Sepsis has a higher rate of readmission than heart failure, but the federal government does not penalize hospitals for excessive readmissions due to sepsis.
Despite being the number one killer of hospital patients, a factor in late deaths, and leading cause of hospital readmissions, sepsis is not used by the federal government as a measure for care quality and reimbursement penalties, according to a study by the University of Pittsburgh School of Medicine and VA Pittsburgh Healthcare System.
"One thing we know is that patients who do get sepsis get rehospitalized very frequently," said lead author Florian B. Mayr, MD, faculty member in Pitt's Department of Critical Care Medicine and the Center for Health Equity Research and Promotion at the VA Pittsburgh.
The Centers for Medicare & Medicaid Services tracks and penalizes hospitals for excessive readmissions for heart attack, heart failure, chronic obstructive pulmonary disease, and pneumonia.
"Sepsis has always been under-appreciated. It's well known among intensivists," he says. "We know how commonly we see sepsis in the hospital, and particularly in the intensive care unit. But people have not taken as much notice as when you talk about heart failure or pneumonia."
For their study, Mayr and his colleagues analyzed data from the 2013 Nationwide Readmissions Database, which comprises 49% of U.S. inpatients, for the four conditions and sepsis. They found that sepsis accounts for 12.2% of readmissions, followed by 6.7% for heart failure, 5% for pneumonia, 4.6% for COPD and 1.3% for heart attack.
The estimated average cost per readmission for sepsis was $10,070, compared to $9,533 for pneumonia, $9,424 for heart attack, $9,051 for heart failure and $8,417 for COPD.
"The awareness is definitely increasing, and our study and other recently published studies make the repeated point that this is a big problem," Mayr says.
"Maybe adding it to the Hospital Readmissions Reduction Program may fuel incentives and innovation to reduce unplanned or avoidable readmissions and the associated costs."
The study was published this month in the JAMA, and Mayr says the findings highlight the need for coordinated efforts to develop new medical interventions aimed at improving sepsis outcomes and reducing readmissions.
"If we, as a nation, place such high emphasis on reducing readmissions for the other four conditions, then we really need to look for opportunities to improve outcomes for sepsis, which has a higher rate of readmission than heart failure," Mayr says.
"People who survive an initial episode of sepsis often don't do well. They return to the hospital frequently, accrue new health conditions, and have significantly elevated death rates."
The National Institutes of Health estimates that sepsis may occur in more than 1 million U.S. patients every year, and that between 28% to 50% of these patients do not survive. Patients who survive the condition often continue to suffer related health problems.
"Many people think infections and sepsis are short-term illnesses and that once patients are discharged from the hospital, they are better," said study senior author Sachin Yende, MD, associate professor in the Pitt School of Medicine and vice president of Critical Care at the VA Pittsburgh.
"But all research to date shows that sepsis has serious, lingering consequences, and patients continue to have problems well after they are discharged."
Mayr says the study provides "another building block" in the case for using sepsis as a quality measure. "Maybe it's time that we take it to the same level as pneumonia, heart attacks and heart failure and work on incentives that improve outcomes."
Americans living in rural areas are more likely than urban dwellers to die from preventable afflictions. A move by the Trump administration and Congress to consider block grant funding for Medicaid could threaten the means to address these rural health issues.
Two stories this month illustrate the dire needs and perilous status of healthcare delivery in rural America.
First, the Centers for Disease Control and Prevention has issued a new report that shows that many of the 46 million or so people living in rural America, roughly 15% of the population, are more likely than their urban counterparts to die from five preventable diseases.
According to CDC, potentially preventable deaths in 2014 included 25,000 from heart disease, 19,000 from cancer, 12,000 from unintentional injuries, 11,000 from chronic lower respiratory disease, and 4,000 from stroke.
The percentages of potentially preventable deaths were all higher in rural areas than in urban areas. The findings were detailed in a new rural health series in CDC's Morbidity and Mortality Weekly Report.
Furthermore, unintentional injury deaths were 50% higher in rural areas than in urban areas, due in part to motor vehicle crashes and opioid abuse. Making matters worse is the challenge of accessing trauma care and emergency medical services in remote, sparsely populated areas.
"This new study shows there is a striking gap in health between rural and urban Americans," said CDC Director Tom Frieden, MD, in commentary accompanying the report. "To close this gap, we are working to better understand and address the health threats that put rural Americans at increased risk of early death."
None of this is surprising. This column has written extensively over the years about the special health needs for rural Americans and the challenges of delivering coordinated, effective care to these underserved areas.
