Dear John,

The November issue of Health Affairs covers a range of topics, including the effects of innovative payment models on patient care, the shifting nature of primary care physician visits, descriptions of and responses to growing affordability challenges in health care, and the burden of firearm injury.

Care Models

The significant burden of poor mental health provides accountable care organizations (ACOs) with an incentive to emphasize mental health care for their patients.

Yet Jason Hockenberry and coauthors, after following Medicare patients with depression or anxiety symptoms as they move into ACOs, find a 24 percent decline in treatment visits and no “discernible improvements in patient-reported depression or anxiety symptoms at twelve months” after enrolling in the ACO.

The Medicare Care Choices Model (MCCM) allows eligible Medicare beneficiaries to receive supportive and palliative care services from hospice providers, along with conventional treatment.

Keith Kranker and coauthors compare deceased MCCM enrollees with those who had been enrolled in traditional Medicare and find that MCCM enrollees “experienced improved end-of-life care, had lower Medicare expenditures and acute care service use, and used hospice more than the comparison group."

Physicians

Against the backdrop of a general decline in primary care physician visits, Lisa Rotenstein and colleagues analyze survey data and find that the proportion of these visits with a preventive focus nearly doubled between 2001 and 2019.

Preventive visits were, on average over the period studied, more than 15 percent longer than problem-focused visits, with the greatest rate of increase seen for Medicare beneficiaries.

The Health Professional Shortage Area (HPSA) program was launched in 1965 with the goal of improving access to physicians in underserved regions.

Justin Markowski and colleagues examine nearly fifty years of county-level data and find no “statistically significant changes in county-level mortality rates or physician density after HPSA designation.”

Affordability

Didem Bernard and colleagues examine the health-related financial burden on American families, using a comprehensive measure that includes out-of-pocket spending, medical debt, and cost-related care delays.

They determine that 27.0 percent of adults younger than age sixty-five live in families with at least one of these indicators of financial strain.

When they used a looser definition of financial strain, that share increased to 45.4 percent.

Gary Claxton and coauthors report findings from the twenty-fifth annual KFF Employer Health Benefits Survey.

The average annual premium for employer-sponsored family health insurance coverage was just shy of $24,000 in 2023, a 7 percent increase from 2022.

More than half of employers with fifty or more workers believe that their employees have a high or moderate level of concern about affording their health plan’s cost sharing.

In a DataWatch, Simon Haeder and colleagues show that merging rural and urban Affordable Care Act Marketplace rating areas in Texas significantly reduced rural premiums and improved the choice of carriers and plans for rural residents.

List prices of newly launched life-altering gene therapies can now reach into the millions of dollars.

In a Policy Insight, Caroline Horrow and Aaron Kesselheim present a taxonomy of possible payment approaches for these therapies, describing mechanisms that include risk pools, reinsurance, subscription models, outcomes-based agreements, and more.

In a Narrative Matters essay, Paula Steiner, a former health insurance plan executive, considers the role of profit in health insurance and health care.

Reflecting on her professional experiences, she concludes that “our national fixation on profits is a trap.” The real issue, she believes, is that “we have willingly limited who and what we pay for when facing the bills but rejected such thinking when confronting the illness.”

Firearms

Zirui Song and coauthors quantify the effects of child and adolescent firearm injuries among a commercially insured population.

They find large increases in pain, psychiatric, and substance use disorders among survivors and increases in psychiatric disorders among the parents of survivors.

There are even larger increases in psychiatric disorders and mental health use for parents and siblings after a fatal firearm injury.

Nathaniel Glasser and coauthors analyze firearm suicide rates over the course of the past twenty years.

Patterns in suicide rates by age are quite stable, with a small increase in rates in more recent years.

The authors find significantly higher firearm suicide rates in states with less-strict firearm policy environments, pointing out that “the difference in suicide rates between states with less- versus more-strict firearm policy environments was nearly as large as the nation’s overall homicide rate during the same period.”

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During November, we're highlighting indigenous voices and research on native populations.

  
In a July 2023 Forefront series, "Private Sector Solutions for Health Equity," Kurt Brenkus, founder and CEO of Indigenous, writes that fixing our nation's fractured American Indian/Alaska Native health care system will require more than the public sector of federal, state, and tribal governments, but the private sector as well.