Against the backdrop of the so-called safety net hospital (those with heavy Medicare, Medicaid claims utilization) as a healthcare-related industry and campaign ’12 meme, there is interesting data out in JAMA this week that either supports Mitt Romney’s assertion that the “very poor” are taken care of in this country quite adequately, or there is reason to believe that P4P measures (or, at least the idea, anyway) are superficially quite similar in non-safety net acute care centers in terms of ultimate patient dispositions.
Researchers studied whether patients were admitted to the acute hospital within eight hours ED admission or if they were to be discharged, transferred or moved to observation within four hours of coming to the ED. They found that
compliance with proposed ER length-of-stay measures for admitted, discharged, transferred, and observed patients to not differ between safety-net and non-safety-net hospitals
Although length-of-stay (LOS) data is interesting, it is not compelling — quite limited in its implications, actually. Currently there is no “accepted” ED LOS strict guideline in the U.S. Digging deeper into this study (abstract-only text cited above available without a JAMA susbscription), one can infer more from the upper decile of data — in which LOS significantly increased among both types of institutions (10-15 h in length), the authors citing mostly acute patient decompensations in mental illness as the reason for protracted admission LOS.
Still, the trial provides renewed attention over a surrogate care parameter just a few years ago was hailed as an agreeable target upon which to base healthcare reform on spending within the government sector. These days, the study may only serve as yet another reason why P4P as a quality measure is so derided by many as the ACA is just beginning to take hold.
Probable GOP nominee for president, former Mass. Gov. Mitt Romney, came under attack over the past couple of days for comments on discounting the “very poor” as this demographic benefits from the existence of a societal “safety net” for the delivery of essential services — presumably basic healthcare among them. Terming the gaffe as simply a “misspoken” choice of words, the GOP frontrunner initially found it difficult to run from those words and their implications from members of his own party and the Democrats.
Chief rival Newt Gingrich jumped on the metaphorical bandwagon early.
Gingrich said both Romney and Democratic President Barack Obama think poverty can be solved with a safety net.”What the poor need is a trampoline so they can spring up,” he said. “So I want to replace a safety net with a trampoline.” Romney spokeswoman Amanda Henneberg responded that Gingrich was joining Democrats in “distorting Mitt Romney’s comments.”
South Carolina Gov. Jim Demint, a prominent force of social conservatism within the party, was a little more sanguine.
“He needs to address it,” DeMint told Roll Call. “Because I know he does care about the poor. But I think he was trying to make a case that they’re taken care of. But, in fact, I would say I’m worried about the poor because many are trapped in dependency, they need a good job; they don’t need to be on social welfare programs. I think he needs to turn that around because — the middle class is key, and we have to focus on that. And, really, the problem with the middle class is not successful people, it’s politicians — but the key to making our country successful it to get everyone on that economic ladder.
Typical “bootstrap” rhetoric, to be sure, but a teachable point for Romney; because, as it applies to healthcare — let’s take Medicaid, for example — his disavowal of basic healthcare delivery to the poor (and elderly) runs in stark contrast to his pledge to “fix it” — meaning the “safety net”. What does Mitt Romney want to fix, exactly? Continued taxpayer subsidied care for the indigent without further acknowledgement, or does he want to weaken an already painfully inadequate payor of healthcare in chronically cash-strapped states — threatening any stake they have as the reform law takes hold? In his efforts in trying to explain away his current campaign gaffe, Romney has made his stance on healthcare reform much murkier in this young election season. | LINK
Embattled WI governor, Scott Walker (R), issued a statement yesterday opposing the implementation of a state exchange as provisioned by the ACA — opting to defer action on the measure until the case is heard by the SCOTUS in March. In doing so, he will be returning almost $40 M in federal funding earmarked for the healthcare exchange. Whether this is earnest on his part or merely a symbolic gesture to Wisconsin GOP faithful in the wake of a pending certified recall vote on his office remains to be seen. Walker has always been against the passage of the reform law, instead focusing on efforts to deny federal assistance in doing so (states which choose this path will have to demonstrate fiscal independence on healthcare exchange creation by 1/1/13 or will be mandated a program by the feds).
Is this entire episode a game of chicken by Walker in light of his sudden vulnerability? It is, if one listens to the rhetoric from the state’s Democrats on the issue. Advocacy groups are also weighing their own disapproval of the governor’s intentions. The SOCTUS will hear testimony on the constitutionality of the reform law (notably, the mandate for coverage) over a two day period by the end of March. By the end of Februrary numerous amicus briefs will be filed by both Obama admin (DOJ) and plaintiffs (states) in the case. In spite of all the rancor surrounding this issue, it will difficult to envision striking of the mandate provision, much less the entire reform law as two lower courts have offered split decisions on the matter — prompting the SCOTUS to act quickly on a decision on the entirety of the ACA well before the election. | PDF brief from UCB Labor Center in support of the ACA’s constitutionality
Could retail be the solution to comprehensive healthcare delivery? Well, if big-box retailer Walmart has anything to say about it — then, bring it on! Stretching the idea of retail minute clinics to extremely absurd heights, the retailer wants to partner with other entities to increase care access ahead of the tsunami of increased coverage sure to occur once reform kicks in a couple of years from now. It lays out its plans in a 14-page Request for Information [PDF].
In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research.
The other entities, sometimes labeled as “vendors” in Walmart’s RFI, appear to be (healthcare) organizations which have the potential to collaborate on best practices for many chronic conditions — enabling the partner vendor to benefit in terms of quality, accountability, delivery of healthcare services in order to maximize their bottom lines.
This mode of healthcare delivery raises concerns, to be sure. Could we be seeing an entirely new way of the delivery of healthcare as a pure commodity to be negotiated and priced like any other product? Will it encourage other major national retailers to follow suit? What will this do to the traditional model of healthcare organizational delivery of primary care? Will it enhance it? Will it make it more accountable to third parties? How will this model benefit insurance companies’ approach to premiums in an altered delivery marketplace? Quite an interesting development in the ongoing saga of the cost of healthcare in this country. | LINK
The reining in of costs associated with spiraling Medicare coverage amidst the proposed so-called “doc-fixes” addressing incessant threats of congressionally mandated cuts has many on the Hill wondering what will the Super Committee do to remedy the situation? FYI, the Super Committee is the bipartisan congressional panel made up of 6 Dems and 6 GOPers tasked with putting the brakes on deficit spending to the tune of $1.5T over the next ten years. Issues of Medicaid and Medicare spending are high on the panel’s agenda.
Specifically, futher tightening of Medicare eligibility rules and block-grant funding of Medicaid are mong the most rancorous of discussions — so much so, that at least one Republican moderate senator has chosen to distance herself from the Super Committee recommendations forthcoming. Sen Olympia Snowe (R-ME) also cites her support of branded pharma rebates (something her GOP colleagues really aren’t enthusiastic about) as another mechanism to trim costs.
The ramped-up schedule endorsed by the panel has states, insurance companies, and policywatchers of reform on the edge of their collective seats as issues of funding of the Medicare hospice benefit funding and possible elimination of the SGR formula for determining Medicare reimbursements to phsyicians and hospitals are discussed along with Medicaid funding. | LINK
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
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DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