Numbers of studies and population data have shown us that people living in rural areas generally tend to be older, sicker, poorer, less likely to have health insurance, and have less access to care than their urban counterparts. In addition, they are more likely to use tobacco, more likely to be obese, and more likely to have the health issues associated with overweight, including high blood pressure.
A Call for Block Grants
The grim CDC findings were released amid reports that the Trump Administration and Republicans in Congress will attempt to shift Medicaid to a block-funding program.
It's expected that such a shift would mean considerable cuts to federal match funding for Medicaid, which President Trump pledged he would oppose during the campaign. Proponents say that block grants reduce fraud and waste and give states more flexibility to fashion Medicaid programs that fit their needs.
Skeptics remain concerned, however, that the block grant proposal is a ruse designed to shift costs to states.
"While we strongly support maintaining and increasing flexibility for states proposals that suggest states be provided with more flexibility and control must not result in substantial and destabilizing cost shift to states," Massachusetts Republican Gov. Charlie Baker said in a Jan. 11 letter to Congress.
"We are very concerned that a shift to block grants or per capita caps for Medicaid would remove flexibility from states as the result of reduced federal funding," Baker wrote. "States would most likely make decisions based mainly on fiscal reasons rather than the healthcare needs of vulnerable populations and the stability of the insurance market."
Baker suggested in his letter that every state's current federal/state share for Medicaid, which can range from 80/20 to 50/50, serve as a baseline for any reforms.
Be Afraid
Count me among the skeptics.
States already have flexibility to create Medicaid waiver programs, as Gov. Baker and former Indiana Republican Gov. Mike Pence, now the vice president, can attest. Block grants provide political cover in the name of states' rights and flexibility, when their real purpose is to reduce federal expenditures, which Congress will need to offset the loss of revenue from proposed tax cuts.
The Trump Administration and Congress have already begun dismantling the Affordable Care Act with no alternative plan in place, which would dramatically reduce the numbers of Medicaid enrollees.
Now they want to radically refashion the federal funding mechanism for Medicaid, which very likely will reduce funding, and impede access to healthcare that rural Americans so desperately need.
A Cleveland Clinic study finds that patient advocacy groups often receive funding from for-profit industry, raising questions about independence and conflicts of interest.
In the name of transparency, Sunshine Laws have required physicians, academic medical centers and other providers to disclose funding from for-profit companies. Non-profit patient advocacy groups have been ignored.
A national survey of 439 patient advocacy groups, led by Cleveland Clinic bioethicist Susannah Rose, PhD, found that 67% receive funding from for-profit companies, with 12% receiving over half of their funding from industry. The research was published in the Jan. 17 issue of theJournal of the American Medical Association Internal Medicine.
Rose spoke with HealthLeaders Media about her findings. The following is a lightly edited transcript.
HLM: What prompted this study?
Rose: There were to things that came together for me. I worked with cancer patients at Sloan Kettering for about a decade as a social worker. I linked up with hundreds if not thousands of patients with these advocacy organizations for education, counseling and a lot of things.
When I started to do more research on conflicts of interest when I went to Harvard, I realized there were a lot more investigations related to industry funding of clinical and medical research and physicians and academic medical centers, but I didn't find anything related to patient advocacy groups, despite their powerful role in the biomedical realms of policy making, research, and direct patient care.
HLM: Why have PAGs received no scrutiny?
Rose: In the last decade there has been attention from the media who have looked into these issues more on a case-by-case basis. To my knowledge, before this there were no systematic, scientific, published studies looking at this in the United States.
I think a lot of people just assumed that these non-profit advocacy groups are independent and aren't aware of their industry funding.
HLM: Are for-profit companies using PAGs to exploit the public trust that these groups hold?
Rose: I can't speak on the industry perspective because we didn't look at in this study. However, you can find them quite easily. There are reports published in the marketing literature written by industry representatives who use that approach.
HLM: Relatively speaking, it's not a lot of money, but it seems like PAG funding provides lot of bang for the buck.
Rose: That's right. There are a couple of surprising things about this to me. Two-thirds of patient advocacy groups have industry money. The second issue is that on average, the amounts are not overwhelming in terms of the median amounts.
However, if you look at subgroups, for example [you'll see that] 12% receive over half of their funding from industry. If you are worried about the independence of these organizations, you might be worried about their dependence on certain funding sources.
Receiving more than half of one's funding from industry may be a concern for questioning an organization's independence.
HLM: Has this reliance on industry money been used improperly?
Rose: Our paper doesn't disclose names because of confidentiality. We did include three citations in the discussion section of the paper that focused on the American Diabetes Association, the National Alliance of Mental Illness, and the American Pain Foundation, using journalists who looked at, for example, the American Diabetes Association and their role with Cadbury and other food companies and putting their logo on sugary snacks, things that may not be so good for people with diabetes.
Another concern is the mental health and pain groups that testify in Food and Drug Administration committees in support of approvals for certain medications, but they receive funding from that exact company that makes the medication, and that isn't being disclosed.
There is also the issue of looking for coverage for insurance companies, Medicare and private insurers, to cover very expensive but maybe even potentially harmful medications to certain populations. NAMI in particular was involved in the controversy over the black box warnings with SSRIs and their use in adolescents.
HLM: Should PAGs have uniform disclosure requirements?
Rose: I think so. In terms of disclosure, the only and best way to do this is to set a standard that all of them must meet, for instance, including in the Sunshine Act that currently reports industry funding to all physicians and academic medical centers and some other medical entities.
The Institute of Medicine actually suggested that quite a long time ago in their report on conflict of interests, but the Sunshine Act excluded patient advocacy groups from this legislation.
Industry groups are unlikely to be motivated to do this on their own because, if one organization does it and another one doesn't, it diminishes the returns on being transparent.
The policy advancements on this would be to make standardizations across all nonprofits, including patient advocacy groups.
HLM: Who would do this?
Rose: Congress. They could amend the Sunshine Act, especially as we are not talking about revisions to the Affordable Care Act. It may or may not be possible now given the current political environment. On the other hand, the ACA is open for a lot of potential changes and the Sunshine Act is a provision under the ACA.
HLM: Your study suggests that PAGs would welcome more transparency.
Rose: They would like to learn how to strengthen their policies. These advocacy groups do great things. They drive research. They raise awareness to important issues that maybe nobody would be paying attention to.
They have to get money from somewhere, and industry funding is a main source of income. The question is how can we help them be transparent, and how can they maintain their independence? Because, if they lose public trust, then I worry that we lose a major voice for patients in the public arena.
State and federal officials in the Keystone State this month unveiled the Pennsylvania Rural Health Model. The question to be answered is whether a predictable, fixed funding source will provide sufficient stability to financially stressed rural hospitals.
Pennsylvania has become the latest state to take action to address the plight of rural healthcare.
Gov. Tom Wolf and state and federal stakeholders this month unveiled the Pennsylvania Rural Health Model, a comprehensive, statewide pilot project to improve access to care delivery and population health outcomes.
Under the seven-year pilot project, which went into effect last week and ends in December, 2023, as many as 30 rural critical access and acute care hospitals across the state that opt in will be paid a fixed all-payer global budget that is set in advance for inpatient and outpatient services.
They will also receive monthly Medicare fee-for-service payments and payments from commercial plans.
The Pennsylvania model is the latest in a string of innovative all-payer pilot projects designed by states with the support of the Centers for Medicare & Medicaid Services.
In 2014, Maryland launched an all-payer model that transitions to global payments rewarding value over volume. Last October, Vermont unveiled an all-payer accountable care organization model. CMS has designated Pennsylvania as a Round 2 Design State that could serve as a model for other states considering an all-payer project.
The question to be answered in this pilot program is whether this predictable, fixed funding source will provide sufficient stability to financially stressed rural hospitals that will allow them to transition into a value-based care delivery model designed to meet the specific needs of the communities they serve.
Jeffrey Bechtel, senior vice president for health economics and policy at the Pennsylvania Hospital & Health System Association, calls the model "a paradigm shift, and a move away from fee-for-service with the benefit of a predictable budget."
"The thought here is to transform the way that hospitals operate," he says.
"Rather than being on the hamster wheel of fee-for-service, they will have a predictable budget. They will be required to submit a transformation plan that will allow them to redesign their care delivery to focus on outpatient services and eliminate subscale inpatient services and ultimately share in the value creation."
CMS has provided $25 million in seed money that will be used for data analytics, quality assurance, and technical assistance. CMS and Pennsylvania policymakers will also help local hospitals fashion care models that address the specific needs of their service area.
These innovative programs that empower states to identify and address their specific healthcare needs have been coordinated through the CMS Innovation Center, a creation of the Affordable Care Act, which Congress and the Trump Administration have vowed to repeal. (The nonpartisan Congressional Budget Office this week provides a chilling report on the likely fallout.)
Gov. Wolf and Stephen Cha, MD, director of state innovations at the CMS Innovation Center, said at a media availability last week that the Pennsylvania model will survive even if Congress repeals the ACA.
"The agreement being signed today for this partnership is being signed by the state of Pennsylvania and the federal government, not an administration. We intend to uphold that agreement," Cha said.
"Our excitement about entering into this partnership is predicated on the strength in the model and our belief that this is the right pathway to travel for rural areas all across the country."
Wolf said the Pennsylvania model could provide a road map for improving care access across rural America. "Whether the new administration agrees with the current administration that Pennsylvania or this particular program is right, we are doing something that really transcends any one administration."
This pilot program isn't about just promoting population health. It's about improving the financial health of hospitals and the economic stimulus they spark in rural Pennsylvania.
Hospitals 'Essential' to PA Communities
"About half of Pennsylvania's hospitals lose money on patient care," Bechtel says. "One-in-three have negative total margins. Thirty percent of Pennsylvania's rural hospitals have negative three-year average total margins, and rural hospitals across the Commonwealth have observed declining margins of approximately 5% per year since 2011."
To address this worsening financial climate, hospitals have had to cut back on services. Since 2000, for example, one-third of hospitals in the state have closed their OB units.
About 70% of Pennsylvania is rural, and 20% of the population lives in rural areas. Bechtel says rural hospitals provide access to care for about 1.8 million Pennsylvanians.
In two-thirds of Pennsylvania's designated 48 rural counties, hospitals are among the top five employers. In 14 of the counties, hospitals are the largest employer.
"Not only are these rural hospitals the primary source of care access for their service area, they are often a critical economic driver for the region," Bechtel says.
"Rural hospitals support nearly 50,000 family-sustaining jobs across rural Pennsylvania. That is 27,200 through direct employment plus another 20,300 created in local economies through the economic stimulus of rural hospital spending. The bottom line is that hospitals are essential to their communities."
Standard & Poor's says the outlook for the not-for-profit healthcare sector will be stable in 2017, but the forecast comes loaded with caveats.
The uncertain future of the Affordable Care Act, Medicare and Medicaid is making bond rating agencies anxious.
Standard & Poor's Global Ratings has extended its stable outlook for the not-for-profit healthcare sector in 2017, but not without trepidation.
"This is one of the more difficult decisions we've made," Kevin Halloran, senior director at Standard & Poor's Global Ratings, said in a recent media conference call.
"Everything we look at from a numbers standpoint almost demands a 'stable,' and yet there is a sense in the pit of your belly that maybe the sector isn't as stable as the numbers might indicate," he says.
"We are about to experience a shift in administrations and Congress and some of those changes could be very large and very impactful to the sector and could happen very quickly."
Health systems continue to do better than stand-alone hospitals.
"That's one leading indicator that if you are a little bit smaller, you're a little bit more constrained and you might not succeed going forward," Halloran says. "And secondly, the fairly robust pace of upgrades to downgrades that we saw in '16 appears to be slowing a little."
"As we look forward, it's our belief that the sector has peaked," he says.
"The ACA and its impact along with what hospitals and health systems were going to constrain expenses all came together in 2015. We saw volumes go up. We saw payer mixes improve. We saw upgrades outpacing downgrades, and that really flowed through 2016."
The first three quarters of 2016 were a positive trend with respect to upgrades, but that flat-lined in the fourth quarter, with 11 upgrades and 11 downgrades.
"One quarter does not a trend make," he says. "There was a lot of robust activity in 2015 and it bled into early 2016."
Weakness Coming?
"It appears that this is one of those data points that is starting to say 'there could be some weakness coming in the sector.' It backs up our opinion that we think the sector has peaked from a numeric standpoint. It's hard to hang your hat on these two data points: systems doing better than stand-alones, [and] fourth-quarter results with an even split in upgrades and downgrades. But it is factoring into our thinking."
Martin Arrick, managing director of S&P's Global Ratings' not-for-profit healthcare portfolio, says "healthcare has never been more complicated than it is now" in large part because of the potential for radical change with the repeal of the Affordable Care Act, and major overhauls to Medicare and Medicaid.
"There now is this huge overlay of legislative risk," he says. "We're concerned, and obviously we are going to monitor it fairly closely. It could be traumatic and it's unclear how quickly it could happen."
ACA Equivalent Unlikely
Arrick says it's hard to speculate on what would replace the ACA, because neither the Trump Administration nor Congress have offered any details.
"Obviously, everybody in the field is like 'OK, you've got to replace it with something that creates the same amount of healthcare for the same amount of people,' and I guess we're all feeling that is very unrealistic in terms of expectations," he says. "If it was easy it would have been done already."
Arrick says it's likely that the ACA will be repealed without an equivalent plan in place.
"Our expectations from a credit quality perspective is that there will be huge revenue losses for hospitals and healthcare systems, and in theory there will be some expense reductions because fewer people will be accessing the system as frequently as they are now. That could be a plus or a minus. Our sense is it's likely to be a minus."
With Medicaid expansion, for example, the numbers of uninsured went down and the numbers of insured went up, both of which were credit positives for hospitals and health systems expansion states. It's likely those positive trends could be reversed if Medicaid is swapped out for a block grant program, as some in Congress have proposed.
"That may be revenue-neutral on Day One," Arrick says. "Over time, as medical inflation rises and it's historically always been rising faster than consumer price inflation, our expectation is that some sort of block grant program would not truly capture the increase in costs, and it's like a yearly inflator that fails to keep up over time. It would worsen Medicaid reimbursements."
Block Grants Concerning
Beyond that, Arrick noted that Medicaid is a counter-cyclical program. When states are in recession, Medicaid rolls tend to increase, more federal money comes into the states through the Medicaid program and it has a counter-cyclical impact on the economy.
"With a block grant situation, while we haven't seen the legislation, we have a concern that that mechanism would no longer function as effectively as it does now," Arrick says.
With respect to the proposed Medicare premium support programs, Arrick says the expectation is that vouchers will push more and more costs onto elderly Medicare enrollees.
"I don't know how that would work for providers," he says. "Our expectation is that over time that will contribute to weaker revenues and weaker performance at the provider level."
The Healthcare Leadership Council outlines steps to stabilize the health insurance market, intensify the fight against chronic disease, and accelerate health data interoperability.
The Healthcare Leadership Council has provided a policy agenda for 2017 to the incoming 115th Congress and the Trump administration and urged them to embrace "the opportunity to continue and accelerate the profound transformation of our healthcare system to benefit all Americans."
HLC describes itself as a coalition of chief executives from hospitals, health plans, pharmaceutical companies, device manufacturers, and other segments of the healthcare industry.
"All Americans deserve better healthcare," the letter says. "Fortunately, there is consensus around what "better" means: lower costs, higher quality, greater efficiency, and an improved experience for patients and their families," HLC said in an executive summary.
"A new presidential administration and Congress have the opportunity to make real progress toward achieving that vision, and there are several things we can do right now—quick fixes that build on the successes of the recent past and the robust spirit of innovation seen in every sector of healthcare. There's no need for 30 more years of debate! These actions are achievable and transformative."
The policy recommendations include:
Increasing investments in comprehensive, evidence-based wellness practices that will reduce healthcare costs and improve quality of life.
Achieving system-wide health information interoperability by Dec. 31, 2018.
Reforming the federal fraud and abuse legal framework to enable multi-sector collaborations that will strengthen value-based healthcare efforts.
Strengthening the healthcare workforce by expanding interstate licensure, allowing healthcare professionals to practice to the full extent of their training, and increasing federal funding for graduate medical education.
Taking action to expand the use of telehealth in all accountable care models, managed care, Medicare Advantage, and fee-for-service plans.
Harmonizing federal and state patient privacy laws and regulations to enable the interstate flow of healthcare data.
HLC also recommended a series of near-term actions to stabilize and improve the non-group health insurance market. These include greater flexibility for health plans to design affordable products, creation of platforms that will enable health insurance consumers to compare coverage plans the way they do other consumer goods, curtailing special enrollment periods that contribute to market instability, and granting states the flexibility to establish network adequacy standards.
Federation of State Medical Boards says it's ready to work with the new administration on medical license portability and better state-federal coordination to curb opioid abuse.
Improving medical license portability, removing barriers to telemedicine, and better state-federal coordination in battling opioid abuse are among the top priorities identified by the Federation of State Medical Boards in a letter this week to President-elect Donald Trump.
The FSMB is ready to work with the incoming administration "to ensure that state medical boards continue to play a central role in shaping the future of medical regulation by protecting the public and promoting quality healthcare in the United States," FSMB President/CEO President Humayun J. Chaudhry, DO, said in the letter.
The federation, a non-profit organization comprising 70 state medical and osteopathic licensing and disciplinary boards in the U.S. and its territories, identified four areas that it hopes to act on with the cooperation of the Trump Administration. They are:
Encouraging the work by states to support medical license portability by enacting the Interstate Medical Licensure Compact, which expedites physician licensure that expands access to healthcare, especially in rural and underserved communities.
Strengthening a shared commitment to remove barriers and accelerate access to telemedicine services, especially for military personnel and veterans, in a safe and accountable manner.
Continuing to work with the Centers for Disease Control and Prevention, Drug Enforcement Administration, Food and Drug Administration, Office of National Drug Control Policy, and the Substance Abuse and Mental Health Services Administration to combat opioids abuse, while also balancing access for patients with legitimate needs.
Acknowledging the value of state medical boards in protecting the public and expressing concern about federal interference with states' medical regulatory autonomy.
