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.

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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

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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

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Grants in the total amount of over $1B will be targeted to healthcare orgs that work with federal agencies in an effort to increase the size of the overall healthcare workforce. The Obama administration is expected to announce today the availability of the funds to get initiatives started in as little as 6 months. I must admit, I was sent information on taking part in this effort.

“This will open the inbox for many innovators and organizations that have an idea to bring to the table,” Don Berwick, administrator for the Centers for Medicare & Medicaid Services, said in an interview. “We’re seeking innovators, organizations and leaders that have an idea to bring into further testing.”

Participating orgs with ideas brought to the table will be  grouped in the specially named CMS Center for Medicare & Medicaid Innovation. The initiative, praised by CMS head Don Berwick, is betting on using federal monies as an incentive to get the government involved in vetting other possible ways to spend more frugally ahead of reform and a pending physician shortage by decade’s end — two scenarios that will have to be met forcefully to ensure the onslaught of much needed healthcare delivery that won’t come cheap. | LINK

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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

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Alzheimer dementia continues to be among the most heavily researched and funded chronic diseases in medical science today. The increased awareness, brought into the spotlight and “modernized” more than 20 years ago following the high profile revelations of celebrites and politicians afflicted with the disorder, has led to increased patient education, public policy initiatives, and, of course, greater research monies in the effort to not only treat symptoms, but also to find a cure.

An international advocacy group is now asking municipalities to take awareness a notch higher with the commitment to even greater awareness of the disorder — addressing what it calls a “treatment gap”, hampering any gains on detection of the disorder at its earlier stages. Here in the U.S., the Obama admin is apparently hard at work in developing the country’s first-ever national anti-Alzheimer strategy aimed at sharply cutting the enormous healthcare costs associated with ancillary treatment .

The National Alzheimer’s Project: From Act to Action is an effort to support a committed and effective implementation of the National Alzheimer’s Project Act (NAPA). Information collected from individuals living with the disease, caregivers, providers and other stakeholders will be shared with the U.S. Department of Health and Human Services, which is responsible for creating a national strategy to address the crisis and coordinate across government agencies. This project is facilitated and supported by the Alzheimer’s Association.

Consider this effort an amalgam of citizen awareness and discussion (townhalls) and legislation (congressional passage of the National Alzheimer Project Act) garnering bipartisan^[1] support to fight a scourge that can leave heavy financial tolls on caregivers, families, and the healthcare delivery system itself.^[2] A daunting task, to be sure — but one that is sorely needed. Here’s looking forward to December — the date when the president makes his plans for these initiatives very public. | LINK

1. Just how bipartisan? In 2007, Newt Gingrich co-authored an article in Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association, making the case for the creation of a federal Alzheimer strategy.
2. Alzheimer’s Association advocates sent more than 15,000 email messages to the White House asking the President to sign the National Alzheimer’s Project Act into law; on 1/4/11, he did — making this action the most significant legislative action with respect to Alzheimer funding intiatives up to this point.

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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.

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The initial spin on the recently squared away budget deal preventing a national default relates a necessary evil that not only carries the partisan rift seen in advance of the legislation, but also becomes a harbinger for a financial outlook that, in some ways, looks as bleak as the presumptive default did. Still retaining its triple-A rating, the credit outlook for the United States will be reflected in a “negative” forecast — likely resulting in a downgraded credit status within the next couple of years. Of course, all of this big-picture wrangling really doesn’t mean much to the millions of people whose salaries are paid — in part — by the federal government. A harsh reality at the forefront of this thinking, given the current jobless rate and achingly persistent unemployment levels is the specter of the loss of unemployment insurance for those currently receiving benefits. Minnesota is just one of many states bracing for such an apocalypse which appears to be sparing future cuts in another enormous federal subsidy — Medicaid.

Department of Human Services Commissioner Lucinda Jesson said she was relieved that Medicaid, known as Medical Assistance in Minnesota, is exempted from the initial cut. That doesn’t mean the new bipartisan commission charged with driving down the deficit won’t come after it once the panel breaks out the budget knife. “We are going to track it very closely,” Jesson said Tuesday. She said her department will also keep a close watch on child protection, food support and other assistance for seniors.

What about cuts to the service side of the equation? Since Social Security and Medicaid are specifically exempted from the ravages of the debt ceiling bill, physicians could see an additional 2 percent pay cut on top of double-digit Medicare reductions already slated for 2012 under the debt ceiling deal. Perhaps more concerning is the strong likelihood for major Medicare cuts and overhauls in long term care payments as a by product of a commission^[1] created as part of the deal agreed to on Sunday. Nursing homes would be hit extremely hard in this scenario — potentially affecting care delivery to the most medically complex beneficiaries in the LTC sector. Understandably, the deal reached by a less than jubilant Hill on Sunday has many folks extremely wary about the nation’s prospects on an already shaky economy. Its effects on federally subsidized healthcare delivery ups the ante for lobbyists, providers, and most importantly — patients. | LINK

1. The deal to raise the debt ceiling would task a 12-member bipartisan committee to come up with $1.5 trillion in deficit reduction and would require a significant swath of cuts starting in 2013 if those efforts at reducing the deficit should fail.

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Many states have already agreed to federal funds to kickstart the path toward healthcare cooperatives and exchanges upon the cusp of reform. Funds appropriated by state legislatures will be used to create options for those who would have been denied traditional insurance coverage to be able to enter the competitive healthcare marketplace to obatin that coverage. Since the PPACA was signed into law, over 50 percent of states have begun crafting ways to set up exchanges.

Florida is not one of those states. Citing the burden on taxpayers, Florida’s republican governor is flying in the face of mandates required by the law to create affordable coverage via many mechanisms — chief among them — subsidies for low income healthcare consumers to enter the coverage marketplace. Florida says unless mandated by the courts to accept funds for the creation of exchanges, it’ll stay out of it. What the state is in the thick of at present, however, is its stance (upheld by a federal judge) that the ACA coverage mandate, itself, is unconstitutional. | LINK

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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

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