IMPORTANCE: Under the Affordable Care Act (ACA), more than 30 states have expanded Medicaid, with some states choosing to expand private insurance instead (the “private option”). In addition, while ...coverage gains from the ACA’s Medicaid expansion are well documented, impacts on utilization and health are unclear. OBJECTIVE: To assess changes in access to care, utilization, and self-reported health among low-income adults in 3 states taking alternative approaches to the ACA. DESIGN, SETTING, AND PARTICIPANTS: Differences-in-differences analysis of survey data from November 2013 through December 2015 of US citizens ages 19 to 64 years with incomes below 138% of the federal poverty level in Kentucky, Arkansas, and Texas (n = 8676). Data analysis was conducted between January and May 2016. EXPOSURES: Medicaid expansion in Kentucky and use of Medicaid funds to purchase private insurance for low-income adults in Arkansas (private option), compared with no expansion in Texas. MAIN OUTCOMES AND MEASURES: Self-reported access to primary care, specialty care, and medications; affordability of care; outpatient, inpatient, and emergency utilization; receiving glucose and cholesterol testing, annual check-up, and care for chronic conditions; quality of care, depression score, and overall health. RESULTS: Among the 3 states included in the study, Arkansas (n=2890), Kentucky (n=2898, and Texas (n=2888), there were no differences in sex, income, or marital status. Respondents from Texas were younger, more urban, and disproportionately Latino compared with those in Arkansas and Kentucky. Significant changes in coverage and access were more apparent in 2015 than in 2014. By 2015, expansion was associated with a 22.7 percentage-point reduction in the uninsured rate compared with nonexpansion (P < .001). Expansion was associated with significantly increased access to primary care (12.1 percentage points; P < .001), fewer skipped medications due to cost (−11.6 percentage points; P < .001), reduced out-of-pocket spending (−29.5%; P = .02), reduced likelihood of emergency department visits (−6.0 percentage points, P = .04), and increased outpatient visits (0.69 visits per year; P = .04). Screening for diabetes (6.3 percentage points; P = .05), glucose testing among patients with diabetes (10.7 percentage points; P = .03), and regular care for chronic conditions (12.0 percentage points; P = .008) all increased significantly after expansion. Quality of care ratings improved significantly (−7.1 percentage points with “fair/poor quality of care”; P = .03), as did the share of adults reporting excellent health (4.8 percentage points; P = .04). Comparisons of Arkansas vs Kentucky showed increased private coverage in the former (21.7 percentage points; P < .001), increased Medicaid in the latter (21.3 percentage points; P < .001), and higher diabetic glucose testing rates in Kentucky (11.6 percentage points; P = .04), but no other statistically significant differences. CONCLUSIONS AND RELEVANCE: In the second year of expansion, Kentucky’s Medicaid program and Arkansas’s private option were associated with significant increases in outpatient utilization, preventive care, and improved health care quality; reductions in emergency department use; and improved self-reported health. Aside from the type of coverage obtained, outcomes were similar for nearly all other outcomes between the 2 states using alternative approaches to expansion.
The ACA Hospital Readmissions Reduction Program applies penalties for high readmission rates. Among Medicare beneficiaries, rates declined after the ACA went into effect. There was no significant ...association between changes in observation stays and readmissions.
Hospital readmissions within 30 days after discharge have drawn national policy attention because they are very costly, accounting for more than $17 billion in avoidable Medicare expenditures,
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and are associated with poor outcomes. In response to these concerns, the Affordable Care Act (ACA), which was passed in March 2010, created the Hospital Readmissions Reduction Program. Since October 2012, the start of fiscal year (FY) 2013, the program has penalized hospitals with higher-than-expected 30-day readmission rates for selected clinical conditions. In FY 2013 and 2014, these conditions were acute myocardial infarction, heart failure, and pneumonia. Total hip or knee replacement and . . .
When legislation was enacted in 1983 establishing prospective payment for hospitals, the incentives for hospitals changed dramatically. Cost-based payments for hospital days and services were ...replaced with a set payment per admission that was based on the patient's diagnosis-related group. The goal of the legislation was to encourage shorter lengths of stay and more efficient care, but policymakers were also concerned about possible increases in readmissions. Higher rates of readmissions, they thought, might be a consequence of the legislation either because patients might be prematurely discharged from the index hospitalization or because services might be “unbundled” by hospitals in an . . .
This study was based on a large survey of patients' experiences in the hospital. Hospitals with the highest nurse-staffing levels received the highest ratings from patients with respect to ...satisfaction with their care. Furthermore, hospitals that received the highest satisfaction ratings from patients provided a modestly higher quality of clinical care than those that received the lowest ratings.
