Research roundup: Medical homes working in poor areas, designing insurance exchanges, health law's effects

Health Affairs: Moving Forward On Health Reform - This edition explores the issues relating to the implementation of the Patient Protection and Affordable Care Act of 2010, including the impact of the law on health insurance as well as state and federal governments, large employers and public opinion and opportunities for small physician practices to pool resources in order support medical homes, among others (June 2010).

Health Affairs: Insurance Exchanges Under Health Reform: Six Design Issues For The States - Highlighting challenges of the state-based exchanges created by the new health law, the authors write: "Although the law provides some guidance in structuring these new exchanges, it leaves many key decisions to the states." They note: "Successfully implementing exchanges will require public-private partnerships, expertise in insurance operations and marketing, and a series of strategic decisions." The paper examines such issues as to how the exchanges will be organized and governed, the rating rules for insurers and the "range of benefit options," among others (Kingsdale and Bertko, June 2010).

Robert Wood Johnson Foundation: Section 125 Plans In The Post-Reform Environment: Issues For Individual Insurance - Prior to the enactment of the Patient Protection and Affordable Care Act (PPACA) this year "several states passed laws requiring or encouraging employers who did not offer group health coverage to establish a cafeteria plan pursuant to section 125 of the tax code in order to allow employees to purchase individual health insurance on a pre‐tax basis."

"While the language of PPACA precludes using section 125 plans for exchange‐based individual insurance, it leaves open the possibility of section 125 plan use outside of an exchange. PPACA provides fairly strong arguments that non‐exchange‐based individual insurance policies may be purchased through a section 125 plan, but it fails to state so explicitly," the author concludes (Monahan, 6/11).

Kaiser Family Foundation: This issue brief (.pdf) "examines new opportunities under the health reform law for states to balance their Medicaid long-term care delivery systems by expanding access to Medicaid home and community-based services (HCBS) programs. The brief outlines key provisions of the new law that expand HCBS benefit options, broaden financial and functional eligibility criteria, and provide additional financial incentives for states to further shift their Medicaid long-term services budgets to non-institutional settings" (June 2010).

Commonwealth Fund: Developing Innovative Payment Approaches: Finding The Path To High Performance - The success of the health law's payment initiatives to improve the efficiency of health care "will depend on the ability to identify and carry out needed changes in the way health care is delivered and paid for and the flexibility to tailor innovations to the circumstances in which they are applied," write the authors of this issue brief (.pdf). They examine ways the development, implementation and evaluation of payment approaches can be improved and the role of the Center for Medicare and Medicaid Innovation, scheduled to launch in 2011, that "will test innovative payment and service delivery models" (Guterman and Drake, 6/8).

Archives Of Internal Medicine: Medical Home Capabilities Of Primary Care Practices That Serve Sociodemographically Vulnerable Neighborhoods - This study examines whether primary care practices that largely serve minority or low-income populations have the services to qualify for funding as "patient-centered medical homes."

Based on survey data from a sample of physicians from 412 Massachusetts practice sites, the authors report that "contrary to expectations … practices serving disproportionate shares of patients residing in neighborhoods with high prevalences of minority race/ethnicity or economic disadvantage were more likely than others to have the following 3 key structural capabilities: on-site language interpreters, multilingual clinicians, and frequently used, multifunctional [electronic health records]. In addition, minority disproportionate-share practices were more likely to have staff to assist patient self-management of chronic disease, and economic disproportionate-share practices were more likely to report physician awareness of patient experience ratings" (Friedberg et al., 6/14).

Journal of the American Society of Nephrology: Racial Composition Of Residential Areas Associates With Access To Pre-ESRD Nephrology Care - "Clinical practice guidelines for chronic kidney disease emphasize the importance of timely referral to a nephrologist for patients expected to require renal replacement therapy. Nevertheless, approximately 33% of end-stage renal disease (ESRD) patients in the United States do not see a nephrologist before initiation of chronic dialysis," according to this study examining the racial composition of where a patient lives and access to kidney specialists prior to starting dialysis.

Based on a retrospective analysis of 92,000 white and black adults who began dialysis between June 2005 and October 2006, the authors report, "as the percentage of blacks in residential areas increased, the likelihood of not receiving pre-ESRD nephrology care increased." But they conclude: "racial composition of residential areas associates with access to nephrology care but not with quality of the nephrology care received" (Prakash et al., 6/17).

Archives Of Internal Medicine: Free Clinics In The United States - "Very little is known about free clinics despite their being one of the few viable options for uninsured people with limited funds," according to this study detailing the "attributes of free clinics and [analyzes] their contribution to the safety net," as measured by a national mail survey of free clinics. "Overall, 1007 free clinics operated in 49 states and the District of Columbia," with Alaska being the "lone exception." With the clinics providing care for 1.8 million people, the author concludes: "Free clinics have passed the point in history when they can exist below the radar. At the same time, policymakers and other safety net providers must acknowledge the important role that free clinics play. Formal integration of free clinics into the safety net has the potential to strengthen the overall health system, which is important regardless of the outcome of the national health reform debate" (Darnell, 6/14).

National Center For Policy Analysis (.pdf): Emergency Room Visits Likely To Increase Under ObamaCare - The author asserts, that because of the new health law: "emergency room costs will increase for two reasons: 1) about half the newly insured will enroll in Medicaid and Medicaid patients seek emergency room care more often than the uninsured, and 2) while the newly insured will try to increase their consumption of care, the absence of any program to create more providers will force patients to turn to emergency rooms as the outlet for increased demand" (Goodman, June 2010).

CDC's Morbidity and Mortality Weekly Report Emergency Department Visits Involving Nonmedical Use of Selected Prescription Drugs --- United States, 2004--2008 - "The number of ED visits involving nonmedical use of prescription or over-the-counter drugs increased rapidly during 2004--2008, and by 2008 matched the number of ED visits involving illicit drugs.  ... Given the societal burden of the problem, additional interventions are urgently needed, such as more systematic provider education, universal use of state prescription drug monitoring programs by providers, the routine monitoring of insurance claims information for signs of inappropriate use, and efforts by providers and insurers to intervene when patients use drugs inappropriately (6/18).