The insurance industry lobby blocked creation of the public option, though of course for poor people and the elderly there are still the “public options’ of Medicaid and Medicare.
The co-ops were meant to lower insurance prices by challenging the industry giants’ dominance.
“I don’t want to sound like an apologist for the co-ops. I was never a fan,” said the No. 2 Democrat on the House Ways and Means Health Subcommittee, Mike Thompson of California, at a congressional hearing last week. “What most of us wanted was the public option. That would have provided the competition needed.”
The greatly shrunken co-op program remains a target for GOP, even as it gets unenthusiastic help from Democrats. Their final fate may have to await the results of next year’s elections.
Two conservative activists argue in The Wall Street Journal that Medicaid expansion has been shown to be a bad deal for states that have implemented it. They say that new enrollees and their costs have exceeded estimates and threaten to overwhelm states’ budgets.
Cancer patients insured by California’s health plan for low-income people are less likely to get recommended treatment and also have lower survival rates than patients with other types of insurance, according to a new study by University of California-Davis researchers.
While other studies have linked Medicaid insurance status to worse cancer outcomes, the UC-Davis study appears to be the first to examine the impact of various kinds of health insurance across more than one kind of cancer.
Understanding how well Medicaid (called Medi-Cal in California) serves cancer patients is crucial, experts say, because as much as 10 percent of California’s Medicaid expenditures go to cancer care. And Medi-Cal has grown to cover more than 12 million Californians – nearly a third of the state’s population.
“What’s striking is how similar the findings were for Medi-Cal members and the uninsured,” said Kenneth Kizer, M.D., director of the University of California at Davis’s Institute for Population Health Improvement, which conducted the study. “If we weren’t spending billions of Medi-Cal dollars on cancer care perhaps that would not be surprising, but you’d think that the outcomes might be better when you’re spending that much money.”
The UC Davis researchers used California Cancer Registry data to study the experiences of about 700,000 Californians diagnosed with breast, colon, rectal, lung and prostate cancer between 2004 and 2012. They tracked how early these patients were diagnosed, their quality of treatment and their five-year relative survival rates according to their type of insurance. The types were Medi-Cal, Medicare, dual Medi-Cal/Medicare (for lowest-income seniors), private insurance, Department of Defense (DOD) insurance and Department of Veterans Affairs (VA) insurance.
Among the findings:
* Medi-Cal patients were diagnosed with advanced (stage IV) prostate cancer more than three times as often as patients with private insurance or DOD coverage.
* Medi-Cal patients with breast, colon or rectal cancer were more likely to be diagnosed at an advanced stage and to have worse five-year survival rates than people with other types of insurance.
Low-income seniors covered by Medicare and Medi-Cal, known as “dual-eligible patients,” were the least likely to receive recommended treatment for breast and colon cancer.
VA patients waited the longest to be treated for breast, colon, rectal, lung and prostate cancers, but their outcomes compared favorably to patients with other types of health insurance and they were generally more likely to receive recommended treatment.
What researchers still don’t know, Kizer said, is the reason for these disparities. It’s possible that Medi-Cal patients drop on and off the rolls, missing preventive screenings that could help detect cancers earlier. Audits and studies also have shown that some of the state’s Medi-Cal patients have difficulty getting access to doctors and specialists.
Researchers also can’t explain why Medi-Cal patients are less likely than patients with other kinds of insurance to receive recommended treatment after they are diagnosed. And they also don’t know whether cancer patients fare better or worse in Medi-Cal managed care programs, which now cover most of California’s Medicaid population.
“It’s not acceptable to have these variations” based on insurance coverage, particularly regarding breast and colon cancers for which preventive screenings are well-established and effective, said Christina Clarke, a research scientist at the Cancer Prevention Institute of California and a consulting associate professor at the Stanford University School of Medicine. She was not involved in the study.
“What’s particularly poignant is that we’re seeing these big disparate outcomes among groups in cancers where we have strong playbooks. That’s the tragic thing here,” Clarke said. “There’s a body count and we’d like to figure out a better way to insure that all Californians are getting the recommended screening for these deadly cancers and treatment according to guidelines. We have a lot of work to do.”
CMG afterword: How much of these bad figures could be improved with better coordinated care and more attention paid to the social determinants of health?
