The federal government shutdown does not delay the health insurance exchanges from launching as scheduled. Health insurance coverage begins on Jan. 1, 2014 for those who sign up by Dec. 15.
The sun rose in the East this morning and health insurance exchanges opened for business, vacating predictions in some corners that this critical provision of the Patient Protection and Affordable Care Act would usher in The Apocalypse.
The six-month extended enrollment period runs until March 2014 and coverage begins on Jan. 1, 2014 for people who sign up by Dec. 15.
While the success of the exchanges has been the subject of widespread speculation, nobody really knows who or how many of the estimated 24 million eligible people will sign up for coverage.
"It's a good thing that they have six months to figure it out," says Paul Lambdin, director of Deloitte Consulting. "We have to remember this is an outreach to a large part of the population that may be somewhat hard to reach given the demographics and [they are] very unfamiliar with the product."
A Commonwealth Fund survey released this week found that 76% of U.S. adults are aware of the PPACA's individual mandate, while only about 40% are aware that the health insurance marketplaces open today and that financial help for premiums is available. Commonwealth Fund vice president Sara Collins said the survey found that once people were made aware of the marketplaces, 61% of those who are potentially eligible said they would be likely to shop for coverage.
In addition, the survey found that only 32% of adults with incomes under 250% of the federal poverty level of $28,725 for an individual and $58,875 for a family are aware of the subsidies, compared to 47% of those with higher incomes.
"These survey findings demonstrate that people who need the health insurance coverage the marketplaces will offer want to shop for plans and find out if they are eligible for financial help," Collins said in prepared remarks.
"However, more work needs to be done to ensure that people who may be eligible are aware of the marketplaces and the subsidies. State and federal efforts to educate people about the marketplaces during the six-month enrollment period beginning in October need to be intensive enough to help close the information gaps this survey highlights."
Unfortunately for health insurance companies and the federal government, the Commonwealth Fund survey showed that only 55% of young adults ages 19 to 29 who are potentially eligible for the coverage said they would be likely to use the marketplaces, compared to 65% of those ages 30 to 49.
Adults with health problems were slightly more likely to say they would use the marketplaces than adults with no health problems (65% vs. 57%). Supporters of the exchanges are banking on a healthy mix of younger enrollees to offset the cost of care provided for older and sicker people.
Clare Krusing, spokeswoman for America's Health Insurance Plans, says the plans have focused on making the coverage affordable to attract younger enrollees, but it's not clear if they'll sign up.
"Experience in the states clearly demonstrates that enacting health insurance reforms without ensuring broad participation, particularly among those who are younger and healthier, will have significant unintended consequences for consumers and employers," Krusing says.
"The healthcare reform law will expand access to insurance and broaden insurance benefits. Everyone can sign up, including those with pre-existing medical conditions. These new benefits bring new costs. Financial assistance will be available to help qualifying individuals and families pay for coverage. Even with this new assistance, the new benefits will cause some people who currently have insurance to pay more than they do today. When faced with higher health care costs, many younger, healthier people may choose to forgo purchasing coverage until they need it, especially when the penalty for not having insurance is as low as $95. If this happens, costs will go up for everyone, young and old."
To get the word out on the exchanges and help consumers find the right coverage, the Department of Health and Human Service has enlisted more than 900 volunteer "Champions for Coverage" across the nation. The champions include the American Academy of Family Physicians, American Nurses Association, Lutheran Services in America, and YWCA USA.
"We are both excited and thankful to have such a wide variety of businesses and organizations that want to get involved and help us spread the message about these new opportunities for people to access quality, affordable health insurance with open enrollment beginning tomorrow," Marilyn Tavenner, administrator for the Centers for Medicare & Medicaid Services said in prepared remarks.
The exchanges are not tied to annual spending bills, so they will continue to operate even in the wake of the federal government shutdown triggered by stalled budget talks in Congress.
The demand for primary care doctors is being fueled by health reform mandates as well as physician turnover, which has been on the rise over the past three years, a physician recruitment report finds.
Primary care doctors and mid-level staff continue to be in high demand with healthcare organizations preparing for coordinated care and the Affordable Care Act.
The Association for Staff Physician Recruiters' 2013 In-House Physician Recruitment Benchmarking Reportfinds that nearly 70% of responding organizations searched for a family medicine physician in 2012. Other top searches for physicians included hospitalists, internists, pediatricians and emergency medicine. Advanced practice providers made up more than 17% of all searches. Approximately 38% of nurse practitioner searches and 43% of physician assistant searches were for primary care.
