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Health Affairs’
September Issue

Bethesda, MD - The September issue of Health Affairs, a variety issue, includes a number of studies examining aspects of payment reform, the impact of certain ACA provisions, the value of some high-cost anticancer drugs, and more. It also includes a DataGraphic examining aging and health.

DATAWATCH: New evidence of rapid physician practice consolidation, 2013–15.
In the past few decades, group physician practices have become more of the norm, and the proportion of physicians in larger groups has grown. David Muhlestein and Nathan Smith, with Leavitt Partners in Salt Lake City, Utah, looked at Medicare’s Physician Compare data for the period 2013–15 to examine physician consolidation for both primary care providers and specialists. According to the data, the proportion of physicians in groups of nine or fewer declined from 40.1 percent in 2013 to 35.3 percent in 2015. During the same period, the proportion of those in groups of one hundred or more increased from 29.6 percent to 35.1 percent (see the exhibit below). The authors note that these changes were significantly more pronounced among primary care providers than among specialists. The percentage of primary care physicians in the smallest group size declined more (5.7 percent for primary care providers, compared to 1.1 percent among specialists), and the percentage of primary care physicians in the largest group increased more (4.5 percent, compared to a 1.1 percent among specialists). The authors note that their findings demonstrate a continuation of physician consolidation.

New anticancer drugs increase life expectancy—and cost much more.
There has been an ongoing debate among health policy makers over the value of new anticancer drugs, given their high cost. David Howard of Emory University and coauthors analyzed data from the Surveillance, Epidemiology, and End Results (SEER)–Medicare database for patients with metastatic breast, lung, or kidney cancer or chronic myeloid leukemia, comparing patients diagnosed during the years 1996–2000 with those diagnosed in 2007–11. Overall, the authors found large increases in medical costs, but also significant gains in life expectancy. For example, among metastatic breast cancer patients receiving physician-administered anticancer drugs, life expectancy increased by thirteen months, with additional lifetime costs of $72,000. Breast cancer patients who forwent this treatment saw smaller changes in life expectancy and costs. The authors conclude that their results highlight the importance of considering outcomes and overall costs when assessing the value of anticancer drugs as a group. They note that their findings suggest that the cancer drugs approved over the study period are cost-effective by conventional standards.

Contraception and the ACA: Coverage mandate increased use of long-term methods.
One provision of the Affordable Care Act (ACA) eliminated, for most private health insurance enrollees, patient cost sharing on all contraceptive methods approved by the Food and Drug Administration. In what is believed to be the first study to examine how this coverage changed women’s contraceptive choices, Caroline Carlin of Medica Research Institute and coauthors used claims data for a sample of Midwestern women ages 18–46 with employer-sponsored insurance from a regional health plan, examining medical and pharmacy claims for the period 2008–14. According to the authors, the reduction in cost sharing was associated with a 2.3 percentage point increase in the choice of any prescription contraceptive, with much of the increase coming from increased selection of long-term contraceptive methods (such as IUDs and contraceptive implants). The authors conclude that when high out-of-pocket spending on long-term contraception methods is not a factor, women are more likely to choose the most effective methods, compared to when such spending is a factor.

A related study in the September issue:

DATAWATCH: Massachusetts health reform at ten years.
In April 2006, Massachusetts enacted legislation to bring about near-universal health insurance coverage and improve access to affordable health care. Sharon Long of the Urban Institute and coauthors analyzed a variety of data sources to examine health insurance coverage and health care access and affordability over time and across population subgroups. They found that by 2015 the uninsurance rate in the Bay State had been reduced to 2.5 percent. The authors also note that many vulnerable populations in the state, including immigrant, minority, and low-income adults, and many communities across the state have higher uninsurance rates, and among those with coverage, there are continuing gaps in access and affordability. They also observe that strategies to reduce the growth in health costs are primarily focused on shifting provider reimbursements from fee-for-service to value-based payments. The authors conclude that Massachusetts’s experiences highlight the challenge for all states to ensure that expanded coverage under the ACA reaches eligible populations and supports access to affordable care, particularly for vulnerable people with higher health care needs and fewer economic resources.

A study about a different state’s ACA experience:

Aging & Health: A home-based care program reduces disability.
In recent years, policy makers have become increasingly aware of the nonmedical factors that can help or impede value-based care. Sarah Szanton and coauthors of Johns Hopkins University report on an effort to reduce the impact of disability among homebound low-income adults, funded by the Center for Medicare and Medicaid Innovation, as part of the Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program. This particular demonstration project, begun in 2012, brought a team of professionals to work with elderly low-income Baltimore residents for five months in the period 2012–15, to improve residents’ performance of certain activities of daily living, or ADLs. According to the authors, 75 percent of the 234 study participants improved their performance of ADLs, 65 percent improved their performance on related tasks such as shopping and managing medication, and 53 percent reduced their symptoms of depression. The authors note that with a modest cost of $2,825 per participant, the CAPABLE program has been praised as a way to improve lives and save taxpayer money, as well as enhance older adults’ ability to age in place.

Sub-Saharan Africa: Training did not improve care quality for pregnant women, sick children.
Evaluating how much in-service training and supervision affect the quality of care for pregnant women and sick children in sub-Saharan Africa, Hannah Leslie of the Harvard T. H. Chan School of Public Health and coauthors examined nationally representative health system surveys from seven countries in the region, pooling data from Kenya, Malawi, Namibia, Rwanda, Senegal, Tanzania, and Uganda between 2006 and 2014. This is one of the few studies to analyze training and supervision in a multicountry sample, drawing upon observations of over 5,000 providers. For antenatal care, the authors found that receiving both recent in-service training and supervision was associated with a small difference in quality score. Also, the quality of sick child care was moderately associated with both training and supervision. Clinical quality increased slightly when a greater percentage of training topics or supervisory actions were covered, but quality did not exceed 50 percent of expected performance. “In-service training and supportive supervision as delivered were not sufficient to meaningfully improve the quality of care in these countries,” the authors conclude. “Greater attention to the quality of health professional education and national health system performance will be required to provide the standard of health care that patients deserve

About Health Affairs

Health Affairs is the leading journal at the intersection of health, health care, and policy. Published by Project HOPE, the peer-reviewed journal appears each month in print and online, with additional Web First papers and health policy briefs published regularly at You can also find the journal on Facebook and Twitter. Read daily perspectives on Health Affairs Blog. Download monthly Narrative Matters podcasts. Tap into Health Affairs content with the iPad app.