The retooled GAMC health plan initiated due to the budget crisis in this state earlier this year appears to be at a crossroads of sorts — and it involves payments to the participating safety-net hospitals.

The discussions began because Hennepin County Medical Center (HCMC) in Minneapolis has had a smaller percentage of potential patients enroll than the other three participating hospitals and, as a result, is getting paid more than twice the amount per patient.

The capitated-type payments to the hospitals which have the resources to participate in the GAMC overhaul was introduced as a way to complement patient enrollment caps to each of those participating hospitals. However, it appears that there is a breakdown in access-to-care and cost-per-patient parity, with HCMC getting the lions’ share of patients outside of the scope of its available general assistance medical funds. | LINK

CMS has informed state Medicaid directors the terms of qualification for federal matching funds for administrative costs toward information technological infrastructures. Specifically, states must comply with the following stipulations: administration of Medicaid incentive payments to Medicaid eligible professionals and eligible hospitals; oversight of the Medicaid electronic health record (EHR) Incentive Program; and the pursuit of initiatives that encourage the adoption of certified EHR technology for the promotion of health care quality and the electronic exchange of health information.

Besides the latter bullet point above, the entrance of individual states into EHR IT initiatives carries with it a commitment to Medicaid funds in this era of reform. Some states are already on board, like California — whose governor couldn’t be more excited to get the ball rolling.

“What we are launching today is a new era for healthcare,” Schwarzenegger said. “Through a simple broadband link, this state-of-the-art system will save lives by instantly connecting people from across the state, including under-served and rural areas, with the best and brightest doctors. The California Telehealth Network marks the beginning of a new digital highway that will fundamentally change the future of how healthcare is provided.”

Others, like Minnesota, are leaving some state government agencies — and patients they serve — in a lurch.

Millions of dollars in health care funds seemingly destined for Minnesota after last week’s emergency session of Congress have yet to clear a final hurdle: the signature of Gov. Tim Pawlenty, an outspoken critic of the new federal spending.

UPDATE: In an unsurprising PR move, leading Dem candidate for Pawlenty’s job come November — former one-term U.S. Senator Mark Dayton — wants Pawlenty to just accept fed funds. | LINK

The underlying tenet of heatlhcare reform in this country is access. Achieving that access is a means to an end that separates reform’s political ideology essentially down partisan lines. The ongoing Medicaid saga and its “role” via the states is thorn in the current administration’s side as reform gets underway. With some jurisdictions embracing federal matching funds upfront to finance care in the near term, others are downright hostile to enter in to a commitment when individual states’ financial outlooks are so shaky.

A new study highlights the reality facing states whose budgets are so tenuous (in this case, California), the conflicting scenario between guaranteed healthcare access and the depletion of funds to finance it generally leads to one conclusion: no matter what state governments do to cut spending in one healthcare sector, costs seem to go up in another — sometimes at a far greater rate.

Increasing numbers of Americans, especially adults on Medicaid, are using hospital emergency rooms for their health care, say researchers from the University of California, San Francisco. [..]

The findings suggest that access to primary care is a key problem, Tang [the researcher/author] said. “Whether it’s primary care physicians are not accepting new patients with Medicaid or that there aren’t enough primary care physicians, we need to dig a little bit deeper,” she said.

More spending the answer? Seems really audacious at this point to even ask that question, let alone think it. | LINK

The Obama administration can take solace in some favorable news to become official later this week, as the annual Medicare and Social Security trustees report detailing the entitlement programs’ fiscal health becomes public. The report says that the budget will realize approximately $8B in savings at the dawn of reform, with a trajectory of almost a half a trillion in overall savings by the end of the 2010s.

Although not considered a particularly incendiary demographic with respect to Obama’s reform goals, the nation’s senior citizens have expressed concern over the solvency of Medicare over the next decade. It is safe to assume that the administration will use this news as a talking point to assuage those fears — in addition to running ads like this as a surrogate method.

Critics of the Obama admin’s plan to trim Medicare and Medicaid costs are quick to point out the presumed diversion of those implied savings into subsidies for the uninsured over the next decade — a move, they say, does nothing to retain solvency into the 2020s or save on healthcare costs in the long term. | LINK to report [PDF]

Health care coordination seems to the mechanism by which many healthcare pundits on either side of the the debate agree on how significant waste in spending can be cut. North Carolina’s Medicaid program is utilizing the medical home model as an example of that type of care coordination.

Moving beyond Medicaid FFS and traditional managed care partnerships, the delivery of care in this context identifies the appropriate patient populations based upon services meeting certain primary care needs. Physicians are paid higher reimbursements and a specialized “care-coordination” fee as incentive to continue participation. Community care networks made up of primary care teams in multiple locations serving Medicaid enrollees are headed by physicians and serve as the de facto health plan for those patients.

This model is another example of putting state healthcare spending to practical use, empowering physicians who manage it not only to have a stake in its success but also to remain intimately involved in quality healthcare delivery at the state level. | LINK

On Monday, Medicare (and Medicaid) turn 45. And to celebrate, the government will be touting its annual open enrollment. Well, okay, the feds will also be throwing in a plug for government’s role in health reform and what benefits are in store for those who were spring chickens when Medicare became law. Who better to message than the avuncular Andy Griffith?