ASPR Executive Director Jennifer Metivier says the report includes metrics on nearly 5,000 physician and advanced practice provider searches conducted in 2012 by in-house recruiters employed by healthcare organizations across the country.
Nearly 33% of open positions remained unfilled at year's end, and recruiting proved to be even more difficult for non-urban areas. The study found a statistically significant difference in the 34.9% of open positions in healthcare organizations serving populations of 10,000 or less compared with those 29.5% open positions for organizations in populations of more than 500,000. Specialties that were least likely to be filled were dermatology, infectious disease, OB/GYN subspecialties, endocrinology/metabolism and neurology.
Approximately 63% of the reported searches were for hospital or integrated delivery systems, while 13% were for physician-owned practices.
The study found that physician turnover has been on the rise over the past three years; from 5.6% in 2010, to 6.3% in 2011, to 7.2% in 2012. "This trend is not surprising," Metivier said. "With the improvement in the economy and the housing market, we're seeing more physicians being able to relocate or retire, resulting in increased turnover."
The ASPR findings are consistent with those of other physician recruiters. In August Merritt Hawkins noted in its annual report that family physicians topped the list of the 20 most sought-after specialties for seven straight years.
Merritt Hawkins said the demand for primary care doctors is being fueled by health reform mandates that will shift healthcare delivery away from fee-for-service and toward quality outcomes, wellness, and population health.
After two decades of mostly declines, the percentage of Americans with health insurance inched up between 2011 and 2012, according to a new study. But with the advent of health insurance exchanges, the future level of insured people is impossible to know.
After two decades of mostly declines, the percentage of Americans with health insurance inched up between 2011 and 2012, according to a new study from the nonpartisan Employee Benefit Research Institute. The study also found that a downward trend in employer-based coverage since 2000 leveled off between 2011 and 2012. But with the advent of health insurance exchanges, the future level of insured people is impossible to know.
Paul Fronstin, director of EBRI's Health Research and Education Program and author of the report, attributed the improved coverage trends to a combination of factors. "Premium growth has been moderate compared with past years, and you have more people working with access to coverage, and the unemployment rate is falling, which means that employers aren't cutting back as much," Fronstin says. "We aren't looking at a V shape. We are talking about a fall all of these years and then it stopped."
The numbers in the study are gleaned from the U.S. Census Bureau's March 2013 Current Population Survey and reflect 2012 results, which is the latest available data. As a result, Fronstin says the study does not necessarily reflect any workplace coverage trends that may be shifting with the six-month open enrollment period for the individual plans that will be sold on the health insurance exchanges beginning October 1.
Even with the overall declines over the past 18 years, employer-based coverage remains the dominant source of healthcare coverage for most working non-elderly adults, ages 18–64. In 2012, 58.5% of the nonelderly population had employment-based health benefits, down from the peak of 69.3% in 2000 from 1994–2012. The 2011 level was 58.4%, essentially the same as 2012. The working-age population with health insurance coverage increased to 82.3% in 2012, up from 82% in 2011 and 81.5% in 2010. The uninsured rate for that group was 17.7% in 2012, down from 18% in 2011, the report says.
Fronstin says it's all but impossible to predict how the exchanges and the individual market will affect employer-based coverage in the coming years because estimates have been all over the map.
"When you look at [Congressional Budget Office] estimates on what is going to happen, they show a lot of people losing coverage but a lot of people gaining coverage," he says. "You are going to have some small businesses that will go to these exchanges that never offered coverage before because they never had a vehicle. They don't have to worry about that one sick person making coverage unaffordable for them. There could be a lot of dynamics here."
"CBO did some scenario modeling about 18 months ago and basically they came up with four scenarios," he says. "The worst scenario was 20 million fewer people with employer-based coverage as of 2019, and the best scenario was something like 5 million more covered by employer-based coverage. I throw up my hands; I can't make a prediction. What ultimately happens in terms of the number of people covered by employer-based coverage depends upon our assumptions."
The Census data from 2012 found that those most likely to get their coverage from employers include full-time, year-round workers; public-sector workers; workers in manufacturing; managerial and professional workers; and people in wealthy families. Poor families are most likely to be covered by Medicaid or the Children's Health Insurance Program.
The EBRI study found that the overall percentage of people with public-program health coverage was unchanged in 2012, accounting for 22.6% of the nonelderly population. The percentage with individually purchased health coverage was slightly higher in 2012 but has basically hovered around 7% since 1994.
