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Anti-ACA Texas wants Feds to renew $6.2 billion a year Medicaid deal

The Texas State Capitol.


For Kaiser Health News

Texas rejected billions in federal aid to expand Medicaid under the Affordable Care Act, calling the program “broken.”  The leading Texas politicians opposed the ACA. But now it’s asking the Trump administration to renew a deal that’s brought the state an additional $6.2 billion a year under Medicaid to help care for the poor.

Half the money is used to help hospitals finance care for the uninsured, and the rest goes to hospitals and other providers to test regional programs to improve care and access, such as opening school-based health clinics to steer people away from expensive emergency room visits.

State officials are hoping to win a 21-month extension of an agreement that began in 2011 and will expire in December.

The Trump administration signed off on a similar pact with Florida in April, increasing extra Medicaid funds to that state from $600 million a year to $1.5 billion annually. In December, the Obama administration extended a pact with Tennessee to 2021. It is worth at least $500 million a year to the state.

Several states receive such funds but Texas’s allocation is the highest. To put Texas’ request in perspective, $6.2 billion represents more than a third of what the federal government now contributes to the state’s Medicaid program annually. Texas kicks in the balance to pay for its $29 billion Medicaid program, which covers nearly 4.8 million people.

Hospitals are counting on the cash to absorb the costs of uncompensated care, which they say has escalated even as the state’s uninsured rate fell from 20 percent in 2013 to 16 percent in 2015, according to the Kaiser Family Foundation’s estimates. (Kaiser Health News is an editorially independent program of the foundation.)

Without the money, programs and services to the poor will have to be cut, including many new clinics opened to expand access, hospitals say.

“Absent the dollars from the waiver, we would have to start to close the clinics and cut back on the manpower,” said George Masi, CEO of Harris Health System, a large public health system based in Houston.

The uninsured rate has fallen in Houston, but surrounding Harris County still has more than 1 million people without insurance.

Population-health programs vs. hospitals


Eric Hunter, CEO of safety-net health plan CareOregon, said that if its population-health efforts were as successful as he’d like, hospitals would significantly cut back on their services.

“I tell hospitals, and they hate when I tell them this, ‘In my perfect world, I would never need you,’” Mr. Hunter told panelists at a Politico event. “My goal is to put you out of business. If we can do the right thing, all you’ll have is an ER for when somebody gets in a car wreck.”

But many  providers won’t have  access to strong community health programs such as CareOregon’s.

Karen DeSalvo, M.D., former national coordinator for health information technology at the the Department of Health and Human Services, pressed for culture changes that include breaking down data silos that block providers from seeing the full picture of a patient’s, or a  community’s, health.

Dr. DeSalvo said: “It means that we really have to rethink how we look at health.”

To see the Politico event, please hit this link.


The Triple Aim in Canada and U.S.


In this second part of a three-part Med Page Today series comparing the U.S. and Canadian health systems, Michael Smith looks at the comparison in terms of the Triple Aim.

To read the piece, please hit this link.



Lessons for hospitals from the Uber mess

Paul Keckley, Ph.D., the healthcare analyst, writes in Hospitals & Health Networks about  lessons to be drawn from Uber’s public-relations nightmare. Among them:

“Social media exposes an organization’s culture. Despite anti-disparagement warnings in separation agreements intended to mute shop secrets from former employees, the proliferation of information sharing via social media and in sophisticated competitor intelligence gathering done by top-tier organizations makes keeping workplace secrets virtually impossible. And it’s especially important to manage relationships with employees who leave or are dismissed from an organization: Their impact on the organization’s performance and reputation is profound.’’

‘’Hospitals are tough places in which to work. Highly talented and opinionated professionals work in settings where margins are shrinking and media attention is intense. Hospital boards must pay close attention to how CEOs behave; who they promote, keep or run off; and how our workplaces are affected.’’

“Boards must broaden their CEO evaluation processes beyond usually perfunctory annual reviews tied to their compensation. They must gather objective data about the workplace culture from employee surveys and direct interaction with the human resources team. They must identify areas for improvement in hiring, performance measurement and cultural healthiness, directing these suggestions to CEOs and key senior managers. They must be vigilant about how their CEOs behave and be willing to make changes when they are known to bully or condescend in interactions with peers and subordinates.’’

To read more, please hit this link.

So near and yet so far

Med Page Today is publishing a series on how and why Canadian and U.S. health systems developed so differently.  Michael Smith, the writer of the series, summarizes the Canadian system:

  • “It’s universal — All citizens and legal residents are covered for hospital care or physician treatment
  • “It’s free — in the sense that there is no direct cost to patients at the point of care (but the money comes from tax revenue)
  • “It’s portable — Patients from Ontario, for instance, can get still get care if they fall ill elsewhere in the country
  • “It’s administratively simple — Doctors deal with a single payer on an established fee schedule
  • “In general, prescription drugs are not covered outside of the hospital setting and neither is dental care, so many Canadians turn to private or employer-provided insurance to cover those gaps or pay themselves. Most provinces and territories do provide drug coverage for some groups, with variations across the country.’’

Hit this link to read the first article.

In Boston, thumbs down for EMRs


Some leading Boston physicians decry the EMR empire. To read more, please  hit this link.

FTC acts to stop Sanford’s takeover of N.D. physician group


The Federal Trade Commission, worried about less competition and resulting higher consumer prices, has acted to stop a large rural nonprofit healthcare system from acquiring a big North Dakota physician group.

The agency and the state attorney general have filed a complaint  in federal district court seeking a temporary restraining order and preliminary injunction to stop the deal between Sanford Health and Mid Dakota Clinic pending an administrative trial,   scheduled to begin on Nov. 28.

