction to stop the merger of Penn State Hersey Medical Center and PinnacleHealth System, largely on the grounds that the commission misrepresented the affected market area.
      • Justice John E. Jones III, U.S. District Court for the Middle District of Pennsylvania (George W. Bush appointee) said that the FTC had drawn too narrow of a geographic market: “Given the realities of living in Central Pennsylvania, which is largely rural and requires driving distances for specific goods or services, it is our view that these [other] 19 hospitals  . . .  provide a realistic alternative.”
    • The judge also said that the merged entity would benefit patients, and that recent policy efforts have encouraged hospitals to find efficiencies and cut costs in this way. Some legal experts are calling this the “Obamacare made me do it,” defense, and fear that it may take hold nationwide as a strategy to boost mergers past federal review.
      • Justice Jones: “This decision further recognizes a growing need for all those involved to adapt to an evolving landscape of healthcare that includes, among other changes, the institution of the Affordable Care Act, fluctuations in Medicare and Medicaid reimbursement, and the adoption of risk-based contracting. Our determination reflects the healthcare world as it is, and not as the FTC wishes it to be.”
      • The FTC vehemently disagrees. FTC Chairwoman Edith Ramirez: “Despite parties’ frequent claims to the contrary, risk-based contracting does not preclude the exercise of market power.”
    • The FTC has already begun the process of appealing the decision in federal appeals court, asking for an emergency motion to stay the merger.

    Health Affairs: Variation in health outcomes: The role of spending on social services, public health, and health care 2000-09

    • A new study in Health Affairs looks at the association between variation in state-level health outcomes and how states allocate spending between healthcare and social services.
    • Used data from the Behavioral Risk Factor Surveillance System, the CDC, and the National Center for Health Statistics for all 50 states to calculate state-level health outcomes (including but not limited to BMI, prevalence of asthma, and state-level mortality rates for AMI, lung cancer, and type 2 diabetes) and spending on social services and public health relative to healthcare spending to estimate any association between the two variables.
    • Findings:
      • States with a higher ratio of social to health spending had significantly better health outcomes for:
        • Adult obesity
        • Asthma
        • Mortality rates for AMI, lung cancer, type II diabetes
        • Mentally unhealthy days
        • Days with activity limitations
      • Implications: spending more on social services and public health rather than just on healthcare “may be key to understanding variations in health outcomes across the states,” but as the authors note from these findings we “cannot infer causality”.

    WSJ: Insurers’ Losses Deepened on ACA Plans in 2015

    • McKinsey & Co released a report showing that the insurance industry’s cumulative margin on ACA exchange plans was between -9% and -11% in 2015; only a quarter of plans made a profit.
    • These losses are roughly double the losses in 2014 (-4.8%), which McKinsey attributes to rising medical loss ratios.
    • Despite the losses, McKinsey reported some optimism:
    • “The analysis suggests that the health law’s subsidies, which help lower-income people purchase health plans, should prevent a ‘death spiral,’ in which an insurance market gets caught in a cycle of increasing rates and shrinking customer pools. The consultants also say that some insurers are finding profits in certain types of plan designs, notably those with limited networks of health-care providers, and health maintenance organization-style plans that tightly manage the health care people can get.”
    • Erica Coe, co-leader of McKinsey center for U.S. Health System Reform: “It may require a very different business model.”

    WSJ/The AP: House passes $622 million bill to fight Zika

    • Despite a White House veto threat and a warning from CDC director Tom Frieden that it wouldn’t be enough to respond to the growing threat of Zika, House Republicans pushed through a $622 million bill on Wednesday to battle the mosquito-borne virus.
    • Three months ago, President Obama requested $1.9 billion to fight Zika.
    • The passage of this bill sets up challenging negotiations with the Senate, which is moving ahead this week with a $1.1 billion plan.
    • President Obama said that the money should be added to the budget deficit rather than be offset with cuts to other programs; the House bill, however, limits the use of the money to the current budget year (which ends Sept. 30) and also cuts funds to fight Ebola.
    • Tom Cole (R-OK) said “Everything that needs to be done has been done”.
    • The White House says that the plan is inadequate but on Wednesday, White House press secretary Josh Earnest said “I don’t have a veto threat to issue”.
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