A sudden catastrophic loss of heart function, or cardiac arrest, occurred significantly less among adults who acquired health insurance via the Affordable Care Act (ACA), according to new research in Journal of the American Heart Association, the Open Access Journal of the American Heart Association/American Stroke Association.

In a study of emergency medical services in an urban Oregon county before and after the ACA, researchers noted that the incidence of cardiac arrest was significantly lower among middle-aged adults after they gained health insurance through the ACA, primarily through Medicaid expansion.

Among adults between 45 and 64 years old, the incidence of cardiac arrest decreased by 17 percent. In contrast, the incidence remained the same among adults over age 65 with consistently high rates of health insurance coverage, primarily through Medicare.

“Cardiac arrest is devastating and under-recognized cause of premature death for both men and women older than 45 years,” said study lead author Eric Stecker, M.D., M.P.H., associate professor of cardiology at Oregon Health & Science University’s Knight Cardiovascular Institute in Portland, Oregon. “Health insurance allows people to engage in regular medical care, which is crucial for the prevention of cardiovascular disease and the diagnosis and treatment of conditions that can cause cardiac arrest.”

In the United States, more than 350,000 cases of out-of-hospital cardiac arrest happen each year. Cardiac arrest occurs when the heart’s regulatory system suddenly malfunctions, causing an abnormal heart rhythm. Death occurs if immediate medical attention, including CPR, isn’t started after cardiac arrest.

In this study, researchers used records for emergency medical services in Multnomah County, Oregon, to identify patients with out-of-hospital cardiac arrest. They then compared this information to U.S. Census Bureau data for the county’s adult population in the years before ACA implementation (2011-2012) and after ACA implementation (2014-2015). The study was part of a larger research project led by the study’s senior author Sumeet Chugh, M.D., director of the Heart Rhythm Center at Cedars-Sinai Heart Institute in Los Angeles.

“These findings underscore the important role of prevention in the battle against sudden cardiac arrest, which affects almost a thousand Americans every day,” Chugh said. “Less than 10 percent of these patients make it out of the hospital alive, so by the time we dial 9-1-1 it is much too late. For this reason, effective primary prevention is vital.”

Although the results of this small, preliminary study show an association between health insurance and lower rates of cardiac arrest, they do not prove cause and effect. To prove that health insurance decreases the rate of cardiac arrest, it is necessary to do larger studies that control other possible influences and include more diverse groups of patients.

Still, the results confirm the American Heart Association’s support of the ACA’s expansion of Medicaid and other health insurance coverage.

“It is critical to more comprehensively identify the health benefits of insurance and to carefully consider public policies that affect the number of uninsured Americans,” Stecker said.

In an accompanying editorial Mary Fran Hazinsky, R.N., MSN, and Carole R. Myers, Ph.D., RN., note expanded Medicaid services have reduced deaths in other states but call these findings “intriguing.”

“The hypothesized relationship between healthcare expansion and decline in [out-of-hospital cardiac arrest] incidence is certainly a timely question that requires further study,” they wrote. “A follow-up study should be based on a framework that looks more broadly at a complement of social and other determinants of health, and accounts for the various dimensions of access, and evaluates access by looking at utilization.”

Hazinsky is a former consultant for the American Heart Association.

Co-authors are Kyndaron Reinier, Ph.D., M.P.H.; Carmen Rusinaru, M.D., Ph.D.; Audrey Uy-Evanado, M.D.; Jonathan Jui, M.D., M.P.H.; and Sumeet Chugh, M.D. Author disclosures are on the manuscript.

The National Heart Lung and Blood Institute funded the study.

Women in Tennessee who were diagnosed with breast cancer were more likely to be diagnosed with late stage disease after a substantial rollback of Medicaid coverage for adults in the state, according to a new analysis. When investigators compared women living in lower-income areas with those in higher-income areas, low-income areas saw the greatest shift to late stage diagnosis. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings point to the potential negative health impacts of limiting Medicaid enrollment.

There is considerable interest in understanding the benefits and harms associated with Medicaid expansions and contractions. The Affordable Care Act expanded eligibility for Medicaid, although the Supreme Court later made this expansion voluntary. More recently, the proposed American Health Care Act seeks to limit Medicaid enrollment substantially.

To examine the health implications of policies that contract Medicaid benefits, a team led by Wafa Tarazi, PhD, of Virginia Commonwealth University, and Lindsay Sabik, PhD, of the University of Pittsburgh, analyzed 2002-2008 Tennessee Cancer Registry data and compared women diagnosed with breast cancer who lived in low-income zip codes with a similar group of women who lived in high-income zip codes, before and after Tennessee’s restrictions on Medicaid enrollment in 2005.

