How price and quantity factors drive spending in nongroup and employer health plans.

OBJECTIVES: To describe how spending in private, nongroup health insurance plans compared to spending in employer plans and to attribute those spending differences to components related to provider prices and quantity of care. DATA SOURCES: The 2016 commercial claims and enrollment data of three large, national insurers from the Health Care Cost Institute. STUDY DESIGN: We compared per member per month spending across three employer and three nongroup market segments, including on-exchange, off-exchange, and short-term plans, to average commercial spending. We constructed price indices in each market segment and then decomposed spending differences into those attributable to differences in prices, health risk, plan generosity, and other factors. DATA COLLECTION/EXTRACTION METHODS: We selected all medical claims for enrollees in commercial plans. We excluded enrollees with Medicare Advantage coverage or those for whom the majority of claims were covered by a secondary payer. RESULTS: Provider prices were 4.1% lower in on-exchange plans (p < 0.001) and 1.4% lower in off-exchange plans (p < 0.001), compared to average prices in the same geographic area. In contrast, prices in employer plans were within roughly a percentage point of those averages. Differences in average spending were much larger than price differences. Off-exchange enrollees spent 20% less than the sample average (p < 0.001), whereas on-exchange enrollees spent 12% more (p < 0.001). Those differences were driven largely by variation in health risk, with variation in prices, plan generosity, and other factors contributing smaller amounts. CONCLUSIONS: Our results indicate that provider prices in nongroup plans are much closer to the prices paid by employer plans than to the substantially lower prices paid by public payers. In addition, health risk was the largest contributor to differences in spending. Lowering provider prices and attracting healthier enrollees in nongroup plans may be crucial for lowering premiums.

Massachusetts health reforms: uninsurance remains low, self-reported health status improves as state prepares to tackle costs.

The Massachusetts health reform initiative enacted into law in 2006 continued to fare well in 2010, with uninsurance rates remaining quite low and employer-sponsored insurance still strong. Access to health care also remained strong, and first-time reductions in emergency department visits and hospital inpatient stays suggested improvements in the effectiveness of health care delivery in the state. There were also improvements in self-reported health status. The affordability of health care, however, remains an issue for many people, as the state, like the nation, continues to struggle with the problem of rising health care costs. And although nearly two-thirds of adults continue to support reform, among nonsupporters there has been a marked shift from a neutral position toward opposition (17.0 percent opposed to reform in 2006 compared with 26.9 percent in 2010). Taken together, Massachusetts's experience under the 2006 reform initiative, which became the template for the structure of the Affordable Care Act, highlights the potential gains and the challenges the nation now faces under federal health reform.

Coverage, access, and affordability under health reform: learning from the Massachusetts model.

While the impacts of the Affordable Care Act will vary across the states given their different circumstances, Massachusetts' 2006 reform initiative, the template for national reform, provides a preview of the potential gains in insurance coverage, access to and use of care, and health care affordability for the rest of the nation. Under reform, uninsurance in Massachusetts dropped by more than 50%, due, in part, to an increase in employer-sponsored coverage. Gains in health care access and affordability were widespread, including a 28% decline in unmet need for doctor care and a 38% decline in high out-of-pocket costs.

American primary care physicians' decisions to leave their practice: evidence from the 2009 commonwealth fund survey of primary care doctors.

The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years. Just over half (53%) of the physicians age 50 years or older and 30% of physicians between age 35 and 49 years may leave their practices for these reasons. Having such plans was associated with many factors, but the strongest predictor concerned problems regarding time spent coordinating care for their patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine. Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons. Provisions of the Patient Protection and Affordable Care Act that reduce the number of uninsured patients as well as innovations such as medical homes and accountable care organizations may reduce pressures that lead to attrition in the primary care workforce. Reasons why primary care physicians' decide to leave their practices deserve more attention from researchers and policy makers.

The impacts of state health reform initiatives on adults in New York and Massachusetts.

