While Congress ponders dismantling the Patient Protection and Affordable Care Act (PPACA), researchers are exploring how its existence—and potentially its absence—could affect healthcare. This week, the act provided a framework for two studies, one looking at the donut hole and another at cherry picking, and both provided food for thought.
In this month’s Health Affairs, Liam O’Neill, PhD, and Arthur J. Hartz, PhD, published an analysis of outcomes at cardiac specialty hospitals compared with general hospitals, focusing on specialty physicians who perform PCI procedures at both hospitals. The PPACA has limited growth of specialty hospitals, but these hospitals also are said to have lower mortality rates and high patient satisfaction.
They found that the general hospitals were more likely to treat the uninsured, Medicare beneficiaries and ethnic and racial minorities. The cardiac hospitals had lower mortality rates. Mortality rates for procedures performed by specialty physicians at cardiac hospitals were almost a percentage point lower than the state average (0.68 percent vs. 1.5 percent). Yet mortality rates for procedures performed by specialty physicians at general hospitals were almost a percentage point higher than the state average (2.27 percent vs. 1.5 percent). Hmmm.
To be clear, cherry picking is my word. The authors wrote, “One interpretation of these results is that physicians steer the most profitable patients to the hospitals in which they have a financial interest.”
They added, “Quality metrics based solely on administrative data may be inadequate to account for differences in patient severity between cardiac and other hospitals. As a policy matter, quality outcomes at the physician level should include all procedures done at all facilities, not just those performed at a cardiac hospital.”
The second study, published in Circulation: Cardiovascular Quality and Outcomes, compared Medicare Plan D beneficiaries with cardiovascular conditions who reach the coverage gap known as the donut hole and are 100 percent responsible for cardiovascular drug costs with counterparts who have financial assistance. They found that those facing complete out-of-pocket costs were 57 percent more likely to discontinue cardiovascular medications, but were no more likely to switch drugs, die or be hospitalized.
PPACA would gradually close the donut hole, but proponents of the coverage gap argue it nudges beneficiaries toward using only essential or lower-cost prescription drugs. Based on their findings, the researchers counter it leads to “abrupt discontinuation.”
The bigger question is what affect yo-yo drug adherence has on beneficiary outcomes. Under Medicare Part D, at year’s end the slate is wiped clean and enrollees again have access to Medicare drug coverage, until they tumble into the donut hole. Given its short follow-up period and other limitations, this study could not answer that question.
And, what affect does yo-yo legislation have on physicians, hospitals and others in the healthcare industry? Do you commit and backtrack if PPACA is repealed or hold out and scramble if it remains intact? What is your strategy? Email to let me know.
Cardiovascular Business, editor