Overall, nonelderly women in Tennessee were diagnosed at later stages and experienced more delays in treatment in the period after restrictions. There was also a 3.3 percentage point increase in late-stage diagnosis for women living in low-income zip codes relative to women living in high-income zip codes.

“We show that when a large population in a state loses Medicaid coverage, low-income women are more likely to be diagnosed with breast cancer at later stages, suggesting that they did not receive screening or other primary care that may have facilitated earlier diagnosis,” said Dr. Tarazi. “Our findings are important for policy makers who are considering changes to the Medicaid program.”

Dr. Sabik stressed that late-stage cancer is more costly to treat than early-stage cancer and is associated with a greater risk of death. “Medicaid rollbacks may contribute to widening disparities in health outcomes between low-income women and their wealthier counterparts,” she said.

In an accompanying editorial, Sujha Subramanian, PhD, of RTI International, and Nancy Keating, MD, MPH, of Brigham and Women’s Hospital, noted that federal and state policy makers will likely continue to consider rollbacks of Medicaid expansions to save money or address fiscal shortfalls. “It is important that these policy makers understand that such short-term policies have longer-term consequences for the health of the low-income population, for whom Medicaid is often the only health insurance coverage option,” they wrote.

An analysis of billing records for more than 12,000 emergency medicine doctors across the United States shows that charges varied widely, but that on average, adult patients are charged 340 percent more than what Medicare pays for services ranging from suturing a wound to interpreting a head CT scan.

A report of the study’s findings, published in JAMA Internal Medicine, also notes that the largest hospitals markups are more likely made to minorities and uninsured patients.

“There are massive disparities in service costs across emergency rooms and that price gouging is the worst for the most vulnerable populations,” says Martin Makary, M.D., M.P.H., professor of surgery at the Johns Hopkins University School of Medicine and the study’s senior investigator. “This study adds to the growing pile of evidence that to address the huge disparities in health care, health care pricing needs to be fairer and more transparent,” adds Makary, whose widely published research focuses on health care costs and disparities.

For the study, Makary and his team obtained Medicare billing records for 12,337 emergency medicine physicians practicing in nearly 300 hospitals all 50 states in 2013 to determine how much emergency departments billed for services compared to the Medicare allowable amount.

The Medicare allowable amount is the sum of what Medicare pays, the deductible and coinsurance that patients pay, and the amount any third party such as the patient pays.

In addition, using the 2013 American Hospital Association database, the research team identified size, urban/rural status, teaching status, for-profit status, regional location and safety-net hospital status for each emergency medicine department whose billing data were made part of the analysis. Using the zip code for each emergency department, the researchers also estimated poverty rates, uninsured status and minority populations for those using each emergency room, based on data from the 2013 U.S. Census Bureau.

The researchers then calculated each service bill’s markup ratio, defined as the relationship between the billed charges and the Medicare allowable amount. For example, a markup ratio of 4.0 means that for a service with a Medicare allowable amount of $100, the hospital charged $400, or 300% over the Medicare allowable amount.

Makary and his team found that emergency departments charged anywhere from 1.0-12.6 times ($100-$12,600) more than what Medicare paid for services. On average, emergency medicine doctors had a markup ratio of 4.4 (340 percent in excess charges), or emergency medicine physician charges of $4 billion versus $898 million in Medicare allowable amounts.

The researchers also analyzed billing information for 57,607 general internal medicine physicians 3,669 hospitals in all 50 states to determine whether any markup differences, and how much, existed between emergency medicine physicians practicing in a hospital’s ER, and general internal medicine physicians who see patients at hospitals.

On average, charges were greater when a service was performed by an emergency medicine physician rather than a general internal medicine physician. Overall, general internal medicine physicians had an average markup ratio of 2.1 compared to the Medicare allowable amount.

Makary found that wound closure had the highest median markup ratio at 7.0, and interpreting head CT scans had the greatest within-hospital variation, with markup ratios ranging between 1.6 and 27.

For a physician interpretation of an electrocardiogram, the median Medicare allowable rate is $16, but different emergency departments charged anywhere from $18 to $317, with a median charge of $95 (or a markup ratio of 6.0). General internal medicine doctors in hospitals charged an average of $62 for the same service.

Overall, emergency departments that charged patients the most were more likely to be located in for-profit hospitals in the southeastern and Midwestern U.S., and served higher populations of uninsured, African-American and Hispanic patients.

