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Person at a cocktail party to me: Do you think the Governor will expand Medicaid

Me to the person: If the past is prelude I think he will consider it for another two years then let the next governor decide, thus allowing many more people to be killed by lack of access to health care in Alabama then will ever be killed by terrorists in Alabama.

The Governor couldn’t decide what to do about Obamacare and poor people so he appointed a task force. His call made it pretty clear that, although Obamacare wasn’t the answer, there were indeed questions that needed to be answered. In the “Whereas” section, for example:

  • Shortages of healthcare professionals in 65 of 67 counties
  • 40th out of 50 states in primary care physicians
  • 594.000 working people between the ages of 50 and 64 wihtout health insurance
  • 10 hospitals closed in the past 3 years
  • etc, etc, etc

The task force met off and on for about 6 months and had one recommendation:

  • Find a way to close coverage gap that makes health insurance inaccessible to hundreds of thousands of Alabamians.

They didn’t specifically say “the medicaid expansion as written into the Affordable Care Act (Obamacare) will solve 90% of the “Whereas”s” but they, by recommending this one thing, got awfully close.

The Alabama TEA Party response was posted on-line last week. Consistent with the national talking points, it goes something like:

We Alabamians pay enough taxes and would rather keep people with mental illness in jails, have hospitals go under, and allow people to avoid health care and die of treatable illnesses because of fear of bankruptcy rather than pay an extra $10 a year per person in taxes because we are TAXED ENOUGH ALREADY.

Fittingly, on the TEA party editorial page was an advertisement for Farxiga. which made the list of Huff Po’s worst drugs of 2014:

But the more frightening news is that patients taking Farxiga in studies done for the FDA were more than five times more likely to contract bladder cancer than the patients who took an older diabetes drug.

Priced at only $10 a day and advertised as first line treatment, I am sure it’ll end up in many physician’s sample closets. Uninsured patients with diabetes, then, who are unable to afford insulin (which is surprisingly expensive) will get lots of Farxiga samples. With any luck, they will contract bladder cancer. Because they are lucky enough to get cancer, assuming the blood in their urine scares them enough to seek care AND assuming they can find a urologist who will scope them on credit, become Medicaid eligible in Alabama. Then they can get insulin for their diabetes and get their bladder cancer treated. Don’t know why the task force didn’t recommend this, instead.

A primary contributor to Costa Rica’s success has been its focus on the well being of its people.  For Costa Rica, health and education are priorities for the success of their nation.

The attention to health has brought this middle-wealth country’s health indicators in line with those of OECD countries.[viii]  In 2001 the average life expectancy at birth in Costa Rica was 76.6 years.[ix]  In 2000, 97% of births were attended by skilled professionals, 89% of the pregnant women were given prenatal care, and 93% of children under 1 had health insurance.[x]  From 1990 to 2000 life expectancy increased by 0.8 years, the fertility rate dropped, and the population grew due to an influx of Nicaraguan immigrants.[xi]  In 2000 there were 16 physicians and 3.2 nurses per 10,000 population.[xii]  In 1999 there were 12,000 people living with HIV/AIDS, giving an adult prevalence rate of 0.54%.[xiii]  However, Costa is the only Central American country to provide antiretroviral treatment to all patients through its social security system.[xiv]  The leading causes of death were cardiovascular disease and neoplasms, which is comparable to many OECD countries.[xv]  Spending on health care has increased steadily over recent years, and in 2000 it composed 9% of the national GDP.[xvi]

(report to the Global Economic Council, 2002)

I received an e-mail today from Doctors for America. This group is a “national movement of physicians and medical students fighting for a system in which everyone has equal access to quality healthcare.” I signed up (membership is free) when the “Obamacare” debate was raging to express my core belief in access to quality healthcare publicly. Several other physicians in my group signed up as well. At one point there was a map and we accounted for a large majority of the Alabama membership.

