Sue Ducat
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Health Affairs’ April Issue: Maternity Coverage, Children, Disability & More

Bethesda, MD - The April issue of Health Affairs, a variety issue, contains studies about hospital pricing, health coverage for pregnant immigrant women, seat-belt use in the United States, and the amount of US physicians’ clinical time spent on computer-related tasks.

Hospital chargemasters: how much do they affect what patients and insurers actually pay?
Over the past few decades, researchers have noted a widening gap between official hospital list prices and the amounts actually paid by patients and insurers. To better understand the role of the chargemaster, Michael Batty of the Federal Reserve Board and Benedic Ippolito at the American Enterprise Institute examined data covering the period 2002–14. According to the authors, basic hospital characteristics were strong predictors of which hospitals set higher list prices: A large, for-profit, urban hospital that was a member of a chain had list price markups that were 360 percent higher than those of a small independent, rural, nonprofit hospital. The authors found that higher list prices were also correlated with higher payments from the uninsured and privately insured patients. In the case of the uninsured, they used the passage of California’s Hospital Fair Pricing Act to provide causal evidence that hospitals with higher list prices generated higher payments from patients. The authors found that list prices are an increasingly important indicator of which hospitals ultimately receive higher payments—which suggests potential causal channels for this relationship.

Effects of insurance coverage for pregnant immigrant women in the United States.
Despite federal restrictions on coverage for recent immigrants and undocumented immigrants in the United States, the 2002 Children’s Health Insurance Program (CHIP) unborn child option allowed states to use federal funding to provide health services to mothers during pregnancy and delivery-related care regardless of their immigration or legal status. Laura Wherry of the University of California, Los Angeles, and coauthors used 1998–2013 data from the National Center for Health Statistics to compare pregnancy-related care and infant health outcomes in states expanding coverage for pregnant immigrant women with those in states that did not. The study found an approximately one-third decrease in the share of immigrant women with low education who received no prenatal care in states expanding access to care compared to states that did not. However, the authors did not find significant changes in the incidence of low birthweight, preterm birth, being small for gestational age, or infant death when comparing the same groups. They conclude that the results do not rule out the possibility of longer-term improvements in the health of these children and that the goal of achieving sustained health improvements may benefit from other programmatic tactics.

Also of interest:

PRACTICE OF MEDICINE: Half of physicians’ clinical time spent on computer tasks.
Measuring how physicians spend their clinical time is essential in making clinic staffing decisions and improving the accuracy of payment for physician services. Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute and coauthors analyzed electronic health record (EHR) data for the period 2011–14 from nearly 500 physicians in a community-based health care system in one of the first studies using such data to understand how physicians spend their time. The authors found that each day the physicians logged an average of 3.08 hours on face-to-face office visits (49 percent of their time) and 3.17 hours (51 percent of their time) on desktop medicine activities, which included communicating online with patients, ordering tests, reviewing test results, sending staff messages, and other tasks (see the exhibit below). Since physicians are reimbursed for office visits, lab work, and medical procedures but not for desktop medicine tasks, the authors suggest that their findings highlight the misalignment of the current fee-for-service payment policy and the potential for physician burnout with EHR use. This study is the first of Health Affairs’ new series, The Practice Of Medicine, which explores the broad practice environment and how features of that environment affect practitioners. The series is supported by the Physicians Foundation.

DATAWATCH: Seat-belt noncompliance still a problem in most US counties.
Seat-belts have proven to significantly reduce harm from motor vehicle crashes, and the US Department of Health and Human Services’ Healthy People 2020 initiative includes the goal of 92 percent or greater seat-belt compliance for front-seat occupants. Jacob Sunshine and coauthors of the University of Washington examined the results of a longitudinal telephone survey conducted by states in collaboration with the Centers for Disease Control and found that the national prevalence of compliant seat-belt use (those who responded that they “always” used them) was 85.9 percent in 2012, the latest year in which county level information was available. While this represents an increase of 8.4 percent from 2002, only 2.2 percent of US counties had achieved the Healthy People 2020 objective. Among the authors’ findings: counties within states with primary enforcement laws (officers may issue a ticket for seat-belt noncompliance even if there is no other traffic infraction) have overall compliance rates that are more than 10 percentage points higher than rates in counties without such laws. According to the National Highway Traffic Safety Administration, in 2015 deaths from automobile crashes had the largest percentage one-year increase since 1966. To help address this growing problem, the authors recommend that primary seat-belt enforcement laws be adopted by remaining holdout states.

Also of interest:

Disparities in cesarean births in Mexico.
Mexico is the country in the Americas with the second-highest prevalence of cesarean deliveries (second only to Brazil). Sylvia Guendelman of the University of California, Berkeley and coauthors used 2014 Mexican birth certificate data to perform population-level data analyses on more than 600,000 first-time mothers. According to the authors, 48.7 percent of these births were cesarean deliveries. Individual Mexican states’ rates ranged widely but presented no clear geographical patterns. The study also revealed that enrollees in Seguro Popular, the public health insurance program, had lower cesarean birth rates than those in other insurance programs and those without insurance. The widest difference, however, was in the delivery location: cesarean rates in private birthing facilities occurred almost twice as often as those taking place in other facilities. “Mexico’s continuing transition toward universal health coverage through Seguro Popular…may help curb the cesarean epidemic,” the authors conclude. “To do this, the health care system must tackle access barriers to public hospitals…, increase the number of qualified staff members to oversee and support women through the labor process, and educate women about the benefits of vaginal birth.”

Also of interest:

The impact of ACA Medicaid expansion on dental visits: mixed results.
Dental coverage for adults is an optional benefit under Medicaid, one that about half of states offer. With thirty-one states and the District of Columbia expanding Medicaid eligibility under the Affordable Care Act (ACA), how many more low-income Americans sought dental care? To answer this question, Astha Singhal of Boston University and coauthors compared 2010 and 2014 data collected by the Centers for Disease Control and Prevention. The study found that 1.5 million more low-income adults reported having a dental visit in 2014 than in 2010. However, among states expanding Medicaid that offer dental benefits, there was a decline in usage among adults with children, who had enjoyed this access before the ACA’s implementation (see the exhibit below). These results provide evidence that the addition of new low-income patients may be straining the capacity of providers willing to treat low-income patients and that additional policy initiatives may be needed to expand the size of this subset of the dental care delivery system. 

About Health Affairs

Health Affairs is the leading peer-reviewed journal at the intersection of health, health care, and policy. Published monthly by Project HOPE, the journal is available in print, online, and on mobile and iPad app. Additional and late-breaking content is found at To update your subscription preferences, please visit our Alerts page on the website.