The takeover would create a physician group with at least 75 percent share of primary care and several other healthcare services in its market.

The FTC said the deal would violate antitrust law by significantly  cutting competition for adult primary-care physician services, pediatric services, obstetrics and gynecology services, and general surgery physician services in the greater Bismarck and Mandan metropolitan area.

Sanford Health is the largest, rural, not-for-profit healthcare system in the country, with among other facilities,  45 hospitals and 289 clinics in nine states and three countries. Mid-Dakota has over 90 clinicians.

The FTC asserts that the deal that it would be the only physician group offering general surgery physician services in the affected area.

“This merger is likely to reduce significantly the competitive options available to medical insurance providers, which in turn will lead to deteriorating terms for provision of medical care, including higher prices and lower quality,” said Tad Lipsky, acting director of the FTC’s Bureau of Competition.

Sanford Health and Mid Dakota Clinic currently compete to join commercial insurers’ provider networks, which Lipsky said spurs the organizations to improve their technology, expand services, recruit high-quality physicians and provide patients with convenient and accessible physician and surgical services. “The transaction would eliminate that competitive pressure,” he said.

But the two healthcare organizations told The Bismarck Tribune that the FTC’s actions are “extremely frustrating” because they relied on national, legal and economic experts to evaluate the partnership.

“The best way to describe our reaction is that we are exasperated with the delay that the FTC’s inquiry has already caused and that these proceedings will continue to cause,” Shelly Seifert, M.D., board chair of the Mid Dakota Clinic, told  the newspaper.

To read more, please hit this link and this one.

Providers denounce Senate GOP leaders’ healthcare bill


Leaders of the hospital sector and other major healthcare groups have denounced the Senate Republican leadership’s  Affordable Care Act repeal bill as  little or no improvement over the House bill, which  providers have criticized as imperiling the health of millions of patients.

Rick Pollack, president and CEO of the American Hospital Association, said of the”Better Care Reconciliation Act of 2017”:

“Unfortunately, the draft bill under discussion in the Senate moves in the opposite direction {from protecting coverage}, particularly for our most vulnerable patients. We urge the Senate to go back to the drawing board and develop legislation that continues to provide coverage to all Americans who currently have it.”

Bruce Siegel, M.D., president and CEO of America’s Essential Hospitals, said: “For the hospitals that protect millions of Americans and their communities—our essential hospitals—this bill might even accelerate decisions by some to reduce services or close their doors.”

“The Senate healthcare bill released today is just as bad as the version passed by the House of Representatives last month and is a threat to the health of America,” said George Benjamin, M.D., executive director of the American Public Health Association. He asserted that  Senate Republicans had committed “legislative malpractice.”

David O. Barbe, M.D., president of the American Medical Association, chimed in with:

“The AMA is reviewing the Senate health system reform legislation, guided by our key objectives that people who are currently insured should not lose their coverage and that Medicaid, CHIP and other safety-net programs should be adequately funded. The AMA strongly opposes Medicaid spending caps, and we have grave concern with a formula that will not cover needed care for vulnerable patients.”

And  Bernard J. Tyson, chairman and CEO of Kaiser Permanente, said:  “First, we need to cover more people, not fewer people.” He suggested   a three-part test to determine what healthcare progress ought to look like: Does it achieve wider  access, affordability and better outcomes?

Centers for Medicare & Medicaid Administrator Seema Verma, a Trump appointee, not surprisingly, praised the bill.

“I appreciate the work of the Senate as they continue to make progress fixing the crisis in healthcare that has resulted from Obamacare. Skyrocketing premiums, rising costs and fewer choices have caused too many Americans to drop their insurance coverage. Today, Obamacare is in a death spiral and millions of Americans are being negatively impacted as a result. They are trapped by mandates that force them to purchase insurance they don’t want and can’t afford.” {The term “Obamacare” is usually used by Republicans as a derogatory term for the Affordable Care Act, the law’s official name.}

“The Senate proposal is built on putting patients first and in charge of their healthcare decisions, bringing down the cost of coverage and expanding choices. Congress must act now to achieve the president’s goal to make sure all Americans have access to quality, affordable coverage.”


Physicians on the ACA



Hit this link to read what a bunch of physicians think of the Affordable Care Act as the Republican majority on Capitol Hill  tries to kill it.

Bundled payments: Retrospective vs. prospective


Roman representation of  their god Janus, who looks forward and back.

François de Brantes and Suzanne Delbanco discuss in Health Affairs whether the debate over retrospective vs. prospective bundled payments is an unneeded distraction.  Among their observations:

“Some believe that the holy grail of bundled payments is prospective bundles—setting a price for a course of care that has not yet occurred and paying only that amount at the start of the episode of care. The thinking behind prospective payment is that the incentives for cost containment will be stronger because providers will be loath to overspend when they know there’s no chance of additional payment. They also sound administratively simpler for the payer—just cut one check, and don’t worry about figuring out who did what. …

“However, prospective bundled payments can be difficult to implement because they require deciding which provider receives the funds and can be trusted to distribute them properly among all providers involved in an episode. Legal and turf issues can stymie the effort.

“The difference between retrospective and prospective payments is not significant enough to delay implementation of bundled payment in the hopes of perfecting prospective bundling. Payers shouldn’t go into a retrospective bundled payment arrangement without having agreed upon a budget for a procedure or other episode of care in advance, even though they may settle debts and credits on the back end. In addition, providers, like most people, have an aversion to loss, and if the payment arrangement includes downside risk, they will work hard to avoid any losses. This means that waiting for the means to implement prospective bundles on a broad scale is not sufficient cause for delaying the use of bundled payment.”

To read the Health Affairs piece, please hit this link.

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