Combine the complexities of fee-for-service government reimbursements with the intricacies of funding for coordinated care systems; the possibilities of funding an accountable care commission of sorts as a payment governing body; and the simple inertia that current levels of healthcare spending have created in a wasteful state system — and you’ve got a recipe for an overwhelming stalemate. There is a glimmer of hope that one faction’s action will get the legislative ball rolling on this issue: some hospital systems in the state plan to release details on the creation of governance to oversee spending in their ranks. | LINK

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What’s more surprising than this development is the lack of safety funding for depleted federal and state programs; the Obama administration has yet to guarantee any sort of budgetary proposal or stimulus mechanism for saving these programs. In the state of Georgia, waiting lists for accessibility to HIV treatments is up to almost 1300 persons.^[1] In Florida, almost three-hundred.

An increasingly sad state of affairs in this early drive toward reform. This segment of the indigent care population could succumb to the same restrictions on eligibility those who are mentally ill perennially seem to face from many government-run programs. Will it take a redux of the same levels of prevalence rates of HIV not seen in 20 years to jar the Obama administration to attention on this issue? | LINK

1. Pregnant women, children and adolescents, and patients with “extreme conditions” can be exempt from the waiting list.

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In Massachusetts, where everyone is covered, premium rates continue to soar. Because that state subsidizes everyone’s care, those purchasing short-term plans within that its healthcare marketplace often drive up costs for those who are responsible for paying into the system — both individuals and employers. It appears that short term coverage for sicker people increase the cost of care delivery at a greater rate than anticipated among Massachusetts’ more chronically ill. The governor and insurers are working to close this loophole by restricting purchasing periods. | LINK

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On quality, the U.S. stood out “particularly with symptoms of more fragmented, poorly coordinated care,” Schoen said. In 2008, for instance, 14% of American adults with a chronic condition reported receiving the wrong medicine or the wrong drug dose in the past two years.

When compared to, say, Sweden or any other European country — an interesting stat. But getting out of the apples-and-oranges mentality allows us to see nuggets like this in a more sobering light. When placed in the context of Obama’s reform plight, it signals a call for urgency in healthcare delivery. | LINK

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A think tank’s new study sheds some light on this potentially incendiary issue: Medicaid is the prime payer of long term care (LTC) healthcare delivery in this country. Many states are concerned that Medicaid costs as a percentage of state budgets will nearly double by 2030, from the current 20 percent to 35 percent in some states. In some cases, costs can triple. LTC accounts for about a quarter of that expense. All the talk about the disappearance of patients from physicians’ Medicare rolls may be just the iceberg’s tip. Companies could be forced to jettison Medicaid beneficiaries; proposals to tax some healthcare and health plans to curb Medicaid cost increases are even on the table. As states’ problems with unemployment grow (here in MN, it’s at a ‘moderate’ 7 percent), Medicaid-related healthcare expense continues to increase in tandem. Not a rosy outlook at all. | PDF LINK

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Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. [..] Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system.

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The $6.4 billion measure would reverse a 21 percent cut in physician payments that was to kick in Friday, raising the possibility that some doctors might begin to turn away those covered by Medicare.

To the GOP, this action means implementing yet another interim budget-neutral respite on the road toward Medicare payment . To the Democrats, it means saving face among healthcare reform advocates for another six months — just in time for the midterms. | LINK

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Medicaid, a core component of the recently enacted Patient Protection and Affordable Care Act, will now cover all low-income individuals, regardless of age or family status, with incomes up to 133 percent of the Federal Poverty Level. However, I would argue that Medicaid is not the best way to advance universal insurance coverage. The program is firmly anchored in the states, whose glaring inability to lead the way is most evident in their fiscal constraints: during difficult financial times, such as now, unemployment, the number of uninsured households and Medicaid caseloads all rise, just when the states confront declines in their revenues. For example, average enrollments in 2009 increased by 5.4% and spending by 7.9% but revenues were down by 7.5%. Consequently, many localities have eliminated or reduced certain benefits (including dental care, hearing aids, glasses, rehabilitation services) and decreased provider fees (leading to less access to doctors, especially specialists). Even in “better” times, Medicaid is a source of continuing financial strain.

