March 14, 2012
1:47 pm
There was a disturbing juxtaposition of news items this week.
First, the Congressional Budget Office came out with new forecasts showing that, under health reform, the number of Americans enrolled in the Medicaid program will be even greater than expected. Even before these new numbers emerged, it was estimated that more than 15 million Americans would be moved into the Medicaid program because of the new eligibility thresholds established by the Patient Protection and Affordable Care Act.
We saw a preview of the potential impact of Medicaid expansion through a study issued by the Annals of Emergency Medicine. The study, authored by Dr. Atil Ginde of the University of Colorado School of Medicine, found that, between 1999 and 2009, 39.6 percent of Medicaid patients visited an emergency room compared to just 17.7 percent of privately insured patients.
The reason, Dr. Ginde determined, that Medicaid patients are more than twice as likely to be in an ER is because not only are they in poorer health generally, but they are less likely to be seeing a primary care physician. This situation is not likely to improve once health reform is fully implemented. In fact, it could severely worsen. As Dr. Ginde put it, “Our findings are particularly worrisome in light of the additional 16 million people who will be added to the Medicaid rolls over the next decade. The shortage of primary care providers in the U.S. seems to affect Medicaid patients disproportionately and more harshly.”
And, I would add, Medicaid’s significantly lower reimbursement rates compared to private insurance make it even more difficult for physicians to see Medicaid patients.
If the CBO trends, showing fewer people receiving employer-based private coverage and more individuals enrolled in Medicaid, continue, policymakers are going to have to revisit the mechanisms being used to provide Americans with health coverage.
October 28, 2011
9:38 am
As a study published in Health Affairs this week points out, anyone who believes they have a handle on what will happen when Medicaid undergoes an unprecedented expansion this decade is kidding themselves.
The study by a trio of professors at Harvard University’s School of Public Health shows a huge possible variation in the number of low-income Americans who enroll in Medicaid once eligibility is expanded in 2014 to include anyone below 138 percent of the federal poverty level. The expansion, according to the researchers, could be as low as 8.5 million individuals or as high as 22.4 million, with a range of possible federal spending increases from $34 billion to $98 billion annually.
What I find particularly interesting about this study, though, is the projected impact on healthcare utilization. Because Medicaid has lower cost-sharing than private insurance, there is an expected increase in the demand for health services among those who move from private plans to Medicaid once eligibility levels change. Between the larger Medicaid population and this increased utilization, the Harvard researchers say the U.S. will need anywhere from 4,500 to 12,100 additional physicians to care for new Medicaid patients.
Here’s a critical passage in the report:
“These changes may pose major challenges in healthcare access because in recent years an increasing number of physicians have stopped accepting Medicaid patients. The Affordable Care Act does provide enhanced Medicaid reimbursement to primary care clinicians for 2013-2014, but this may not be enough to ensure an adequate supply of providers for new Medicaid patients.”
Some of us have continued to argue that coverage does not necessarily mean access. It is, without question, vitally important to provide coverage for the nation’s uninsured population, but it’s still an open question as to whether Medicaid expansion is the most effective tool for doing so.
August 19, 2011
8:05 am
The Healthcare Leadership Council has never endorsed candidates for public office and we’re not going to start doing that now. I have to say, though, that there is a tangible benefit to Texas Governor Rick Perry (R) announcing his candidacy for President. It presents an opportunity to have a real debate about the merits of medical liability reform.
In his campaign, Perry will undoubtedly talk about the gains Texas has realized since its state legislature passed a measure capping non-economic damages in medical liability suits. Conversely, pundits and bloggers have already started taking shots at Lone Star-style tort reform ever since Perry announced his run for the White House.
A good example was found this week in The Incidental Economist blog. Relying heavily on the work of the interest group Public Citizen, a virulently anti-tort reform organization, the blog makes the case that Texas liability reform has not succeeded in reducing healthcare costs or the number of uninsured citizens.
Those opposed to tort reform tend to make these apples-and-oranges arguments. It’s akin to saying, if reforms make my car insurance premiums go down, shouldn’t I also have safer roads and better gas mileage. The fact is that malpractice insurance premiums and the costs associated with defensive medicine are just two components in the overall healthcare cost equation. (A logical question would be, what would healthcare costs be in Texas had tort reform not been enacted.)
And, as for the uninsured population, Sarah Kliff, formerly of Politico and now with the Washington Post, does a nice analysis here regarding the reasons Texas has a relatively high number of uninsured citizens.