Readers would do well to read this Hospitals and Health Networks article by Ian Morrison about the states’ expanding role in healthcare reform. He focuses on the fact that more and more states, with huge purchasing power, are consolidating their purchasing activities and coordinating with private players.
“Increasingly, states including Washington and Arkansas are using this combined purchasing power to transform the healthcare marketplace and coordinate their payment reform efforts with private purchasers. Public purchasers (acting in concert with willing private purchasers) can have a powerful influence on healthcare transformation.”
He writes that the states will:
“Drive value-based purchasing across the community, starting with the state as ‘first mover.”’
“Improve health overall by building healthy communities and people through prevention and early mitigation of disease throughout the life course.
“Improve chronic illness care through better integration of care and social supports, particularly for individuals with physical and behavioral ‘co-morbidities.”’
Mr. Morrison cites Washington State’s Health Care Innovation Plan, which we at Cambridge Management Group are very familiar with because of our ongoing work in Oregon and Washington State.
In that plan, “foundational building blocks” include, he notes, “robust quality and price transparency, activated and engaged individuals and families, regionalized transformation efforts, accountable communities of health, leveraged state data capabilities, practice transformation support, and increased workforce capacity and flexibility.”
Other examples in his piece include:
“Arkansas has initiated multi-payer-based episodic payment initiatives and patient-centered medical home programs.
“Minnesota’s multi-payer payment and delivery system reform strategy primarily is tied to spreading an ACO concept (the Minnesota Accountable Health Model framework) among Medicare, Medicaid, commercial payers and self-funded populations in the state.
“Oregon’s recent multi-payer efforts center on spreading the coordinated care organization model {like ACOs} introduced into the state Medicaid program in 2012.
“Vermont is at the forefront of state efforts to reform its health insurance payment and delivery system, and continues to actively test value-based payment approaches with multiple public and private payers.”
The victory of Tea Party friend Matt Bevin as Kentucky governor, defeating Democrat Jack Conway, in one of the few Southern states to embrace the coverage expansions of the Affordable Care Act, suggests that the ACA will continue to be a loser for Democrats in the South even as it has been popular in many Democratic states.
The division of America continues apace.
Mr. Bevin has said he would end or at least dramatically modify the state’s Medicaid expansion and would abolish the state-based exchange, called Kynect. Both were established under outgoing Democratic Gov. Steven Beshear, who couldn’t run again because of term limits.
Modern Healthcare noted that “the Obama administration has hailed Kentucky’s success at extending health benefits to more residents under the Affordable Care Act. The number of uninsured in the state dropped from 20 percent in 2013 to about 9 percent this year.”
The magazine reported that “Bevin may face some opposition, however, if he moves to eliminated the programs. In a recent poll, fewer than a quarter of respondents were in favor rolling back the healthcare programs and more than half were opposed.
“But even some residents who are enrolled in the expanded Medicaid program or an exchange plan supported Bevin.”
“Bevin has said he wants to at least modify the state’s Medicaid expansion to require recipients to pay premiums for coverage, as have Indiana and other Republican-led states.”
We’ll see how popular the new government becomes if he tries to impose premiums on low-income consumers who have had the new coverage for free.
Melanie Evans reports in Modern Healthcare that “{m]ost hospitals lose money on every Medicaid patient they treat, and those losses are mounting as millions of Americans gain coverage through state programs that provide insurance to no- and low-income residents.”
“But for not-for-profit hospitals, at least, those losses may have one positive side effect.
“Larger Medicaid losses will inflate what is already the biggest reported benefit to communities that hospitals must show to maintain their tax-exempt status. One estimate pegged hospitals’ total tax breaks at $24.6 billion in 2011.”
She notes that ”with charity care declining, Medicaid losses are growing as a share of not-for-profit hospitals’ total community benefit. It’s unclear if this will increase scrutiny of their tax exemptions.”
Month after month, Natalia Pedroza showed up at the doctor’s office with uncontrolled diabetes and high blood pressure. Her medications never seemed to work, and she kept returning to the emergency room in crisis.
Walfred Lopez, a Los Angeles County community health worker, was determined to figure out why.
Lopez spoke to her in her native Spanish and, little by little, gained her trust. Pedroza, a street vendor living in downtown Los Angeles, shared with him that she was depressed. She didn’t have immigration papers, she told him, and her children still lived in Mexico.
Then she mentioned something she hadn’t told her doctors: She was nearly blind.
