Archives for 2020

Political rivals reveal deal to expand Medicaid to Kansas families earning up to 138% of federal poverty level. The cost would be offset by a surcharge to hospitals, and the plan would take effect by Jan. 1, 2021 #ksleg via @timvcarpenter @sherman_news https://t.co/d3uzvaYNyW

— CJOnline (@CJOnline) January 9, 2020

Details to come.

But the expansion looks to be fast with a 1/1/21 start date and it will be a full expansion to 138% FPL so it could potentially be a state plan amendment expansion with waivers either not needed or able to be sequentially added to the program. There is no work requirement. There is a work referral program, but that is common.

Elections matter, and here are some of the results of all the hard work Kansans put in over the 2018 campaign season.

Kansas to expand MedicaidPost + Comments (14)

Dr. Amy Finkelstein and team have a special report in the New England Journal of Medicine. They conducted a rigorous randomized control trial of the Camden Coalition of Healthcare Providers. The Camdem Coalition has gotten a ton of press about their “hot spotting” method of identifying folks who use a lot of medical services and then wrapping these folks in a bundle of care coordination and some social services. Prior assessments had found that using a simple pre/post analysis of the individuals included in the program that this approach saved a lot of money and reduced hospitalizations. Finkelstein and her team conducted a random assignment evaluation to see what is happening without intervention and therefore what the intervention is doing. And their initial findings of looking only at re-admission to hospital is that the hot spotting approach is not doing much:

RESULTS
The 180-day readmission rate was 62.3% in the intervention group and 61.7% in the control group. The adjusted between-group difference was not significant (0.82 percentage points; 95% confidence interval, −5.97 to 7.61). In contrast, a comparison of the intervention-group admissions during the 6 months before and after enrollment misleadingly suggested a 38-percentage-point decline in admissions related to the intervention because the comparison did not account for the similar decline in the control group.

WOW

So what is happening?

It all depends on the shape of the assumed counterfactual. Comparing people against themselves has an implicit assumption that the crisis that prompted their eligibility is a permanent phase change and the new steady state. Any change from that steady state could then be attributed to the intervention.

Another shape of trajectory could be reasonably assumed. We could hypothesize that a spike is often just a spike and it will naturally recede. A spike will trigger the intervention but at least some if not all of the future decline in utilization/re-admissions/costs could/would have occurred even if no intervention happened.

Figuring out the right counterfactual and therefore the shape of the response without an intervention is critical to evaluation. The Finkelstein study shows that the observed response of people with a huge spike is a natural decline in utilization with or without intervention. This change in the shape of the counterfactual is critical to this evaluation that shows that this program of hot spotting on at least this metric of re-admission is not doing so hot.

Good evidence is critical. Most experiments will either return null results or return slightly significant results. That is okay. My priors have changed significantly in the past sixteen hours. Hot spotting has a very plausible and facially coherent logic model of change but the evidence this morning is saying that the plausibility of actual results is far lower now than it was before the evaluation was published. This is a big deal.

Hot spotting ain’t so hotPost + Comments (16)

Scott in comments yesterday raised an interesting scenario that has been marinating in the back of my mind for a while now:

My son and wife had their daughter on 31 Dec by inducement a year ago (date chosen for purely financial reasons as the scheduled inducement was for 3 Jan until they realized that deductibles, etc reset at 1 Jan.

New Years’ Day is the 2nd least likely birthday after Christmas.

I am curious if researchers have been able to leverage the January 1 reset day as a means of evaluating the effectiveness of the Earned Income Tax Credit and other child related tax code features?

My now 11 year old daughter is a mid-afternoon New Years Day baby.  She was due on the 28th or the 29th.  She decided to take her time.  We had a low deductible plan that rolled over into a high deductible plan at 12:01 AM on January 1st.  She was ready to greet us well after that threshold was crossed.  Between the deductible resetting and our inability to claim her as a dependent and get child tax credits for a December birth, she cost us several thousand dollars in a year where we knew that we were going to be stretched thin.

The deductible hit was immediate.  I think we got the bill three weeks after birth.  We were able to claim her as a tax deduction fourteen months after birth instead of two months after birth if she had been born eighteen hours earlier.

I am curious if there is research that looks at long term outcomes using the January 1st birth eligibility discontinuity as there is a huge swing in very early life parental financial resources available.  Kids who were born on December 30th or 31st  are fundamentally similar to kids born on January 1 or January 2 except for the presence of a significant resource infusion due to a policy cut-off.  I would expect that we should see the late December kids to have better outcomes than the early January kids because their parents will have significantly more financial resources in the first three to six months of the baby’s life.  More resources might translate into less parental stress which could lead to better bonding and security for the infant.  Another pathway could be simply that the baby’s diaper gets changed more often as there is more cash to buy diapers and therefore the risks of abuse are lowered.  I’m speculating here but I am truly curious.

New Years babies and resourcesPost + Comments (21)