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Hospital Quality And Care: Health Affairs' August Issue



Bethesda, MD — The August issue of Health Affairs contains a cluster of articles focusing on hospital quality and care. Other subjects covered in this variety issue: ways state vaccine exemption laws affect disease outbreaks; how states with strong health insurance rate review managed lower premiums; characteristics of health care "super-utilizers," and others.

State Vaccination Exemption Laws, Exemption Rates, And Disease Outbreaks.
In the United States, it is left to individual states to require that their kindergarteners show proof of vaccinations or have a vaccination exemption before being admitted to school. W. David Bradford and Anne Mandich of the University of Georgia analyzed how state-level vaccination exemption laws affect immunization rates and outbreaks of preventable diseases. By measuring the association between each component of state kindergarten vaccination exemption laws and state vaccination exemption rates from 2002-12, they observed that policies such as requiring health department approval of nonmedical exemption applications, physician signatures on applications, and criminal or civil punishments for noncompliance significantly affected the reduction of vaccine exemptions. The authors created an index (below) identifying the states with the most (pale blue) and least (dark blue) effective laws. West Virginia and Mississippi do not allow nonmedical exemptions and so were not indexed. According to the authors' data, effective states had lower incidences of pertussis.
States By Quartile Of Exemption Law Effectiveness Index, 2012
Strong State Health Insurance Rate Review Lowers Individual Premiums.
The Affordable Care Act (ACA) requires many health insurance carriers to publicly justify a rate increase of 10 percent or more. In the first study to examine the impact of state review authority on individual premiums, Pinar Karaca-Mandic of the University of Minnesota and coauthors collected data on how states changed their rate review authority and requirements during 2010-13, combining these data with carrier filings. They found that state-level prior approval authority over health insurance rates in the individual market in that period was associated with a 10 percentage point lower rate of increase in premiums. Their study provides early evidence that stronger forms of rate review authority may constrain health insurance premium increases in individual markets.
Profile of "Super-Utilizers": Their Needs May Be Short-Lived.
The skewed distribution of health care costs has drawn attention to "super-utilizers"--people who use the largest share of health care resources. Tracy Johnson of Denver Health and coauthors conducted cross-sectional and longitudinal analyses of 4,774 publicly insured or uninsured super-utilizers at Denver Health between 2011 and 2013. According to their study, over time 3 percent of adult patients met the super-utilizer criteria and accounted for 30 percent of adult charges. However, only one-quarter of super-utilizers at any given time still met that definition one year later. The study also identified clinically important subgroups that may respond to different approaches to reduce avoidable health care use. The authors concluded that these findings have important implications for policy makers and for future program design and evaluation efforts, as previous studies have not fully explored this classification of important patient subgroups and instability of usage at the individual level.
Mental Health Parity Act: More Out-Of-Network Substance Abuse Services Used.
The Mental Health Parity and Addiction Act of 2008 requires large group insurers to cover substance use disorder services at the same level as medical or surgical benefits, whether those services are provided in or out of network. In the first study to evaluate the effects of extending parity to out-of-network substance use disorder care, Emma McGinty at the Johns Hopkins Bloomberg School of Public Health and coauthors reviewed insurance claims for 525,620 substance use disorder service users to examine changes in the utilization of and spending on these services before and after the law's implementation. The study showed that federal parity was associated with increases in: the likelihood of using out-of-network services; the number of out-of-network outpatient visits per user; and average total spending on those services among users. The authors found no changes in out-of-pocket spending due to federal parity, probably because of a rise in the average number of out-of-network substance abuse outpatient visits per user. The ACA requires Marketplace plans to include substance use disorder services as an essential health benefit. The authors note that understanding the effects of this law on out-of-network services is critical.
Also of interest in the August issue are several articles about hospital quality and care: