Tag: ACA

Can Hospitals Survive? Part II

In 1980, while working at the University of Chicago Pritzker School of Medicine, I wrote an article for the Harvard Business Review entitled “The Health Care Market: Can Hospitals Survive?”. This article, and the book which followed, argued that hospitals faced a tripartite existential threat:

1)  ambulatory technologies that would enable physicians to compete successfully with hospitals at lower cost in their offices or freestanding settings, 2)  post-acute technologies that would enable presently hospitalized patients to be managed at home and 3) rapidly growing managed care plans that would “ration” inpatient care and bargain aggressively to pay less for the care actually provided.

I predicted a significant decline in inpatient care in the future, and urged hospitals to diversify aggressively into ambulatory and post acute services.   Many did so.  A smaller number, led by organizations like Henry Ford Health System of Detroit and Utah’s Intermountain Health Care, also sponsored health insurance plans and became what are called today “Integrated Delivery Networks” (IDN’s).

In the ensuing thirty years, US hospital inpatient census fell more than 30%, despite ninety million more Americans.   However, hospitals’ ambulatory services volume more than tripled, more than offsetting the inpatient losses; the hospital industry’s total revenues grew almost ten fold.

Ironically, this ambulatory care explosion is now the main reason why healthcare in the US costs so much more than in other countries.  We use far fewer days of inpatient care than any other country in the world.  But as the McKinsey Global Institute showed in 2008 ambulatory spending accounts for two thirds of the difference between what the US spends on healthcare and what other countries spend, far outstripping the contribution of higher drug prices or our multi-payer health financing system.

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Could Med Students Help Win the Enrollment War?

State health exchanges are facing many challenges in the recent scramble to enroll their residents in the healthcare marketplace. Among the numerous obstacles, including online systemic glitches (Washington state botched the tax-credit calculation while Maryland’s appears to be having just general technical incompetence) and complete lack of knowledge (according to a recent Gallup poll, 71% of uninsured Americans have no clue what the exchanges are), a critical challenge is the quick generation of a new healthcare workforce, namely enrollment counselors and navigators.

According to the Center for Medicare and Medicaid Services, enrollment navigators are supposed to help people enroll, whether through online or paper applications, determine individual eligibility for various subsidies and assistance programs, and generally educate the public regarding the new health exchanges. Certified application counselors differ slightly from navigators, taking a less involved role in the process, but still serving as assistants to people who need help completing their application.

However, in many states, including Florida (1 navigator per 100,000 uninsured citizens as of October 1st), Georgia (only 4 people were certified to be counselors when the exchanges went live) and California (official numbers will be released on November 14th, but current estimates suggest less than 20% of future counselors are fully certified yet), there is a huge workforce shortage which is both reducing the rate of enrollment and contributing to people’s doubts about the Affordable Care Act in general.

Part of the problem is that many states, for several months now, have purposely made it more difficult for people to become certified enrollment employees; Ohio and Missouri are  widely cited as two of those. They have also instituted regulations on what information counselors can and cannot give patients and have tried to implement large fines, such as in Tennessee, which luckily ruled to temporarily restrain these penalties, for those who may unknowingly breach part of the contract.

As a medical student hoping to be more involved in influencing patient care, but unable to do so at a clinical level just yet, the opportunity to serve as an enrollment counselor or navigator is more than timely.

In my home state of California, training and certification to become a Certified Enrollment Counselor is not easy, but it’s doable. The process involves 20 hours of in-person courses, a number of online modules, and a background check. However, the cost of training is compensated—$58 per completed application, to be exact.

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A Plan B For

It is now becoming clear that the Obama administration will not have fixed by December 1 so hundreds of thousands, or perhaps millions, of people will be able to smoothly enroll by January 1.

Why do I say that? Look at this from the administration spokesperson’s daily progress report on Friday:

Essentially what is happening is people [those working on the fixes] are going through the entire process. As we have fixed certain pieces of functionality, like the account creation process, we’re seeing volume go further down the application. We’re identifying new issues that we need to be in a position to troubleshoot.

Does that sound like the kind of report you would expect if they were on track to fix this in less than three weeks? Their biggest problem is that they admittedly don’t know what they don’t know.

The spokesperson also reiterated the administration intends to have Obamacare’s computer system “functioning smoothly for the vast majority of users” by the end of the month.

It’s time for the Obama administration to get real.

It takes months to properly test a complex data system like this. Two things are obvious:

  1. When they launched on October 1, very little of the testing had been completed.
  2. They are now in the midst of that many months long testing and fixing period. It is clear they don’t have a few weeks of work left; they have months of work left.Continue reading…


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