A friend of mine told me the other day, “We’ve seen our insured patient population go from 15% to 70% in the few years since Obamacare.” As a primary care physician in the Midwest, he’s worked for years in an inner-city clinic that serves a poor community, many of whom also suffer from mental illness. Before the Affordable Care Act (ACA), the clinic constantly struggled to stay afloat financially. Too often patients would be sent to an emergency room because the clinic couldn’t afford to provide some of the simplest medical tests, like an x-ray. Now, with most of his patients insured through the Medicaid expansion program, the clinic has beefed up its staffing and ancillary services, allowing them to provide better preventive care, and in turn, reduce costly ER visits.
From the time Medicaid was established in 1965 as the country’s first federally-funded health insurance plan for low-income individuals, state governments have only been required to cover the poorest of their citizens. Before the ACA, some 47 million Americans were uninsured because their incomes exceeded state-determined benchmarks for Medicaid eligibility and they earned far too little to buy insurance through the private marketplace.
The ACA reduced the number of uninsured Americans by mandating that states increase their income requirement for Medicaid to 138% of the federal poverty line (about $1,330 per month for a single individual), and promising that the federal government would cover the cost to do so. However, in a 2012 decision, the Supreme Court left it to the states to decide if they wanted to increase their Medicaid eligibility. If they agreed to adopt Medicaid expansion, the federal government offered to cover 100% of the increased cost in 2014 and 90% by 2021.
Today on Health in 2 Point 00, Jess and I power through a whopping six questions. In this episode, Jess asks me about the merger between Cambia Health Solutions and Blue Cross NC, Alex Azar getting grilled by Rep. Joe Kennedy on Medicaid work requirements, Omada Health adding connected blood pressure and glucose monitors, 23andMe’s new Type 2 Diabetes predisposition test, and raises by Akili Interactive and MAP Health Management. —Matthew Holt
The official 2017 statistics from the U.S. Department of Health and Human Services (DHHS) are out, and there are some good news: The annual growth rate of health care spending is slowing down, and is the lowest since 2013 at 3.9%—it was 4.3% for 2016 and 5.8% for 2015. The bad news is that our health care cost increases are still well above inflation, and that we spent $3.5 trillion in this area, or 17.9% of GDP. Americans spent $10,739 on health care in 2017, more than twice as much as of our direct economic competitors: This per capita health care spending was $4,700 in Japan; $5,700 in Germany; $4,900 in France; $4,200 in the U.K.; $4,800 in Canada; and an average of $5,300 for a dozen such wealthy countries, according to the Peterson -Kaiser health system tracker from the Kaiser Family Foundation, and OECD data. Spending almost a fifth of our GDP on health care, compared to 9-11% for other large developed economies (and much less in China), is like having a chain tied to our ankles when it comes to our economic competitiveness.
Could 2019 be the year when our health care spending actually decreases, or at least grows at a slower pace than inflation? Or will we see instead an uptick in costs for health care consumers?
To answer these questions, we need to look in more detail at the largest areas of health care spending in America, and at the recent but also longer term spending trends in these areas. Using the annual statistics from the DHHS, we can compare the growth in spending in half a dozen critical health care categories with the growth in total spending, and this for the last three years as well as the last decade. Over the last decade, since 2007, these costs grew 52% in aggregate (from $2.3T to $3.5T) and 41% per capita (from $7,630 to $10,740).
What is the effect of expanding Medicaid on overall healthcare costs and use of the emergency room? This type of question can’t easily be answered by observational studies and requires a randomized controlled trial (RCT). But an RCT isn’t easy to perform. However, a natural RCT serendipitously happened in Oregon a few years ago when Medicaid was expanded and the eligibility was deemed by a lottery system.
On this episode of Firing Line, Saurabh Jha (@RogueRad) speaks to Professor Katherine Baicker, a leading economist and the Dean of the Harris School of Public Policy, and principal investigator of the Oregon Health Insurance Experiment, about the landmark study.
Listen to our conversation here at Radiology Firing Line Podcast.
Fueled by Americans’ urgent need for better chronic disease care and insurers’ march from fee-for-service to value-based payments, innovation in population health management is accelerating across the health care industry. But it’s hardly new, and CareMore Health, a recent acquisition of publicly-traded insurer Anthem, has been on the vanguard of the trend for over twenty years.
CareMore Health provides coordinated, interdisciplinary care to high-need patients referred by primary care physicians in nine states and Washington, D.C. The care encompasses individualized prevention and chronic disease management services and coaching, provided on an outpatient basis at CareMore’s Care Clinics. It also includes oversight of episodic acute care, via CareMore “extensivists” and case managers who ensure effective coordination across providers and care sites before, during and after patient hospitalizations.
The majority of CareMore patients are covered by Medicare Advantage or Medicaid, and company-reported results, as well as a Commonwealth Fund analysis, indicate that the patient-centered, relationship-based model leads to fewer emergency room visits, specialist visits and hospitalizations for segments of the covered population. They also suggest that it leads to cost efficiencies relative to comparable plans in its markets of operation.
Among all the talk of waves and tides of the close midterm races around the country, there were tremendous results on election day for Medicaid expansion. Three states – Idaho, Nebraska, and Utah – passed ballot initiatives approving the policy.
On top of that, in Kansas and Maine, governors who had vetoed the policy in the past were replaced with candidates promising to enact it.