Today’s e-mail (also found on their blog) pointed out that the Ryan health care plan was going to be voted on in the Senate and urged us to contact our elected representative to let out voices be heard. My voice often carries a message at odds with our congressional delegation and I tire of writing to them but I recommend that you read the blog post for yourself. To use their summary of the the high points, if passed (and signed by the president) the new law would:

  • Eliminate traditional Medicare and replace it with a voucher for seniors and disabled Americans to buy their own insurance. Each person would receive a fixed-amount voucher to choose a private insurance plan. The value of the voucher would increase with time, but would not rise at the same rate as insurance premium increases.
  • Cut Medicaid funding for states by turning it into a fixed-amount federal block grant program.  With the block grant program, states that are already struggling to cover Medicaid patients would have to make do with decreased federal help.  The Kaiser Family Foundation estimates that within 10 years, 44 million people who would have been on Medicaid in would not have coverage – that includes children, pregnant women, seniors in long-term care, and the disabled.

The proposed changes in the Ryan budget would:

  • Decrease access to health care.  Seniors, disabled, children, and low-income Americans would lose the safety net that currently protects the health and security of millions.
  • Decrease quality and ineffectively control costs. Vouchers and block grants will not reduce the underlying drivers of health care cost growth. Lasting cost control will come from a transformation of the ways we deliver and pay for health care. It will not come from simply shifting the responsibility for paying to America’s seniors and most vulnerable.  Many new delivery system reform projects, such as the Accountable Care Organizations and Patient Centered Medical Homes, will work to encourage quality of care (reduced waste, greater coordination, and improved efficiency), rather than the high quantity of care that is driving up health care costs and doing little to improve patient health.
  • Put patients at increased financial risk. Vouchers for insurance premium support and block grants will control federal health spending over time, but they will do so by shifting financial risk and administrative burdens onto state and local providers, families, communities and vulnerable beneficiaries.

President Obama will veto this if it passes. I remain disappointed in our elected legislators who have an opportunity provided by the Affordable Care Act to force health care providers, big pharma, and to a certain extent patients into producing and consuming more cost effective care. If this effort were undertaken, it should lead directly to better health outcomes and less spending on health care—money that could be spent on other goods and services. Instead they are participating in a thought exercise regarding whether or not health care is a commodity that will respond to market forces.

The American public is of one voice. They do not want a change in benefits, and they want someone else to pay for those benefits. If that ends up with me in a defined contribution plan for health care during the most expensive 30 years of my life, I’m moving.

From Kaiser Family Foundation, information found here

The market has not worked to attract people to rural America to care for our rural citizens (a topic for another day). After doing some research for a talk, it turns out that health care professionals are actually responding appropriately to the market:

Rural residents seeking health care are (as a rule)

  • older than urban residents
  • in poorer health than urban residents
  • more likely to be disabled
  • more likely to be uninsured
  • more likely to face financial barriers in obtaining healthcare
  • more likely to incur travel burdens while seeking care
  • much less likely to receive services than are their urban counterparts if they suffer from serious mental illness. There are specific barriers to mental health access. These include
    • Service fragmentation
    • Lack of transportation
    • Lack of cultural and linguistic competency
    • Poor rates of Medicaid enrollment among people with mental illness
    • Stigma associated with mental illness
    • More poor immigrants

 The south offers more complex set of problems that make the market even less likely to be effective

  • Population is in decline and poverty is increasing in rural areas
  • Rural poverty tends to be persistent, historically complex, self-perpetuating, and psychologically and culturally oppressive
  • One third of the poor in the United States live in rural areas, and the rate of poverty in rural counties is increasing at a faster rate than it is in urban areas
  • Residents of rural counties in the south are more likely to be unemployed, less likely to be Medicaid eligible

All in all, President Obama’s vision, as articulated in his speech on Wednesday, said very well why we need to work to care for our fellow citizens despite there being no profit:

But there’s always been another thread running through our history – a belief that we’re all connected, and that there are some things we can only do together, as a nation.  We believe, in the words of our first Republican President, Abraham Lincoln, that through government, we should do together what we cannot do as well for ourselves. 