Fronstin says it's not clear if the exchanges and a move to the individual market will eventually replace employer-based coverage as the dominant access point for health insurance.
"The Affordable Care Act has changed the playing field like it has never been changed before. Even employers who are offering health benefits are thinking about moving in the direction of creating more of a shopping experience," he says. But he notes that "the federal employees program has been doing this for 50 years, so it's not like this is something new and out of the blue."
Technology is propelling a shift toward a consumer marketplace for insurance. "We are doing this on the Internet with everything else we shop for. You look at Amazon. You look at Travelocity," he says. "There are different websites for different things and people are getting used to shopping with resources and the information that they need to make informed decisions; bar coding things in stores and looking up a review on the Internet. I am not surprised that health insurance seems to be catching up to it."
"It seems daunting now but a couple of years from now it may not. Medicare went through this on a more micro level with the drug benefits in 2006. It was pretty disruptive at first but it settled down."
Hospital associations and the feds are encouraging community and rural health providers to step up for health insurance exchanges. But for many, it's just one more mandate.
As the six-month open enrollment period for the new health insurance exchanges created under the Patient Protection and Affordable Care Act begins on October 1, community and rural hospitals will be the default advisors for patients and consumers trying to find the right coverage.
The nation's three largest hospital associations—American Hospital Association, the Catholic Health Association, and the Federation of American Hospitals—embraced that idea at a joint webcast last week and encouraged the hospitals they represent to play an active role in signing up their patients for coverage through the exchanges.
"People will only enroll if they know that this coverage is available and if they understand how to access these new coverage options," AHA President & CEO Rich Umbdenstock said at the event. "That is where we can help. It is critical that community stakeholders—certainly hospitals, faith groups, civic organizations and others—come together to help make the enrollment process straight forward and widely available."
Meanwhile, the Department of Health and Human Services said this week it would divvy up $2.5 million and give $25,000 each to 52 hospitals and other rural providers to "educate and enroll uninsured individuals and families living in rural America in new health coverage options."
"Soon millions of Americans in rural communities will have new opportunities for quality, affordable health coverage through the Health Insurance Marketplace," HHS Secretary Kathleen Sebelius said in prepared remarks. "Through these awards, trusted community providers will help people understand their coverage options, including whether they can get a discount on costs."
(It's not clear if that money will be nearly enough for the task at hand, but undoubtedly the thousands of tiny rural hospitals out there whose critical access designation is under threat will take comfort in knowing that they are still "trusted community providers.")-
Of course it makes sense that hospital associations would actively press their members to push HIX and that these member hospitals would embrace the challenge as well, if only for the bottom line and regardless of how they feel about the larger reforms under the PPACA. The more insured patients, the more reimbursements, the less charity care, etc.
Lori Real, COO of Bi-State Primary Care Association in Vermont, says the nonprofit is using its $25,000 grant to support outreach and enrollment in select parts of that almost entirely rural state.
"We are working with the Open Door Clinic to provide education and assistance to uninsured residents planning to enroll in Vermont Health Connect beginning October 1," Real told HealthLeaders Media. "Navigators are trained and already providing information through libraries, famers markets, and direct outreach to farmers and farm families in Addison County."
For other providers, the rollout is proving to be more difficult.
"We don't have anyone trained as of yet, but when it comes to it community hospitals in a lot of smaller communities are the main healthcare resource. if not the only one," says Tim Putnam, CEO at Margaret Mary Community Hospital in Batesville, IN.
"There is no other resource that can do it so we have to be there for patients by default. Unfortunately we are not well versed on it yet. There are a lot of variables, and each state and each region in the state have a lot of different options available. We are going to have to get up to speed on this quickly," he says.
While all providers will benefit from serving more insured patients, it seems a little late in the game to be dropping this responsibility into the laps of small hospitals that are already struggling with a host of challenges related to lower admissions and reimbursements and a numbing number of new and complex mandates, ranging from meaningful use Stage 2 to ICD-10.
"It's been one trim or one mandate after another. It is so difficult to keep track of them," Putnam says. "It's just another thing we are going to have to provide, but a big part of our mission is community access to healthcare, so we will figure out a way to do it."
In fact, Putnam sees HIX and other reform challenges as a test of his hospital's mettle, and other community healthcare providers like his.
