November Research Roundup: What We’re Reading

By Emma Walsh-Alker

CHIR had a lot to be thankful for this November, including new health policy research. For the latest installment of our monthly research roundup, we reviewed studies on consumer awareness of Medicaid renewals resuming when the COVID-19 public health emergency (PHE) expires, integrating health equity into value-based payment models, and trends in hospital consolidation across health care markets.

Jennifer M. Haley, Michael Karpman, Genevieve M. Kenney, Stephen Zuckerman, Most Adults in Medicaid-Enrolled Families Are Unaware of Medicaid Renewals Resuming in the Future, Urban Institute, November 15, 2022. Under the Medicaid continuous coverage requirement tied to the COVID-19 PHE, state Medicaid agencies are prohibited from disenrolling beneficiaries for the duration of the PHE as a condition of receiving increased federal funding. Using data from their June 2022 Health Reform Monitoring Survey, researchers at the Urban Institute evaluated the extent to which adults aged 18-64 who are either enrolled in Medicaid or have a family member enrolled in Medicaid or CHIP are aware of this upcoming change.

What it Finds

The majority (62 percent) of the adults surveyed had heard “nothing at all” about the resumption of Medicaid renewals.

Only 5 percent of the survey group had heard “a lot” about the renewals, with the rest of respondents hearing “some” (16.2 percent) or “only a little” (15.7 percent).
More than half (56.5 percent) of adult respondents who enrolled in Medicaid after the continuous coverage requirement began had heard nothing about renewals resuming.

Respondents who had heard anything about the upcoming renewals reported obtaining this information from a variety of sources.

The largest share of these respondents (34.3 percent) indicated they received information from a media source including TV, social media, radio, or a newspaper. The next largest share of the group (30.6 percent) received information from a state agency. About a quarter (24.5 percent) of respondents aware of renewals resuming received information from a health insurer or plan, while 17.8 percent found out from a health care provider, and 6.5 percent heard from another source.
Half (50.4 percent) of respondents aware of upcoming renewals reported receiving a notice that they will need to renew their coverage. Other common messages received included a request to update contact information (reported by 36.4 percent of the group) or verify eligibility information such as income (34.4 percent).
Fewer respondents in this group were informed about other coverage sources available to them if they are determined no longer eligible for Medicaid (29.1 percent) or how to access consumer assistance during the renewal process (21.3 percent).

Why it Matters
With the PHE recently extended into 2023, stakeholders continue to prepare for the massive wave of coverage transitions expected to occur once Medicaid renewals resume. Low levels of consumer awareness about the upcoming resumption of Medicaid renewals are a cause for concern as stakeholders seek to minimize coverage losses. While sources such as social media and news broadcasts may be reaching the widest audience, there are still opportunities for state agencies and health plans to conduct more individualized outreach regarding potential changes to an enrollee’s coverage, and steps they can take to update their information before renewals resume. Providing resources on affordable alternative coverage options and connecting people to enrollment assisters will be especially critical for the 15 million individuals projected to lose Medicaid, many of whom will be eligible for subsidized marketplace coverage.

William K. Bleser, Yolande Pokam Tchuisseu, Humphrey Shen, Andrea Thoumi, Deborah R. Kaye, and Robert S. Saunders, Advancing Equity Through Value-Based Payment: Implementation And Evaluation To Support Design Goals, Health Affairs, November 4, 2022. Value-based payment (VBP) models tie provider reimbursement to quality metrics, cost savings, or both. Researchers completed a scan of relevant policy and literature to identify best practices for the design and implementation of equity-driven VBP models to come up with a set of recommendations.

What it Finds

Researchers recommend that VBP models consider equity in their patient attribution design—how models identify a patient-provider relationship—to avoid excluding marginalized patients from participating in VBP programs.

VBP models attributing patients based on claims data are less likely to capture patients that have fewer encounters with outpatient care settings, but patients of color are more likely to report having no usual source of care than white patients for a variety of reasons, including lack of access or mistrust in the health care system.
To prevent racial and ethnic biases in patient attribution, researchers recommend that VBP models expand the number of health care settings they accept claims from to include telehealth and inpatient hospital visits.
Continued focus on how to eliminate implicit biases in risk adjustment models is also critical to equitable patient attribution.

