Euphemistically, the population of gay and lesbian adults in this country has always been labeled “the ten percent”, owing to the presumptive political implications that have become significantly mainstream since this century began. Epidemiologic research done since the late-1990s had, perhaps more accurately pegged the true LGBT population at around 1 to 2 percent of US adults. The 2000 census is somewhat noteworthy for the initial inclusion of gays and lesbians into its data aggregates.
As a result of this and major political, policy, and mainstreaming of issues that affect and are affected by this population within the past 10 years or so, it seemed that the time was ripe for a re-evaluation of a traditionally marginalized population in heatlhcare policy research. A think tank dedicated to issues such as this has found that roughly 3.5 percent — or over 9M adults in this country — identify as gay or lesbian. (PDF link here.)
It only follows that the lives of the LGBT population are affected by changes involved with healthcare reform as in the other 97 percent of Americans who identify as heterosexual. Issues arising from preventive care coverage (HIV counseling, breast cancer screening etc.), and the specific prohibitions of claim denials for chronic diseases (active HIV infection, hepatitis C, etc.) are major wins for LGBT Americans who would have not received such comprehensive and competent coverage previously. A very good white paper [PDF] explains this in greater detail and relays the challenges that remain for the LGBT community under reform. Read it.
Just over a month into the Medicare competitive bidding program, and patients, their advocates, economists, and just about anyone with a stake in the process has nothing good to say about it. The program, implemented by the government to cut Medicare costs and find the least expensive options for services (like DME), requires that a sealed bid, given to an issuer by an underwriter, come with a prospective price and terms for a contract. At the close date of bidding, the issuer picks the best offer. However, CMS has sharply restricted the numbers of suppliers which can take part in the competitive bidding process.
Patients are complaining that they are not receiving certain goods and services as prescribed by their providers. Poorer quality delivery of services by home care agencies, longer lengths of stays of beneficiaries in acute hospitals due to affected discharge planning, and fewer overall choices for patients for certain DME services — have all contributed to the angst surrounding this process. Critics do not seem to be blasting the process in a strict sense, but they’re concerned that the program’s design undermines transparency, subsists on inaccurate information supplied by Medicare, and increases the potential for fraud and abuse by third parties, as a result.
Overview of the Medicare competitive bidding program | LINK
American Association for Homecare concerns & resources for affected patients and other parties | 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
MedPAC, the Medicare Payment Advisory Commission, is advising Congress to consider imposing a new charge — or copay — for seniors who receive home healthcare-based services. Until this point, home visits for a variety of conditions from nursing and other providers was free of charge. A payment of at least $150 would constitute the amount the commission is advising Congress to implement. It’s all a part of the effort to continue to streamline Medicare and attack waste.[1] So-called dually eligible patients (those on Medicaid, as well) would obviously not be affected.
More than 3M beneficiaries utilize home healthcare services, and, as expected, some lobbies (including the AARP) pushed hard against the imposition of such additional fees required of many patients with low-to-modest incomes. The charge would be collected for each home health agency admission, not for every visit by a nurse or provider. All of this news comes on the heels of a recommendation by MedPAC to increase the levels of Medicare reimbursement to providers by 1 percent in 2012.
Since the late 20th century, innovation in long term care (LTC) has been fueled by a desire of healthcare systems – in this case, owners of skilled nursing facilities — to achieve new quality benchmarks in healthcare delivery at a reasonable cost. Thanks to major pieces of legislation over the past 15 years emphasizing patient safety, healthful outcomes, and cheaper methods of treatment delivery; LTC as a discipline has undergone a sea change for the better. As a geriatrician, I have seen this evolution firsthand. That’s why I absolutely love seeing developments like this
Working with a psychiatrist and a pharmacist, [nurse and resident care coordinator in a Two Harbors, MN nursing home, Eva] Lanigan started a project last year to find other ways to ease the yelling, moaning, crying, spitting, biting and other disruptive behavior that sometimes accompany dementia. They wanted to replace drugs with aromatherapy, massage, games, exercise, personal attention, better pain control and other techniques. [..] Within six months, they eliminated antipsychotic drugs and cut the use of antidepressants by half.
The savings in cost due to the cessation of expensive psychotropics (even if informed consent enabled usage), the avoidance of chemical restraint and its obvious negative effect on patient safety, and the increase in patient quality of life without the need for specialized dementia care (again, at an enormous increase in care delivery cost) are at least three major reasons why innovation in geriatric care is so important in the age of reform. And it’s happening right here in Minnesota. Excellent.
Nobody said that it would be cheap. The Alzheimer Disease International (ADI) report projects worldwide costs of over $600 for 2010. It’s no coincidence that this news comes out today — on World Alzheimer’s Day. The ADI report combines the most recent global data on disease prevalence and research. ADI predicts that as populations age, dementia cases will almost double every 20 years to around 66 million in 2030 and 115 million in 2050 — much of the rise from disease incidence in poorer nations.