Medicaid’s state-by-state approach to insuring the poor also has produced an inequitable, haphazard distribution of health care. Different jurisdictions vary widely in such factors as immigrant status, the number of older people, size of their rural population, availability of physicians and facilities, financial resources and the political will to pay for uninsured households—all factors affecting the unevenness in Medicaid practices. The type and level of services individuals obtain depend on their geographic location or on which party or governor is in power at any particular moment.

Thus, building on Medicaid—adding roughly 16 million low-income people to its rolls—will only intensify current problems and inequities. Newly insured people will still face the same second-class medical care, access impediments, and other wide-ranging failings of the current Medicaid program. Complicating the issue, even as the states are initiating the complex and costly implementation process, twenty one places are suing the federal government over the expansion mandate.

At the same time, elected national officials (including many Democrats) want to rein in deficit spending, as illustrated by the recent elimination (by the House of Representatives) of the $24 billion stimulus extension bill that at least 30 states were counting on to sustain their already reduced 2011 Medicaid plans. If the Senate does not restore it, we are likely to see even leaner benefit packages. The national and state governments have always had a contentious relationship over Medicaid funding, now exacerbated by the recent legislation. The newest layers of bureaucratic red tape set additional hurdles for the states to sort out.

Just as problematic, in order to enact health care reform, President Obama and congressional leaders had to placate key provider groups, making deals with them that precluded any genuine cost controls. Thus, insurance premiums will continue to rise, drug companies will charge their usual exorbitant fees and other suppliers of services will cash in, rendering overall costs far greater than projected. We may get far greater health insurance coverage, a laudable achievement, but will we be getting our money’s worth?

About the Author:

[Laura Katz Olson is professor of Political Science (Lehigh University) and author of The Politics Of Medicaid (Columbia University Press, 2010). She has written numerous books on the politics of healthcare policy and healthcare delivery of the aging population. She has lectured extensively on issues related to women's studies, Social Security, Medicare, and long-term care policy. Her other published works are: The Political Economy of Aging: The State, Private Power, and Social Welfare; Aging and Public Policy: The Politics of Growing Old in America; Age Through Ethnic Lenses: Caring for the Elderly in a Multicultural Society; and The Not So Golden Years: Caregiving, the Frail Elderly, and the Long-Term Care Establishment.]

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The Senate had rejected a Finance Committee compromise^[1] that would have delayed the cut in Medicare payments to physicians until 2012, along with measures to extend unemployment benefits and provide $24 billion to states to cope with their Medicaid programs. Senate Republicans have apparently had enough — as CMS now has the greenlight to move forward on the cuts which were to have initially been implemented on June 1. This entire episode is a reminder of how serious matters are for primary care to sustain itself in a slowly recovering economy and increasingly prudent healthcare marketplace — which now, in a new reform-minded environment, has to manage to do more with less. The calling for innovation for the recruitment of primary care physicians has never been greater this century than as a result of this moment.

1. The compromise would have decreased the total cost to $118 billion and the overall deficit impact by some $20B;  it would have delayed the planned Medicare cuts and provided a 2% raise for physicians through November 30, rather than for the 19 months as part of the original bill. Essentially, the compromise would have amounted to a short term “fix” of the SGR — the method by which the cuts are computed in the face of increasing healthcare expenses by the government.

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But can this benchmark be increased with greater physician input and cooperation? According to the AHIP, it must. The insurance lobby says the path to complete compliance in this area could go a long way in reducing overhead for Insurance, collectively. They contend that providers and insurers must share in the innovation invested on both sides to make this happen. | LINK

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