New England Journal offers perspectives on health law

The New England Journal of Medicine dedicates a significant amount of its current issue to research and perspectives on the new health reform law, the Patient Protection and Affordable Care Act, which is abbreviated as ACA (5/12).

Christopher C. Jennings, and Katherine J. Hayes, Jennings Policy Analysts: "Although the political far right may characterize the [Patient Protection and Affordable Care Act] as a one-size-fits-all government takeover of our health care system — and the far left may wish it were — the insurance reforms in fact embrace a hybrid federal-state approach. The new statute envisions and permits varied approaches to applying federal rules and regulations. ... Done right, the implementation of the ACA can achieve the advantages of a minimum national standard for coverage and greater equity among Americans without sacrificing the states' traditional roles, responsibilities, and flexibility. Done wrong, implementation will create excess layers of bureaucracy, and delay will ensure that this historic health care reform legislation falls far short of its goals."

Jon Kingsdale, executive director of the Massachusetts Health Insurance Connector Authority: "The focus on health insurance exchanges in the [ACA] is one sign of just how politically mainstream the new law is. Not only are exchanges market-based, but also the ACA decentralizes them, delegating primary responsibility to the states. ... But I'm a realist: I know that controversies will arise over their proper function and mission. ... After all, an accessible, customer-friendly, easy-to-use market is still only as good as the products it offers. Whether an insurance exchange looks more like a Walmart than a flea market will depend on whether doctors organize themselves into efficient, patient-responsive systems of care. In the United States, reforming the organization and delivery of medical care has always been the biggest challenge in the struggle to produce better care at sustainable cost."

Jonathan Gruber, M.I.T.: "[T]he real question concerns how far the ACA will go in slowing cost growth. ... There is no shortage of good ideas for ways of doing so, ranging from reducing consumer demand for health care services, to reducing payments to health care providers, to reorganizing the payment for and delivery of care, to promoting cost-effectiveness standards in care delivery, to reducing pressure from the threat of medical malpractice claims. There is, however, a shortage of evidence regarding which approaches will actually work — and therefore no consensus on which path is best to follow.

"Given this uncertainty, it is best to cautiously pursue many different approaches toward cost control and study them to see which ones work best. That is exactly the approach taken in the ACA ... analysis by both the Congressional Budget Office and the CMS actuary show that the ACA will substantially reduce the federal deficit, only slightly increase national medical spending (despite an enormous expansion in insurance coverage), begin to reduce the growth rate of medical spending, and introduce various new initiatives that may lead to more fundamental reductions in the long-term rate of health care cost growth."

The following studies also were included in this issue as "special articles." For related press coverage, see today's Morning Edition.

Yunjie Song, Jonathan Skinner, Julie Bynum, Jason Sutherland, John E. Wennberg and Elliott S. Fisher, the Dartmouth Institute for Health Policy and Clinical Practice:  "Among all Medicare beneficiaries, residence in regions of the United States that have a higher intensity of services is associated with a higher reported prevalence of common chronic illnesses. Whether this is due to a higher disease burden or to differences in diagnostic practices in high-intensity regions (or both) was unknown. To address this question, we followed Medicare beneficiaries for 2 years before and 3 years after a move and found that a move to a region with a higher intensity of practice as compared with a move to a region with a lower intensity of practice was associated with greater increases in diagnostic testing, the number of recorded chronic conditions, and HCC risk scores, with no apparent survival benefit."

"The newly passed health care reform legislation includes substantial increases in funding for comparative-effectiveness research programs and establishes major initiatives that will move Medicare and Medicaid toward bundled payment systems. Our findings underscore the need for additional efforts to advance risk-adjustment methods as reform proceeds."

Stephen Zuckerman, Timothy Waidmann,  Robert Berenson (Urban Institute) and Jack Hadley (George Mason University):  "Although geographic differences in Medicare spending are widely considered to be evidence of program inefficiency, policymakers need to understand how differences in beneficiaries' health and personal characteristics and specific geographic factors affect the amount of Medicare spending per beneficiary before formulating policies to reduce geographic differences in spending."

"We used Medicare Current Beneficiary Surveys from 2000 through 2002 to examine differences across geographic areas. Unadjusted Medicare spending per beneficiary was 52% higher in geographic regions in the highest spending quintile than in regions in the lowest quintile. After adjustment for demographic and baseline health characteristics and changes in health status, the difference in spending between the highest and lowest quintiles was reduced to 33%. Health status accounted for 29% of the unadjusted geographic difference in per-beneficiary spending; additional adjustment for area-level differences in the supply of medical resources did not further reduce the observed differences between the top and bottom quintiles."