Clearly targeted at those seniors who still think “death panels” are an essential creation of the Obama plan for reform, the ad — which begins airing in some markets today — will mostly focus on the benefits for seniors inherent in standalone or the program’s supplemental plans under reform. There will be no mention, however, of the major way the new reform law will maintain Medicare solvency well into the next couple of decades: trimming the fat from Medicare Advantage payouts from plans which originally saw benefit under the George W. Bush administration’s 2003 Medicare Modernization Act. | LINK

The fact that President Obama is naming Don Berwick, MD, CMS head via recess appointment shows his commitment to quality in healthcare delivery. It’s welcome news given that his drive for cost and access were the other cornerstones of recently passed reform legislation. Via the WH blog:

There’s no question that Don Berwick is the right choice to be our next CMS administrator: he’s the founder of the Institute for Healthcare Improvement and has spent decades as a practicing physician and a Harvard professor. He’s dedicated his career to finding ways to make our health care system work better for patients and cost less for taxpayers.

The choice of Berwick to fill this post is the perfect fit for an administration in search of the holy grail in healthcare delivery: quality. | LINK

The U.S. Senate is the target of criticism of budgetary concerns on the left and on the right, as the weekend before most states’ new fiscal years begin. At issue is the stalled bill on unemployment benefits and extensions, which was the outcome of hours of debate and an ultimate (mostly) party line vote to block future consideration. States’ Medicaid packages were to figure in heavily, as many government-run healthcare programs were in dire need of funding in the face of the alternative — severe budget cuts in not only the state level, but also the local and municipal levels. Governors on both sides of the ideological aisle decried the Senate’s rejection of aid to their states in the form of another six months of Medicaid assistance. (Here in Minnesota, our governor has already rejected the earmark of funds as part of the balanced budget for this biennium.)

Also,

Making the situation more difficult for states, the recent passage of the federal health care overhaul bars them from rolling back eligibility on Medicaid, so the cuts would have to come from elsewhere in their budgets — and would likely include layoffs from different parts of the state governments, many of which have already seen big cuts — or by slashing things like payments to Medicaid providers.

Will governors have to go to Washington to lobby for the inclusion of this provision in this latest legislative battle? Unless the bill is revived next week in the House in an effort to address this critical setback, the issue of Medicaid financing will suddenly become much more complicated than it usually is this time of year. After all, state budgets have to be balanced. | LINK

President Obama’s recent remarks surrounding the commitment to Americans the promise of lower insurance premiums for healthcare access are all over the news and healthcare blogosphere this morning. The interested reader and health policy wonk also can’t avoid the latest goings on with Medicare legislation. But what about Medicaid? Obscured by concerns of healthcare providers’ battles with looming cuts to Medicare and patients’ bills of rights in their tussles with Insurance; the fears many states have with changes to Medicaid policy in lieu of reform are just as newsworthy.

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

• It’s on. The mega union only needed 66%. They got over 80% ‘yea’. [LINK]
• At ninety days into the new reform law, Obama makes public safeguards inherent within. [LINK]
• FDA approves new diagnostic test that more rapidly detects antibodies and antigens. Excellent. [LINK]
• More controversy than there needs to be? The president’s pick to be new CMS chief engenders strong feelings on both sides [LINK]

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.

An exclusive to Doctor Pundit, by Laura Katz Olson, PhD

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.

Read the rest of this entry »

If anyone needs any proof of how irrelevant the American Medical Association has become in its advocacy of the physicians the organization is supposed to represent, one needs look no further than in the last minute unexpected rejection of the postponing of cuts (21%) to Medicare reimbursement schedules. So much for being in the physicians’ corner on this issue. Senate Republicans essentially killed the measure via a vote along party lines. Initially, there was hope for a compromise fashioned at the eleventh hour by Max Baucus (D-MT) — one of the key figures in the establishment of many of the provisions set forth in the reform bill’s passage earlier this year.

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. [↩]

Unlocking Medicaid fraud can be as tortuous and labyrinthine a process as making sense of the legislation itself. Often, grandiosity characterizes elaborate institutional methods involving private entities bilking the government out of untold billions that essentially are absorbed by the government even after prosecution of the offenders — only adding to the cost outlay of the entitlement program.

Alternatively, fraud indirectly involving Pharma is fast becoming an issue because, for certain populations, Medicaid has been responsible for much of the cost of care delivery via drugs — many of which are branded. Where the legislation should draw the line, however, is in the unauthorized use of many of those medications explicitly granted a warning by the FDA as prohibited. Drugs used to treat mental illness — particularly as unauthorized in children, and reimbursible under Medicaid — fall squarely within this class of rules.

Nowhere is this occurring as rapidly as in the child foster care system, in which these children — often burdened with multiple placements, obvious parental neglect, and the influence of illicit drugs and criminal environments — are exposed to rather abusive prescribing practices by providers using psychotropics to treat what amounts to a troubled lifestyle … instead of frank mental illness. | LINK