Author Insights: Limited Quality Improvement But No Cost Reduction in Medical Home Pilot
The concept of the patient-centered medical home model is that it redesigns care around the patient’s needs. It offers patients one-stop shopping, with a primary care clinician and interdisciplinary physicians, specialists, nurses, and care managers working together all in one place. For patients with complex or chronic diseases, this may decrease the need for multiple visits to various clinicians, improve coordination of care between clinicians, and give such patients a regular point of contact, such as a care manager who can help them navigate the day-to-day challenges of their condition. To encourage physicians to adopt the model, payers have offered financial incentives.
Numerous pilot studies of the patient-centered medical home model are under way. So far, the data suggest only modest quality improvement over usual care and offer little evidence that this model reigns in costs. Mark Friedberg, MD, MPP, a researcher at RAND, and his colleagues analyzed data from a large multipayer pilot of primary care practices in southeastern Pennsylvania featuring a medical home based on standards set by the National Committee for Quality Assurance. The analysis included 64 243 patients in the pilot practices and 55 959 control patients. The researchers found a modest improvement in the quality of care for only 1 of 11 measures, and no reductions in care utilization or costs.
Dr Friedberg discussed his findings with news@JAMA.
Medicare Data Show Wide Differences In ACOs’ Patient Care
The release is the first public numbers from Medicare of how patient care is being affected by specific networks. These accountable care organizations, or ACOs, are among the most prominent of Medicare’s experiments in changing the ways physicians and health care facilities work together and are paid. The ACOs will be able to keep some of the money they save, but they also take on some of the financial risk if their patients end up being costly.
Health Care Cost Emergency Declared By San Francisco Labor
It’s a national epidemic finally getting some long overdue attention. To put rising costs in perspective, a dozen oranges today would cost $134 if adjusted at the same rate of price inflation that we’ve seen in healthcare since 1945.
And, it’s only getting worse. California health insurance premiums soared 185% since 2002. But we’ve heard these complaints before, it’s not new.
What is new is that the largest unions in San Francisco are doing something to reign in price gouging by insurers like California-based Kaiser Permanente, the nation’s largest HMO with 9.1 million subscribers.
For UNITE-HERE Local 2, one of the city’s largest unions representing 13,000 employees of restaurants and hotels in and around San Francisco, it has become a necessity.
The union’s senior research analyst, Ian Lewis, told me that his members were confronted with an average increase in health charges of 10% each and every year for the last ten years.
During this time, Local 2 was forced to take action. They had a strike/lockout in 2004, a number of strikes in 2009-2010 and a strike last summer by food and beverage concession workers at AT&T Giant’s Park.
In each and every case, Lewis said, healthcare was a major issue.
In fact, he emphasized, “rising healthcare costs has been the major issue in almost every labor dispute I’ve observed throughout the country during the last ten years. Rising costs have to be dealt with or working people will continue falling behind.”
Local 2’s experience is not an exception.
SEIU 1021 represents 54,000 members in northern California and has lent its considerable influence to a labor campaign supported by the San Francisco Labor Council that seeks to hold all California insurers accountable for their price increases.
The union argues on its website that “health insurance premiums and out of pocket health costs are eating up our paychecks and straining family budgets. Last year, San Francisco’s government Health Service System (HSS) estimates that from 2010 to 2012, one health care provider [Kaiser] charged $87 million above the true cost of care.
“We estimate the City will try to shift extra healthcare costs to city workers and our families. In one example, the cost for the Kaiser option — an employee plus one — will rise to $1,200 more a year,” wrote SEIU 1021 Vice President of Representation Karen Joubert.
Furthermore, the union indicates, the city’s HSS analysis shows “per member per month” costs from Kaiser soared between 31%-54% during the past seven-year period despite an actual overall decline in members using Kaiser services.
The union is currently negotiating for its 12,000 San Francisco city workers so their concerns are gaining more attention.
Sally Covington, staff member of SEIU 1021 with expertise in healthcare policy and benefits, painted a similar picture at a Feb. 24 healthcare forum sponsored by the San Francisco Labor Council.