Our study found that inequality is then further compounded on poor, minority groups, who are more likely to receive services from hospitals that charge the most,” says Makary.

While the study was limited by lack of data on facility and technical fees also charged by the hospital, as well as lack of patients’ insurance type and the actual amount patients ultimately paid, Makary says the study highlights the urgent need for legislation that will protect uninsured patients.

“This is a health care systems problem that requires state and federal legislation to protect patients. New York has passed a law that requires hospital and insurance companies to agree on a cost for the care so patients are not billed egregious amounts. Patients really have no way of protecting themselves from these pricing practices,” says Tim Xu, a fourth year medical student at the Johns Hopkins University School of Medicine and the paper’s first author.

Models such as the Maryland Waiver, Makary adds, where prices are set at the same rate no matter what hospital a patient goes to, can increase price transparency and protect patients. Currently, at least 7 states have passed some legislation to protect uninsured patients from paying so called charge master prices, a list of billable services developed and closely guarded by each hospital, noting prices that are usually highly inflated and charged mainly to uninsured and other “self pay” patients. However, Makary says a national model is necessary to unveil what is currently an inexplicably chaotic and opaque pricing system.

Article: Variation in Emergency Department vs Internal Medicine Excess Charges in the United States, Martin A. Makary, MD, MPH et al., JAMA Internal Medicine, doi: 10.1001/jamainternmed.2017.1598, published online 30 May 2017.

More than 8 million children enrolled in the Children’s Health Insurance Program (CHIP) could be at risk of losing coverage if federal funding for the program is not extended this year. Children with chronic conditions are most vulnerable, and their families could face substantial cost increases if they lose CHIP coverage and need to shift their insurance to a Marketplace plan, according to a Yale study.

The findings were published in the April issue of Health Affairs.

CHIP is a main source of government-sponsored health insurance for children in low-income families. A quarter of those children – 2 million – have chronic conditions, such as diabetes or asthma, that require more care at greater cost. To determine the impacts on those children if Congress fails to extend CHIP later this year, a team of Yale researchers compared CHIP coverage with Marketplace plans nationwide. The Marketplace, developed as part of the Affordable Care Act, is an online exchange that allows families to shop for health insurance plans, often with support of government subsidies.

To conduct their analysis, the research team used data from CHIP and Marketplace plans, as well as utilization data on children with chronic conditions. They calculated out-of-pocket costs for children enrolled in either plan in every state. Finally, they analyzed costs for children at four different income levels.

While the researchers found that both CHIP and Marketplace plans are effective in providing coverage for children with chronic conditions, they concluded that CHIP is the preferable alternative. “CHIP plans provide better and more generous coverage,” said first author Alon Peltz. “The amount that families may need to pay if CHIP goes away and children need to enroll in a Marketplace plan could be quite significant.”

If low-income families shift from CHIP to Marketplace plans, their annual out-of-pocket expenses could rise significantly, as much as $233 to $2,472, depending on income level and the child’s health care needs. Families with children who have epilepsy, diabetes, or a mood disorder could face the steepest costs increases, the researchers said.

“As policymakers consider alternatives for providing coverage for this vulnerable population of children, we encourage them to be particularly mindful of the cost burden families might encounter,” Peltz noted.

While CHIP, established in 1997, was reauthorized through 2019, funding expires in September 2017. Loss of federal funding could force states to cut benefits or even discontinue their programs altogether.

In the event that CHIP is not funded, and families switch to Marketplace plans, the researchers suggested ways the latter plans could be made more affordable. Modifications include enhancements to current cost-sharing protections; a review of co-payments for prescription drugs and hospitalizations that drive out-of-pocket costs; and close monitoring of deductibles.

“We found that minor modifications in the way marketplace subsidies are structured could put them in line with the CHIP program,” Peltz said. “However, given the uncertain future of the Affordable Care Act, extending funding for CHIP is likely the best strategy for providing stability and security for those families who need it most.”

Other Yale authors are Amy J. Davidoff, Cary P. Gross, and Marjorie S. Rosenthal.

The authors received funding from the Robert Wood Johnson Foundation to support this research.

Article: Low-Income Children With Chronic Conditions Face Increased Costs If Shifted From CHIP To Marketplace Plans, Alon Peltz, Amy J. Davidoff, Cary P. Gross and Marjorie S. Rosenthal, Health Affairs, doi: 10.1377/hlthaff.2016.1280, published April 2017.

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