This report released October 6, 2009 by the National Center for Assisted Living (NCAL) found that Medicaid spending on home- and community-based services (HCBS) increased 81.5 percent from FY2001 to FY2007, while nursing home spending grew 9.8 percent over the same period.  The report found that, from 2001 to 2007, Medicaid nursing home spending went from $42.7 billion to $46.9 billion while HCBS spending increased from $9.2 billion to $16.7 billion.  In addition, the number of people receiving Medicaid services in licensed assisted living settings increased 44 percent from 2002 to 2009 and HCBS Medicaid waivers now cover services in residential settings in 37 states while an additional 13 states provide coverage directly though the state Medicaid plan. 

From the report's major findings:

Full Report: http://www.ahcancal.org/ncal/resources/Documents/MedicaidAssistedLivingReport.pdf 

National Center for Assisted Living. (2009). State Medicaid reimbursement policies and practices in assisted living. Robert L. Mollica

A report released by the Committee for a Responsible Federal Budget presents analyses of federal health care reform legislation using data from the CBO, Office of Management and Budget (OMB), Joint Commission on Taxation, and the Library of Congress, to conclude that none of the bills does enough to control health care costs.

From the report:

Even setting that $245 billion aside, though, the House still fails to achieve anything more than token deficit neutrality. Although the bill would technically balance out over ten years – excluding the updates – this would largely be due to surpluses collected before the implementation of the coverage measures. As the bill is written, surpluses would turn to deficits by 2014 (or in 2015 if we exclude the cost of physician payment updates), and these deficits would grow every year, reaching $65 billion by 2019. Even excluding the cost of updating physician payments, the bill would still increase the deficit by around $25 billion in 2019.

Committee for a Responsible Federal Budget . (2009). Evaluating health care plans: an analysis of the short- and long-term fiscal implications of reform plans.

Full report: http://crfb.org/sites/default/files/Evaluating_Health_Care_Plans.pdf

This National Committee for Quality Assurance (NCQA) report on the state of health care quality, released on October 22, found  that overall health care quality in America—including private and public coverage—has been virtually stagnant since 2008.  Previous NCQA reports have found health care quality had improved significantly every year for the past 12 years and NCQA attributes the reversal to the economy and the fee-for-service (FFS) payment model.  In addition to the overall trends, the NCQA report notes that the percentage of patients receiving quality care for many conditions, including for M/SU conditions, remained under 50 percent while some M/SU conditions displayed quality reductions.

From the Executive Summary:

There are probably multiple reasons for the flat results of 2009. First, and perhaps most important, is the lagging U.S. economy. The current downturn began in the fourth quarter of 2008, but employers and health plans had already begun to shift their focus almost entirely to the cost of coverage. When purchasers are buying on the basis of cost alone, plans naturally follow suit and pay more attention to negotiating discounts and less to improving performance. And the most effective tool — tying payments to performance — is not being utilized enough, especially by the giant Medicare program.

Millions of Americans lost their jobs and insurance; many shifted to Medicaid and the Children’s Health Insurance Program (CHIP); others became uninsured. Several states have made enormous strides in focusing their Medicare and CHIP programs on quality but they are not yet the majority. While more than half of Americans with private insurance are in a HEDIS-reporting plan, only 25 percent of Medicaid beneficiaries and 17 percent of Medicare beneficiaries are.

The National Committee for Quality Assurance. (2009).The State of Health Care Quality 2009.

Full report: http://www.ncqa.org/Portals/0/Newsroom/SOHC/SOHC_2009.pdf

This Commonwealth Fund report examines the relationship between medical practices’ costs and medical home activities, finding that medical homes were associated with modest information technology cost increases, but no other additional costs.  However, the authors acknowledge that the absence of a clear association between the level of medical home implementation and practice cost may stem from data limitations or an insufficient definition of “medical home”.

From the Executive Summary:

Based on data from the 35 practices in the final analysis sample, we found no evidence of additional costs associated with higher levels of MH activity; our estimates suggested that there was less than a $1-per-month difference in patient costs between the third of study practices with the highest PPC-PCMH scores (which measure MH intensity) and those in the middle and lower thirds. The average total cost per full-time-equivalent (FTE) physician was $517,000 for all 35 practices. Although the mean total cost per FTE physician increased slightly across the three score categories, the Low and High means were within one standard error of one another, meaning that the differences were not statistically significant. Support staff costs exhibited a similar pattern.

The Commonwealth Fund. (2009). Incremental cost estimates for the patient-centered medical home. Zuckerman, Stephen, Merrell, Katie, Berenson, Robert, Gans, David, Underwood, William, Williams, Aimee, Erickson, Shari & Hammons, Terry.

Full report: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2009/Oct/1325_Zuckerman_Incremental_Cost_1019.pdf

This article discusses the implications of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial for private and public payers.  The STAR*D trial found that, for second- and third-line treatment, no second-generation antidepressant was superior to another in terms of effectiveness or of the overall incidence of harmful effects.  The authors conclude that the findings have allowed payers to construct coverage rules with greater confidence.

Little, A., Hansen, R. A., Gartlehner, G. (2009). Impact of the STAR*D trial from the perspective of the payer. Psychiatric Services, 60, 1463-1465. DOI: 10.1176/appi.ps.60.11.1463 http://ps.psychiatryonline.org/cgi/content/abstract/60/11/1463 

Authors: Alison Little, Richard A. Hansen, Gerald Gartlehner, Carrie Gray. 

This article, published in the New England Journal of Medicine (NEJM), considers the complexities surrounding linking provider payments and quality of care and health outcomes, noting that, among other issues,  reimbursement must be adjusted for patients' coexisting conditions to prevent hospitals for treating only low-risk patients to achieve high quality ratings. 

Wang, C. J., Conroy, K. N., Zuckerman, B. (2009). Payment reform for safety-net institutions—improving quality and outcomes. NEJM, 361(19), 1821-1823.

Authors: C. Jason Wang, Kathleen N. Conroy, Barry Zuckerman.