On these shores, it is known only too well that the costs of treating the symptoms, developing drugs to reverse the disease process itself, covering ancillary costs associated with caregiving, and the constant research in the race for a cure will add to the burden President Obama’s healthcare initiatives must overcome in the next 10 years. The main advocacy organization in the U.S. isn’t waiting; it has already begun pushing for the funding and implementation of a national “dementia plan”. | LINK [PDF]
The response of seniors and healthcare providers to a new Medicare bidding program for so-called durable medical equipment (DME) will be somewhat compelling to Democratic legislators in Congress who will not apparently stand in the way of House Energy and Commerce Chairman Henry Waxman (D-CA) and his push for the program. Under the tenets of the bill [HR-3790], reimbursements for devices such as wheelchairs and oxygen supply units would be cut as an inevitable consequence of the bidding process. Unknown is whether this legislation (which will be tested in some markets beginning in Jan. ’11) would eventually make this sector of healthcare more expensive — increasing costs in other sectors, such as acute care (longer hospital stays) or subacute care (augmented skilled nursing and physical therapeutic delivery systems). | LINK
Although the results of a study from the Annals of Internal Medicine are out today noting an increase in the rate of sexually transmitted infections (STIs) among those taking drugs for erectile dysfunction, this item “hot off the wires” practically invites the media to take a stance assuming direct causation.
Jokes aside — and you can assume that lead-ins are probably replete with them — the compelling numbers[1] suggest a greater problem afoot: the overall numbers of sexually active men over 55 years of age is increasing. Re-evaluating incidence and prevalence rates to include this ever-burgeoning population will only become more commonplace in medical education as this retrospective study underscores one major point: the necessity of other types of trials studying the effects of preventive practices toward STIs in those much younger and applying them to this patient population. | LINK
The use of medical technology is as commonplace today as the doctor’s ubiquitous black bag was sixty years ago. Technological advances have been both blessing and bane, allowing those who benefit to live longer, as with their chronic diseases. Of course, for many patients, this means being sicker longer. In end of life care scenarios, one such advance is creating complications — the automatic internal cardioverter-defibrillator (AICD), a life changing device use to pace and assist heart failure patients whose disorder would have shortened lives just a few years ago. An interesting tidbit of medical news today notes that the willful disconnection of such a device rarely occurs in such end of life discussions with patients and families in the way that cessation of drugs and other aspects of medical care are. An advocacy group of cardiologists and other medical subspecialists is out to change that. It has released guidelines on the withdrawal of support in the hospice and palliative patient and the ethics surrounding such an action. | LINK
Although the prevalence rate of dementia is higher overall in women over 65; this is due to a variety of factors — overall elderly age demographic prevalence, hormonal declines (circulating estrogens), and the presence of certain vascular related disorders, just to name a few. But what about the incidence of dementia in a male spouse as an association for the incidence of dementia in females — both of whom had no signs of the disorder initially?
A trial published in the latest Journal of the American Geriatrics Society shows that over 1000 patients (married couples in a single Utah county) were followed for a period of at least 12 years[1]. Initially without the diagnosis of Alzheimer dementia, those caregiving wives developed dementia along with their husbands in 30 cases. Although the study did not specifically examine wives as caregivers using explicit criteria, most lived in the same space as the male spouse at the time of diagnosis. An interesting result that should spur more study in the gerontological (social scientific) realm of dementia treatment and incidence in the community. | LINK
Is Florida sensing an “advantage” for its subsidized healthcare delivery? If the legislature’s voting is any indication, the state could be on the path to privatization of its Medicaid program in its entirety. Facing an extreme budget crunch, Florida could allow state-based and national for-profits contracts with the government program to help pay for care.
States’ Medicaid funds are usually matched by government subsidy to assist in the delivery of care to all ages who qualify on a means-tested basis. Traditionally, elderly long term care and care of the disabled have been responsible for the lions share of costs to many states’ healthcare coffers. And in a system where private payers in Medicaid managed care plans are increasingly denying payment to hold on to profit, privatization is an option.
So it doesn’t come as a surprise that HMOs and other plans are lobbying hard for this; the Florida GOP couldn’t be happier.
Republicans in the Legislature say Florida can’t afford to wait, or rising Medicaid costs will overwhelm the budget. Almost all states have some portion of Medicaid recipients in so-called “managed care,” but Florida would be one of the first to put the elderly and disabled requiring special care in the hands of commercial HMOs.
Advocates of taxpayer-subsidized care to this patient population say that the state is “abdicating its care” in this case, as fears of a corporatized healthcare infrastructure threaten care access (to physicians who cannot afford to provide care) in the name of profits while incentivization to get the patient better and out of Medicaid will be sacrificed. Senate Republicans want to move — and fast. Dems “want more data”. Should be a lightning-rod issue in a state with fireworks in yet another political arena. | 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.