And specifically about healthcare:

We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff, may strike any one of us. “There but for the grace of God go I,” we say to ourselves, and so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, and those with disabilities.

The New England Journal of Medicine published a nice article on the constitutuionality of the Affordable Care Act. In it, there is a lot of information regarding the rhetoric versus the reality.

On the possibility of repeal

However, legislation that overturns the ACA has no chance of becoming law during the next 2 years; in the short term, congressional repeal is a symbolic cause, rather than a realistic possibility

On the politics of repeal

Pushing for repeal nonetheless allows Republican congressional leaders to assuage their conservative base. But it also represents a risky political strategy. Overturning the law would effectively deinsure 32 million Americans, deregulate the insurance industry, strip insured persons of coverage protections and enhanced benefits, and worsen the projected federal budget deficit – all while the number of people without insurance gallops upward, along with premium prices. A campaign to repeal health care reform could enable Democrats to paint Republicans as doing the bidding of the insurance industry.

Where things stand now

Moreover, parts of the ACA have already gone into effect. Repealing the entire bill would mean that some Americans would lose benefits – including insurance reforms that allow parents to keep children on their plans until the age of 26 and that prohibit insurers from imposing lifetime limits on coverage.

On the mandate

Most legal scholars believe that the mandate is constitutional, and another federal judge in Michigan agreed in a recent ruling.

Why the law seems unpopular

The dilemma for reformers is that too many Americans believe in controversial provisions of the law that don’t exist, such as the imaginary “death panels,” whereas not enough Americans are familiar with or identify as part of the law popular provisions that are real, such as enhanced Medicare coverage of preventive services and new consumer protections for Americans with private insurance.

Why it will likely succeed

Government health insurance programs, once they are in place, often prove enormously popular regardless of the controversy surrounding their enactment; Medicare is an important case in point. The ACA may yet overcome partisan polarization, its amorphous structure, and public skepticism and thereby follow a similar course. But for that to happen, the law’s key provisions must first be fully implemented.

So what is going to happen? As I told a group this past week, the real problem is trying to provide seamless coverage so that folks who develop an illness are not left dying in the street because everyone tries to dodge responsibility for paying for the care required.  Senators from Massachusetts and Oregon have proposed a revision to the Act that would allow states to opt out if they can demonstrate their plan offers equivalent coverage to that required by the  Affordable  Care Act. As a person living in a state that continued building schools intended for a single race for at least 15 years following “Brown vs the Board of Education of Topeka,” I would like to see how they will determine equivalency before I feel good about revision. Let’s move ahead.

As I was poking around the AHRQ website looking at funding opportunities I ran across a state specific health “dashboard” that highlighted some different findings. I’m used to seeing Alabama not fare well when compared to other states. This set of measures hit closer to home as they are looking at measures that are more specific to primary care. While we did very poorly on some measures (48th best in colon cancer deaths, 35th best in care for congestive heart failure), we also had a notable exceptional measure (7th in communication with providers for certain Medicare beneficiaries).

This is the healthcareometer from the site for Alabama. You can see that unfortunately we are doing measurably worse than we were at baseline. I hope our physician governor will challenge those of us involved in care delivery to shoot for “strong” or “very strong” when the next snapshot is taken.

Dale Quinney, Executive Director of the Alabama Rural Health Association, sent me the following assorted random facts that point to just how dire the needs are (or just how great the opportunities are) in rural Alabama.

51 of Alabama’s 55 rural counties are currently classified as having a shortage of primary care physicians.  Only Coffee, Dallas, Marion, and Pike counties are not currently considered shortage areas.  (This classification measures the provision of MINIMAL rather than OPTIMAL care.) 


