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

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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

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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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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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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

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Sounds innocuous enough. But one state is asking the government to reclaim those funds. Vermont, which has some 2800 low-income seniors scheduled to receive the Part D refund checks, is asking beneficiaries to return the money. Since the state of Vermont is funding drug costs for its beneficiaries via public-funded insurance programs (OVHA), it is asking seniors to return the checks — as the state is on tap to receive almost $600,000 in rebates due to the action.

While the goal of the feds is to eliminate this troublesome provision as part of Obama’s healthcare reform package, this episode does highlight the difficulty some states have with federal mandates to cover certain costs associated with the delivery of healthcare when they essentially don’t agree with those mandates. By the way, if seniors decide not to refund the government’s money, says Vermont, they will be subject to a $250 deductible in their state-subsidized insurance plan for drug costs. | LINK

1. Next year, the rebates will be replaced with discounts that will increase each year until the gap is effectively eliminated in 2020.

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If this happens, the newly unemployed will have to find alternatives — meaning anything from sliding scale/public health options to researching the open market for premiums that may encompass the vast majority of their unemployment benefits.

Providers and states will be affected, as Medicaid reimbursements and offerings could take a hit.

As the president continues to grapple with the worst oil fiasco in the nation’s history, a tepidly stingy economy, and the spectre of losing his party control in both houses of Congress this fall; he surely must be noting this apparent irony in the mere months since passage of healthcare reform. If the Senate votes to end the COBRA subsidy, beneficiaries in this situation may face setbacks in getting access to care, as reform’s legislative safety nets won’t kick in for another 4 years. | LINK

1. COBRA — Former employees pay the entire cost for their health insurance. In exchange, they retain the availability of the benefits and the network of doctors and hospitals they’ve always had.

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With the new focus of GAMC as one of operating within a strict healthcare (capitated) budget of sorts, many beneficiaries of the program in its former incarnation are not only finding it as challenging to negotiate it in order to retain the level of care they have gotten used to; they are also realizing that its current policy is somewhat finite and inflexible.

That is, until they are able to take advantage of a state-run program using matched federal funds later this year, they are realizing that access to that care has just become as complicated — almost intentionally so. Such is the case of a Duluth man with schizophrenia who now has to travel to the Twin Cities in order to receive the care he has become accustomed to, by necessity.

“I don’t really like the idea of going to the Twin Cities, but I need comprehensive care,” said [John] Micklick, who suffers from mental illness and several chronic conditions. “I’ve got to be careful, because I know if things get too stressful, that’s when I start hearing things and seeing things.”

[...]

But like thousands of others who live outside the metro area, Micklick’s choices for medical care are: Get help at his local hospital emergency room, look for clinics willing to give free care or commute to the Twin Cities.

Not much room for choice, as an initial wish-list by the state of participating providers has been slashed from almost twenty throughout greater Minnesota to just four in the Twin Cities metro — also out of economic necessity. Until a new governor is installed this fall, care access under this program will continue to be a challenge. Although, this will relax once federal funds and (promised) higher reimbursement rates for providers kick in, it is no guarantee that the level of subsidized care for poor childless adults who qualify for the program will benefit in exactly the same way — even if that  governor becomes a Democrat. The constantly fluctuating nature of healthcare reform will see to that. | LINK

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