This was obviously great news for supporters of Medicaid expansion with the total number of expansion states firmly at 36.
What were the issues?
In Idaho, the Expansion ballot initiative was designed to provide insurance covers for individuals under the age of sixty-five and whose income is below 138 percent of the federal poverty level and who are not eligible for any other state insurance cover.
Among the proponents of Medicaid in Idaho was State representative Christy Perry a Republican and staunch Trump supporter. She had over the years attempted to push for the expansion through the state legislature but faced resistance from statehouse leaders.
The scenario in Idaho applies to Utah and Nebraska, with the ballot initiative being necessitated by the strong opposition from the majority of Republicans and statehouse leaders. In Utah, opponents of the Expansion argued that the initiative would bankrupt the state treasury. In Nebraska caution was given against reliance on federal government financing for state programs noting that often the national government scale back or neglect supporting state programs without proper transitional mechanisms.
However, it was difficult to debate against the fact that Medicaid would free up resources invested by the state governments in local insurance programs and that the federal government is legally obliged to pay 90% of the cost of the policy.
We tested whether new payment mechanisms could be harnessed in health care delivery reform to reduce health and health care disparities. Here’s what we found.
First, there were facts that couldn’t be ignored:
#1: Children in rural Oregon on Medicaid suffered more health-related dental challenges compared to children with private insurance, including the pain, systemic health problems and disruptions to education that come with them. Advantage Dental, the state’s largest provider of Medicaid services, was determined to do something about it.
#2: New mothers on Medicaid in a New York City hospital were less likely to have a postpartum care visit compared to privately insured women. As a result, they missed assessments and screenings for a number of health conditions, some of which can lead to chronic health problems throughout their lives. For many women, the postpartum visit is one of the few chances to engage them in ongoing health care. The providers and care teams at the Icahn School of Medicine and the Mount Sinai Health System wanted to find out what it takes to increase postpartum visit rates.
#3: In Fairfax County, Virginia, multi-racial and multi-ethnic populations being served in three County-funded safety-net clinics were less likely to receive the typical high-quality care provided for hypertension, diabetes, and cervical cancer screening when compared to their Hispanic counterparts. The providers and teams at the Community Health Care Network stepped forward to address the issue. Continue reading…
We missed our chance to do a Happy Hour Health in 2 Point 00 at Connected Health in Boston (but let’s be honest, those are usually not the most cogent pieces of information in health and technology). Join Jessica DaMassa as she gets my take on the conference starting with #S4PM’s event, where I met some incredible people, including Patty Brennan and Doug Lindsey, who spoke about their experiences with health care knowledge (deploying it and creating it!). Danny Sands and e-Patient Dave even had quite the musical performance there, singing about e-Patient blues. Susannah Fox, Don Berwick, Don Norman were at Connected Health 18, presenting their new initiative, L.A.U.N.C.H. I even interviewed Jesse Ehrenfeld, the chair elect of AMA, and his spoke to him about the digital health play book that the AMA just released. A company to take note of that wasn’t at #CHC is Devoted Health, who just raised $300m. Devoted is looking at building a better Medicare Advantage “payvider” for seniors. If you are interested in Guild Serendipity’s conference which empowers and engages female CEOs and Cofounders, come join us in San Francisco October 26-27, SMACK.health is sponsoring the women’s health houses – Matthew Holt
By KENNETH D. MANDL, MD; DAN GOTTLIEB;
JOSH C. MANDEL, MD
The opportunity has never been greater to, at long last, develop a flourishing health information economy based on apps which have full access to health system data–for both patients and populations–and liquid data that travels to where it is needed for care, management and population and public health. A provision in the 21st Century Cures Act could transform how patients and providers use health information technology. The 2016 law requires that certified health information technology products have an application programming interface (API) that allows health information to be accessed, exchanged, and used “without special effort” and that provides “access to all data elements of a patient’s electronic health record to the extent permissible under applicable privacy laws.”
After nearly two years of regulatory work, an important rule on this issue is now pending at the Office of Management and Budget (OMB), typically a late stop before a proposed rule is issued for public comment. It is our hope that this rule will contain provisions to create capabilities for patients to obtain complete copies of their EHR data and for providers and patients to easily integrate apps (web, iOS and Android) with EHRs and other clinical systems.
Modern software systems use APIs to interact with each other and exchange data. APIs are fundamental to software made familiar to all consumers by Google, Apple, Microsoft, Facebook, and Amazon. APIs could also offer turnkey access to population health data in a standard format, and interoperable approaches to exchange and aggregate data across sites of care.
A few weeks ago, I saw a young patient who was suffering from an ear infection. It was his fourth visit in eight weeks, as the infection had proven resistant to an escalating series of antibiotics prescribed so far. It was time to bring out a heavier hitter. I prescribed Ciprofloxacin, an antibiotic rarely used in pediatrics, yet effective for some drug-resistant pediatric infections.
The patient was on the state Medicaid insurance and required a so-called prior authorization, or PA, for Ciprofloxacin. Consisting of additional paperwork that physicians are required to fill out before pharmacists can fill prescriptions for certain drugs, PAs boil down to yet another cost-cutting measure implemented by insurers to stand between patients and certain costly drugs.
The PA process usually takes from 48-72 hours, and it’s not infrequent for requests to be denied, even when the physician has demonstrated an undeniable medical need for the drug in question.