To eliminate all shortage designations, Alabama needs an additional 128 primary care physicians.  402 additional primary care physicians are needed to provide optimal care. 


All 55 rural counties are currently classified as having a shortage of dental care providers.    To eliminate all shortage designations, Alabama needs an additional 288 dentists.  348 additional dentists are needed to provide optimal care.  Alabama’s only dental school currently admits only 55 students each year. 


All 55 rural counties are currently classified as having a shortage of mental health care providers.    To eliminate all shortage designations, Alabama needs an additional 44 psychiatrists.  185 additional psychiatrists are needed to provide optimal care. 


More than one half of all actively practicing primary care physicians in Alabama are aged 50 years or more. 


It is estimated that the number of annual office visits to primary care physicians in Alabama will increase by more than 1,785,000 by the year 2025 – primarily due to the aging of Alabama’s population.  Over 904,000 of these additional office visits will involve rural physicians.  This increase does not consider such adverse factors as obesity with nearly one third of all adult Alabamians currently being obese, not simply overweight. 


Only 20 of Alabama’s 55 rural counties have hospitals that perform obstetrics.  In 1980, 46 of these counties had hospitals performing obstetrics. 


More than one in every five (22.1 percent) rural Alabamians are eligible for Medicaid services.  This is nearly one half ((44.5 percent) for rural Alabama’s children. 


The per capita personal income for rural Alabama residents is $29,170 which is over 21 percent lower than the per capita income of $37,109 for urban residents and over 27 percent below the figure of $40,166 for the nation.  Five rural Alabama counties (Wilcox, Bullock, Barbour, Sumter, and Bibb) are among the 250 poorest counties in the nation. 


The motor vehicle accident death rate in Alabama’s rural counties is 25.1 deaths per 100,000 population.  This rate is only 14.6 for the nation.  30 rural counties have motor vehicle accident death rates that are more than double the national rate with eight having rates that are more than triple the national rate.  While there are a number of reasons for this disparity, the great variation in  emergency medical service among the counties must be recognized as a contributing factor. 


Nearly one in every ten (8.5 percent in 2000) rural Alabama households have no vehicle for transportation.  This percentage is in double digits for 22 rural counties.

Although I’ve alluded to the organizational structure known as the ACO here and posted a link to a really funny video about them here, I’ve never actually made the effort to fully describe the organizational structure or the implications for primary care and primary care training. This was because of fear that I might fall asleep writing about it. This changed after my discussion with Paul Grundy this past week which I spoke of here. Paul encouraged me to look into the structure because he is convinced that it is a mechanism to fund the Patient Centered Medical Home method of care delivery. I tend to believe him because he has been correct so far about “where the puck is going to be.” I will attempt to describe this in such a way that I will not sleep while writing and hopefully you won’t sleep while reading, either. 

Accountable Care Organizations were first described in Health Affairs by Elliot Fischer and others in 2007.  They described an established  pattern to healthcare delivery where physicians tend to use the same “referral networks” either because of formal relationships or informal arrangements. The relationships tended to involve groups of primary care physicians, specialists, and hospitals. These relationships resulted in care that could be characterized on a spectrum with some care being predictably very high quality, some very low quality, and the majority of care delivered in the middle. The question not answered by this research was “whether changes in incentive would result in improved care for all?”. The investigators clearly identified that a level of accountability, organization, and aligning incentives with desired outcomes tended to predict patients getting measurably better care. 

Fast forward to 2010. The Patient Accountability Act is passed and included in it is language that holds CMS responsible for implementing Accountable Care Organizations by January 2012. CMS has identified the following groups as being able to form an ACO:

Who can form an ACO

 A: The statute specifies the following:

1) Physicians and other professionals in group practices

2) Physicians and other professionals in networks of practices

3) Partnerships or joint venture arrangements between hospitals and physicians/professionals

4) Hospitals employing physicians/professionals

5) Other forms that the Secretary of Health and Human Services may determine appropriate.