Active outreach to underserved patient populations is needed to increase access to and engagement with VBP models.

Researchers recommend that VBP advisory boards and focus groups continue to include representatives from underserved patient populations.
Clinicians can serve as useful messengers to communicate with patients about a VBP model and how it could benefit them. Additionally, payers should consider using more widely accessible outreach methods such as text messaging to provide information about VBP.
Cultural competency and “cultural humility”—the practice of understanding the complexities of a patient’s identity and experiences—should be prioritized in all outreach surrounding a VBP model. Payers can adopt quality measures related to provider communications and health literacy to promote these goals.

VBP models should foster cross-sector collaboration to address social determinants of health issues.

Researchers highlight the Accountable Health Communities model, which established financial incentives for social needs screenings and promoted integration of clinical and community services.
Health data exchange networks and integrated technology platforms can also help connect patients to community resources. For instance, the state of North Carolina pioneered a shared platform called NCCARE360 to connect patients with local services.

Evaluation of VBP models’ performance should be grounded in equity-based metrics, which require more robust data collection.

Why it Matters
By creating a financial incentive for providers to address social determinants of health in seeking to improve care quality, VBP models have the potential to advance health equity. However, if these payment models are not explicitly designed to benefit marginalized groups, the focus on value could also perpetuate inequities. The Centers for Medicare & Medicaid Services (CMS) recently announced an updated Medicare model, “ACO REACH,” which instructs participating accountable care organizations to measurably reduce health disparities in their beneficiary populations beginning in 2023. As value-based payment garners continued attention at the state and federal level, these recommendations for equity-based VBP design and implementation can inform policymakers and payers initiatives.

Brent D. Fulton, Daniel R. Arnold, Jaime S. King, Alexandra D. Montague, Thomas L. Greaney, and Richard M. Scheffler, The Rise Of Cross-Market Hospital Systems And Their Market Power In The US, Health Affairs, November 2022. Using hospital system data from the American Hospital Association’s annual survey between 2009–2019, researchers examine trends in hospital mergers and acquisitions that occurred across separate geographic markets and how shifts in market power may be impacting consumers. Researchers used urban “commuting zones”—a grouping of areas within which employees typically commute to work, which serve as a proxy for where consumers travel for hospital services—to define the geographic markets in which hospitals participate.

What it Finds

From 2010 to 2019, 1,500 hospitals joined a hospital system, bringing the percentage of hospitals in a hospital system up 58 percent in 2009 to 67 percent in 2019.

Individual hospitals joining state hospital systems accounted for the majority of this increase.

While the majority of hospital systems owned ten or fewer hospitals in 2019, the largest hospital systems comprised a disproportionate share of hospital ownership, accounting for 65 percent of all hospitals within systems.
Within the commuting zones studied, hospital systems had an average market share of 23 percent, while independent hospitals’ market share averaged 13 percent.
Hospital systems that owned hospitals in two or more commuting zones were categorized as “cross-market,” and may have more leverage in contract negotiations with payers.

Of the 368 total hospital systems operating in 2019, 216 systems (59 percent) were cross-market systems.
Researchers identified hospital systems in urban commuting zones with potential “enhanced cross-market power,” or the ability to leverage market power across different geographic markets during contract negotiations with payers. The number of hospital systems with enhanced cross-market power increased by 54 percent over the study period, from 37 to 57 systems.

Why it Matters
Hospital systems are increasingly consolidating market power across the country, often leading to higher costs for patients. Although cross-market hospital mergers have generally not been deemed anticompetitive because hospitals in different service areas are competing for different patient populations, authors of this study emphasized that in contract negotiations with payers, hospital systems may leverage power in one market to establish higher prices across markets (for instance, by requiring insurers to contract with multiple hospitals in the system as a condition of their contract with a particular hospital). While some antitrust enforcement action has occurred regarding cross-market mergers, notably in California, this consolidation trend and its potential anticompetitive consequences are worth monitoring as policymakers seek to curb rising health care costs.