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

Illinois will offer this week the first-in-the-nation coverage plan for its uninsured since health reform was enacted. Currently, the state has almost 2 million uninsured by estimates. The plan to place them on coverage rolls will not reach them all — only a fraction, actually. Illinois’ Pre-existing Condition Insurance Plan can only enroll enough in its high risk pool because of federal funding limitations.^[1]

The creation of high-risk insurance pools under reform is one way over the next 4 years President Obama has said he will rein in coverage costs by mimicking enrollment/disenrollment policies of states; creating service areas of operation with HHS guidance; issuing creditable appeals processes for enrollees; preventing employers from creating disincentives for employee enrollment in those pools; and utilizing accountability rules to prevent fraud.

Illinois is the first state to test the waters in this transition to healthcare exchanges set to begin in 2014. | LINK

1. Funding comes from premiums and from the federal government, which is giving the state $196 million to run the plan until 2014 when healthcare exchanges will be required under the 2010 Affordable Care Act. [↩]

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

As President Obama’s vision of healthcare reform begins to gel in the minds of physicians, health systems, insurers, and policymakers alike; the phased rollout of coverage mechanisms by Big Insurance will provide a timeline of sorts into the character of reform from a third-party perspective.

Via mandates, deadlines, and tax breaks; insurance coverage will be moving forward in the first half of the 2010s at a deliberate and measured pace — eventually covering some 30 M Americans without coverage and adequate access, as promised by Obama. One of the care delivery mechanisms is in the coordination of care of those with chronic diseases (such as diabetes, obstructive lung disease, and asthma) and the incentivization of primary care providers in those systems who choose to embrace such a plan.

Coordination of care reduces the fragmentation of delivery to those with chronic illness. Improving referral systems, rewarding primary care providers’ participation in innovative models such as the medical home, and emphasizing the importance of preventive care services in reimbursement schemes are important first steps to increasing access, decreasing acute care costs, and increasing quality in healthcare delivery. | LINK

Needy HIV+ patients a victim of the economic recession? With the rise once again in jobless claims in this country and the possibility of a much-maligned scenario of a double-dip recession, government programs that formed the cornerstone of HIV and AIDS treatment for patients who could not afford traditional access to those treatments are now closing — creating a fallout in states in which waiting lists are the result.

What’s more surprising than this development is the lack of safety funding for depleted federal and state programs; the Obama administration has yet to guarantee any sort of budgetary proposal or stimulus mechanism for saving these programs. In the state of Georgia, waiting lists for accessibility to HIV treatments is up to almost 1300 persons.^[1] In Florida, almost three-hundred.

An increasingly sad state of affairs in this early drive toward reform. This segment of the indigent care population could succumb to the same restrictions on eligibility those who are mentally ill perennially seem to face from many government-run programs. Will it take a redux of the same levels of prevalence rates of HIV not seen in 20 years to jar the Obama administration to attention on this issue? | LINK

1. Pregnant women, children and adolescents, and patients with “extreme conditions” can be exempt from the waiting list. [↩]

Have you been rejected for insurance coverage because of a pre-existing condition? Have you been without coverage for at least 6 months? Finally, are you a legal U.S. resident? If you hit the trifecta, you qualify for the HHS’s Pre-existing Condition Insurance Plan. Kathleen Sebelius makes the announcement today.

Today, the Pre-Existing Condition Insurance Plan gives them a new option — the same insurance coverage as a healthy individual if they’ve been uninsured for at least six months because of a medical condition. This program will provide people the help they need as the nation transitions to a more competitive and fair marketplace in 2014.

The plan covers primary and specialty care and begins today in states where HHS implements the program. States with their own programs will roll out the initiative later in the summer.^[1] One’s income is not a consideration. | LINK

1. In 21 states, the federal government will run the program. Twenty-nine states plus the District of Columbia will run their own plans. Premiums can run anywhere from $100 – $1000/month and vary by region. [↩]

While many states, like Minnesota, aren’t interested in creating high-risk insurance pools using federal funds under reform at this point, Gov. Schwarzenegger is moving forward with California’s commitment to do so. Until 2014, when insurers are required to cover patients in spite of deleterious pre-existing conditions, Schwarzenegger has signed bills allowing a fraction of that state’s uninsured to purchase coverage in high-risk pools.

In Massachusetts, where everyone is covered, premium rates continue to soar. Because that state subsidizes everyone’s care, those purchasing short-term plans within that its healthcare marketplace often drive up costs for those who are responsible for paying into the system — both individuals and employers. It appears that short term coverage for sicker people increase the cost of care delivery at a greater rate than anticipated among Massachusetts’ more chronically ill. The governor and insurers are working to close this loophole by restricting purchasing periods. | LINK

A study commissioned by the Commonwealth Fund confirms for some the dire straits quality healthcare delivery finds itself in today in the United States on the cusp of a reform effort. While, superficially, results like this are designed to provoke an immediate response (like from those on par with the Michael Moores of the world) — I find that the greatest asset findings like this can generate is creation of tough questions when one is forced to take a look at key quality indicators that reform will impact over the next decade.

