Against the backdrop of the so-called safety net hospital (those with heavy Medicare, Medicaid claims utilization) as a healthcare-related industry and campaign ’12 meme, there is interesting data out in JAMA this week that either supports Mitt Romney’s assertion that the “very poor” are taken care of in this country quite adequately, or there is reason to believe that P4P measures (or, at least the idea, anyway) are superficially quite similar in non-safety net acute care centers in terms of ultimate patient dispositions.
Researchers studied whether patients were admitted to the acute hospital within eight hours ED admission or if they were to be discharged, transferred or moved to observation within four hours of coming to the ED. They found that
compliance with proposed ER length-of-stay measures for admitted, discharged, transferred, and observed patients to not differ between safety-net and non-safety-net hospitals
Although length-of-stay (LOS) data is interesting, it is not compelling — quite limited in its implications, actually. Currently there is no “accepted” ED LOS strict guideline in the U.S. Digging deeper into this study (abstract-only text cited above available without a JAMA susbscription), one can infer more from the upper decile of data — in which LOS significantly increased among both types of institutions (10-15 h in length), the authors citing mostly acute patient decompensations in mental illness as the reason for protracted admission LOS.
Still, the trial provides renewed attention over a surrogate care parameter just a few years ago was hailed as an agreeable target upon which to base healthcare reform on spending within the government sector. These days, the study may only serve as yet another reason why P4P as a quality measure is so derided by many as the ACA is just beginning to take hold.
Embattled WI governor, Scott Walker (R), issued a statement yesterday opposing the implementation of a state exchange as provisioned by the ACA — opting to defer action on the measure until the case is heard by the SCOTUS in March. In doing so, he will be returning almost $40 M in federal funding earmarked for the healthcare exchange. Whether this is earnest on his part or merely a symbolic gesture to Wisconsin GOP faithful in the wake of a pending certified recall vote on his office remains to be seen. Walker has always been against the passage of the reform law, instead focusing on efforts to deny federal assistance in doing so (states which choose this path will have to demonstrate fiscal independence on healthcare exchange creation by 1/1/13 or will be mandated a program by the feds).
Is this entire episode a game of chicken by Walker in light of his sudden vulnerability? It is, if one listens to the rhetoric from the state’s Democrats on the issue. Advocacy groups are also weighing their own disapproval of the governor’s intentions. The SOCTUS will hear testimony on the constitutionality of the reform law (notably, the mandate for coverage) over a two day period by the end of March. By the end of Februrary numerous amicus briefs will be filed by both Obama admin (DOJ) and plaintiffs (states) in the case. In spite of all the rancor surrounding this issue, it will difficult to envision striking of the mandate provision, much less the entire reform law as two lower courts have offered split decisions on the matter — prompting the SCOTUS to act quickly on a decision on the entirety of the ACA well before the election. | PDF brief from UCB Labor Center in support of the ACA’s constitutionality
Political coalitions here in Minnesota have largely towed the Democratic line, having gone decidedly blue in the last presidential election in spite of reports that the state was a purple one “in play” in an ultimate result that was anything but close. The building within the democratic base also stands to reap benefits with respect to the reform law by its inception in 2014.
This, according to an MIT healthcare economist.
[Jonathon Gruber] told members of a governor’s task force Thursday that the federal health care law will reduce the health insurance racial disparities in Minnesota. [...] Gruber projects that almost 300,000 additional Minnesota residents would gain insurance coverage by 2016, and that those who currently buy health insurance on the individual market could pay 20 percent less in premiums after taxes.
Gruber was speaking in terms of the savings generated by increased access to healthcare with the advent of exchanges under reform. Dem Governor Mark Dayton has recently formed a couple of healthcare task forces — one of which will exclusively work to develop an exchange to increase access to the state’s un- and under-insured. | LINK
Say it isn’t so. Healthcare activists and state insurance commissioners are unlikely bedfellows in the fight to keep Medigap coverage plans static, avoiding the wide swath of projected cuts under the banner of entitlement reform in this term of Congress. House Speaker Boehner has made no secret of his plans for so-called entitlement reform, and Medicare programs are vulnerable, it is assumed.
Medigap plans are insurance supplementals which beneficiaries receive in paying for services not covered under traditional Medicare. The average Medigap beneficiary is more ill and older, and it is perceived by many lawmakers in favor of reform that massive savings within Medicare could be realized over the near term with cost shifting of the most popular (and usually more expensive) gap renewable policies.
Some state commissioners are crying foul and that implementation of such a move in the name of reform may be illegal — as beneficiaries are entitled to renewable Medigap benefits under fed law. Since 2003, when George W. Bush signed the MMA into law, much focus has been on Medicare Advantage plans and structure. In this Wild West scenario of budgetary slashing in Congress, the “sanctity” of Medigap legislation is at risk; some states have created working groups to inform beneficiaries and the general voting public of the issues. | LINK
Ever wonder how the preparations for healthcare exchanges are proceeding? The Kaiser foundation has constructed a brief [PDF] which allows one to reasearch states’ plans in progress. To review, the establishment of healthcare exchanges by the feds under reform is meant to enable consumers to compare a selection of qualified health insurance options in order to find the plan that best meets their needs and budget — with a significant amount in taxpayer subsidies devoted to this purpose.