Pedroza’s doctor, Janina Morrison, was stunned. For years, Morrison said, “people have been changing her medications and changing her insulin doses, not really realizing that she can’t read the bottles.”
Health officials across the country face a vexing quandary – how do you help the sickest and neediest patients get healthier and prevent their costly visits to emergency rooms? Los Angeles County is testing whether community health workers like Lopez may be one part of the answer.
Lopez is among 25 workers employed by the county to do everything possible to remove obstacles standing in the way of patients’ health. That may mean coaching them about their diseases, ensuring they take their medications or scheduling medical appointments. Their help can extend beyond the clinic walls, too, to such things as finding housing or getting food stamps.
The workers don’t necessarily have a medical background. They get several months of county-sponsored training, which includes instruction on different diseases and medications, as well as tips on how to help patients change behavior. They are chosen for their ability to relate to both patients and providers. Many have been doing this job for friends and family for years – just without pay.
“By being from the community, by speaking their language, by having these shared life experiences, they are able to break through and engage patients in ways that we as providers often can’t,” said Dr. Clemens Hong, who is heading the program for the county. “That helps break down barriers.”
For now, they work with about 150 patients, many of whom have mental-health issues, substance-abuse problems and multiple chronic diseases. The patients haven’t always had the best experience with the county’s massive health care system.
“They tell us, ‘I am just a number on this list,’” Lopez said. “When you call them by name and when you know them one-on-one … they receive that message that I care for you. You are not a number.”
By spring, Hong said he hopes to have hundreds more patients in the program.
Community health workers have been used for decades in the U.S. and even longer in other countries. But now officials in various counties and states — including Massachusetts, Pennsylvania and Oregon — are relying on them more as pressure grows to improve health outcomes and reduce Medicaid and other public costs, experts said.
“They are finding a resurgence because of the Affordable Care Act and because healthcare providers are being held financially accountable for factors that occur outside the clinical walls,” said Dr. Shreya Kangovi, assistant professor of medicine at the University of Pennsylvania and director of the Penn Center for Community Health Workers.
Kangovi said community health worker programs, however, are likely to fail if they don’t hire the right people, focus too narrowly on certain diseases or operate outside of the medical system. They also need to be guided by the best scientific evidence on what works.
“A lot of people think… they can sort of make it up as they go along, but the reality is that it is really hard,” she said.
Hong, who designed the program based on lessons learned from other models, said Los Angeles County is taking a rigorous approach. It is conducting a study comparing the costs and outcomes of patients in the program against similar patients without assigned workers.
The patients are chosen based on their illnesses, how often they end up in the hospital and whether doctors believe they would benefit.
To Lopez, 43, the work is personal. A former accountant from Guatemala, Lopez has a genetic condition that led to a kidney transplant. Like some of his patients, including Pedroza, he is now on dialysis.
He tries to use his experience and education to get what patients need. But even he runs into snags, he said. One time, he had to argue with a clerk who turned away his patient at an appointment because she didn’t have identification.
“The hardest part is the system,” Lopez said. “Trying to navigate it is sometimes even hard for us.”
Lopez and his fellow community health worker, Jessie Cho, sit in small cubicles in the clinic at Los Angeles County-USC Medical Center, the county’s biggest and busiest public hospital. Throughout the day, they accompany patients to visits and meet with them before and after the doctor does. They also visit patients at home and in the hospital, and give out their cell phone numbers so patients can reach them quickly.
Cho said the patients often can’t believe that somebody is willing to listen to them. “Nobody else on the medical team has it as their job to provide empathy and compassion,” she said.
Morrison, the clinic physician, said both workers have become an essential part of the health team.
“There is just a limited amount I can accomplish in 15 or 20 minutes,” Morrison said. “There are all these mysteries of my patients’ lives that I know are getting in the way of taking care of their chronic medical problems. I either don’t have time to get to the bottom of it or they are never going to really feel that comfortable talking to me about it.”
Natalia Pedroza, who wears a colorful scarf around her head and speaks only Spanish, is a perfect example. Morrison said before Lopez came on board, “I wasn’t getting anywhere with her.”
Initially, Lopez had a hard time helping her understand her health conditions and overcoming her distrust of the system. When they first met, Pedroza believed the dialysis that kept her kidneys functioning was the cause of her health problems. And she didn’t get why Lopez was always around.
