For the first time, a major private coporation is partnering with a local hospital in assisting Medicaid beneficiaries in obtaining legal assistance in squabbles with the entitlement over public health care delivery, housing, medical equipment, and other basic needs guaranteed by Medicaid. It’s not just any partnership. The corporate entity is Wal-Mart, and it insists it will not be an adversarial force to the feds. The retailer’s involvement with a local Arkansas hospital is being piloted and could become a model for future national rollout. These medical-legal partnerships, as they are called, are designed to promote changes in the healthcare public-private policy sphere by becoming part of the beneficiaries’ heatlhcare team — alongside providers and hospitals.
Onsite, legal professionals become a part of the healthcare team. Doctors will refer patients to lawyers for legal assistance when appropriate. Just as a pediatrician refers a patient to a radiologist for a broken bone, a healthcare provider may refer a patient to an onsite attorney when an underlying social circumstance impairing a patient’s health is detected.
Lest one believes that this is some conservative vs. progressive battle implemented by activists to inflame further the current drive toward reform in this administration — think again. These MLPs have the backing of the traditionally liberal-leaning American Bar Association. It is the hope of the parties involved that providing this type of legal assistance to Medicaid beneficiaries will usher in a new area of accountability by building broad public-private networks with a common goal enriching Medicaid care delivery as reform begins to take shape. | LINK
Drug shortages in hospitals were somewhat of a rarity at one time. For many reasons (not all of them economic) a trend in the late 2000s continuing up to today notes a disturbing pattern of many pharmaceuticals whose usage permeates multiple departments in an acute care setting. From the emergency department to the ICU, this problem is just beginning to percolate.[1] In fact, in the month of May 2011 alone, major shortages in a range of agents contributed to the over 90 such cases in the first quarter of ’11. Antibiotics such as ciprofloxacin (already on an endangered species list in many hospitals due to increasing resistance patterns) lead the pack.
The major reasons cited? Product recalls (less of an issue with fewer NDAs), contaminated vials, demand fluctuations, and improvements on the manufacturing end (production plants). From an economic standpoint, lower profit margins for generics allows for less of an incentive for manufacturers to produce the low cost agents — creating a problem for their availability. Higher cost branded drugs may also create more of a problem during an availability crisis because substitutions may not render the same quality of care — representing a case for comparative research as a marker for quality. Although the overall numbers of deaths due to pharmaceutical shortages pales in comparison to the incidence of other more numerous causes of avoidable and preventable hospital deaths,[2] the issue of med availability is a compelling one that deserves increased scrutiny. | LINK
The current economic crisis that is afflicting many states, including Minnesota, renders no amount of negotiation trivial (or, even civil at times, for that matter) and is gripping many states in political gridlock. With a Democrat chief executive and a Repub controlled legislature, Minnesota is no exception. One of the state’s largest agencies — the Dept. of Human Services — is receiving the lions share of scrutiny as it is a major source of govt spending. It follows that, with the gridlock in St. Paul, a shutdown could be looming; that could have an enormous effect on state subsidized health care spending.
Not all healthcare entities in the state are bracing for the worst in the current legislative impasse amid a $5B budget deficit. Hospitals in Minnesota are proud to trumpet their contributions to a growing, if sputtering, economy.
In all, the state’s 148 hospitals generated $27.2 billion and created 214,108 jobs in 2009, according to the most recent data available from the Minnesota Department of Employment and Economic Development, which ran the numbers for the Hospital Association.