"The FSMB welcomes the opportunity to work with your Administration on these priorities, as well as initiatives focused on promoting quality health care in the United States," Chaudhry wrote.
The Milken Institute School of Public Health at the George Washington University and The Commonwealth Fund offer some troubling projections if Congress repeals just two key provisions of the Affordable Care Act.
Repealing the Patient Protection and Affordable Care Act without first providing at least some inkling of what will replace it could threaten one of the most dynamic job creation machines in the U.S. economy, a report suggests.
The U.S. economy created more than 2.1 million jobs in 2016, of which 421,700 were within the healthcare sector, according to preliminary figures from the Bureau of Labor Statistics.
That means that the healthcare sector accounted for 20% of all new jobs in 2016. That includes about 260,000 new jobs in ambulatory services, and 139,000 new jobs in hospitals; a little more than 35,000 new jobs per month, a pace down slightly from the 471,600 healthcare jobs created in 2015, BLS data show.
Since 2010, the year that the "job-killing" Affordable Care Act was signed into law, BLS data show that the economy created 15.2 million jobs, of which 2 million were in healthcare, representing nearly 13% of all jobs created in a six-year span of sluggish job growth in the slow emergence from the Great Recession.
Generally speaking, healthcare jobs are good jobs, particularly in economically depressed areas where decent jobs are scarce and it's not uncommon for the local hospital to be one of the largest employers in the region.
Healthcare jobs provide a clean and safe working environment and they pay better than other sectors, particularly for skilled clinicians and administrators.
They tend to offer decent benefits, including health insurance, which means that the public doesn't have to subsidize labor costs (at least not directly) as it often does in the service industry for low-end retail and fast food workers
About 60 cents or more of each healthcare dollar goes toward employee compensation. That's money that is often immediately circulated back into local economies in the form of car payments, groceries, durable goods, movie tickets, restaurant tabs, and property and sales taxes.
Of course, there are downsides to high job growth in healthcare. The United States spends far more on healthcare than any other advanced nation on earth. The approximately $3.2 trillion in healthcare expenditures each year accounts for nearly 18% of the gross domestic product. Every dollar spent on healthcare is one dollar that is not spent on education, or infrastructure, or public safety or other vital needs.
Projected Consequences of Repeal
President-elect Donald Trump and the Republican-controlled Congress have vowed to repeal the ACA as soon as possible, even though they have no plans for how to replace it.
With that in mind, a study from the Milken Institute School of Public Health at the George Washington University and The Commonwealth Fund offers some troubling projections if Congress repeals two key provisions of the ACA: Medicaid expansion; and the premium tax credits used to subsidize health insurance premiums for low- and middle-income people.
According to the study, if just those two provisions are eliminated:
About 2.6 million jobs will be lost across all 50 states and the District of Columbia in 2019. Job losses would affect every state, but 10 would suffer the biggest hits: California (334,000 jobs), Florida (181,000), Texas (175,000), Pennsylvania (137,000), New York (131,000), Ohio (126,000), Illinois (114,000), Michigan (102,000), New Jersey (86,000), and North Carolina (76,000).
One-third (912,000) of the total 2.6 million job losses would be concentrated in healthcare; nurses, health technicians, and other medical personnel would likely be laid off in 2019. The remaining two-thirds of losses would be in other industries, including construction, real estate, retail trade, finance, and insurance.
Gross state product, the state equivalent of national gross domestic product, could fall by $256 billion in 2019 alone. From 2019 to 2023 that same economic indicator could drop by $1.5 trillion.
The resulting economic disruption could trigger reductions in state and local tax revenues, amounting to $48 billion lost over five years.
State and local governments would get hit with shrinking tax revenues at the same time they are facing increased demand for healthcare services from the millions of people losing their health insurance. States could be juggling painful choices about what services to cut or whether to raise tax rates to maintain a safety net for their residents.
All states could suffer economic distress if the Medicaid expansions are cancelled—even the 19 states that have not expanded the program. That's because the economic benefits of Medicaid expansion flow across state lines: businesses and individuals who benefit from the economic growth buy goods and services not only in their own states but also in other expansion and non-expansion states.
By all means, let's have a debate on the Affordable Care Act. Congress and the Trump Administration should try to find a workable alternative, or improve upon what's already out there. Vice President-elect Mike Pence, for example, implemented a market-based Medicaid expansion in Indiana when he was governor there. We can debate the merits of the plan, but at least it appears to be a legitimate attempt to find a solution.
It is ridiculous to argue, however, that it's sound, responsible public policy to repeal the massive, sweeping, complicated ACA without an inkling of how you'll replace it.