But he helped her — by getting her appointments, for instance, and helping arrange for Pedroza to get pre-packaged medications so she wouldn’t have to read the directions. Now Pedroza thinks Lopez is helping her to get better.
On a recent afternoon, Lopez sat down with Pedroza before her medical appointment.
“How are you feeling?” he asked in Spanish.
Pedroza responded that her hair was still falling out and that she still felt sick. She also said she hadn’t been checking her blood sugar because she didn’t know how to use the machine. Lopez calmly demonstrated how the machine worked, and then the two spent several minutes chatting about her job and her neighborhood.
Lopez said he believes he has a made a difference for other patients as well. On a recent Sunday, a 43-year-old patient with chronic pain who initially refused his help texted that he planned to go to the emergency room because of a headache. Lopez reached Morrison, who agreed to squeeze him into the schedule a few days later. And the patient didn’t go to the ER.
Lopez persuaded another patient, a 56-year-old woman, to take her blood-pressure medication before her appointments so that when she arrived, the doctors wouldn’t get worried about her numbers and send her to the hospital.
In one case, his ability to bond with a patient almost undermined his goal of getting the man the help he needed. The patient, who was depressed, said he didn’t want to go see a mental health counselor because he was more comfortable talking to Lopez.
“It was touching,” Lopez said. “I was about to cry.”
Tod Newcombe, writing in Governing magazine’s Web site, notes that the technology upon which most states run their Medicaid programs “is old, clunky and slow. To make matters worse, the expansion of Medicaid in a number of states under the Affordable Care Act has only put more pressure on these aging systems. Now nearly a quarter of states are looking to modernize them…. But officials aren’t eager to risk a lot of money on another system that will be old, clunky and slow by the time it’s completed.”
Mr. Newcombe suggests that states looking for a better way to manage to manage their Medicaid programs might look at breaking up their Medicaid Management Information Systems “into pieces and turn some of those pieces into a service.”
He notes that in in April, “the Centers for Medicare and Medicaid Services proposed updating the polices that govern the certification process for building a MMIS, and thus making it easier to develop separate modules for, say, claims management or pharmacy benefits, instead of building the entire system at once. The federal agency is also revising its development requirements so that states will find it easier — and less risky — to adopt alternatives, such as contracting for a service.”
North Carolina is overhauling its Medicaid program. The governor and state lawmakers are using a mixture of healthcare models to put the major players — doctors, hospitals and insurers — all on the hook to keep rising costs in check.
For many of the Republicans who control the state legislature, the reason for the change is simple: budget predictability.
“For years and years and years, Medicaid has been considered the budget Pac-Man that eats up all the dollars that people in this chamber would like to see spent on many, many other things,” Rep. Bert Jones said during the North Carolina House’s debate of the bill last month. Gov. Pat McCrory signed the overhaul into law on Sept. 23.
The state, which has not expanded Medicaid under the health law, struggled with huge Medicaid cost overruns from 2010 through 2013. That sent lawmakers looking for a better way to manage it, even though a signature part of the program has won national awards for quality and cost.
The lawmakers settled into two camps: One camp wanted to use a managed-care model, which basically means paying large insurance companies a specific amount per person covered and relying on the companies to contain costs.
“The alternative idea was to contract with what are called accountable care organizations,” said Wake Forest Prof. Mark Hall, “which is a newly emerging idea both at the state level and the federal level to organize systems of healthcare finance and delivery that are led by doctors and hospitals.”
The federal government is pushing that model for Medicare, the government insurance program for the elderly. The idea is to put the doctors and hospitals in charge of the health of a certain population of people. If they can provide care that keeps people healthy and saves money, doctors and hospitals can share some of that savings.
Some state lawmakers worried that the doctor-and-hospital model wouldn’t save enough money. Others worried the insurance company model would skimp on care. So they settled on a mixture of both.
Will that create “a Frankenstein’s monster?” That’s the question Hall, the Wake Forest professor, asked earlier this year.
“We proposed the thought that hybridizing these two separate ideas might be freakish, but in fact, I don’t think it is,” he said. “I think it’s actually a very sound and carefully thought-out use of the best of both models.”
Outside of North Carolina, Oregon is also contracting with both MCOs and ACOs, and a few other states are exploring how to encourage provider organizations to play a bigger role in Medicaid managed care.
In the meantime, North Carolina is drawing from the managed-care/insurance company model to change how it pays for Medicaid.