The Effects of the Massachusetts Health Reform on Financial Distress
A major benefit of health insurance coverage is that it protects the insured from unexpected medical costs that may devastate their personal finances. In this paper, we use detailed credit report information on a large panel of individuals to examine the effect of a major health care reform in Massachusetts in 2006 on a broad set of financial outcomes. The Massachusetts model served as the basis for the Affordable Care Act and allows us to examine the effect of coverage on financial outcomes for the entire population of the uninsured, not just those with very low incomes. We exploit plausibly exogenous variation in the impact of the reform across counties and age groups using levels of pre-reform insurance coverage as a measure of the potential effect of the reform. We find that the reform reduced the total amount of debt that was past due, the fraction of all debt that was past due, improved credit scores and reduced personal bankruptcies. We also find suggestive evidence that the reform lowered the total amount of debt and decreased third party collections. The effects are most pronounced for individuals who had limited access to credit markets before the reform. These results show that health care reform has implications that extend well beyond the health and health care utilization of those who gain insurance coverage.
California says 14,500 must redo Obamacare applications after glitch
By Soumya Karlamangla7:05 PM PST, February 28, 2014
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California's health insurance exchange said about 14,500 people have to redo their online applications for Obamacare coverage because of a software error.
The state's announcement late Friday comes shortly after a five-day outage of the Covered California enrollment website.
About 14,500 people who partially completed applications or updated them Feb. 17-19 -- just before the website went down -- have to either start over or resubmit any changes they made, the exchange said.
Covered California said it will contact the affected consumers and help them complete the sign-up process by March 15 for coverage that takes effect April 1.
“We regret any inconvenience this has caused,” Peter Lee, executive director of Covered California, said in a statement. “Our enrollment website has been up and running this week, and we look forward to helping consumers get the health coverage they want.”
The lost information and website glitches come at a tough time for the exchange, which is in the midst of a final enrollment blitz before the March 31 sign-up deadline. The state had been signing up more than 7,000 people per day, on average, in February.
Covered California said completed applications for an additional 6,500 people were also affected by the software troubles. But the state said that it is restoring the data and that those people don't need to take any additional steps.
The exchange is also working to restore information on 16,000 people who were deemed eligible for Medi-Cal, the state's Medicaid program for the poor. They are to be contacted by the exchange as needed.
Covered California attributed the website problems to a "software malfunction during a planned maintenance outage" this month.
Commentary: MaineCare compromise would tackle two big problems, state senator says
The proposal would institute major management reforms while extending coverage to thousands, Roger Katz says.
AUGUSTA — To mention the word “MaineCare” under the State House dome is the equivalent of throwing off your gloves in a hockey game. It’s an invitation to a brawl.
about the author
Roger Katz is a Republican state senator from Augusta.
But I am invoking MaineCare in this column for a different purpose – as an opportunity for Democrats and Republicans to find common ground.
Let me start with two incontrovertible facts.
CHRONIC MISMANAGEMENT
First, the MaineCare program has been a management mess for years. It is an equal opportunity problem; it has tormented Republican, independent and Democratic governors alike.
The system reimburses some providers for more than they are owed, while others don’t get enough. For the past dozen years, like clockwork, the governor has submitted supplementary appropriations requests to cover the “unexpected” cost overruns of MaineCare. Then every few years or so, as with Riverview Psychiatric Center right now, the federal government penalizes the state for making illegal expenditures, and the Legislature has to scramble to fill yet another budget gap.
This is no way to run a railroad. Meanwhile, the railroad is growing. In the 15-year period between 1997 and 2012, MaineCare costs to the General Fund increased by $500 million, and the proportion of the state General Fund budget dedicated to MaineCare grew from 13 percent to 24 percent.
For Democrats and Republicans who care about having state funds available in the future for our university system, for early childhood education, for highways, for public schools and for municipal aid, MaineCare is a major problem. It is a system with chronic mismanagement, growing to absorb more and more of discretionary state spending over time. It must be addressed.
That is fact No. 1.
BIG BOOST TO MIDDLE-CLASS WORKERS
The second fact is more simple – in many ways, the MaineCare expansion that the federal government is offering Maine is a sweet deal. It would bring around $330 million a year into the state were we to accept it. Almost $1 miilion a day. Every day. Sundays included.
This new money would pay for rural clinics, family doctors, home care workers, nurses, X-ray technicians, hospitals and health workers of all kinds. The money would support between 2,000 and 2,500 middle-class health care jobs in Maine (and many other indirect jobs).
Maine Voices: Consider paying for private insurance instead of Medicaid expansion
The state should get out of the insurance business and give beneficiaries a stake in their health care costs.
