Federal Insider

Hospitals in Medicaid Expansion States See Less Uncompensated Care
Since the landmark June 2012 U.S. Supreme Court ruling upheld the Affordable Care Act (ACA) but allowed states to decide whether to expand Medicaid, debates in state capitals have stalled this part of the law in many areas of the country. Now a new study that shows the economics of Medicaid expansion seem to favor the promise of the law, that with more Medicaid coverage, hospitals would see less uncompensated care.

The study, performed by the Colorado Hospital Association (CHA), found a 29% increase in Medicaid volume for states that expanded Medicaid with a parallel 30% decline in charity care. The researchers used data from 465 hospitals in 30 states from the first quarter of 2014, gathering data from Jan. 1—the official launch of Medicaid expansion—to March 31. The study found that hospitals in states which chose not to expand Medicaid experienced no changes outside normal variation in Medicaid volume or uncompensated care.

“While media reports have detailed increases in Medicaid volume in hospitals located in expansion states, we now have definitive proof that such increases are translating into reduced self-pay and charity care cases,” said Steven J. Summer, president and CEO of CHA.

Currently, 26 states and the District of Columbia have expanded their Medicaid program with ACA federal funding. The federal government funds most of the cost of expanding Medicaid to cover residents with a household income up to 133% of the federal poverty level. The full CHA report is available online, http://tinyurl.com/chastudy.

CDC Updates HIV Testing Guidelines
The Centers for Disease Control and Prevention (CDC) updated its recommended HIV testing algorithm, citing a new era of HIV testing in the United States due to new tests recently approved by the Food and Drug Administration (FDA).

Under the new algorithm, testing begins with a combination immunoassay that detects HIV-1 and HIV-2 antibodies as well as HIV-1 p24 antigen. Next, reactive specimens undergo supplemental testing with an immunoassay that differentiates HIV-1 from HIV-2 antibodies. Specimens that are reactive on the initial immunoassay and nonreactive or indeterminate on the antibody differentiation assay proceed to HIV-1 nucleic acid testing for resolution.

FDA has now cleared or approved three combination tests that detect both HIV antigen and antibody, and one test that differentiates HIV-1 from HIV-2 antibodies.

CDC issued the new recommendations in the same issue of the Morbidity and Mortality Weekly Report that examines HIV screening programs in New York and New Orleans, both of which identified previously undiagnosed HIV infections using the new algorithm (MMWR 2014:63;537–41). In particular, the New Orleans program identified antibody-negative acute infections in five (6%) of the 77 patients with newly diagnosed HIV.

Federal Panel Notes Lack of Evidence for Vitamin D Screening

The U.S. Preventative Services Task Force (USPSTF) issued a draft recommendation on screening for vitamin D deficiency that highlights conflicting evidence and the lack of an internationally recognized, commutable reference standard for vitamin D tests. The USPSTF recommendation is an “I” statement, meaning that the panel feels there is insufficient evidence to assess benefits and harms.

In the draft recommendation, USPSTF emphasized that there is no consensus definition of vitamin D deficiency or what cutpoint should be used to determine it. Moreover, of the current assays for total serum 25-hydroxy vitamin D (25-OH D)—including competitive protein binding, immunoassay, high pressure liquid chromatography (HPLC), and combined HPLC and tandem mass spectrometry (LC-MS/MS)—none can be assessed for accuracy, according to the panel, which called the sensitivity and specificity of these tests “unknown due to the lack of studies using an internationally recognized reference standard.” The panel also noted that variability between assay methods and even among labs using the same methods may differ by 10–20%.

The National Institute of Standards and Technology (NIST) developed a standard reference ­material for 25-OH D in 2009, but this program has “limited impact on improving accuracy of immunoassay methods.”  In addition, since 2010, the Vitamin D Standardization Program has worked on standardizing vitamin D measurement internationally, but the program’s protocols are not yet available for commercial use.

Finally, the panel underscored a further lack of consensus over whether total serum 25 OH-D is the best indicator of vitamin D status compared to bioavailable 25 OH-D.

USPSTF recommended that researchers tackle several areas: agreeing upon a cutpoint to define vitamin D deficiency, sensitivity, and specificity of vitamin D assays using an internationally accepted reference standard, and determining whether total serum 25 OH-D is the best measure of vitamin D deficiency in all populations. The panel also called for more studies that evaluate which treatment regimens may benefit specific vitamin D–deficient populations. The draft recommendation statement is available on the USPSTF website, www.uspreventiveservicestaskforce.org.

Free Preventive Care Adding Up

About 76 million Americans in private health insurance plans are newly eligible to receive expanded coverage for one or more recommended preventive health care services without cost sharing because of the Affordable Care Act (ACA), according to the Department of Health and Human Services (HHS). Under the ACA, most insurance plans, including private marketplace plans, must cover a set of recommended preventive services like screening tests and immunizations at no out-of-pocket cost to consumers. Screening tests must receive an A or B recommendation from the U.S. Preventative Services Task Force.

The data from HHS was broken down across states, age, race, and ethnic groups. For example, the report found that expanded preventive services have a large effect on women. A total of 48.5 million women are estimated to benefit from free preventive services, including well-woman visits, screening for gestational diabetes, cervical cancer screening, HIV screening, and other services. The full report is available from the HHS Office of the Assistant Secretary for Planning and Evaluation, http://aspe.hhs.gov/.

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