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The Opelika-Auburn News asked Representative Bentley some questions about the problems that will be facing Alabama during the next 4 years. Below is his answer for fixing the problem:

Alabama figures to be millions in the hole with upcoming Medicaid costs. What do you propose this state does to keep itself from what could be an economic disaster once stimulus funds expire?

To reduce fraud in Medicaid, which is a joint state-federal program, I will implement electronic medical records for patients. This will improve health care, reduce costs, and provide more data for the state to use in Medicaid fraud investigations. I will also bar any health care provider guilty of fraud from participating in the states Medicaid system.

As I have detailed in the past, it probably won’t be that easy. I hope that Dr Bentley talks to Commisioner Steckel should he be elected. In a recent interview published in Governing Magazine she did not mention Medicaid fraud as our biggest problem.

Steckel’s primary concern centers on the bill’s cost – and on states’ loss of discretion. States currently enjoy considerable leeway in determining who qualifies for Medicaid. While certain populations, such as the disabled and institutionalized, and low-income pregnant women with children, must be covered, states are free to set eligibility levels for low-income families at an extremely low threshold – and states in the south and west generally have. Maine, Minnesota and New Jersey have been more generous: They cover working parents who earn up to (or even slightly more than) 200 percent of the federal poverty level. A few have even gone further. Arizona, Massachusetts, New York and Vermont have received permission from the federal government to offer coverage to the poorest childless adults.

Health reform ends that discretion. Instead, all states will be required to expand eligibility to at least 100 percent of the federal poverty level for childless adults. The scope of this expansion is huge. According to the Kaiser Family Foundation, Medicaid funded services for 59 million people in 2008. Expanding access to adults earning up to 100 percent of the federal poverty level would add another 10 million to 14 million people to the program. That worries Steckel.

“We are already seeing about 5,000 new [Medicaid] recipients every month,” Steckel says, and while most of the new enrollees are low-cost children, “it’s still an added cost to the budget.” Worse, given the fact that it typically takes a year after job growth resumes for people to leave Medicaid, it’s a cost that shows no sign of diminishing anytime soon. Steckel estimates that the cost of Medicaid expansion could approach $400 million. In a state Medicaid budget of $1.2 billion, that’s a big figure.

Some states similar to Alabama are looking forward to the new health care environment and the opportunities it will bring. I would encourage Dr Bentley to look beyond partisan rhetoric and seek out real answers to improve the health of our citizens.  I hope he remembers learning primum non nocere in medical school.

Jonathan Cohn has a very nice piece in the New Republic about Blue Cross, the transition from community rating to risk rating, and the transition from not-for-profit to ginormous profits. I recommend reading it as it explains better than I can why we’re in this mess. In sum, this is a very skewed market. A market based overhaul, while possible, would require a rethinking of our national sense of “goodness” (would we really be willing to let people die on the streets for the sin of being sicker?).

The question for those of us in Alabama is why, when Alabama Blue Cross is a not-for-profit, are our costs not lower. It would seem that not paying attention to the stock prices would make it a kinder, gentler company. After reading this article, I feel I gained a little insight into our unique problems.

First, apparently it may be that competition from the other insurers might be bad. When BC/BS of Alabama was the only game in town, it could afford to offer community ratings because it was a sole source provider. With other insurance companies bidding on insurance for businesses, Blue Cross claims (and they are probably correct) that they must offer rates and packages competitive with these insurers otherwise the HR folks won’t choose BC/BS. This was explained to me by the medical director of a HMO I used to work with when I was pushing him to offer more comprehensive care. he said he could push quality for an entire presentation and then the CEO would point out that the competitors rates were $1.00 per employee lower and what was he going to do about that? Without a benefits floor, it’s all about price.

Secondly, BC/BS is competing with itself. Every year or so, it goes to the client and discusses the new cost of care based on what happened in the company last year. The companies, for the most part, pay for all of their own costs and BC/BS takes a cut off the top (called a third-party adminstration fee). Don’t think the CEOs aren’t aware of which employees have cost them health care dollars and aren’t asking what can be done to alter benefits and render health care less expensive. Again the answer may be “nothing” but my bet is that if BC/BS offers that answer, United Health gives a different answer that may be more than a little draconian.

Lastly, we (Americans and Alabamians) are already paying for the most expensive health care utilizers. Almost 50% of the health care dollar is funded through our taxes and much of that goes to Medicare and Medicaid. Everyone (well 96%) of folks over 65 are Medicare eligible and consume quit a bit of health care in their last 20 – 30 years. Medicaid in Alabama covers the vast majority of premature infants. The goal of all good companies is to reduce risk. The best way to reduce health care risk is to move people who will consume health care completely out of the risk pool. Again, done potentially through manipulating copays and other means.