As of now, doctors bill Medicaid after they provide services, so the incentive is to provide more services. In the new system, the state will set budgets up front for whomever it puts in charge of managing care. If those managers go over budget, they’re on the hook – not the state.
That’s becoming the standard approach to payment, says Dan Mendelson, CEO of consulting firm Avalere Health.
“Most states contract for Medicaid through managed care because states don’t want open-ended financial liability,” Mendelson said.
Normally, those states contract with insurance companies. But here’s where the doctor-and-hospital model comes in. North Carolina will open up its bids to insurance companies and doctor-and-hospital systems. It will also set up quality metrics to track how they do.
Game on, says Julie Henry of the North Carolina Hospital Association.
“We’re moving in this direction in other arenas in healthcare, not just for the Medicaid population, but for commercially insured patients and for Medicare patients,” she said.
Henry points out some doctor-and-hospital systems in North Carolina are already meeting quality metric standards and saving money under Medicare. Some insurance companies are posting similar results.
Patient advocates say one system isn’t necessarily better than the other.
“We think it’s important to focus on not just who we hand a big bucket of money to, but what are the rules for spending that money,” said Corye Dunn, of Disability Rights North Carolina.
She says making sure the quality metrics are effective will be a crucial part of the overhaul process.
Also, lawmakers set a cap of 12 percent for how much money can go toward administrative costs and profits.
“The challenge lies in the fact that Medicaid is already a very lean program, and there’s just not a lot of fat to cut out there,” said Joan Alker of the Georgetown University Center for Children and Families. “The concern is, will the managed care company save money the right way or the wrong way?”
Some worry the risks of the overhaul outweigh the benefits. Cost overruns have not been a problem the past two years. And many in North Carolina’s medical community take pride in effective parts of the old program.
A Republican legislative leader on healthcare policy, Rep. Nelson Dollar, voted against the overhaul. And Democratic Rep. Gale Adcock, a nurse practitioner from Wake County, told other lawmakers to consider a guiding principle in healthcare.
“First, do no harm,” she said on the House floor. “I’m very fearful that if we pass this bill, we will do harm.”
The version that passed will change the award-winning part of the program, called Community Care of North Carolina. Community Care is a network of doctors, nurses and pharmacists who coordinate care for roughly 80 percent of Medicaid patients. A recent state audit found that Community Care has been saving the state money and improving patient outcomes.
As insurers and hospital systems take over those functions, Community Care President Dr. Allen Dobson says his organization will look to partner with them.
“We expect we’ll play a fairly significant role,” Dobson said. “It will be different. We may move from having one customer, which has been the state, to having multiple customers.”
One of the Republicans who led the overhaul effort, Rep. Donny Lambeth, says Medicaid is not broken in North Carolina. But he says as health care evolves, the state needs to keep up.
“Fact is, we can actually do better in North Carolina for these Medicaid beneficiaries,” Lambeth said on the House floor. “Do you think quality in North Carolina across all the providers is equal and good? I can tell you it is not.”
Lambeth says the new quality metrics will make it easier to track that. He says it’ll take three to four years to get federal approval and implement the changes.
This story is part of a reporting partnership that includes WFAE, NPR and Kaiser Health News
Care New England’s Women & Infants Hospital in Providence, right next to Rhode Island Hospital, owned by rival chain Lifespan. Some observers think that this proximity is financially and clinically bizarre.
Timothy Babineau, M.D., Lifespan chief executive, told Rhode Island Public Radio that the talks “are in very early stages’’ and are in response to Care New England’s recent request for partnership proposals.
As Scott Mackay of RIPR noted: “The two large hospital chains, which control roughly 70 percent of the state’s healthcare market, have been down this read twice before, only to see the efforts crash amid a series of state regulatory and financial challenges.”
“The recent evolution of medical care in southern New England may augur in favor of such a combination now. Obamacare and the expansion of the federal Medicaid program have given hospitals more revenue. Yet, the competition from Massachusetts is, if anything, stronger than ever, with Bay State health providers moving relentlessly to poach patients, particularly those with private health insurance, from Rhode Island.”
“A merger would make sense on many levels, especially in building a stronger Rhode Island-based medical provider network. Many medical observers have long wondered why Women & Infants Hospital, which shares a campus with Rhode Island Hospital, is in Care New England, while Rhode is part of Lifespan.”
