Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt
For my health care tidbits this week, I am featuring the the Urban Institute report on the uninsured that’s released today. “Between March 2019 and April 2021 the percentage of U.S. adults reporting they had employer-sponsored coverage declined from 65% to 62.3%, a decrease of approximately 5.5 million adults. The share of adults reporting public coverage increased from 13.6% to 17.5% percent, an increase of approximately 7.9 million adults”. So like it or not we are slowly becoming a public health plan nation–of course the public health plan picking up the slack is Medicaid. And that in practice means we are 2 nations. “In April 2021, the uninsurance rate in non-expansion states was more than double that of expansion states (18.2% versus 7.7%)”.
Which means that Texas & Florida (the two big non-expansion states) really don’t care about their people’s health. And taking a look at their governors’ current attitudes towards COVID, you would not be surprised.
Innovation in Medicaid is HAPPENING – and not only is it capable of creating better, less expensive healthcare for Medicaid members, but Cityblock Health is proving that it can also be the underpinning of a business worth over $1B dollars.
Dr. Toyin Ajayi, Cityblock’s co-founder & President, walks through the company’s novel business model, which goes AT-RISK to take care of some of the highest risk patients in all of healthcare. Here’s how it works: the startup contracts with health plans that provide Managed Medicaid services, helps them identify groups of patients that are of highest risk or rising risk, then takes over the financial and clinical accountability for that group. Cityblock then envelopes those members in a suite of highly personalized services that address both their healthcare needs and the social care challenges that are connected to them. In short…Cityblock is a medical practice built at the bustling intersection of value-based care and social determinants of health.
Toyin talks through some examples of the unique challenges facing the 75,000+ members Cityblock works with, particularly what they are learning about what it takes to “earn the right” to provide this population with care. But, is the high-touch, tech-infused core of their model defensible? What stops a huge national Managed Medicaid health plan like Centene or Molina from simply replicating this within their own multi-billion-dollar enterprises? Competition, expansion, funding, and outcomes – we get into it all, and hear Toyin’s near-term vision for Cityblock as it puts the nearly $500M its received in venture funding to work on “transforming the healthcare ecosystem for those who need it most.”
Episode 60 of “The THCB Gang” was live-streamed on Thursday, July 1st. Matthew Holt (@boltyboy) was joined by policy consultant/author Rosemarie Day (@Rosemarie_Day1); THCB Editor and soon-to-be medical student at Yale, and first time #THCBGang participant Christina Liu (@ChristinayLiu) and–making a rare but welcome appearance –venture investor & soccer mogul Marcus Whitney @marcuswhitney We had a great wide ranging chat about Medicaid, venture capital and the unnecessarily excessive rigors of applying to medical school, and what that means for health equity.
The video is below but if you’d rather listen to the episode, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
Mothers deserve more than a day of recognition this year—they deserve the whole month, and more. The pandemic has been particularly hard on women, especially poor women and women of color.
To demonstrate the appreciation mothers deserve this Mother’s Day, we should get them something they really need: health care. To improve maternal health, we should look to the Medicaid program, long a pathway to accessible, quality health care for low-income Americans. Medicaid is especially important for mothers; it covers close to half of all births in the U.S.
Now, states have the opportunity to do even more for moms.
The American Rescue Plan signed into law in March gives every state the option to extend Medicaid maternity coverage for up to 12 months postpartum, a significant increase from the current limit of just 60 days. Illinois has already announced it will extend postpartum coverage; other states should follow. Extending the guaranteed coverage period will increase access to postnatal care during this ‘fourth trimester’ to ensure that women can access treatment for common conditions like postpartum depression as well as preventing organ prolapse or hemorrhage. Not only mothers will benefit. Parental insurance is associated with better health for children, including a lower risk of adverse childhood experiences.
In addition, the American Rescue Plan offers an opening to expand Medicaid with even more federal funding than is currently available through the Affordable Care Act. The 12 states, mostly in the South, that have not expanded their Medicaid programs are leaving hundreds of thousands of women without the support they deserve.
Expanding Medicaid programs will provide robust access to health care to more women and reduce maternal morbidity and mortality, which has reached crisis proportions among many women of color. Black and Indigenous women are more likely than other women to die during pregnancy, childbirth, and the postpartum period. According to the CDC, the maternal mortality rate is 2.5 times higher for Black women than white women. Disparate access and uneven quality of care, higher rates of chronic illness, and racism all play a part in that grim statistic.
The disproportionate burden of maternal mortality and adverse outcomes from childbirth has long-lasting effects on mothers and their children. Black newborns have an increased risk for long-term complications resulting from pre-birth complications. They may also face generational poverty and trauma in the long run if they are born to a mother who dies during childbirth.
If you would like to visit the meeting place of America’s two great contemporary pandemics –COVID-19 and structural racism – you need only visit America’s Nursing Homes.
This should come as no surprise to Medical Historians familiar with our Medicaid program. Prejudice and bias were baked in well before the signing of Medicaid and Medicare on July 30, 1965.