It looks like some of the tools to reform this system may make it to the President’s desk for signature. If not, the current system is still far from market based despite what some people  claim.

Forgive me as I yell at the Press Register. Deroy Murdock’s syndicated column (you can find it with Google, I’m not going to help) either provides talking points to conservative talk radio or takes marching orders from conservative talk radio and is carried in the Mobile newspaper this morning. In it, he misrepresents  an analysis of the current health care legislation done by the Health and Human Services Chief Actuary. A misrepresentation that is, oddly enough, consistent with Republican Leadership and Talk Radio News. Following is the ACTUAL conclusion:

  • 33 million more people would have REAL health care access (not just access to Emergency Departments if dying)
  • Medicare and Medicaid would probably COST LESS
  • Total health expenditures would increase transiently as more people get coverage
  • Long term care would probably cost more than estimated
  • The effect of comparative effectiveness research is unknown.

It’s just a lot easier to defend a deeply held belief if you are able to avoid facts, I guess.

While at the Alabama Academy of Family Physicians meeting this weekend, the discussion turned (as it is in a lot of places) to health care reform, the climate in Alabama, and whether primary care can survive the next 10 years in Alabama. As I have chronicled the environment for Family Physicians in private practice is not very favorable and Medicaid in Alabama is inherently unstable. To give ourselves yet something else to worry about that we can’t control, the conversation around the table moved the suspicion that the major payors (Blur Cross and Medicaid) are attempting to transform the care delivery system by dropping the reimbursement so low that non-physician providers will be the only ones who can afford to provide primary care services.

This concern has been around at least since the HMO “revolution”. The New York Times ran an article detailing the demise of the primary care physician and the rise of non-physician primary care in 1997. On the service, it is an appealing concept. Advanced practice nurses take less time to train (5 years with undergrad counting) than physicians (7 years post-baccalaureate). To the untrained eye as well as to the partialist physician, what I do seems “so easy a caveman could do it” so why should we waste physician resources on primary care? Lastly, patient satisfaction is always higher for visits to advanced practice nurses when reported than it is to physicians.

 So why am I not unemployed? As my friend Bob Bowman has posted, Family Medicine Advanced Practice Nurses spend only 3.5 years in primary care before moving onto something else. They will constitute at best only 12% of the primary care workforce. Expansion of training to take advantage of the more rapid training cycle without fundamental change in the delivery system will result in more Advanced Practice Nurses but no more in primary care practices. It is true that Advanced Practice Nurses are likely to practice in rural areas when they go into primary care and this must be captured and expanded upon.

It is true that if 30,000,000 folks who do not currently have access are given access, there will be a signficant unmet need for primary care. As Lori Heim, the president of the American Academy of Family Physicians stated, our  common goal of improving access should dictate the relationship between physicians and Advanced Practice Nurses. I suspect there is enough business in the new model of healthcare for both groups.

I entered into a discussion regarding the potential impact of health care reform on the Medical School at the University of South Alabama. Being a Family Physician I find myself much less attuned to “saving someone’s life” as I become more attuned to “keeping them from getting that way in the first place”. A lot of medical education here in Mobile still takes place at the University of South Alabama Medical Center. I was surprised to learn that 1/3 of the admissions to this facility were almost certainly preventable. As I began pushing “advanced primary care” as a solution I was reminded that these are people who are poor, non-compliant, and really may not capable of participating in their health care to any greater extent than making their way to the hospital when in extremis.

I began a literature search to see whether a town such as Mobile, which has 18 different locations serving the poor and disenfranchised, could do any better than we are doing now. I know that North Carolina had shown a reduction in hospitalizations as well as costs by implementing this process over the state but that’s not the same as a years worth of diabetic admissions in an inner city hospital.

It turns out, folks have shown success in urban health centers. By working with this population, they “showed significant improvement on eight out of nine health status scales and showed statistically significant improvement for all nine diabetes clinical indicators evaluated through chart audits. One key finding was improvement in performance of quarterly HbA1c tests for each patient (control group 23% pre increased to 30% post and study group 0% pre increased to 46% post)”. Although outcomes are still sketchy, it is becoming clear that programs such as this reduce hospitalizations and other types of encounters with the care delivery system thus saving money.

What are the implications for medical student education? I would like to believe that if incented correctly the Community Health Centers could develop resources such as Community Mental Health Centers have done to outreach to patients who have barriers preventing them from obtaining care for their chronic diseases. Learners who need to learn about chronic illness will need to move out of the hospital setting and into the community health or private practice setting to do so. Won’t that be a change?