The American Hospital Association published a summary of what an ACO is believed to be in May 2010. They identify the minimum that is in the law:

ACOs must have a formal legal structure to receive and distribute shared savings to participating providers.  

There must be enough primary care professionals to treat their beneficiary population (minimum of 5,000 beneficiaries) as deemed sufficient by CMS.

Each ACO must agree to at least three years of participation in the program.

Each ACO will have to develop sufficient information about their participating health care professionals to support beneficiary assignment and for the determination of payments for shared savings.     

ACOs will be expected to include a leadership and management structure that includes clinical and administrative systems.     

Each ACO will be expected to have defined processes to promote evidence-based medicine, report on quality and cost measures, and coordinate care.     

ACOs will also be required to produce reports demonstrating the adoption of patient-centered care.     

I must admit I was a little disappointed when I read this summary because it didn’t seem to me that this organizational structure would do anything to reduce the profound overutilization we have in this country and we were in for more of the same. I was more heartened when I read the Health Affairs policy brief published in August 2010. In this brief (worth a read in its entirety) the basic features are fleshed out in much greater detail:  The speculation is that ACOs will be able to qualify in one of three categories  based on willingness to accept risk. The reporting of outcomes will be mandatory but the acceptance of risk for bundled care (for example, treatment of congestive heart failure which involves a primary care doctor, cardiologist, and a hospital) will offer greater reward. 

Basic Features: The version of health reform legislation originally passed by the House would have given the Centers for Medicare and Medicaid Services (CMS) authority to pilot test a variety of different structural and payment approaches for ACOs. The Senate version that was enacted into law focused instead on one model that is now able to become a part of Medicare, not just a pilot program. The model embodies a few basic features proposed by some policy analysts:  

  • Invisible Enrollment. Patients who receive most of their care from ACO-affiliated providers would be treated as “assigned” to the ACO. At least at the outset, they would not be formally enrolled, would not be required to obtain services through the ACO, and might not even know the ACO existed. The assignment process would allow payers to define a population for which the ACO could be held accountable. Critics of this approach believe that patients should have a choice about participating in an arrangement that could reward providers for reducing services.
  • Performance Measurement. Over some period of time, payers would collect data on utilization and costs for the ACO population and on measures of quality of care and population health. A provider could be required to meet minimum quality standards in order to continue to participate in the ACO. In addition, quality reporting requirements would encourage improvements in ACO-wide information systems, a key factor in developing coordinated care.
  • Shared Savings. Spending for the population of patients in a particular ACO could be compared to targets based on past experience for the same patients, or to spending for similar patients in the community who were not assigned to the ACO. If the ACO was found to have saved money, it would receive some share of the savings. Just how the savings would be divided among the participating providers is a major question that each ACO will need to resolve on its own.
  • Evolution Toward Stronger Incentives. In the beginning, there would be no downside risk: The ACO would not share in the losses if treatment of its patients cost more than expected, though this could change over time.

Elliot Fisher (who conceived of the idea) has published another Health Affairs article (subscription required) entitled “A National Strategy to put Accountable Care into Practice.”  where he discusses the types of information that the ability to act will determine which the level risk the organization will be allowed to undertake. For Tier 1, for example, care providers will have to identify numbers of patients who have been screened for easily detectable and treatable cancers to allow prospective patients to compare groups. Tier 2 will be expected to maintain high levels of childhood immunizations, high levels of glucose control in diabetics, and high levels of blood pressure control. Tier 3 will need to control entire episodes of care such as hip replacements, diabetes care and this control will include the patient experience.

So the question comes up…isn’t this just another name for an HMO (which the American public rejected)? Fellow blogger Jason Safrin has put together a comparison. He points out that

However, there are three main differences between ACOs and HMOs.