Another piece worth reading is an op-ed in the New York Post this week, written by a Texas tort reform advocate, about the number of New York doctors heading south because of New York’s high malpractice premiums. The op-ed tells the story of an obstetrician whose medical liability premiums were heading toward $200,000 per year, making it impossible to continue to do business.
Now, Texas patients benefit from the services of that doctor and over 1,200 other physicians that have made the New York-to-Texas exodus since the latter state passed liability reform.
With the study released this week in the New England Journal of Medicine showing that three-fourths of the nation’s physicians will likely be sued at some point in their career – with a 99 percent probability in the high-risk specialties – let’s hope that Governor Perry’s candidacy does indeed ignite a national debate over the need for medical liability reform.
November 11, 2010
4:37 pm
The Washington Post and New York Times are ablaze today with top-of-the-page headlines about the proposals being made by the co-chairs of President Obama’s bipartisan commission on deficit reduction. There may be a bit of an overreaction to the draft report since there’s no assurance it will receive the necessary support of 14 (out of 18) commission members, and Congress is under no obligation whatsoever to adopt the proposals.
Nonetheless, the commission co-chairs Erskine Bowles, former chief of staff to President Clinton, and former U.S. Senator Alan Simpson deserve credit for taking on the tough task of trying to curb the nation’s burgeoning red ink. Their report doesn’t hesitate to put some political sacred cows on the chopping block in the name of deficit reduction.
The healthcare provisions of the co-chairs’ proposals illustrate the difficulty in trying to reconcile two very important goals Americans want to see achieved – reducing deficit spending and improving our U.S. healthcare system. The Bowles-Simpson report illustrates how difficult it is to achieve one without potentially undermining the other.
For example, the draft report calls for the creation of a public health insurance option, a policy notion that Congress soundly rejected in the health reform debate. As we’ve discussed ad nauseum, a public option will certainly drive down payment rates to physicians and hospitals, but those costs would then be shifted to private payers. And a public option with arbitrarily-low costs would reduce the amount of competition in the insurance marketplace, a development that wouldn’t serve consumers well.
The report calls for strengthening the Independent Payment Advisory Board to an even greater degree than called for in the new health reform law. This would create an even more potent entity in terms of simply axing healthcare spending, but without a focus on how to elevate healthcare value.
The report says doctors and other health providers will have to be paid less. At the same time, we’re faced with the need to recruit more people into the medical profession to deal with the tens of millions of newly-insured Americans entering the system.
Yes, there is an urgent need to address the nation’s rising deficits, and the health sector has to do its part. But, understanding the challenges we’re facing in the years ahead, with one in every three Americans expected to have diabetes by the year 2040 and other chronic diseases on the rise, we have to look at the healthcare system as more than just numbers on a balance sheet.
Work needs to accelerate on delivery reform, on payment reform, on changing the tort system (which, to their credit, the commission co-chairs recommend) to reduce defensive medicine costs, on attacking the chronic diseases that account for 75 cents of every health dollar we spend.
But deficit reduction and quality healthcare should not be treated as an either-or choice. The commission’s work is an essential exercise in numbers, but we can’t forget the real patients and consumers who would be affected.
August 13, 2010
9:53 am
We should be concerned about a report this week in the Journal of the American Medical Association (JAMA), which presents a picture of increased crowding in the nation’s hospital emergency rooms, with Medicaid patients making up the lion’s share of the rising demand for ER services.
According to JAMA:
• The number of patients visiting emergency rooms rose from 95 million in 1997 to 117 million in 2007. This 23 percent increase in a decade significantly exceeds what could have been reasonable expected based on population growth.
• In 1999, there were almost 694 ER visits, on average, for every 1,000 Medicaid enrollees. In 2007, there were over 947 visits for every 1,000 individuals on Medicaid.
• The ER visit rate stayed relatively stable over that time period for Medicare patients, the privately insured and even the uninsured, telling us that Medicaid beneficiaries are driving the growth in emergency room traffic.
With Medicaid expansion playing such an important role in the implementation of health reform and the projected decline in the nation’s uninsured population, the JAMA study takes on great importance. Because Medicaid pays such comparably low reimbursement rates to physicians, many doctors won’t see Medicaid patients. This increase in patient traffic has caused ER wait times to jump by 50 percent during the 1997-2007 period examined in the study.
As the study’s authors wrote, it is a “critical concern” how emergency rooms are going to deal with the 16 million Americans who are expected to be added to Medicaid rolls once health reform is fully implemented.
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