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Six steps to address worst insurance problems

 

Timothy Jost, writing for the Commonwealth Fund, proposes six steps that he says that Congress should take immediately to address the most pressing health-insurance problems, before trying to make  broader, systemic changes in America’s fragmented healthcare “system”.

They are:

“First, it must focus on the individual market, where we face an immediate crisis.”

“Second, we need solutions that can be implemented immediately through existing programs.”

“{T}hird, we may need to accept short-term increases in federal spending to get us through the immediate difficulties, as we have when our country has faced other crises. … But in the short term, simply shifting the burdens to individuals who will lose insurance coverage or face much higher deductibles and premiums is not acceptable.”

“Fourth, Congress should reinstitute the ACA’s risk corridor program for 2018 and 2019 for any county with fewer than two insurers.”

“Fifth, Congress should leave the individual mandate in place until it can devise a credible replacement. ”

“Sixth, Congress should rework the premium tax credit formula for 2018 through 2020 to allow younger enrollees to claim more generous tax credits.”

To read Mr. Jost’s essay,  please hit this link.


America’s lousy healthcare, continued

 

The Commonwealth Fund reports:

“An 11-country survey {by the Commonwealth Fund} finds that adults in the United States are far more likely than those in other countries to go without needed care because of costs and to struggle to afford basic necessities such as housing and healthy food. U.S. adults are also more likely to report having poor health and emotional distress. Bright spots for the U.S. include rates of timely access to specialist care, discussion with a physician about ways to lead a healthy life, and coordinated hospital discharge planning.”

All in all, it’s another sign of how bad the U.S.  healthcare system is compared most of the rest of the Developed World. It is also by far the most expensive.

To read the report, please hit this link.


Predicting which patients will be users of expensive care

 

A Commonwealth Fund report looks at identifying patients who are more likely to be users of expensive care and more likely to develop a new chronic disease. Some of the findings:

  • “At baseline, poorer patient self-management—as identified by lower patient activation scores—was associated with a higher prevalence of chronic conditions, including depression and high blood pressure, as well as more ED visits and hospital admissions related to these chronic conditions.
  • “After controlling for baseline chronic conditions and demographic characteristics, patients at the lowest activation level at baseline were 25 percent more likely to develop a new chronic disease in the next calendar year compared to patients at the highest activation level. The same analysis two years after baseline showed a 31 percent difference between the lowest and highest activation groups. Three years after baseline, the difference was 21 percent.”
  • “Patients with the lowest activation score at baseline had a 62 percent greater likelihood of having an avoidable hospitalization compared to the most activated group one year later (again, after controlling for baseline demographics and chronic conditions). Two years later, the difference between the least and most activated groups was 40 percent, while three years later the difference was still 30 percent.”The researchers conclude:

    “A patient’s activation level, or ability to self-manage health and health care, is linked to risk of developing a chronic disease and using expensive and avoidable health care services in the future. By stratifying populations by activation level, healthcare delivery systems might better identify and support patients with limited self-management skills, helping to improve outcomes and prevent unnecessary costs.”

    To read the report, please hit this link.


Videos: New ways to pay for and deliver care

 

Videos: Here are the first three animated videos of the Commonwealth Fund’s new series illustrating new approaches to paying for and delivering healthcare.

They look at how these reforms could make life better for patients, clinicians hospitals and other healthcare organizations.


Health centers struggle to treat many new patients

By SARAH VARNEY, for Kaiser Health News

See this link for the accompanying PBS video.

SAN DIEGO

The Affordable Care Act unleashed a building boom of community health centers across the country. At a cost of $11 billion, more than 950 health centers have opened and thousands have expanded or modernized.

In San Diego, new clinics have popped up on school campuses and busy street corners. Cramped storefront clinics have been replaced with gleaming, three-story medical centers with family medicine, radiology and physical therapy on site. They are outfitted to care for new immigrants in dozens of languages from Spanish to Somali.

The community health centers are the country’s largest primary-care system for low-income patients, now working to absorb a tsunami of new Medicaid enrollees.