By Martin Jones
FREEPORT — MaineCare advocates are excited about a new expansion proposal by Sens. Roger Katz, R-Augusta, and Tom Saviello, R-Wilton, because it’s the camel’s nose under the tent, and because it’s a Republican camel.
about the author
Martin Jones of Freeport is a financial analyst who writes about health care and other public policy.
The proposal would expand Medicaid to an estimated 70,000 new enrollees with incomes between 100 and 138 percent of the federal poverty level for three years, at which point it would have to be re-authorized by the Legislature.
This is advertised as a compromise, but for all practical purposes, the extension would be permanent. Once that many new enrollees have free health care in any form, it would be practically impossible to take it away, even if the federal government waffles on its promise to pay 100 percent of expansion costs for three years, declining to 90 percent in 2020.
Democrats in the Legislature understand this perfectly, and Sen. Katz probably does, too, which makes one wonder why he bothers with the three-year sunset charade.
Sen. Katz is right that the current MaineCare program is dysfunctional in many respects, and that its cost trajectory is unsustainable. To fix this, he proposes that the state shift from fee-for-service Medicaid to a managed care system, as a number of other states have done in an effort to control costs. However, the results for access, quality of care and cost savings have varied widely.
•First, managed care systems often narrow the choices patients have for doctors and hospitals. Not all providers accept Medicaid patients, and a managed care system could reduce the number of options even further and could result in significant inconvenience for patients, especially in rural areas.
•Second, in most Medicaid managed care programs the burden for savings is entirely on providers, who must stay within an expenditure limit for the patients they serve or lose money. The result is that providers have an incentive to stay below the expenditure cap by limiting services to patients. State officials like the idea of placing the burden of controlling costs on providers, but for patients it doesn’t always work so well.
The best idea that Sens. Katz and Saviello have is buried in a single subsection of the legislative proposal and isn’t even mentioned by Sen. Katz in a recent op-ed column for the Press Herald (“Commentary: MaineCare compromise would tackle two big problems, state senator says,” Feb. 27).
It is a proposal to study the possibility for a private option along the lines of proposals for Medicaid expansion in Arkansas, Iowa and Pennsylvania.
LePage’s Medicaid expansion rhetoric is straight out of ‘1984’
In George Orwell’s dystopian novel “1984,” the Ministry of Truth is one of four departments responsible for running the government. It does the opposite of what its name suggests. It changes history to suit its message and broadcasts slogans like “Ignorance is strength” and “War is peace.” This is doublethink: Twist the facts, and dismiss any inconvenient truth.
The Maine Department of Health and Human Services is apparently employing the concept of doublethink as it continues its attack against Medicaid expansion, resorting to distortion of facts to serve an ideological purpose.
On Friday, the department, which has staunchly opposed expansion under Gov. Paul LePage, questioned the preliminary analysis of the nonpartisan Office of Fiscal and Program Review, which found expanding Maine’s health insurance program to 70,000 low-income people would cost the state $ 683,520 over three years.
DHHS Commissioner Mary Mayhew called the independent analysis “nonsense,” saying the office “clearly chose to ignore the facts,” and that “one must question the motivation of doing so and the integrity of the process.” When truth is not on your side, fight those who speak it.
The state costs are projected to be low because the federal government is obligated to pay 100 percent of the cost for newly eligible Medicaid recipients the first three years; the bill proposed by Sen. Roger Katz, R-Augusta, would roll out Medicaid expansion for only three years unless the Legislature voted to renew it. Considering three years of costs for benefits and personnel not covered by federal funds, the fiscal office projected expansion would save the state $3.4 million the first year and cost just under $290,000 in the second and $3.8 million in the third.
Yet DHHS says you shouldn’t believe the nonpartisan fiscal office. Rather, you should believe its partisan office. What’s more, you should believe that expansion would actually cost 123 times the amount the nonpartisan office says — $84 million by 2017 — based on suspect reasons, including per-recipient Medicaid costs that DHHS suddenly claims are nearly 80 percent higher than it haspreviously claimed those costs to be.
Never mind that the fiscal office’s analysis of a different Medicaid expansion bill last year was frequently used by Republicans making the case against expansion. The information is only true when it suits a purpose.
The rhetoric surrounding Medicaid expansion from the LePage administration has gone entirely Orwellian. Apparently, it is not “compassionate” for the state to accept federal funds to expand health coverage to about 70,000 low-income adults.