In the coming weeks, expect to see more studies and projections about the potential for disaster if the ACA is taken out with nothing to replace it.
As Republicans in Congress prepare to make good on their promise to repeal Obamacare, new data provides a snapshot of the nearly 20 million people who gained health insurance under the landmark legislation.
Sometimes, numbers speak louder than words.
A report from the Robert Wood Johnson Foundation and the Urban Institute provides a granular look at the 19.2 million people who've gained health insurance coverage from 2010-2015 under the Patient Protection and Affordable Care Act.
For all its warts and pimples, Obamacare has reduced the number of uninsured Americans to historic lows, even in the 21 states that refused to expand their Medicaid programs, and which often did little or nothing to support health insurance marketplaces selling commercial plans within their jurisdictions.
The Urban Institute census comes just as a Republican-controlled Congress is preparing to repeal the ACA and replace it with some vaguely worded alternative that will take effect at some as-yet undetermined date.
The timing is not by accident.
"This is something that we began after the elections," says Anuj Gangopadhyaya, a research associate at the Urban Institute and a co-author of the study.
"We thought this would be a great moment to re-assess and talk about where the ACA coverage gains have been realized throughout this country. There isn't any spinning going here. These are the numbers. We just wanted to lay them out and see what the data tells us, and the data speaks for itself."
Before Obamacare is repealed, let's look at some of the key findings taken from the Urban Institute study:
An estimated 19.2 million nonelderly people gained health insurance coverage from 2010 to 2015.
Coverage gains were broad-based; the number of uninsured fell substantially among all Americans under age 65, for both men and women, and across subgroups based on race/ethnicity, levels of educational attainment, and states.
An estimated 2.8 million children from birth to age 18 gained coverage, suggesting that coverage expansions under the ACA and other policy changes for children's coverage implemented from 2010 to 2015 reached children in families above the progress made by prior expansions targeting low-income children.
The number of uninsured adults ages 19 to 34 declined by 8.7 million (42%), and the number of uninsured adults ages 35 to 54 declined by 5.6 million (33%). More than 2 million adults ages 55 to 64, who are at or approaching typical retirement ages, gained coverage from 2010 to 2015. Approximately 5 million women of childbearing age (19 to 44 years old) gained coverage from 2010 to 2015.
Among those gaining coverage from 2010 to 2015, 8.2 million (43%) were non-Hispanic white, 2.8 million (15%) were non-Hispanic black, 6.2 million (32%) were Hispanic, and 2.0 million (10%) were other non-Hispanics.
Americans in every state gained health insurance coverage. States that expanded Medicaid under the ACA saw larger percentage reductions in their number of uninsured residents than did states that chose to not expand Medicaid (45% compared with 29%). Nonetheless, 6.9 million people living in states that did not expand Medicaid gained health insurance.
California's uninsured rate fell 53.4%, translating into 3.8 million people gaining coverage. More than 2.3 million people gaining coverage from 2010 to 2015 lived in the Midwestern states of Illinois, Michigan, Ohio, and Wisconsin, with uninsured rates declining between 38% and 49%.
Florida and Texas, two non-expansion states, saw about 3.3 million people gain coverage as statewide uninsured rates fell 36% and 27%, respectively.
A particularly ironic statistic finds that 87% of adults who gained coverage did not have a college degree, and that includes 6.2 million non-Hispanic whites, a demographic that soundly voted for Donald Trump, who made repealing Obamacare a central pillar of his campaign.
Repercussions of Low-Information Voters
"This is a low-educated group. That's across races and states but that was definitely something that stood out in terms of describing exactly who we are talking about here," Gangopadhyaya says.
The numbers of insured could have been even higher if more states had shown a willingness to compromise. "I don't think it's too much of a stretch to conclude from this that we would have seen even more improvements if the states were more in lockstep for the Medicaid provisions," Gangopadhyaya says.
"We saw nearly 3 million children getting coverage throughout the five years," he says. "That's amazing because most of the ACA provisions were targeted not for children but for non-elderly adults. It means there was some reach in the ACA beyond the Medicaid and CHIP programs that were already in place."
What's going to happen to these 19.2 million newly insured Americans when the ACA is repealed? Nobody really knows because it's not clear what would follow the ACA.
"If some of these provisions are lifted without adequate replacement provisions, it's fair to say, you are going to see a drop in coverage and an increase in non-insurance rates following such an action," Gangopadhyaya says.
Hospitals with the highest incidences of readmissions (low performers) saw the highest reductions in readmissions when the financial penalties started kicking in.
A new study suggests that financial penalties provide an effective incentive to reduce avoidable readmissions, particularly at low-performing hospitals.