At age 58, after several worrisome decades without health insurance, Lori Simpson is finally getting treatment for her dangerously high blood pressure, a serious thyroid disorder and, after years of double vision that had made it difficult for her to work and care for her grandchildren, surgery for her eyes.
“I have nine medications that I get every month, and mine comes to a little over two hundred dollars,” Simpson said. Prescription medications for her husband, a diabetic, cost $400 a month. “We don’t pay anything, it’s all covered. It’s just amazing.”

Simpson goes to the Family Health Centers of San Diego, which saw an increase of 24,000 patients, almost overnight, after the Medicaid expansion began in January 2014. Dr. Chris Gordon, the center’s assistant medical director, said it was a rush that primary-care clinics have been waiting for ever since President  Obama signed the health law in 2010.

“We’ve anticipated this for years and have been planning for it,” Gordon said. “We have capacity to take on patients. These are patients that haven’t had access before because they just didn’t have the financial means to get in. And now all of a sudden, they actually get to come in, get to spend time with somebody and get to feel like they’re heard.”

Still, problems have plagued the roll out. Three million more people than expected have signed up for Medicaid in California. Other states have also witnessed surges far beyond initial projections, including Kentucky, Michigan, Oregon and Washington State.

As successful as California has been at enrolling millions in Medicaid and in building new primary-care clinics, patient advocates said the Medicaid expansion has exacerbated long-standing shortages in specialty care. Community clinic directors say that it’s often difficult to find cardiologists, orthopedists and other specialists to see their patients and that low-income Californians still face formidable hurdles when they need medical treatment.

For Alessandro Gonzales Gomez, the search for specialty care has been burdensome. Gomez spent years working as a car salesman and auto-parts delivery driver. But now, at age 60 and living alone, he shuffles around his home in an Escondido trailer park, hampered by spells of dizziness that disrupt his daily prayers and curtail his driving.

Gomez is insured under Medicaid, but most of the specialists he needs to see are an hour away. During the drive to a recent doctor’s visit, Gomez said he became dizzy and turned his car around. He went back to the primary-care clinic that had referred him and told them, “’I can’t do this, it’s too far,’” Gomez said. He asked the clinic director about doctors who might be closer, “And she told me that that’s the way it worked out, that there were only certain doctors that would contract with them.”

One of the doctors Gomez has managed to reach is Dr. Ted Mazer, one of the few ear, nose and throat surgeons in San Diego County who accepts Medicaid patients. Mazer said the state does not pay specialists enough to cover their costs.

“If we’re doing some certain surgeries, I can be out of the office for two hours, and we might get $300. My overhead is more than that, so that’s a loss,” Mazer said.

Mazer sees only a limited number of Medicaid patients, but he often agrees to treat those like Qadir Khoshnaw, a 19-year-old in need of a complicated nose surgery. But Mazer said the state is failing to provide this level of care for all Medicaid patients.

“If it was working, I would not have patients coming here from Oceanside and Fall Brook and from the Mexican border and the Imperial County area and the Riverside border,” Mazer said. “I’m one office. Why am I seeing all of those people? Because nobody else is available in their communities to see them. Why not? Because the rates are unacceptable, the hassles from the managed-care plans, as well as the state are unacceptable to most offices to deal with.”

The complaints extend beyond San Diego.

A withering audit by the state of California released this summer found that regulators could not verify if health plans had enough doctors in their Medicaid networks or if the distances patients had to drive were unreasonable. The audit also found that the state’s call centers were overwhelmed, with phone representatives answering just half of incoming calls.

And too often, those obstacles have forced patients to seek help in expensive hospital emergency rooms. In a recent national survey, three out of four emergency room physicians said patient volume had increased, a pressing concern the Medicaid expansion was meant to address.

Emergency room visits at University of California at San Diego Health Systems have increased 11 percent since the Medicaid expansion, says Dr. Christian Tomaszewski, the hospital’s emergency room medical director. “A lot of these patients are coming here looking for sub-specialty care,” he said. “They need an orthopedist for a complicated fracture. They might need a head and neck doctor for some complicated throat problem. And they’re using the emergency department as a gateway to have access to that kind of care.”