Hospitals with the highest nurse-staffing levels received the highest ratings from patients with respect to satisfaction with their care. Furthermore, hospitals that received the highest satisfaction ratings from patients provided a modestly higher quality of clinical care than those that received the lowest ratings.
The quality of health care in the United States varies according to region and setting and is too often inadequate.
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In response to uneven care among hospitals, federal policy makers and private organizations have launched an important program to collect and publicly report data on the quality of the health care Americans receive. The Hospital Quality Alliance (HQA) program,
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overseen by private and public entities, including the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission, is leading this effort in the hospital sector, producing quarterly reports on the provision of effective services for common conditions. Although . . .
Hospital participation in the Bundled Payments for Care Improvement initiative for five common medical conditions was not associated with changes in Medicare payments, clinical complexity, length of ...stay, emergency department use, hospital readmissions, or mortality.
In the past decade, provision of financial incentives for a higher quality of care (pay for performance) has spread across the country and beyond. In October, the federal government introduced pay ...for performance to all hospitals paid by Medicare nationwide. Yet most studies of pay for performance have shown modest or inconsistent effectiveness in improving quality.
An early but influential study of the Premier Hospital Quality Incentive Demonstration (HQID), involving more than 250 hospitals and serving as the model for the federal program, showed an increase of 2.6 to 4.1 percentage points in process-quality measures during the first 2 years . . .
Health policy experts are focusing on the prevention of hospital readmissions as a way to improve quality and reduce costs. This study showed wide variation in hospital readmission rates but only a ...weak association between discharge planning and readmission. The publication of discharge-planning data is unlikely to reduce readmission rates.
Health policy experts are focusing on the prevention of hospital readmissions as a way to improve quality and reduce costs. This study showed wide variation in hospital readmission rates but only a weak association between discharge planning and readmission.
The U.S. health care system faces challenges on two fronts: pressure to improve quality
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and the necessity to reduce costs.
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Unfortunately, quality-improvement efforts often increase costs even when they are “cost-effective,” and efforts to constrain costs can lead to concerns about reductions in the quality of care. Thus, improving care in clinical areas where efforts can lead simultaneously to better outcomes for patients and lower costs represents an important step forward.
Preventing readmissions is one such opportunity. Previous studies have indicated large variations in readmission rates among hospitals
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and noted substantial problems with the transition of care from the . . .
Major policy uncertainty continues to surround the Affordable Care Act (ACA) at both the state and federal levels. We assessed changes in health care use and self-reported health after three years of ...the ACA's coverage expansion, using survey data collected from low-income adults through the end of 2016 in three states: Kentucky, which expanded Medicaid; Arkansas, which expanded private insurance to low-income adults using the federal Marketplace; and Texas, which did not expand coverage. We used a difference-in-differences model with a control group and an instrumental variables model to provide individual-level estimates of the effects of gaining insurance. By the end of 2016 the uninsurance rate in the two expansion states had dropped by more than 20 percentage points relative to the nonexpansion state. For uninsured people gaining coverage, this change was associated with a 41-percentage-point increase in having a usual source of care, a $337 reduction in annual out-of-pocket spending, significant increases in preventive health visits and glucose testing, and a 23-percentage-point increase in "excellent" self-reported health. Among adults with chronic conditions, we found improvements in affordability of care, regular care for those conditions, medication adherence, and self-reported health.
The Affordable Care Act expands Medicaid in 2014 to millions of low-income adults in states that choose to participate in the expansion. Since 2010 California, Connecticut, Minnesota, and Washington, ...D.C., have taken advantage of the law's option to expand coverage earlier to a portion of low-income childless adults. We present new data on these expansions. Using administrative records, we documented that the ramp-up of enrollment was gradual and linear over time in California, Connecticut, and D.C. Enrollment continued to increase steadily for nearly three years in the two states with the earliest expansions. Using survey data on the two earliest expansions, we found strong evidence of increased Medicaid coverage in Connecticut (4.9 percentage points; $$p ) and positive but weaker evidence of increased coverage in D.C. (3.7 percentage points; $$p=\mathbf{\boldsymbol{0.08}}$$). Medicaid enrollment rates were highest among people with health-related limitations. We found evidence of some crowd-out of private coverage in Connecticut (30-40 percent of the increase in Medicaid coverage), particularly for healthier and younger adults, and a positive spillover effect on Medicaid enrollment among previously eligible parents.
In 2016, Medicare started mandatory bundled payment for joint-replacement surgery in randomly selected areas. Hospitals receive bonuses or pay penalties based on spending through 90 days after ...discharge. In the first 2 years, there was a slight reduction in spending.
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