“We must show compassion for all Maine people,” LePage told Maine residents last month in his State of the State address. “We must protect our hard-working families from the higher insurance premiums and higher taxes that will result from further expansion.”
Compassion, evidently, is to leave some of Maine’s poorest residents without an affordable option for coverage that could improve their health, both physical and mental, and their financial position. And expansion, evidently, will cause higher health insurance premiums for everyone else when, in fact, it’s more likely to lead to premium reductions. In determining how much they expect to save by expanding Medicaid, a number of states have factored in lower health insurance costs for their state employees and retirees. With fewer uninsured people, these state analyses have determined, hospitals will have fewer unpaid costs from treating the uninsured to shift to those with insurance.
One principle of “Newspeak,” the official language of Orwell’s Oceania, is to remove any nuance from language. That’s exactly what LePage and Medicaid expansion opponents do by frequently characterizing the entire population that could benefit from an expanded Medicaid program as “able-bodied.” Why, after all, do the “able-bodied” deserve help from everyone else?
Help us serve low-income patients in Maine by expanding Medicaid
Posted March 04, 2014, at 12:35 p.m.
Recently, as leaders from the federally qualified health centers of Washington County, we spent a day in the Hall of Flags at the State House in Augusta to showcase the resources, initiatives and services we provide to our communities. We talked to legislators and lobbyists about our vital role helping our underserved population access quality health care. The health centers were joined by Washington County’s two hospitals, Healthy Maine Partnerships, Head Start and other organizations that make a daily difference.
While shining a light on the myriad of services we provide, including dental, medical and mental health services, we talked about patients, trends and needs. We emphasized our constant effort to ensure that our patients have consistent access to affordable health care especially for the newly insured under the Affordable Care Act. Our message was clear, direct and nonpartisan.
Our day was full of cordial conversations with Democrats and Republicans alike, and we emphasized the great need and how each community-based, cost-efficient health center’s positive impact is being harmed when existing, effective and necessary programs like MaineCare are threatened.
At our event, House Speaker Mark Eves, D-North Berwick, talked about his willingness to seek a compromise, and all legislators seemed interested in our services for thousands of patients. Besides talking about the range of our services, we stressed how an additional $300 million in federal funds to the state of Maine would ease the hard times for many people.
With those funds, Maine will provide health care service to an additional 70,000 people while thoughtfully looking at ways to reduce costs. The recent proposal by Sen. Roger Katz, R-Augusta, to accept the federal funds while adding necessary reforms to our state’s large and cumbersome welfare system is a sensible compromise.
While eligibility levels for people have significantly increased in states implementing the Medicaid expansion, there are large coverage gaps for Maine and other states not expanding. Sadly, Maine is one of 25 states that have not chosen to accept the federal funds, and it’s hurting poor parents and other adults who otherwise remain ineligible.
The states with their own exchanges leap-frogged those without and currently are exceeding federal enrollment targets. We can’t afford to fall further behind. In Maine, through coordinated, community-based efforts, we have enrolled 20,000 people, but through this compromise legislation, we can expand health care to more people in need.
The compromise legislation is sensible, prudent and the right thing to do for our low-income friends and neighbors. With these federal funds, we will provide the necessary services while continuing to achieve program efficiencies, management and savings.
The federally qualified health centers in Washington County and throughout the state play an important role in helping our citizens access health care services while being a model of an efficient state-federal partnership. We accept all forms of insurance and have established sliding fees for our uninsured and very low-income patients. Without an expanded MaineCare, it makes it increasingly difficult to maintain our fiscal sustainability.
Bangor hospital touts robotic hysterectomy procedure
Posted March 05, 2014, at 5:33 a.m.
BANGOR, Maine — Eastern Maine Medical Center will reach a “surgical milestone” on Wednesday by performing the state’s first single-incision hysterectomy with the help of a robot.
Dr. Pamela Gilmore will perform the procedure using the hospital’s da Vinci robotic surgery system, removing the patient’s uterus through one tiny incision in the navel.
Along with EMMC, MaineGeneral hospital in Augusta and Maine Medical Center in Portland also perform robotic hysterectomies. EMMC is the first hospital in Maine to perform the procedure robotically with just a single incision, Gilmore said.
“We’re introducing a new dimension to gynecologic surgery,” she said Tuesday during a demonstration of the robotic system at the hospital.