At nearby Scripps Mercy Hospital, visits by new Medicaid patients are up 30 percent due to the health law. “It’s a great thing they have insurance,” said Dr. David Cracroft, the hospital’s medical director. “They come for care, but the overall goal was to get them into a primary-care doctor’s office or get them the specialty care that they need, and oftentimes that’s difficult for them to achieve.”

California’s Medicaid program is a budgetary behemoth that falls to Jennifer Kent to manage. As director of the Department of Health Care Services, Kent acknowledged the growing pains as the state stretches to provide health care for nearly one in three Californians.

“We are struggling just as every other state is in terms of how do we bring people into California, how do we grow primary care providers, and then more importantly, how do we provide specialists in areas where there may not be specialists today,” Kent said.

Still, her department is closely measuring complaints and unnecessary hospital stays. Further, undercover agents investigate provider networks and call out deficiencies in the private health plans the state pays to provide care. But Kent says problems with physician access are isolated and are being addressed.

Gov. Jerry Brown, a Democrat, has championed the Medicaid expansion, but like other governors, he has been leery of paying physicians more money just as the state confronts a drop in federal aid. The federal government covers the entire cost of the Medicaid expansion until 2017, but that support scales down gradually, reaching 90 percent in 2020.

Instead, Brown’s administration has pushed the state to spend its money revamping a medical delivery system accustomed to serving poor children, the elderly and disabled to better serve low-income working adults. Across the country, adults on Medicaid are sicker than those with private insurance, and poverty often upends their lives: they change addresses often and can be difficult to reach.

“We have a working population that really has challenges in terms of accessing care in a more traditional sense,” Kent said. “We’re having to work with the providers to say you’re going to have to stretch, in terms of the hours that you offer, using alternative locations and working with nurse practitioners and physician assistants.”
Despite the challenges, there is evidence progress is being made. A recent survey by the Commonwealth Fund found that in states that expanded Medicaid, 93 percent of those who signed up in the past two years are satisfied with their coverage.

For Alessandro Gonzales Gomez, he says he’ll continue to the long drives across the county to see the doctors he needs because his Medicaid card has opened up doors, even if those doors are often difficult to reach.

This story was created in collaboration with PBS Newshour. Jason Kane contributed to this report.


Diabetes treatment needs ‘disruptive innovation’

diabetes

The universal symbol for diabetes.

This piece from the Commonwealth Fund identifies the financial, institutional and regulatory-policy barriers that have hindered the diffusion of diabetes-care innovations  and other successful healthcare innovations through accountable-care reforms.

The authors conclude that “disruptive innovation” in diabetes care is essential in the fight against this costly global disease.


Webinar on value-based physician compensation

 

The Commonwealth Fund announces a seminar that will discuss “early lessons from 16 initiatives in which physician compensation was tied to factors other than productivity, including clinical quality, patient satisfaction, and access to care.

It’s titled “A Webinar on Value-Based Physician Compensation in an Age of Payment Reform.”

On the panel:

  • Moderator: Mark Zezza, assistant vice president, The Commonwealth Fund.
  • Mary Beth Dyer, senior consultant, Bailit Health Purchasing.
  • Alexa Boer Kimball, M.D., medical director, Massachusetts General Physicians Organization.
  • Bill Gil, president and chief executive officer, Facey Medical Foundation, in California.

Focus on current, not future, Medicare costs

 

The Commonwealth Fund says that Medicare  has undergone changes that make long-term financial forecasts difficult to make and trust when making policy decisions. Rather, it says, the focus should be on containing the program’s current costs.

It says:

“Although the aging U.S. population and rising healthcare costs are expected to increase the share of gross domestic product devoted to Medicare, changes made in the program over the past decade have helped stabilize Medicare’s financial outlook—even as benefits have been expanded. Long-term forecasting uncertainty should make policymakers and beneficiaries wary of dramatic changes to the program in the near term that are intended to alter its long-term forecast: the range of error associated with cost forecasts rises as the forecast window lengthens. Instead, policymakers should focus on the immediate policy window, taking steps to reduce the current burden of Medicare costs by containing spending today.”


