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Substantial Health And Economic Returns From Delayed Aging May Warrant A New Focus For Medical Research by Dana Goldman and others (Health Affairs)

 Recent scientific advances suggest that slowing the aging process (senescence) is now a realistic goal. Yet most medical research remains focused on combating individual diseases. Using the Future Elderly Model—a microsimulation of the future health and spending of older Americans—we compared optimistic “disease specific” scenarios with a hypothetical “delayed aging” scenario in terms of the scenarios’ impact on longevity, disability, and major entitlement program costs. Delayed aging could increase life expectancy by an additional 2.2 years, most of which would be spent in good health. The economic value of delayed aging is estimated to be $7.1 trillion over fifty years. In contrast, addressing heart disease and cancer separately would yield diminishing improvements in health and longevity by 2060—mainly due to competing risks. Delayed aging would greatly increase entitlement outlays, especially for Social Security. However, these changes could be offset by increasing the Medicare eligibility age and the normal retirement age for Social Security. Overall, greater investment in research to delay aging appears to be a highly efficient way to forestall disease, extend healthy life, and improve public health.

Trends Underlying Employer Sponsored Health Insurance Growth For Americans Younger Than Age Sixty-Five by Carolina-Nicole Herrera and others (Health Affairs)

Little is known about the trends in health care spending for the 156 million Americans who are younger than age sixty-five and enrolled in employer-sponsored health insurance. Using a new source of health insurance claims data, we estimated per capita spending, utilization, and prices for this population between 2007 and 2011. During this period per capita spending on employer-sponsored insurance grew at historically slow rates, but still faster than per capita national health expenditures. Total per capita spending for employer-sponsored insurance grew at an average annual rate of 4.9 percent, with prescription spending growing at 3.3 percent and medical spending growing at 5.3 percent. Out-of-pocket medical spending increased at an average annual rate of 8.0 percent, whereas out-of-pocket prescription drug spending growth was flat. Growth in the use of medical services and prescription drugs slowed. Medical price growth accelerated, and prescription price growth decelerated. As a result, changes in utilization contributed less than changes in price did to overall spending growth for those with employer-sponsored insurance.

Accountable Care Organization Formation Is Associated With Integrated Systems But Not High Medical Spending by David Auerbach, Hangsheng Liu, Peter Hussey, Christopher Lau, and Ateev Mehrotra (Health Affairs)

Medicare’s approximately 250 accountable care organizations (ACOs) care for a growing portion of all fee-for-service beneficiaries across the United States. We examined where ACOs have formed and what regional factors are predictive of ACO formation. Understanding these factors could help policy makers foster growth in areas with limited ACO development. We found wide variation in ACO formation, with large areas, such as the Northwest, essentially empty of ACOs, and others, such as the Northeast and Midwest, dense with the organizations. Key regional factors associated with ACO formation include a greater fraction of hospital risk sharing (capitation), larger integrated hospital systems, and primary care physicians practicing in large groups. Area income, Medicare per capita spending, Medicare Advantage enrollment rates, and physician density were not associated with ACO formation. Together, these results imply that underlying provider integration in a region may help drive the formation of ACOs.

The Quality Of Care Delivered To Patients Within The Same Hospital Varies By Insurance Type by Christine S. Spencer, Darrell J. Gaskin, and Eric T. Roberts  (Health Affairs)

In attempting to explain why hospitals vary in the quality of care delivered to patients, a considerable body of health policy research points to differences in hospital characteristics such as ownership, safetynet status, and geographic location as the most important contributing factors. This article examines the extent to which a patient’s type or lack of insurance may also play a role in determining the quality of care received at any given hospital. We compared within-hospital quality, as measured by risk-adjusted mortality rates, for patients according to their insurance status. We examined the Agency for Healthcare Research and Quality’s innovative Inpatient Quality Indicators and pooled 2006–08 State Inpatient Database records from eleven states. We found that privately insured patients had lower risk-adjusted mortality rates than did Medicare enrollees for twelve out of fifteen quality measures examined. To a lesser extent, privately insured patients also had lower risk-adjusted mortality rates than those in other payer groups. Medicare patients appeared particularly vulnerable to receiving inferior care. These findings suggest that to help reduce care disparities, public payers and hospitals should measure care quality for different insurance groups and monitor differences in treatment practices within hospitals.

Understanding State Variation In Health Insurance Dynamics Can Help Tailor Enrollment Strategies For ACA Expansion by John Graves and Katherine Swartz (Health Affairs)

The number and types of people who become eligible for and enroll in the Affordable Care Act’s (ACA’s) health insurance expansions will depend in part on the factors that cause people to become uninsured for different lengths of time. We used a small-area estimation approach to estimate differences across states in percentages of adults losing health insurance and in lengths of their uninsured spells. We found that nearly 50 percent of the nonelderly adult population in Florida, Nevada, New Mexico, and Texas—but only 18 percent in Massachusetts and 22 percent in Vermont—experienced an uninsured spell between 2009 and 2012. Compared to people who lost private coverage, those with public insurance were more likely to experience an uninsured spell, but their spells of uninsurance were shorter. We categorized states based on estimated incidence of uninsured spells and the spells’ duration. States should tailor their enrollment outreach and retention efforts for the ACA’s coverage expansions to address their own mix of types of coverage lost and durations of uninsured spells.