With robotic procedures, a surgeon manipulates tiny surgical instruments using hand controls at a computer system situated a few feet away from the patient. A video camera on one of the arms provides a view inside the patient’s body.
Hysterectomies also can be performed several other ways, such as through a large abdominal incision or through less invasive approaches, including a small opening at the top of the vagina, or laparoscopic surgery, in which the surgeon manipulates instruments and a tiny lighted camera through small incisions in the navel and abdomen.
The da Vinci robot has been promoted heavily by many hospitals nationally as a cutting-edge surgical technology. The system, with a price tag of more than $1 million, has come under greater scrutiny as its use has skyrocketed.
The FDA is investigating a spike in the number of problems reported with robotic surgeries. In December, EMMC robotic surgeon Dr. Michelle Toder said some of the reports were old or involved incidents that weren’t the fault of the robotic technology.
In March 2013, a leading obstetrician-gynecologists group questioned the use of surgical robots for routine hysterectomies, citing a study that found robots led to no better results than other procedures but cost much more.
“There is no good data proving that robotic hysterectomy is even as good as — let alone better — than existing, and far less costly, minimally invasive alternatives,” James Breeden, president of the American Congress of Obstetricians and Gynecologists said in the March statement.
Sizing up Obamacare, unions urging unified push for single-payer system
Cite increasing burden at bargaining table
By David Sims
The Chief-Leader (New York), March 3, 2014
The Chief-Leader (New York), March 3, 2014
The Affordable Care Act’s changes to the nation’s health-care business mean good and bad things for organized labor, but a Feb. 27 LaborPress event on its impact focused more on pushing for a single-payer system in the state to relieve the increased pressure on unions.
The event, hosted by the District Council of Carpenters, featured union leaders and health-care administrators debating the new landscape as New York State begins selling health-care plans on the open marketplace as part of the exchanges offered under the ACA.
Buyers’ Remorse
Despite labor’s broad support as President Obama worked to pass the ACA in 2010, unions have grown increasingly wary of “Obamacare,” fearing that workers will be siphoned off from their plans to cheaper state-based exchanges, driving up premiums for those remaining in the union health-care system.
But the panelists at the LaborPress “Strategy Roundtable on Winning Better Healthcare,” moderated by Cornell Union Leadership Institute co-director Gene Carroll, said that unions should look beyond the ACA’s flaws and push for even more fundamental changes.
State Assemblyman Richard Gottfried, who chairs the Assembly’s Health Committee, noted unions’ evolved relationship with providing health care over the years, recalling that in 1967, the AFL-CIO opposed a statewide universal health plan pondered by then-Governor Nelson Rockefeller.
“There was a time when labor regarded the delivery of health benefits as one of the great things that it did,” he said. “I really think that at this point the labor movement does not regard its responsibility for delivering health benefits a big plus. Most strikes occur over health benefits. Most of the time, when labor is not able to deliver significant improvement in wages, it’s because every effort is devoted to health benefits.”
In the city and around the country, unions struggle with the unwieldy costs of health-care plans, with employers and governments always eager to cut back or pass more costs onto members. With ACA coming into effect, the system will get worse, not better, Mr. Gottfried said.
Making Workers Pay
“The availability of the exchanges is encouraging more and more employers to shift coverage to workers or drop it entirely,” he said. Noting that Governor Cuomo had proposed covering the health-care costs of those earning up to 200 percent above the poverty line, he said the continuing shift to more government-subsidized coverage “will add to the magnetic power of non-union coverage, of exchange coverage, to draw people out of existing coverage.”
Mr. Gottfried has written a bill proposing a single-payer health system for New York State that he said would bypass all of the problems of an insurance-based system. “It should be paid for publicly. The revenue should not come through regressive premiums, regressive co-pays and regressive deductibles,” he said.
“I would love to see that happen at the federal level. I think it’s pretty clear the environment in Washington has moved us further away,” he continued. “In New York, particularly as people have seen that with all the fixes to the system ACA has done it is still not a system that really can work for people ... there is renewed interest in the bill that I first introduced. We’re working to get it to the floor in the Assembly again.”
Communications Workers of America Local 1180 President Arthur Cheliotes said labor had to organize better and inform members as a collective about the realities of health care to better push for reforms like the ones Mr. Gottfried was suggesting.
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