On quality, the U.S. stood out “particularly with symptoms of more fragmented, poorly coordinated care,” Schoen said. In 2008, for instance, 14% of American adults with a chronic condition reported receiving the wrong medicine or the wrong drug dose in the past two years.

When compared to, say, Sweden or any other European country — an interesting stat. But getting out of the apples-and-oranges mentality allows us to see nuggets like this in a more sobering light. When placed in the context of Obama’s reform plight, it signals a call for urgency in healthcare delivery. | 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.

Is this the beginning of frugality by the government on healthcare benefits (as an extension of jobless benefits) as the nation slowly churns itself through an intensely phlegmatic recovery? Lawmakers may be on the brink of nixing the COBRA subsidy for the newly unemployed — meaning that for those who lost jobs from the outset of this month, COBRA^[1] benefits will be no more. The House has taken this bit of legislation away, and now, it heads to the Senate for a vote.

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. [↩]

It is well known that at this point in the debate on healthcare reform, one major benefit for the healthcare consumer is the retaining of adult children under their parents’ plan until the age of twenty-five. Not only does coverage in this demographic become extended over previous plans, it also creates a comparative level of coverage in policyholders whose benefits lapsed prior to passage of the healthcare reform law — closing potentially troublesome gaps in coverage. Although it is somewhat unclear how much this provision will cost the taxpayer upon initiation later this year, it is here to stay. Apparently, this is music to the ears of young patients who either let policies lapse because of prohibitive costs or considered themselves not especially desirous of coverage due to their generally good health and young age (the so-called ‘invincible’ demo).

The potential for subsidized coverage has recently forced many in this age group to reconsider forgoing it — mainly because that coverage is increasingly within reach.

Many young adults will be covered through other provisions of the health act. About 7.1 million, more than half the total, will be eligible for Medicaid beginning in 2014 because their income is less than 133 percent of the federal poverty level, or about $14,404 for a single person and $29,327 for a family of four.

Provided they take the leap and participate in insurance exchanges, the healthy young stand to qualify for much in the way of taxpayer subsidized care — offsetting traditionally higher premiums without such legislation. After all, it’s either this, or pay a penalty. As reform begins to unfold over the decade of the 2010s, the social engineering involved in creating collective thought with regard to healthcare coverage as being the norm — and not the previously regarded far-flung option in this age demo — is a goal of Obama’s administration as it seeks to transform preventive healthcare delivery. | LINK

How’s this for the ultimate Medicare entitlement irony? Medicare Part D offers, among many other benefits, the option for qualified beneficiaries to enroll in medication therapy management (MTM) plans with their pharmacy. The goal is to create a better informed patient-as-consumer among  myriad Medicare D  beneficiaries who suffer from many chronic illnesses requiring substantial polypharmacy — and hence, costs, to maintain their current state of health, improve it, and hopefully prevent further comorbid decline. To qualify for such a benefit within Part D, the beneficiary must be enrolled in the Medicare Part D drug program, have at least three chronic health conditions, take eight or more medications covered by Part D and spend at least $3,000 yearly on the medications.

Sounds fair enough and tailor-made for many seniors in the program. But there’s one problem: expense. Increasing numbers of racial minorities — predominant among them, Latinos and African-Americans — cannot afford many of those Part D-covered medications. They are less likely to gain medical access for a host of reasons, and cultural encumbrances make that latter problem more profound. Researchers studying this issue cite the potential problems that may occur with widening the racial healthcare disparity in terms of access — whether it be for affordable pharmacy or acute medical care. If it is incumbent upon the Obama administration to enrich Medicare on many levels, the systematic exclusion of many patients not able to take part in any part of the entitlement may set out to increase future healthcare costs if access to these government programs remains prohibitive | LINK

Healthcare legislation in Minnesota is coming down to the wire. Sure, the governor has okayed legislation to allow alcohol in the University’s football stadium, but he has promised to veto any bill brought forth by the Dem-controlled lawmaking body that he says will cost the state dearly if its Medicaid program is expanded. GOP lawmakers (in the minority) do not support such a move, leaving the governor well-positioned to uphold his threat for a veto.

Meanwhile, tensions are flaring in the run-up to a possible nursing strike among the region’s major healthcare systems. Hospitals, derailed the by the surprise termination of a morally bankrupt spokeswoman,^[1] are on alert with a vote next week on whether to go ahead with what would be a major nursing walkout of an approximate 12000-member strong workforce. | LINK

1. She failed to disclose a prior conviction and reprimand from the South Dakota Board of Nursing for the embezzlement of funds from the HR department at her previous employer. [↩]