Researchers at Harvard and Beth Israel Deaconess Medical Center in Bostonexamined Medicare fee-for-service hospitalization data from more than 2,800 hospitals across the country between 2000 and 2013.
Based on 30-day readmission rates after initial hospitalization for acute myocardial infarction, congestive heart failure or pneumonia, researchers found that hospitals with the highest incidences of readmissions also saw the highest reductions in readmissions when the financial penalties started kicking in.
Study co-senior author Robert W. Yeh, MD, director of the Smith Center for Outcomes Research in Cardiology at BIDMC and associate professor of Medicine at Harvard Medical School, spoke with HealthLeaders Media about the study. The following is a lightly edited transcript.
HLM: What did your study find?
Yeh: Our initial goal was to examine whether or not the implementation of the HRRP [Medicare Hospital Readmissions Reduction Program] was followed by subsequent declines in readmission rates. We did confirm that.
It did look like there was an inflection point right about at the time of the passage of the ACA that looked like readmissions rates started to take a downturn.
Our second question was about whether some of these hospitals are penalized more than others. The way that the legislation probably was designed, you would hope to see that the hospitals that were penalized the most were the ones that had the worst readmissions rates and were the most highly incentivized to improve and hopefully the ones that improved the most.
That is what we observed. We observed that when we separated hospitals into four penalty groups, maximum, high, low and none, the hospitals that received the highest penalties did have the most rapid decline in their 30-day readmissions for those penalized conditions.
HLM: So, "skin in the game" works?
Yeh: I think so. It's a quite clear example that when hospitals are reimbursed, not just for how much they do but how well they do it, it makes an impact on their behavior.
That is what you would expect from an individual and this seems to incentivize organizations to act collectively to move in the same direction.
We are always careful about what is cause and effect. We know that readmissions penalties were followed by declines in readmissions, and they did so in a dose-dependent fashion; the more penalties you got the more you declined.
If I take off my epidemiologist hat, it does look like they work. The data is consistent with readmissions penalties working.
HLM: Were patients' socio-demographics factored into your findings?
Yeh: We did find that those hospitals that had the worst readmission rates and incurred the highest penalties were the hospitals that treated a higher percentage of minority of patients, a higher percentage of dual-eligible patients, a higher percentage of women, and the patient characteristics did look like they had more co-morbidities.
Those hospitals tended to be large, academic urban hospitals.
One of our concerns going in was that perhaps those hospitals that have high readmission rates were being penalized for things they can't control, but that is not support by the data.
If those hospitals had no control over their readmission rates, we would not have expected them to lower their readmission rates more dramatically than any other group. But it was quite clear that it was especially those hospitals that reacted the most favorably to the readmission penalties by dropping their readmission rates most significantly.
They dropped at about a 25% faster clip than hospitals that were not penalized.
HLM: Should socio-demographics be a factor in readmissions metrics?
Yeh: It's a broader debate than what we were able to look at in this study, but personally, I do think there are important socioeconomic factors that influence readmission rates that have nothing to do with the care those hospitals provide. They have to do with community resources and cultural influences on healthcare practices and outpatient medical care provided.
I sit on both sides. I see it as important to factor in. At the same time, these are exactly the types of hospitals that you want to see improve. In some ways by giving those hospitals a cushion for taking care of these patients, do you disincentivize them from improving? That is a two-edged sword and that is why there is such a fierce debate. The truth lies somewhere in the middle.
Yeh: If readmissions correlated precisely 100% with mortality, then we would not need it as a metric, because we have mortality as a metric.
The fact that those are not correlated does not mean to me that readmissions are not a useful metric. It is true that there are many readmissions that are for reasons that probably have very little to do with hospital quality. It's a blunt instrument, no doubt.
As clinicians in hospitals, we can't say, 'we're doing everything right and there is no waste in the system.' There are preventable readmissions. We know that.
Readmission rates should not be zero, but the fraction of those readmissions that are preventable with better communication and care redesign should be prevented and that's what these readmissions measures are trying to target.
HLM: What can be tweaked to make readmissions a more effective measure?
Yeh: The main question is what are the actual interventions that are reducing readmissions? One of the challenges when we use administrative claims data is that they lack granularity; precise reasons for why patients get readmitted.
If you don't know the precise reasons for readmissions, it's hard to design rational approaches to prevent them. You need to go into your own health system and get detailed electronic medical record data or chart review and understand who are these patients who are coming back, not at the 1,000-foot level like we have done here, but on the individual patient level and understand what are the things that may have prevented that individual patient from getting readmitted.
It's not sexy, splashy research, but when we aggregate and understand those reasons we can design appropriate interventions.
