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Health Affairs August Issue: Variations in Health Care


Bethesda, MD

Health Affairs' August variety issue includes a number of studies demonstrating variations in health and health care, such as differing obstetrical complication rates and disparities in care for diabetes. Other subjects in this variety issue include the impact of ACA coverage on young adults' out-of-pocket costs; and how price transparency may help lower health care costs.

For mothers-to-be, huge differences in delivery complication rates among hospitals. Four million women give birth each year in the United States. While the reported incidence of maternal pregnancy-related mortality is low (14.5 per 100,000 live births), the rate of obstetric complications is nearly 13 percent. Laurent Glance of the University of Rochester and coauthors analyzed data for 750,000 obstetrical deliveries in 2010 from the Healthcare Cost and Utilization's Nationwide Inpatient Sample. 
They found that women delivering vaginally at low-performing hospitals had twice the rate of any major complications (22.55 percent) compared to vaginal deliveries at high-performing hospitals (10.42 percent). For cesarean deliveries, the difference was even more pronounced: Women undergoing C-sections at low-performing hospitals were nearly five times more likely to experience a major complication than women at a high-performing hospital: 20.93 percent versus 4.37 percent. (Hospitals were classified as having low, average, or high performance based on a calculation of the relative risk that a patient would experience a major complication.) The authors conclude that narrowing the quality gap in obstetrical care could lead to improved outcomes for large numbers of women.

In California, low-income neighborhoods are hot spots for diabetic lower-extremity amputations. For patients suffering from diabetes and other chronic conditions, few studies have identified geographic patterns linking incomes to major preventative disease complications. In what is likely the first population-level study to assess the relationship between poverty level and lower-limb amputation in the United States, Carl Stevens of the University of California, Los Angeles and co-authors examined California's facility discharge data for 2009. Of the 6,828 Californians experiencing at least one diabetes-related amputation that year, the authors found that the rate of diabetes-related amputations in low-income neighborhoods is roughly twice that of affluent areas. To ameliorate this problem, the authors recommend deploying multidisciplinary primary care facilities to improve access in underserved urban and rural communities. 

On a related topic, Sam Harper of McGill University in Montreal and co-authors calculated annual state-specific life expectancies for blacks and whites from 1990 to 2009. They found considerable variation and uneven progress across states for the past two decades, with the strongest gains among states in the Northeast region. According to the authors’ findings, New York State made the most progress in reducing the national black-white difference in life expectancy. 

ACA dependant coverage has reduced high out-of-pocket spending. Since September 2010 the Affordable Care Act (ACA) has required insurers to let young adults up to the age of twenty-six remain on their parents’ private insurance plans. Susan Busch of Yale University and co-authors have found that this policy is associated with a statistically significant reduction in the share of young adults facing annual out-of-pocket health expenses greater than $1,500. The authors looked at the Medical Expenditure Panel Survey (MEPS) for the years 2007–11 for young adults ages 19–29 at the end of each survey year.  The study found that 2.9 percent of those between the ages of 19–25 faced expenses greater than $1,500 after the enactment of the provision, compared to 4.2 percent in the years before. For their slightly older peers (ages 26–29) not on their parents' plans, 5.4 percent had out-of-pocket costs greater than $1,500 after the ACA’s enactment, compared to 4.4 percent before. The authors conclude that the dependent care coverage provision in the ACA provides financial protection for young adults at a time when they often face high debt burden but low wages. 

Other studies on health care coverage for children in the issue:

Revealing MRI Prices Triggered Competition. An insurer-initiated price transparency program was initiated to encourage patients needing MRIs to select high-value providers. Sze-jung Wu and Andrea DeVries of HealthCore and co-authors provide the results from this program. Selected members from the program group were informed about price differences among MRI facilities and offered assistance in choosing different providers. The control group did not receive price information. For the intervention group, the authors identified a $220 cost reduction (or 18.7 percent) per test and a decrease in hospital-facility use from 53 percent in 2010 to 45 percent in 2012. They note that the program’s success prompted higher-cost facilities to lower their prices, resulting in a 30 percent reduction in the difference between hospital and nonhospital facilities in the intervention group. The study demonstrates that price transparency offers the potential to reduce health care costs.

Also in the August issue: 
About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print, with additional Web First papers published periodically at The full text of each Health Affairs Web First paper is available free of charge to all website visitors for a one-week period following posting, after which it switches to pay-per-view for nonsubscribers. Web First papers are supported in part by a grant from The Commonwealth Fund. You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download our podcasts, including monthly Narrative Matters essays, on iTunes. Tap into Health Affairs content with the new iPad app.