|WHAT WE’RE READING
Stuff we read this week that made us think.
A comprehensive look at the effects of Medicaid expansion
Anyone interested in understanding the impact of the Obama-era Medicaid expansion should read the review out yesterday from Kaiser Family Foundation, which provides the most comprehensive look yet at the effects of extending coverage to low-income Americans. Researchers evaluated 324 studies published since 2014 assessing clinical, economic, and access-related outcomes in states that adopted Medicaid expansion. The results are almost universally positive. States that expanded Medicaid saw sharp declines in their uninsured rates, particularly for vulnerable populations (although some waiver provisions dampened this effect). While some studies show that expansion led to longer wait times to access specialist appointments, it was broadly shown to increase access to care for low-income populations; in particular, access to cancer care, behavioral health and smoking cessation support improved. Medicaid expansion also appears to have led to improved health outcomes and quality of care, and lower health disparities. Individuals and states also fared better financially with expansion. Medicaid expansion was associated with improved individual healthcare affordability and fewer medical bankruptcies. It improved state budgets, offsetting state costs for services like substance abuse and behavioral health and may have stimulated broader economic growth. Providers also fared better in expansion states, with improved margins and lower rates of uncompensated care. Taken in full, the article highlights a growing health disparity between states which expanded Medicaid and those that did not. The 14 states that have yet to expand largely held out on ideological grounds—and will see the relative health status of their residents fall as their tax dollars support Medicaid expansion in other states.
Evaluating hospital quality evaluations
A welcome new study from a group of highly regarded researchers was published this week in NEJM Catalyst, attempting to evaluate the various (and often contradictory) hospital quality rating systems that have proliferated over the past several years. The evaluators constructed a rigorous process to identify the strengths and weaknesses of four different ratings services: the Leapfrog Group, Healthgrades, U.S. News & World Report, and the Star Ratings system used by the Centers for Medicare and Medicaid Services (CMS). Based on the review, none of the four ratings approaches received an “A” grade. U.S. News performed best, earning an overall grade of “B” for its “responsive[ness] to changes in measurement science”, its specialty- and procedure-specific rankings, and (controversially) its inclusion of “reputation” as a key criterion for evaluating hospitals. Leapfrog earned a “C-” grade, based on the self-reported nature of its surveys, its lack of formal audits, and the use of secondary sources of data for non-surveyed hospitals. Healthgrades was the worst performer, with a “D+” grade, based on methodological concerns about its use of outcomes metrics and the way it classifies and compares hospitals. And CMS’s Star Ratings were given a “C” based on their position as a neutral, non-commercial evaluation, despite concerns about the weighting of performance criteria and the comparison of vastly different kinds of institutions. The authors propose several measures to improve the evaluation of hospital quality but bemoan the lack of a “gold standard”, independent source of rankings. Perhaps the most entertaining part of the NEJM Catalyst piece is the comments section, in which some of those receiving poor grades weighed in with angry responses. Seems like no one likes being graded, even the graders.
Come fly with me (surgeon)
Stories of Americans seeking lower-cost surgeries at foreign hospitals are nothing new, but a recent New York Times piece profiles the sweetest “medical tourism” deal we’ve seen. In July, 56-year-old Donna Ferguson flew to Galenia Hospital in Cancún, Mexico, to undergo a total knee replacement. Not only did her husband’s employer pay all medical and travel expenses, she received a $5,000 cash bonus after the surgery. Ferguson’s surgeon, who traveled from Wisconsin to perform the procedure, got a pretty good deal as well. He was paid $2,700, three times the Medicare rate. The arrangement was constructed by Denver-based North American Surgical Hospital, who has managed treatment for a “couple dozen” patients at the Cancún hospital since 2017. These kinds of deals make for compelling stories but are unlikely to provide a scalable solution, and are a symptom of, not a cure for, our high-cost healthcare system. This approach, in which a surgeon is paid more to operate outside the US, and the patient gets a $5,000 bonus to travel, is ultimately an indictment of high hospital prices as the primary cost driver of surgical care.