When Medicare Cuts Hospital Prices, Seniors Use Less Inpatient Care by Chapin White and Tracy Yee (Health Affairs)

The Affordable Care Act permanently slows the growth in Medicare hospital prices. To better understand the effects of those price cuts, we used data from ten states for the period 1995–2009 to examine the market-level relationship between Medicare prices and hospital utilization among the elderly. Regression analyses indicate that a 10 percent reduction in the Medicare price was associated with a 4.6 percent reduction in discharges among the elderly. This volume response to price cuts appears to be accomplished through hospitals’ reduction in their numbers of staffed beds. They did not leave beds empty; instead, they reduced their scale of operations. Based on our results, we conclude that the Affordable Care Act will help reduce inpatient hospital utilization in the future. From a federal budgetary standpoint, lower utilization is good news, but the implications for patient care and health outcomes are not yet clear.

More Americans Living Longer With Cardiovascular Disease Will Increase Costs While Lowering Quality Of Life by Ankur Pandya, Thomas Gaziano, Milton Weinstein, and David Cutler (Health Affairs)

 In the past several decades, some risk factors for cardiovascular disease have improved, while others have worsened. For example, smoking rates have dropped and treatment rates for cardiovascular disease have increased—factors that have made the disease less fatal. At the same time, Americans’ average body mass index and incidence of diabetes have increased as the population continues to live longer— factors that have made cardiovascular disease more prevalent. To assess the aggregate impact of these opposing trends, we used the nine National Health and Nutrition Examination Survey waves from 1973 to 2010 to forecast total cardiovascular disease risk and prevalence from 2015 to 2030. We found that continued improvements in cardiovascular disease treatment and declining smoking rates will not outweigh the influence of increasing population age and obesity on cardiovascular disease risk. Given an aging population, an obesity epidemic, and declining mortality from the disease, the United States should expect to see a sharp rise in the health care costs, disability, and reductions in quality of life associated with increased prevalence of cardiovascular disease. Policies that target the treatment of high blood pressure and cholesterol and the reduction of obesity will be necessary to curb the imminent spike in cardiovascular disease prevalence.

Surgical Skill and Complication Rates after Bariatric Surgery by John Birkmeyer and others (New England Journal of Medicine)

Clinical outcomes after many complex surgical procedures vary widely across hospitals and surgeons. Although it has been assumed that the proficiency of the operating surgeon is an important factor underlying such variation, empirical data are lacking on the relationships between technical skill and postoperative outcomes. We conducted a study involving 20 bariatric surgeons in Michigan who participated in a statewide collaborative improvement program. Each surgeon submitted a single representative videotape of himself or herself performing a laparoscopic gastric bypass. Each videotape was rated in various domains of technical skill on a scale of 1 to 5 (with higher scores indicating more advanced skill) by at least 10 peer surgeons who were unaware of the identity of the operating surgeon. The technical skill of practicing bariatric surgeons varied widely, and greater skill was associated with fewer postoperative complications and lower rates of reoperation, readmission, and visits to the emergency department.

Who Is in Control? The Determinants of Patient Adherence with Medication Therapy by Sergei Koulayev, Niels Skipper and Emilia Simeonova (National Bureau of Economic Research)

Non-compliance with medication therapy remains an unsolved and expensive problem for health care systems around the world. Yet we know little about the factors that determine a patient’s decision to follow treatment recommendations. This study uses a unique panel dataset comprising all prescription drug users, physicians, and all prescription drug sales in Denmark over seven years to analyze the contributions of doctor-, patient-, and drug-specific factors to the adherence decision. Our findings have important implications for the design of incentive schemes targeted at improving chronic disease management.

Fifty Years of Family Planning: New Evidence on the Long-Run Effects of Increasing Access to Contraception by Martha Bailey (National Bureau of Economic Research)

This paper assembles new evidence on some of the longer-term consequences of U.S. family planning policies, defined in this paper as those increasing legal or financial access to modern contraceptives. The analysis leverages two large policy changes that occurred during the 1960s and 1970s: first, the interaction of the birth control pill’s introduction with Comstock-era restrictions on the sale of contraceptives and the repeal of these laws after Griswold v. Connecticut in 1965; and second, the expansion of federal funding for local family planning programs from 1964 to 1973. Building on previous research that demonstrates both policies’ effects on fertility rates, I find suggestive evidence that individuals’ access to contraceptives increased their children’s college completion, labor force participation, wages, and family incomes decades later.

Identifying the Health Production Function: The Case of Hospitals by John Romley and Neeraj Sood (National Bureau of Economic Research)

Estimates of the returns to medical care may reflect not only the efficacy of more intensive care, but also unmeasured differences in patient severity or the productivity of health-care providers. We use a variety of instruments that are plausibly orthogonal to heterogeneity among providers as well as patients to analyze the intensity of care and 30-day survival among Medicare patients hospitalized for heart attack, congestive heart failure and pneumonia. We find that the intensity of care is endogenous for two out of three conditions. The elasticity of 30-day mortality with respect to care intensity increases in magnitude from -0.27 to -0.71 for pneumonia and from -0.16 to -0.33 for congestive heart failure, when we address the identification problem. This finding is consistent with the hypotheses that care intensity at hospitals tends to decrease with hospital productivity, or increase with unmeasured patient severity.

ACA Standoff by Jeffrey Drazen and Gregory Curfman (New England Journal of Medicine)

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