Hospitals in Minnesota, especially those in rural areas, may be huge economic drivers of activity, but the spending on healthcare — in the acute care setting — will always outpace the cost of care delivered in a strictly preventative sense. Including safety nets, which were created to attend to those with limited access to healthcare resources, many hospitals still account for heavy spending — eventually encroaching on the need for public matching funds to offset explosive growth in the cost of delivery. In troubled economic times, a balance is needed between spending in both the public and private sectors to ensure continued healthcare delivery in a fiscally sound fashion, not a reckless one. Apparently DHS leaders, reps from the MN Hosp. Assn., Governor Dayton, and lawmakers will be meeting to discuss their philosophical approaches to this glaring issue next week. | LINK
The default line of thinking with respect to care access in this country pre-reform was that — whatever the patient outcome — there was “always the ER”. Doesn’t take a rocket scientist to realize that this maxim was emblematic of the proverbial “broken healthcare system”. Seen as part municipal safety-net, healthcare economic loss-leader, and all around (fragmented) primary care clinic, the venerable acute hospital emergency department as an icon of healthcare delivery was, indeed, the jack of all trades and the master of none — at least as far as coordinated, cost-effective, valued delivery was concerned. The healthcare marketplace should be saturated, right? Well, according to a recent report, their availability is shrinking.
Urban and suburban areas have lost a quarter of their hospital emergency departments over the last 20 years, according to the study, in The Journal of the American Medical Association. In 1990, there were 2,446 hospitals with emergency departments in nonrural areas. That number dropped to 1,779 in 2009, even as the total number of emergency room visits nationwide increased by roughly 35 percent.
The study highlights another important aspect to consider in the supply side of things in healthcare policy: EDs really aren’t sucking the healthcare system dry (less than 5 percent of total healthcare costs, taken by itself), and in hypercompetitive healthcare marketplaces, those EDs have to fight to survive. | LINK
A healthcare informatics company issues a report today that I really do not find surprising. The trends of Pharma of late are much fewer fast-tracked medications in the pipeline, decreased NDAs for many novel and like-classed (so-called “me-too” drugs) medications, and — are you ready for this? — much greater healthcare consumer spending on generics, which, according to the report, now make up almost 80 percent of the pharma marketplace.
It would be too easy to blame this on the economy. At the root of this and other findings detailed in the report are forces more complex in the healthcare economy than just the principles of supply and demand. After all, while there are fewer patient visits and greater demand by providers and health systems for payments by third parties, you can bet that Pharma still manages to turn a profit. Just take a look at the volume of sales by therapeutic areas: anti-cancer drugs continue to lead the way.
The top five therapy classes were: oncologics, with $22.3 billion in 2010 spending; respiratory agents, at $19.3 billion; lipid regulators, at $18.7 billion; antidiabetes drugs, at $16.9 billion; and antipsychotics, at $16.1 billion. Growth in spending among these classes ranged from 0.9 percent for lipid regulators to 12.5 percent for antidiabetes medications.
Although consumers, third party payers, hospitals, and providers all appear to be embracing quality provisions as a way to control costs, it is somewhat less clear what this pharmacologic austerity will ultimately mean for the management of chronic disease and how that will impact the cost of healthcare over the next 10 years. | LINK [PDF] to IMS report
No April Foolery here. The time has come: HHS has finally issued longstanding rules as part of reform with regard to accountable care organizations. ACOs are nothing new, of course; but the federal government is betting that greater incentives for increased numbers of physicians to become a part of the process in their health systems is a novel — if not slightly controversial — part of healthcare reform.
Calling the fed govt a “bystander” in the process by which health systems have previously dealt with the quality sector in healthcare delivery, Secretary Kathleen Sebelius figures the time is right for government intervention, noting the move could save almost $1B in costs to taxpayers over three years upon program’s inception next year. Providers who are ready to take the “quality plunge” will have to have the beneficiary number to back that up — with the requirement of serving at least 5000 patients under Medicare.
What does the Congressional Budget Office think that repeal of the ACA would do to the current fed budget? According to the CBO, projecting to 2021, the deficit would increase by over $200B in those first 10 years. [PDF, page 2] Also,
The enacted legislation will increase federal revenues (apart from the effect of provisions related to insurance coverage), mostly by increasing the Hospital Insurance payroll tax and imposing fees on certain manufacturers and insurers. Repealing those provisions would reduce revenues by an estimated $520 billion over the 2012-2021 period.
The report also goes on to note an increase in Medicare and Medicaid spending due to repeal of payment reductions (as provided by the reform law) to hospitals, MA plans, and other services would lead to net increases by at least $57B over the period. GOP lawmakers will probably continue to dispute these findings as they continue to pledge for repeal of at least parts of the law. But does that actually mean the party plans to increase the federal deficit by $210B over the next decade?
