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Problem of Underinsurance and How Rising Deductibles Will Make It Worse

While the Affordable Care Act has significantly reduced the number of uninsured, the number of underinsured Americans grew from 12% of the population in 2003 to 22% in 2010 and has leveled off at 23% in 2014. Currently, 31 million American adults under age 65 are underinsured.

When is someone underinsured? These are the criteria developed by The Commonwealth Fund in a new report on the issue:

  • Out-of-pocket health care costs over the past year, excluding insurance premiums, came to 10% or more of household income; for the poor with an income under 200% of the federal poverty level, the underinsured threshold for annual health care costs is 5% or more of income.
  • Those who didn’t incur health care costs in the past year may be at underinsurance risk if their health plan deductible is 5% or more of household income.

Insurance deductibles have played a key role in the rise of underinsured Americans, with deductible amounts growing faster than family incomes. For employee sponsored health insurance, the number of plans with deductibles in the $1000-$2999 range grew from 7% to 27% between 2003-2014, and plans with $3000 or higher deductibles grew from 1% to 11%.

It’s no surprise that low-income adults or those with health problems are at greatest risk from underinsurance. They may defer or delay health care because of costs. When they do incur medical costs, they can face lingering financial problems as a result.

Source: Collins SR and others. The problem of underinsurance and how rising deductibles will make it worse; findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. Commonwealth Fund Issue Brief, May 2015. http://www.commonwealthfund.org/publications/issue-briefs/2015/may/problem-of-underinsurance


Barr P. Little difference between being insured and uninsured for some Americans. Hospitals & Health Networks Daily, May 20, 2015. http://www.hhnmag.com/display/HHN-news-article.dhtml?dcrPath=/templatedata/HF_Common/NewsArticle/data/HHN/Daily/2015/May/ACA-underinsured-Americans-blog-barr

Commins J. ‘Underinsured’ may be the next healthcare crisis. HealthLeaders Media, May 21, 2012. http://www.healthleadersmedia.com/content/HEP-316567/Underinsured-May-be-the-Next-Healthcare-Crisis

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

TRENDS: Outpatient utilization metrics have been going up

Health, United States, 2015 is available.  This is the latest in an annual compendium of statistics published by the federal government which is drawn from both government and nongovernment sources, including the American Hospital Association.  It’s a good place to start to look for historical trend statistics (usually at the national level) on topics related to health status and health care delivery.

Below are data from one table in this massive report.  The data below are authoritative national estimates, based on a sample survey, that were produced by the National Center for Health Statistics.

Why are utilization metrics expressed as “per 100 persons” or “per 1000 persons” interesting?  Because if you a health planner, you can take a geographical service area with a known population size and calculate the approximate number of physician office visits or hospital outpatient visits or emergency department visits that can be expected from that population in a twelve month period.  Doing a demand analysis would then go on to take into account the local competition and other factors, but national utilization estimates like this can be a helpful way to start.

PHYSICIAN OFFICE VISITS per 100 persons per year (age adjusted)

  • 271  1995
  • 304  2000
  • 325  2010
  • [not available] 2011

Note that this is consistently about 3 physician office visits per person per year.  Does that seem intuitively pleasing to you?  Did you go to see doctors three times last year?  Remember, too, that the above includes children and seniors.

HOSPITAL OUTPATIENT DEPARTMENT VISITS per 100 persons per year (age adjusted)

  • 26  1995
  • 31  2000
  • 33  2010
  • 40  2011

HOSPITAL EMERGENCY DEPARTMENT VISITS per 100 persons per year (age adjusted)

  • 37  1995
  • 40  2000
  • 43  2010
  • 45  2011

Source: Table 82, Visits to physician offices, hospital outpatient departments, and hospital emergency departments, by age, sex, and race: United States, selected years 1995-2011.  In U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. (2015). Health, United States, 2015. Retrieved from http://www.cdc.gov/nchs/hus.htm  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

FUTURE: What will the academic health center look like?

A conceptual framework for the academic health center (AHC)  is proposed in this article which is part of the “New Conversations” series in the journal Academic Medicine.  The framework is built on the concept of the “three-legged stool” – which refers to the academic health center’s traditional missions of patient care, teaching, and research.  The authors overlay the three-legged stool on top of 4 aspects: health, innovation, community, and policy, and discuss what each of the 12 intersections might look like.  For example, where research intersects with community – one would look at how to integrate the AHC’s research program with community research programs.  This model is an attempt to adapt the traditional role of the academic health center to the new health care delivery system that is emerging in the wake of the Affordable Care Act.