"We were here before Medicare existed. We've been through a lot," he says. "We are not talking about organizations that sway with the wind. We act like an umbrella. We still serve the patients regardless of which direction the wind and rain are coming from. We have a lot of history behind us that we have to adapt our organization to fit whatever the rules are and still be able to provide good care for our patients. Everybody who has been in healthcare for a long time realizes that. We walk down the hallways of this organization and have the pictures of the people in the 1930s and 1940s who delivered care and faced their own challenges. This is our time."
Most health insurers say they will take part in health insurance exchanges despite concerns about how the programs will function, technical barriers, and the health status of participants. Meanwhile, a federal study finds that premiums will cost less than originally expected and selection will be broad.
Nearly 70% of health insurance executives responding in a study released today say they will take part in health insurance exchanges despite widespread concerns about how the programs will function, stubborn technical barriers, and the health status of the people they will be covering.
The PwC study, titled Health Exchanges: Open for Business [PDF], found that the access to potentially millions of new customers on the individual market and a fear of being left behind if these exchanges succeed are overcoming the reservations that many health insurance executives have expressed.
The six-month enrollment period for the exchanges—a key component of the Patient Protection and Affordable Care Act—starts on Oct. 1, and coverage begins on Jan. 1, 2014.
"With open enrollment about to begin, large national insurers and new players, some from other industries, are jockeying for position in the new exchange market," Ceci Connolly, managing director of PwC's Health Research Institute, said in prepared remarks. "Investment in retention programs will be crucial to securing the loyalty of a new crop of technologically savvy buyers. Companies should think beyond initial implementation challenges and focus on building a meaningful customer experience, with an eye on cost reduction and personalized communication."
HRI surveyed more than 100 insurance executives about the exchanges and found that:
69% plan to offer coverage on the exchanges, suggesting the rising significance of this new business opportunity
10 of 18 national health insurer executives said they won't offer exchange coverage in all the states where they now have business, and 50% expected to enter additional states after 2014
63% said technology integration and 61% said coordination of subsidies were major barriers to implementation
34% of insurers said understanding newly eligible customers was a major barrier to implementation, suggesting they may not thoroughly understand the challenges associated with attracting and maintaining this new group of buyers armed with the ability to choose—a major shift from the wholesale approach many insurers are used to
91% expect that premium costs, followed by total out-of-pocket costs, will be what consumers care about most
Industry and consumer experts expect that personalized communication, tangible rewards, health management programs, and brand recognition will be factors in consumer choices
Robert Zirkelbach, spokesman for America's Health Insurance Plans, says health plans are entering the exchanges despites significant unknowns: mainly the prohibition against denying coverage to people with pre-existing conditions, and whether young and healthy people will sign up.
"Adverse selection is a huge issue," Zirkelbach told HealthLeaders Media. "The broad agreement is that for the new exchanges to work there needs to be broad participation among young healthy people to offset the cost of those who are older and have high healthcare costs. That is why our industry has been so focused on the issue of affordability. If it is not affordable and young healthy people decide not to purchase, these exchanges won't work."
Zirkelbach says the uncertainty will be mitigated somewhat by federal backstops such as a three-year reinsurance program that is designed to temporarily offset highest-cost enrollees and provide some stability for the plans in the start-up phase.
While there are bound to be glitches when the enrollment period begins, Zirkelbach says many of the plans that will participate in the exchanges have gained relevant experience with the launch of the Medicare Part B program.
"Obviously the exchanges are larger, but when the Medicare Part B program was implemented there were problems, and it was our members who stepped up and helped fix problems while at the same time helping seniors navigate the system to find the right kind of drug coverage," he says. "That is the role we are going to play in the open enrollment for new exchanges."
Also today, the Department of Health and Human Services released a report finding that consumers in most states will be able to choose from an average of 53 health plans in the exchanges, and that most will have a choice of at least two different insurers or more. Premiums nationwide will be around 16% lower than originally expected—with 95% of the eligible uninsured living in states with lower-than-expected premiums—even before taking into account financial assistance.
"We are excited to see that rates in the marketplace are even lower than originally projected," HHS Secretary Kathleen Sebelius said during a media call on Tuesday afternoon. "In the past, consumers were too often denied or priced out of quality health insurance options, but thanks to the Affordable Care Act, consumers will be able to choose from a number of new coverage options at a price that is affordable."
HHS says its report shows that people living in the 36 states where HHS will fully or partly run the health insurance Marketplace—which is HHS's term for the federally operated exchanges—will have an average of 53 qualified health plan choices. Plans in the Marketplace will be categorized as gold, silver, or bronze, depending on the share of costs covered. Young adults will also have the option of purchasing a "catastrophic" plan, increasing their number of choices to 57 on average. About 95% of consumers will have a choice of two or more health insurance issuers, often many more. About one in four of these insurance companies is offering health plans in the individual market for the first time in 2014.