OBJECTIVE: To analyze the effects of health reform efforts in two large states--New York and Massachusetts. DATA SOURCES/STUDY SETTING: National Health Interview Survey (NHIS) data from 1999 to 2008. STUDY DESIGN: We take advantage of the "natural experiments" that occurred in New York and Massachusetts to compare health insurance coverage and health care access and use for adults before and after the implementation of the health policy changes. To control for underlying trends not related to the reform initiatives, we subtract changes in the outcomes over the same time period for comparison groups of adults who were not affected by the policy changes using a differences-in-differences framework. The analyses are conducted using multiple comparison groups and different time periods as a check on the robustness of the findings. DATA COLLECTION/EXTRACTION METHODS: Nonelderly adults ages 19-64 in the NHIS. PRINCIPAL FINDINGS: We find evidence of the success of the initiatives in New York and Massachusetts at expanding insurance coverage, with the greatest gains reported by the initiative that was broadest in scope--the Massachusetts push toward universal coverage. There is no evidence of improvements in access to care in New York, reflecting the small gains in coverage under that state's reform effort and the narrow focus of the initiative. In contrast, there were significant gains in access to care in Massachusetts, where the impact on insurance coverage was greater and a more comprehensive set of reforms were implemented to improve access to a full array of health care services. The estimated gains in coverage and access to care reported here for Massachusetts were achieved in the early period under health reform, before the state's reform initiative was fully implemented. CONCLUSIONS: Comprehensive reform initiatives are more successful at addressing gaps in coverage and access to care than are narrower efforts, highlighting the potential gains under national health reform. Tracking the implications of national health reform will be challenging, as sample sizes and content in existing national surveys are not currently sufficient for in-depth evaluations of the impacts of reform within many states.

Sustaining health reform in a recession: an update on Massachusetts as of fall 2009.

With the passage of national health reform legislation modeled on Massachusetts' 2006 reform initiative, the Bay State continues to provide important lessons for the nation. Most recently, Massachusetts has shown that although it is difficult, sustaining the gains of health reform in a severe recession is possible. The state's uninsurance rate, 4.8 percent for nonelderly adults, remained at a record low in fall 2009. Access to health care improved, and the burden of high health care costs on individuals was reduced. However, challenges remain, as some barriers to care persist and escalating health care costs continue to be an issue.

Massachusetts health reform: employer coverage from employees' perspective.

The national health reform debate continues to draw on Massachusetts' 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This study provides an update on employers' responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers' dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms.

Trends in Medicaid physician fees, 2003-2008.

Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008. This was below the general rate of inflation, resulting in a reduction in real fees. Only primary care fees grew at the rate of inflation-20 percent between 2003 and 2008. However, because of slow growth in Medicare fees, Medicaid fees closed a small portion of their ongoing gap relative to Medicare-growing from 69 percent to 72 percent of Medicare. The increase in Medicaid fees relative to Medicare fees resulted from relative increases for primary care and obstetrical services, but not for other services.

Another Look at the Impacts of Health Reform in Massachusetts: Evidence Using New Data and a Stronger Model.

In April 2006, Massachusetts enacted a comprehensive health care reform bill that seeks to move the state to near universal insurance coverage. The bill included expanded eligibility for public coverage, subsidized insurance, market reforms, requirements for employers, and, most controversial, an individual mandate. A study of the early impacts of the state's initiative found evidence of a substantial drop in uninsurance--from 13 to 7 percent for nonelderly adults (Long 2008). Because that study relied on a simple pre-post comparison, it is possible that the estimates of the impact of health reform reflect both the changes under health reform and factors beyond health reform that changed over the same period, leading to biased estimates of the impacts of reform (Lawrence B. Mohr 1995). This paper expands on the earlier work to estimate the impacts of health reform in Massachusetts using new data and a stronger research design. Specifically, we rely on data over time for Massachusetts and other states from the Current Population Survey (CPS) to estimate difference-in-differences (DD) models (Jeffrey M. Wooldridge 2002).