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The November issue of Health Affairs includes articles covering a broad range of topics, including hospital payment and services, trends related to the Affordable Care Act Marketplaces, the effects of adult Medicaid dental benefits, prescription drug development and usage, and more.

Hospitals

To reduce inappropriate inpatient billing for very short hospital stays, in 2013 the Centers for Medicare and Medicaid Services implemented the Two-Midnight rule, stating that Medicare inpatient payment was appropriate only if a hospital stay was expected to last through at least two midnights.

While the shift from inpatient to observation stays after the rule’s adoption has been previously reported, Sabrina Poon and colleagues analyze 2007–2018 data using additional methods and conclude that the shift is directly associated with the adoption of the rule, it occurred quickly and remained steady in subsequent years, and the shift to observation stays was most pronounced for patients with more chronic conditions.

Marcelo Cerullo and coauthors find private equity acquisition of hospitals is associated with a higher probability of adding profitable hospital-based services, profitable technologies, and freestanding or satellite emergency departments.

ACA & Medicaid

David Anderson and Kevin Griffith examine Affordable Care Act (ACA) Marketplace offerings and find that two-thirds of Americans have more insurer options in 2021 than they did in 2018, partially reversing a trend of insurer exits from 2016 to 2018.

Paul Jacobs and Steven Hill calculate Marketplace premiums from 2015 to 2019 among families with incomes between four and six times the federal poverty level, who are ineligible for federal subsidies.

The share of income required to purchase gold, silver, and bronze plans increased significantly during this period. For example, the premium for the lowest-cost bronze plan grew from 12.2 percent of median family income in 2015 to about 19 percent in 2018 and 2019 for people ages 55–64 in the study population.

The economic shock of the COVID-19 pandemic led to job losses and people moving into the ACA Marketplaces. John Hsu and coauthors analyzed the relationship between state policies and the number and risk profile of these new enrollees. They found larger increases in Marketplace enrollment in states that did not expand Medicaid, and higher-cost enrollees joining a Marketplace in states with narrower enrollment criteria.

Dental coverage for adults is an optional Medicaid benefit. Examining survey data in the context of variation in state policies, Brandy Lipton and coauthors determine that adult Medicaid dental coverage is associated with a one-fifth reduction in the prevalence of untreated caries among children in low-income families after Medicaid-enrolled adults had access to dental coverage for at least one year.

Pharmaceuticals

Even with direct funding, it is difficult to generate investments for development of low-volume drugs given low expected revenue from sales.

As a consequence, policy makers have adopted "pull" incentives, which provide a separate payment stream. Modeling various drug development scenarios, Kevin Outterson concludes that incentives "totaling several billion dollars per drug globally are required to make antibacterial research and development projects economically attractive to commercial sponsors."

Kelly Lenahan and coauthors examine commercial health plans’ prescription drug step therapy protocols that determine patient eligibility for specialty drugs. Across the ten diseases studied, more than half of the step therapy protocols are more stringent than the treatment guidelines adopted by national clinical organizations.

Further, "Different plans applied step therapy protocols with markedly different frequencies and required patients to step through different numbers of prior therapies."

In March 2016, the Centers for Disease Control and Prevention (CDC) released the Guideline for Prescribing Opioids for Chronic Pain. Tarlise Townsend and coauthors investigate data from 2014 to 2018 and find the guideline is associated with lower frequency and intensity of opioid dispensing, including a reduction in patients’ rate of receiving at least one opioid prescription by approximately 20 percentage points by December 2018.

Sarah Loch and coauthors examine the association of neonatal opioid withdrawal syndrome (NOWS) with infant entry into foster care. They find "an increase of one NOWS diagnosis per ten births in a county [is] associated with a 41 percent higher rate of infant foster care entry."

Join Health Affairs for a free virtual event! On November 10, we highlight Kevin Outterson's article "Estimating The Appropriate Size of Global Pull Incentives For Antibacterial Medicines" from the November issue with a special Journal Club session.

On November 12, join Health Affairs Editor-in-Chief Alan Weil as he interviews Michelle McMurry-Heath, CEO of Biotechnology Innovation Organization, for our Policy Spotlight series.

On November 16, Deputy Editor Rob Lott highlights the Leading to Health series and health system transformation with Maninder Kahlon from the University of Texas at Austin during a Lunch and Learn session.

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 and online. Late-breaking content is also found through healthaffairs.org, Health Affairs Today, and Health Affairs Sunday Update.

Project HOPE is a global health and humanitarian relief organization that places power in the hands of local health care workers to save lives across the globe. Project HOPE has published Health Affairs since 1981.

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