Ripple effect of reform? Perhaps, but in light of the federal government’s push to eliminate waste in Medicare, one arena in which costs are paid out in massive amounts — hospital admissions — aims to do its part. A couple of years from now, it will be mandatory for penalties to be applied to hospitals with an unacceptable level of readmission rates among their Medicare patients. Defined as readmissions within 30 days (for such common conditions as pneumonia and heart failure), these cases average out to about $7000 a pop (or more than $11B annually). Of course, it’s all about transparency, and healthcare consumers can get their eyeful of comparators at a site set up by HHS here.
A growing number of hospitals and health systems are already working on the readmissions problem with support from nonprofit groups and foundations. Piedmont Hospital in Atlanta is one. A few years ago, it began participating in Project Boost, a discharge-transition program developed by the Society of Hospital Medicine. Through Boost, Piedmont proactively targets patients who are at high-risk of readmission. Staff members use a checklist to ensure that potential logistical and psychosocial problems are addressed before the patient leaves the hospital. Another priority: scheduling patients before discharge for their first follow-up visit to the doctor.
Meat-and-potato moves by hospitals also include specialized discharge “coaches”, whose job it is to make sure all loose ends surrounding a patient’s discharge — such as medication administration, following doctor’s discharge plans, and other preventable factors on the patient end keep the patient out of the hospital. All of this is a good start — but only a start; in such a discrete, but fiscally important care arena among Medicare services, it’s important for lawmakers, healthcare policy thinkers, and administrators to focus on federally generated care delivery in all care arenas (not the least of which is the Medicaid-heavily financed LTC sector). | LINK
In 2009, more than 1 million patients received some form of organized palliative or end of life care. The vast majority of hospice patients in this country (over 80 percent) are Medicare beneficiaries. A study out in this week’s JAMA takes a look at the types of patients enrolled in for-profit hospice care organizations as opposed to the non-profit providers and finds that the former group provides care to less intensive patients at EOL than latter — suggesting a preference for “less expensive” patients. Consequently, non-profits could be operating at huge potential losses, raising the cost of cares for poorly-equipped or staffed non-profit providers during a Medicare-covered 6 month run.
The team also found that the average length of stay for patients in for-profit hospice was 20 days, while the average length of stay in a nonprofit hospice was 16 days. Because costs are highest at the onset of enrollment and near death, longer stays in hospice are more profitable for providers.
Between 2000 and 2007 the number of for-profit hospice agencies more than doubled, from 725 to 1,660, while the number of nonprofit operators stayed about the same. For-profits have “significantly higher” profit margins than nonprofits, reported the researchers. Indeed, nonprofits, true to their name, operate at a loss.
Before reacting to this study on its face, it’s important to note that it tracked discharged patients from hospice care, lacking data on patients who died during cares; also, there is no indication or measure of quality of care given by for-profits as opposed to non-profit providers and if this contributed to the selection of patients by one provider organization over another. | LINK
President Obama’s push for the digitization of the medical (health) record continues its march toward the goal of complete adoption nationwide by mid-decade. The administration’s desire for this goal as a part of reform is as much a laudable task as it is a daunting one. Cost of complete market saturation among healthcare facilities and systems is one issue. The other? Some providers in more rural and urban areas where care is provided are concerned that EHR adoption will not immediately benefit healthcare delivery to the economically disenfranchised.
Call it the “digital divide” as it relates to the electronic record. Sure, cost of adoption is one thing — but the realization that private and government initiatives over the next four or so years will continue to favor larger systems with heftier resources is quite apparent. To be fair, the feds have allocated some $300M in stimulus funds for this problem. But, just how far will funds go not only to ensure access for the poor and uninsured in economically deprived care environments but also to begin to reverse the all too familiar correlation between poorer health outcomes and lower income levels among patients? | LINK
UPDATE & RELATED: A graphic shows the penetration of EMR adoption by state (criterion: any EMR component use as defined by the CDC in 2010). Happy to see Minnesota at the top of that list! | LINK [PDF]
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.
