The Fraying Link Between Work and Health Insurance

This analysis shows employer-sponsored insurance coverage declining after 2000 due to an economic downturn with rising unemployment, declining family incomes, and more workers moving into temporary or part-time work and other employment arrangements where health benefits were not provided. Employer-sponsored coverage continued to decline after 2003 — despite improvements in the economy and slower growth in health care costs — as the share of employees with access to employer insurance and take-up rates among workers continued to fall. As a result, the rate of uninsured increased, both for workers and for low-income children with access to employer-based coverage.

The decrease in employer-sponsored coverage during this decade represents a marked change from prior years. With the ailing economy, employer coverage is likely to continue to decline and employees will face greater difficulty taking up coverage as cost-sharing increases. In the absence of broader national health reform, these trends will likely lead to increasing numbers of uninsured. The link between work and insurance coverage will be a critical component of any national debate over health care reform.

Turning to Medicaid and SCHIP in an Economic Recession: Conversations with Recent Applicants and Enrollees

This study highlights the contribution that Medicaid and State Children's Health Insurance Program (SCHIP) make to families' economic recovery efforts. The authors suggest a number of approaches for government to provide more assistance in hard economic times, including expanded Medicaid and SCHIP enrollment settings, more eligibility staff, streamlined enrollment processes, expanded eligibility criteria, emergency coverage for families experiencing sudden job loss, unemployment benefit disregards, and help with the transition from employer-based coverage.

This study is important because as the current recession deepens, needs for Medicaid and SCHIP coverage will continue to rise. Many who once had steady employment and incomes will turn to these programs for the first time, even as the programs face increasing budget constraints. Rapid reauthorization of SCHIP and federal fiscal relief to states can improve the capacity of these programs to fill widening gaps in health care coverage.

Diagnostic-Therapeutic Cascade Revisited: Coronary Angiography, Coronary Artery Bypass Graft Surgery, and Percutaneous Coronary Intervention in the Modern Era

This study reveals that there is wide geographic variation in the use of coronary revascularization in the United States. Rates are closely related to rates of coronary angiography. The authors assessed the relationship between coronary angiography and coronary artery revascularization by procedure type (coronary artery bypass graft surgery or percutaneous coronary intervention).

The relationship between coronary angiography rates and total coronary revascularization rates was strong (R2=0.84), but there was only a modest association between coronary angiography rates and coronary artery bypass graft surgery rates (R2=0.41) with the suggestion of a threshold effect. The association between coronary angiography rates and percutaneous coronary intervention rates was strong (R2=0.78) and linear.

The research is significant because it shows that percutaneous coronary intervention (PCI) rates are not only variable, they are strongly associated with coronary angiography. Given the results of recent studies of medical versus invasive management of stable coronary disease, many patients may be getting more treatment than they want or need.

More Isn't Always Better in Coronary Care

This article depicts the diagnostic-therapeutic cascade and the current environment in the field of interventional cardiology using a real life case example. The author follows the history of a 53 year-old man with no chest pain whose stress test — done as part of an insurance policy application — revealed an abnormality on his EKG. This led to an angiogram and suggestion from the cardiologist for a balloon angioplasty, despite the patient's willingness to treat with diet and cholesterol-lowering drugs. The authors point to this case as an example of "invasive cardiology run amok." The article describes the patient as "being treated while healthy," referring to the many cardiac patients without symptoms who are being treated with invasive procedures, and points to "mistaken assumptions" in the field, noting three major studies performed in the late 1970s and early 1980s indicating that for the majority of patients, bypass surgery is no more effective than conservative medical treatment.

This article is significant as it takes the recent research on treatment options for cardiac care into the popular press. It describes the therapeutic cascade in layman's terms and sheds light on the fact that these procedures, which are covered by insurance and cost about $60 billion a year in the United States, are not known to prevent heart attacks.

Lowering Co-payments: Impact of Simvastatin Patent Expiration on Patient Adherence

In an effort to keep up with rising prescription drug costs, health plans have implemented various cost-sharing strategies including prescription medication copayments, tiering, and coinsurance, as well as Value Based Insurance Design Strategies (VBID). VBID argues that if you can increase the use of evidence-based, cost-effective healthcare, you should improve care and may even be able to reduce the overall cost of healthcare by eliminating expensive downstream services and procedures.

The objective of this study was to assess the impact of a decrease in statin copayments on medication adherence and demand for statins. Intervention and control patients had to have purchased at least 1 generic simvastatin and non-simvastatin statin, respectively, after patent expiration. Adherence was calculated with the medication possession ratio (MPR). The results indicated that decreasing statin copayments was associated with adherence increases. However, the overall increase in medication adherence was modest and its clinical significance uncertain.

This article adds to the body of evidence on the impact of copayment reduction on medcation adherence. However, other factors should also be considered. (See also Are Patent Expirations the Answer to Improving Patient Adherence?)

Financial Incentive-Based Approaches for Weight Loss

The purpose of this study was to determine whether common decision errors identified by behavioral economists (such as prospect theory, loss aversion, and regret) could be used to design an effective weight loss intervention. Participants were randomized to three weight loss plans — monthly weigh-ins, a lottery incentive program, or a deposit contract with participant matching — with a weight loss goal of one pound (0.45 kg) per week for 16 weeks. The main outcome measure of the study was weight loss after 16 weeks.

The authors conclude that the use of economic incentives produced significant weight loss during the 16 weeks of intervention but was not fully sustained. The longer-term use of incentives should be evaluated. In addition to being relevant to the field of obesity treatment, a national public health priority, this study is important as we examine incentive approaches around various types of health care benefits; specifically, incentives related to wellness behavior.

Making Medical Homes Work: Moving from Concept to Practice

Despite the vast amount of energy and resources invested in the medical home model to date, relatively little has been written about moving from theoretical concept to practical application, particularly on a large scale. What would an effective medical home program look like? And how should it be implemented?

The authors have identified four critical operational issues in the implementation of most medical home models that they believe have potential to make or break a successful program: (1) how to qualify physician practices as medical homes; (2) how to match patients to their medical homes; (3) how to engage patients and other providers to work with medical homes in care coordination; and (4) how to pay practices that serve as medical homes. Drawing on published data and our on-the-ground expertise.

The results of this analysis can inform clinicians, payers and policy makers as they attempt to build a solid foundation for successful medical home initiatives. Doing so will improve the chances that the medical home concept can serve as a stepping stone to broader reforms in health care payment and delivery systems.

Medical Home: Nurse Practitioners' Role in Health Care Delivery to Vulnerable Populations

Nurse practitioners (NPs) have a long history of providing high-quality health care to vulnerable populations in the United States, particularly populations who participate in public insurance programs including Medicare and Medicaid. Yet, the expanded Medical Home demonstration projects initiated recently by the Center for Medicare and Medicaid Services (CMS) and taken up by Congress did not include NPs. Although Congress did not intentionally seek to exclude NPs originally in the legislation, NP organizations advocating for participation in the medical home demonstration projects encountered roadblocks by CMS because the legislation did not contain NP-inclusive language.

This article reviews the concept of medical home, the role of NPs in the continuity of care for children and families with chronic health conditions, the current legislation addressing the issue of Medical Home in Congress, and the importance of collaboration in the health care system in issues such as health care/medical home to reduce health care costs.