  1. The “accountability” rests with the providers.  Providers or provider groups, rather than insurance companies, are evaluated on the quality and efficiency of care.
  2. Direct contracting with provider organizations without the reliance on a health plan intermediary.
  3. The ACOs allow for flexibility in the type of organization.  Some regions may prefer independent practice associations (IPAs) while others  may prefer a physician-hospital organization (PHO).

In short, it just might be worth a closer look if you and a couple of your closest primary care friends (need at least 2-3) have a robust electronic health record and are willing to take on chronic illnesses and figure out ways to deliver preventive services effectively. Good care should lead to more money. Stay tuned and good luck.

I was in a meeting yesterday and overheard this statement regarding the need to plan for changes in the care delivery system. It got me to thinking about how much we don’t know about the implementation. It turns out the once a law is passed, the devil is in the details and the Patient Protection and Affordability Act is no different.

I figured a good place to look is a textbook entitled “Government in America” and what they say is that

Once Congress, the president, or the Supreme Court makes a policy decision, it is most likely that bureaucrats must step in to implement those decisions. Since bureaucrats are typically less visible and are not elected to their positions, their actions and power are often subjects of considerable debate.

They also point out that

Much depends on whether bureaucracies are effectively controlled by the policymakers that citizens do elect-the president and Congress.

So how does the president exert control?

  • Appointing the right people to head the agency.
  • Issuing executive orders.
  • Tinkering with an agency’s budget.
  • Reorganizing an agency.

In the case of health care reform, here is what those agency heads are saying:

Quote from Anthony Rodgers, M.S.P.H., deputy administrator for the Center for Strategic Planning and Initiatives at CMS:
“The basic medical home model offers better coordination of care and patient care management,” said Rodgers. “But we quickly have to move to more advanced medical homes that have the ability to manage acute and chronic care across the continuum of care.”
Quote from  Mary Wakefield, R.N., Ph.D., administrator of the Health Resources and Services Administration:
Access to health care “is very much about access to health insurance coverage,” said Wakefield. However, she added, access to health care also depends on the availability of a team of highly qualified health care professionals.

She called for a primary care workforce that is “adequate in number, adequate in distribution and adequate in competencies in order to deliver on this (medical home) care model.”

“I want to be clear that President (Obama) going forward and everyone at HRSA understands the importance of addressing this deferred issue — that is a focus on primary care and a focus on building a platform of health care providers,” she said.”

My previous post has generated a bit of interest among folks smarter and more knowledgeable than I about the health care workforce. I refer you to the post for the full comments. I thought Bob Bowman’s comments were important (and long) enough to warrant a separate post which follows. The one thing I think everyone agrees on is that quality is as important as access and we need to find a delivery system that delivers both:

To understand this situation, one must understand that for near poor, poor, lower income, middle income, rural, underserved, less educated, CHC, lowest health literacy, elderly, oldest of the elderly, and all populations in most need of basic health access that are most complex in evaluation and treatment…(Ferrer, Mold, Rosenblatt, Bowman) Are most likely to see family practice physicians

And are seen in locations with the least health spending, resources, support staff, facilities A few years back the Hartford Currant, the oldest newspaper in the US, singled out doctors from certain medical schools as lower quality using questionable measures. Not surprisingly these were front line doctors serving the most challenging populations that other US docs were less likely to care for.Social determinants shape most outcomes for lower and middle income Americans – decisions by patients, access to care, response to treatment, etc. This is also why pay for performance is a bad idea.Osteopathic information and my own research helped me in this area. In the 1960s the AMA became alarmed about the osteopathic patient care influence much higher than osteopathic numbers. The reason was that over 70% were in family practice or general practice with the longest medical careers (over 35 yrs), the most active, the most volume, and the highest primary care retention (over 90%). This resulted in the most patients seen in the least time. With osteopathic down to 35% FPGP by the 1990s and 18% now, this impact has diminished and the truth is that this was a family practice impact all along

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