President Kennedy’s efforting on behalf of health coverage expansion met stiff resistance from the American Medical Association and Southern states in 1960. Part of their strategic pushback was the endorsement of a state-run and voluntary offering for the poor and disadvantaged called Kerr-Mills. Predictably, Southern states feigned support, and enrollment was largely non-existent. Only 3.3% of participants nationwide came from the 10-state Deep South “Black Belt.”
Based on this experience, when President Johnson resurrected health care as a “martyr’s cause” after the Kennedy assassination, he carefully built into Medicaid “comprehensive care and services to substantially all individuals who meet the plan’s eligibility standards” by 1977. But by 1972, after seven years of skirmishes, the provision disappeared.
Matthew Holt talks to David Smith who is working on the Medicaid Transformation Project at Avia, which is looking at how hospitals & health plans can improve health outcomes and in turn, lose less money on Medicaid programs. David talks about the tremendous amount of capital being poured into Medicaid, and how the problem is only getting worse. So the focus of the project is trying to reduce healthcare delivery organizations’ spend on these services. At Avia, they are trying to take the best of model science and the best of digital capabilities to help create more efficient care models for their clients as well as reduce costs.
Zoya Khan is the Editor-in-Chief of THCB and a Strategy Manager at SMACK.health
I feel like the healthcare world just skipped over the $17.3 billion mega-merger between Centene and Wellcare, which just received final regulatory approval last Wednesday. With their powers combined, this new company will create the Thanos of government-focused health plans, hopefully without any of the deranged plans to take over the world. I do get it, 181 million lives are covered by employer-sponsored insurance, between full-risk and self-insured plans. These employer populations have the most disposable income and their HR departments are willing to provide supplemental benefits. However, in my opinion, the future growth of health insurance will be governmental programs like Medicare Advantage (MA), Medicaid managed care, and ACA exchanges. But instead of me telling you this, here is exactly what Centene and WellCare said in a press release to defend the merger:
“The combined company would be the leader in government-sponsored healthcare with increased scale and diversification both geographically and in its managed care service offerings, and enhance access to high-quality services for members. It will offer affordable and high-quality products to its more than 12 million Medicaid and approximately 5 million Medicare members (including Medicare Prescription Drug Plan), as well as individuals served in the Health Insurance Marketplace and the TRICARE program. The combined company will operate 31 NCQA accredited health plans across the country and will have increased exposure to government-sponsored healthcare solutions through WellCare’s Medicare Advantage and Medicare Prescription Drug Plans. It will also benefit from leveraging Centene’s growing position in the Health Insurance Marketplace to new markets. The transaction creates a company with the size and scale to better serve members through enhanced healthcare programs, expanded capabilities and increased investment in technology.”
The notion that hospital readmission rates are a “quality” measure reached the status of conventional wisdom by the late 2000s. In their 2007 and 2008 reports to Congress, the Medicare Payment Advisory Commission (MedPAC) recommended that Congress authorize a program that would punish hospitals for “excess readmissions” of Medicare fee-for-service (FFS) enrollees. In 2010, Congress accepted MedPAC’s recommendation and, in Section 3025 of the Affordable Care Act (ACA) (p. 328), ordered the Centers for Medicare and Medicaid Services (CMS) to start the Hospital Readmissions Reduction Program (HRRP). Section 3025 instructed CMS to target heart failure (HF) and other diseases MedPAC listed in their 2007 report.  State Medicaid programs and the insurance industry followed suit.
Today, twelve years after MedPAC recommended the HRRP and seven years after CMS implemented it, it is still not clear how hospitals are supposed to reduce the readmissions targeted by the HRRP, which are all unplanned readmissions that follow discharges within 30 days of patients diagnosed with HF and five other conditions. It is not even clear that hospitals have reduced return visits to hospitals within 30 days of discharge. The ten highly respected organizations that participated in CMS’s first “accountable care organization” (ACO) demonstration, the Physician Group Practice (PGP) Demonstration (which ran from 2005 to 2010), were unable to reduce readmissions (see Table 9.3 p. 147 of the final evaluation) The research consistently shows, however, that at some point in the 2000s many hospitals began to cut 30-day readmissions of Medicare FFS patients. But research also suggests that this decline in readmissions was achieved in part by diverting patients to emergency rooms and observation units, and that the rising rate of ER visits and observation stays may be putting sicker patients at risk  Responses like this to incentives imposed by regulators, employers, etc. are often called “unintended consequences” and “gaming.”
To determine whether hospitals
are gaming the HRRP, it would help to know, first of all, whether it’s possible
for hospitals to reduce readmissions, as the HRRP defines them, without gaming.
If there are few or no proven methods of reducing readmissions by improving
quality of care (as opposed to gaming), it is reasonable to assume the HRRP has
induced gaming. If, on the other hand, (a) proven interventions exist that reduce
readmissions as the HRRP defines them, and (b) those interventions cost less
than, or no more than, the savings hospitals would reap from the intervention
(in the form of avoided penalties or shared savings), then we should expect much
less gaming. (As long as risk-adjustment of readmission rates remains crude, we
cannot expect gaming to disappear completely even if both conditions are met.)
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.
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.