Neonatal mortalityOne of the things that I have been able to do as an academic “Family Doc” is to continue to participate in the deliver of babies. The word obstetrics is from the Latin obstare which means “to stand by”. That is what I did last night, stand by for a complicated laboring patient who ended up having a sunrise (5:30 am) delivery. By my calculations I have either delivered or supervised the delivery by Family Medicine residents of over 1000 babies. I am struck by how deliveries at “teaching hospitals” have changed since I was a student at Charity Hospital in New Orleans. Medicaid required states to pay for prenatal care beginning in the mid 1990’s. Given a “public option”, many people are happy to use SOBRA Medicaid to pay for their pregnancy care (although in fairness, they don’t have any out-of-pocket expense) and many companies are content to have at least some of their maternity care covered via”the public option” when their employees can’t afford the high deductible insurance.

The stigma attached to being on “public assistance” for maternity care is gone. Many hospitals in Mobile are more than happy to take maternity Medicaid. We have had to compete for these patients and so we deliver babies at a very a nice facility (USA Children’s and Women’s Hospital) with birthing rooms, televisions, and lots of stuff that looks nice and makes patients want to come back. This is in contrast to my memories of Charity, with its open bay wards, communal laboring patients, and lack of involvement (in my memory) of the teaching faculty in the daily management of the patients.

Neonatal mortality has been reduced in the United States from 4/100 births in 1940 to 0.6/100 today. This correlates with the inclusion of maternity care in insurance policies and the growth of Medicaid as a viable payor for maternity care providers. Unfortunately, even for pregnancy care, access is not universal.  There are still great disparities in outcomes that are associated with the race of the mother in this country, almost certainly due to differences in access to healthcare. Mortality and morbidity correlates with state of origin. In Alabama  the current rate is 1.1/100 births, probably reflective of access and underlying conditions. 

Although changes in infant mortality can be attributed to other things as well as access to the health care system, it is clear that improvements in maternity care correlate with the reduction of the use of cash for childbirth and the development of this  public/private partnership, however dysfunctional it may be. When I was in medical school in 1985, prenatal care and a comfortable well attended delivery were clearly luxuries.I have attended this healthcare system during the transformation.  What we need to be discussing is which components of the care work and how to deliver them more efficiently. Instead, we have Senator Kyl who wishes not to pay for anyone else’s childbirth, no matter what.   Why are we as a country even having this discussion?

Tomorrow, we’ll see what happens with what could be a disaster of epic proportions. Alabama Medicaid, whose travails regarding inadequate funding have been well documented, may go completely broke at midnight tonight. At odds are the Governor who is unable to generate an acceptable revenue stream in the general funds to cover a required match for Medicaid dollars (the feds contribute $3 for every $1 we put up), and both the Bush administration and the Obama administration who are unwilling to accept the state’s definition of “match” as being an actual match. As chronicled by the Birmingham news earlier this year, the hospitals actually put a bit of money ($800 million) to try to head off the disaster but the governor and the feds (both Democrat and Republican) don’t see eye to eye on whether the funding source is actual or is a little bit too evanescent (i.e. will exist only to draw down federal dollars).

In 2004 the seeds of the crisis were planted when the state was unwilling to consider a switch from intragovernmental transfers (no real dollars placed, one time resources used) to another method of matching funds that CMS found more acceptable. It was the hospitals, through the Alabama Hospital Association, that put together what they thought was a formula to get around the problems identified by CMS in Alabama’s previous scheme.  

Although unable to give particulars, Commissioner Steckel’s impression of the problem, as presented to the legislature, is as follows: 

“Simply put, the federal government has changed the rules on how hospitals calculate costs, particularly in how they define uncompensated care.”

In her budget presentation this year, Commissioner Steckel pointed out what Medicaid does in Alabama

  • 20%, or nearly 1 million Alabama citizens are eligible for some type of Medicaid coverage
  • Nearly half of all births, or approximately 30,000 births each year, are paid for by Medicaid.
  • 38% of Alabama’s children depend on Medicaid for healthcare coverage.
  • 12.8% of Alabama’s elderly residents are Medicaid eligible.
  • 71% of the nursing home residents in participating facilities are Medicaid eligible.
  • More than 14,000 elderly and disabled individuals participate in one of six home and community-based waivers;
  • Medicaid pays for over 7 million prescriptions a year.

Governor Riley went back up to D. C. earlier this week  to try to rectify the situation. I guess we find out tomorrow whether that misunderstanding was settled and these services can continue or not.