Many physicians’ astonishing ACA ignorance

 

A new survey indicates that five years after Congress passed the Affordable Care Act (ACA), almost half of primary-care physicians don’t know about the pay raises that the  law gave  them.

Yes, many physicians are very, very busy, but the ignorance of the law that affects them so much is, well, amazing.

That survey, conducted this year by the Kaiser Family Foundation (KFF) and the Commonwealth Fund,  reported that 48 percent of primary-care physicians didn’t know enough about the ACA to understand how it was affecting their practices.

One ACA provision raised  Medicare rates for office visits and preventive care by 10 percent from 2011 through the end of 2015. Yet 49 percent of physicians surveyed didn’t know this!

The law also increased Medicaid rates for office visits and vaccine administration to Medicare levels in 2013 and 2014 for primary-care physicians.

The survey found that 47 percent of primary care physicians didn’t know about the  Medicaid payment bump.  This is an important oversight:  Of those who did know about the  bonus, 22 percent said it moved them to see more Medicaid patients.

Clearly, the government and professional organizations need to do a lot more educating of physicians about the Affordable Care Act.

 

 

 

 

 


Transformation of Medicaid managed care

 

Sara Rosenbaum writes in the blog of the Commonwealth Fund:

“The updated proposed Medicaid managed care federal regulation published by the Centers for Medicare and Medicaid Services on June 1 is a formal recognition of managed care’s central role in national Medicaid policy and in the lives of beneficiaries, including families with children, people with disabilities or serious health conditions, and Medicare beneficiaries who also receive Medicaid (known as dual enrollees). Indeed, the proposal represents a regulatory milestone in the life of Medicaid, an acknowledgement of the program’s evolution over the past 25 years, and an exemplar of the reforms and tradeoffs that will determine Medicaid’s transformation from a welfare program into a pillar of national health reform and a major player in the health plan market.”

The new proposed rule, she says,  “aims to foster the growth of companies that offer health plans in both Medicaid and the Affordable Care Act’s health insurance marketplaces to allow consumers to remain with an insurer even when their source of subsidy changes. Second, it aims to promote health plan innovation and improve accountability and beneficiary protections, especially as higher-need populations are moved into managed care. Finally, the rule will help ensure more rigorous federal and state oversight of a burgeoning industry.”

The proposed rule would, Ms Rosenbaum reports:

  • “Extend most of the tougher standards that apply now only to comprehensive managed care organizations to limited-service plans that previously have been subject to less rigorous requirements in areas such as network, access, and quality performance standards.
  • “Tighten current actuarial soundness requirements for states to ensure  payments to their health plans accurately reflect both what is covered under their contracts and the cost of furnishing those covered benefits to specific Medicaid beneficiary groups.
  • “Use an 85 percent medical loss ratio, which would require that insurers doing business with Medicaid programs spend 85 percent of premium revenue on medical care and quality improvement, as a means of measuring whether states and consumers are receiving good value for premiums paid.
  • “Require states to set time and travel standards  to measure the adequacy of provider networks, with a focus on primary healthcare, obstetrical care, pharmacy services, and children’s oral healthcare.
  • “Strengthen beneficiary grievance and appeals protections while simultaneously requiring plan members to exhaust their health plan appeals procedures prior to external review, as people enrolled in qualified health plans sold in the marketplace must do.
  • “Permit states to cover short-term inpatient treatment for mental illness and addiction disorders, thereby setting aside Medicaid’s traditional exclusion of federal funding for such treatments in the case of adults ages 21 to 64.
  • “Actively encourage insurance companies selling both Medicaid and marketplace health plans to advertise this fact, thereby exempting this activity from a longstanding ban on tie-in practices.
  • “Permit plans to offer additional benefits that are permissible under federal Medicaid law but not otherwise included in a state’s Medicaid plan.”

 


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