Among the highlights in the brief report: (1) discussion of governance of exchanges, with some states granting significant control over governance matters at the hands of the excutive branch; (2) plans by states to address conflict-of-interest issues regarding insurance plan representation within governing boards of exchanges; (3) the total amounts paid to states so far in the funding of exchange formations in their individual healthcare marketplaces; and (4) the effect of legal challenges brought forth in some states regarding the constitutionality of the insurance mandate provision of the ACA (most recently, the striking down of the state of Virginia’s challenge filed by its atty. gen.) on the formation of exchanges.
How does obtaining health coverage (insurance) compare to not getting it at all? According to a trial published via the National Bureau of Economic Research (Harvard/MIT), beneficiaries’ quality of life was enhanced and made a “big difference” in those patients’ self-health perceptions and their daily outlook — according to the study’s lead author. A quick glance at the results confirms that all encompassing statement, especially since the study employed the diagnostic “gold standard” in trial research by utilizing a randomized, controlled design.
Taking a look at approximately the first year of coverage for Medicaid beneficiaries in the state of Orgeon, the study showed that healthcare expenditures for those who got coverage increased by almost $800/year. Those who received Medicaid were around 60 percent more likely to get mammograms. Medicaid recipients were over 50 percent more likely to have a regular primary-care doctor. They were also in better shape financially and less likely to have unpaid medical bills. Those who got Medicaid were also far more likely to report themselves in good or excellent health. ED admissions did not decrease; however, the increase in ED utilization by beneficiaries was not statistically significant.
It is clear from the results that coverage, in and of itself, has a positive effect on patients’ perceptions of health and wellness. What is not documented as much at this time is how this translates into outcomes with respect to various chronic problems such as obesity, diabetes, and risk factors (such as serum cholesterol, blood pressure, etc.) for heart disease. Also, it is unclear how these results translate into real numbers once reform increases Medicaid rolls substantially by 2014. Researchers plan on following the participants for at least another year. | LINK
Consider this: With a rate approaching 30 percent, the state of Texas has the highest degree of uninsured in the country. Now consider this: It has always been known in healthcare policy circles that, if given the chance, conservative lawmakers in the state would choose to opt out of Medicaid because of what they see as a wild “unsustainability” in the federal-state program for the short term.
One of the state’s lawmakers, a Senate republican, is introducing a bill whose end result would create administrative partnerships (as presumptive methods to control healthcare costs) among health systems — a compact — that would allow the state opt-out as a feasible way of reining in the cost of healthcare delivery to the poor and uninsured in Texas. The price tag: almost half a billion dollars. While consolidating administrative redundancies to reduce costs, the bill would also have some undesirable provisions, according to healthcare advocates for Texas’s poor:
This law is more designed to set up the legal structures that will allow doctors and clinics and labs and hospitals and health plans to work together to restructure themselves in a way that they can share information and savings if they really not just keep costs down but actually improve people health outcomes. [...] The bill allows Texas to ask the federal government for permission to take its share of funding and join other states in creating a compact, a healthcare program free of federal requirements.
It’s obvious that a federal opt-out is an impossiblity in the Obama administration, but it does open up the possibility for upping the ante in the reform debate via the anti-spending advocacy of the state’s current governor — who just happens to be considering seriously a run for the White House in 2012. | LINK
The WH is striking back at a consulting firm’s report which claims that almost a third of all companies will forego the provision under the ACA which requires them to offer insurance to employees in the manner dictated by the law. According to the study, companies will “radically restructure” the way insurance is offered to employees, opting to selectively determine who receives the crucial benefits and how.
The study, which is being circulated among Republicans, predicts that as many as 30 percent of companies will stop offering health insurance benefits, reduce the level of benefits, or offer benefits only to certain employees. If this prediction holds, the number of Americans who could see changes to their health insurance would be far more than the 9 million to 10 million estimated by the Congressional Budget Office.
The WH response? This finding is essentially an outlier of sorts … most companies will benefit from the provision from a recruitment and retention standpoint — resulting in long term savings for the employer which invests in human capital, thereby directly influencing growth, outpacing dollars spent on coverage.
A central goal of the Affordable Care Act is to reduce the cost of providing health insurance and make it easier for employers to offer coverage to their workers. We have implemented the law at every step of the way to minimize disruption and maximize affordability for businesses, workers, and families. And we agree with experts who project that employers will continue to offer high quality benefits to their workers under the new law. This one discordant study should be taken with a grain of salt.
That this study is getting any media traction at all is not really surprising, given its penchant for stirring the pot on the very contentious issue of the reform law and the efforts at repeal of some parts of the legislation by the GOP. Let’s face it, though; the political posturing on Medicare legislation and the ACA will continue as low-hanging fruit for the GOP whether studies like this are marginalized or not. The major implementation of the reform law in 2014 will be the ultimate proving ground and will be directly influenced by the Commander in Chief , whoever that may be — which is why arguments on all sides of the reform issue are fair game in a down economy and a voter sentiment desperately looking for solutions in 2012.
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
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.