Source: Borden, W.B., Mushlin, A.I., and others. 2015, May). A new conceptual framework for academic health centers. Academic Medicine, 90(5), 569-573.  Retrieved from http://journals.lww.com/academicmedicine/Fulltext/2015/05000/A_New_Conceptual_Framework_for_Academic_Health.14.aspx  Posted by AHA Resource Center (312) 422-2050, rc@aha.org

POPULATION HEALTH: Medical home staffing benchmarks

I was intrigued by a footnote in a current article and followed it to this study published a couple of years ago.  The authors surveyed nine medical practice administrators who had experience with the medical home model.  They developed the following PROPOSED staffing ratios for a patient-centered medical home.

Staff FTEs / 1 Physician FTE (with a provider panel of 2,150)

  • 1.42 clerical
  • 1.33 RN, Medical assistant, Tech, LPN
  • 0.4  RN care manager
  • 0.25 Nurse practitioner/physician assistant
  • 0.25 health coach
  • 0.25 social work and mental health providers
  • 0.2  pharmacist
  • 0.1  nutritionist
  • 0.05 clinical data analyst

Note: The numbers that I report above are a little different from what you are going to see in the published article.  There was an error in some of the line items in Table 2 in the published article.  I contacted the author, Dr. Mitesh Patel, who sent me a corrected table.

Source: Patel, M.S., Arron, M.J., and others. (2013, June). Estimating the staffing infrastructure for a patient-centered medical home. American Journal of Managed Care, 19(6), 509-516. Retrieved from https://aharesourcecenter.files.wordpress.com/2015/05/1a5e8-ajmc-2013-4-1staffinginpcmh.pdf   Posted by AHA Resource Center (312) 422-2050, rc@aha.org


How many older people get hospital-acquired delirium?

Of patients aged 70 or older, about 25 percent will come into the typical hospital already having some symptoms of delirium – but an additional 25 percent will develop hospital-acquired delirium during their hospital stay.  Patients with delirium are likely to stay in the hospital longer, fall more, be readmitted sooner.  Hospital-acquired delirium comes from medication interactions, infections, recovery from surgery, and other not fully understood causes.  There are 200 hospitals that have adopted the Hospital Elder Life Program (HELP) http://www.hospitalelderlifeprogram.org/ which makes use of trained volunteers, primarily, to help older patients avoid hospital-acquired delirium.

Source: Clark, C. (2015, Apr.). Preventing hospital-acquired delirium. HealthLeaders, 18(3), 60-63. Retrieved from http://www.healthleadersmagazine-digital.com/healthleadersmagazine/april_2015#pg64

Link to a literature search about the HELP program:  http://www.hospitalelderlifeprogram.org/about/help-references/

Posted by AHA Resource Center (312) 422-2050, rc@aha.org

ACOs: Do accountable care organizations work?

Do accountable care organizations (ACOs) work?  That is the question addressed by this large-scale study of Medicare patients who were cared for by the newly established Pioneer ACOs in 2012 and 2013 compared to a control group.  The authors, who are with the Centers for Medicare & Medicaid Services (CMS), found that:

  • Costs for both groups increased in 2012 and 2013, but increased less for the ACO patients than for the control group
  • Inpatient hospital utilization was lower for the ACO patients (which was a key factor responsible for the lower rate of increase in costs)
  • Readmission rates were similar
  • There was a higher rate of physician follow-up visits after hospital discharge for the ACO patients

The authors conclude: “In the first 2 years of the Pioneer ACO Model, beneficiaries aligned with Pioneer ACOs … exhibited smaller increases in total Medicare expenditures and differential reductions in utilization of different health services, with little difference in patient experience.”

WHY IS THIS IS AN IMPORTANT STUDY?  Large scale study involving millions of patients — authoritative federal agency source — fundamental issues related to the reshaping of the American health care delivery system.

Source: Nyweide, D.J., Lee, W., and others. (2015, May 4). Association of pioneer accountable care organizations vs traditional Medicare fee for service with spending, utilization, and patient experience. JAMA. Retrieved from http://jama.jamanetwork.com/article.aspx?articleid=2290608 

There are two commentaries on this article:


BENCHMARKS: Patient call center cost per call

In this article about how health systems can improve patient access, the author, a consultant with ECG Management Consultants, discusses open access scheduling, patient navigators, telehealth services, and patient contact centers.  I particularly like the patient contact center statistics that the author provides, based on the experience of this consulting firm.

Patient Contact Centers (Call Centers)

  • $500,000 to $1 million initial capital investment (based on whether or not space is available and whether existing staff can be re-assigned)
  • $1 million ongoing call center cost per 500,000 patient interactions
  • Groups that have 100 or more providers particularly should evaluate this strategy

Source: Gingrass, J. (2015, Apr.). Changing the channel: strategies for expanding patient access. HFM. Healthcare Financial Management, 69(4), 64-68. Retrieved from http://marketing.ecgmc.com/acton/attachment/10977/f-0142/1/-/-/-/-/Changing-the-Channel_Strategies-for-Expanding-Patient%20Access_April-2015.pdf   Posted by AHA Resource Center (312) 422-2050, rc@aha.org


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