The average premium nationally for the second-lowest cost silver plan will be $328 before tax credits, or 16% below projections based on Congressional Budget Office estimates. About 95% of uninsured people eligible for the Marketplace live in states where their average premiums are lower than projections. And states with the lowest premiums have more than twice the number of insurance companies offering plans than states with the highest premiums, HHS says.
The shift away from post-acute hospital-based procedures to ambulatory services, which lack high-cost infrastructures, is "the future of healthcare," according to one health system executive. Keys to revenue growth include economies of scale and joint ventures with physician groups and hospitals.
Ambulatory surgery centers will continue to record volume growth as hospital inpatient surgery volumes continue to shrink, a report from Moody's Investors Service shows.
Moody's senior analyst and vice president Ron Neysmith said in a new study this month that the lower costs for outpatient procedures in ambulatory settings are driving the transition away from hospital-centric care.
"Ambulatory service centers provide care without the high-cost infrastructures associated with hospitals," Neysmith said in prepared remarks. "More procedures can be done safely on an outpatient basis and outpatient facilities are reimbursed on average 57% of the hospital rate for similar procedures, so insurance payors, including Medicare, have increasingly been directing patients to lower-cost settings."
As a result, ambulatory service centers' same-store revenues have been growing in the low- to mid-single digits since 2007 while same-hospital inpatient surgeries have been flat (measured at a 0.22% annual decline) in the same period.
Rob Shelton, director of marketing and communications at SSM Health Care, says the St. Louis–based health system is part of the industry-wide transition into the outpatient setting for several service lines, including imaging, pain management, ambulatory surgery, and urgent care.
"The system is forcing us to move to an ambulatory environment. Medicare and other payers don't want to pay for inpatient stays. For the first time in SSM's history the scales have tipped and more of our business is actually on the outpatient side than on the inpatient side," Shelton says. SSM operates 18 hospitals and 150 outpatient sites across four states.
The shift towards outpatient settings may have been accelerated by the recession, which brought with it higher unemployment and reduced the number of insured people in the marketplace, the Moody's report says. At the same time, elective procedures have dropped owing to the economic uncertainty and because insurance plans have raised copays, deductibles, and other out-of-pocket expenses for patients.
SSM views the shift as "the future of healthcare: services delivered in more of an outpatient ambulatory setting and meeting the needs of our patients," Shelton says. '"When you look at it from a revenue perspective and a volume perspective, we are actually seeing more, and that is across the board on outpatient, and that includes a wealth of different services."
Shelton says SSM is not interested in opening another hospital in the St. Louis market. "We really have shifted focus to the outpatient side," he says. "Hospitals of course have larger overhead. An ambulatory network can have less overhead and give us more penetration into the market. We continue to look at where we need to be in our market across the St. Louis region, whether that is placing physician offices or urgent care centers, imaging centers, rehab centers, pain care centers, any number of things that are performed on an outpatient business."
Moody's Neysmith said the top financial performers among ambulatory service centers will be those that concentrate on higher revenue treatments such as orthopedics and pain management. At the same time, growth in ambulatory service centers could be tempered by reductions in reimbursements, the shift toward bundled payments and value-based care, and the continued acquisition of surgery centers by hospitals. Even with those caveats, Neysmith says ambulatory surgery centers are well positioned to take advantage of an aging population.
"In a highly fragmented market, the larger players with economies of scale and joint ventures with physician groups and hospitals will benefit from patient referrals," he said.
Witnesses representing payers and providers agree that healthcare industry consolidation predates the Patient Protection and Affordable Care Act by at least two decades, but blame each other for rising healthcare costs.
A U.S. House Subcommittee heard a range of perspectives on Thursday from a panel of lobbyists and policy wonks who were asked if the Patient Protection and Affordable Care Act is hurting competition in the healthcare marketplace. The consensus from the panel was maybe, maybe not, and we're not really sure yet.
There was a general agreement from the witnesses that healthcare industry consolidation predates the PPACA by at least two decades. The questions then became whether or not "Obamacare" was accelerating that consolidation and whether that consolidation is driving up healthcare costs.
For the most part, the testimony from lobbyists for the American Hospital Association and America's Health Insurance Plans, covered little new ground but reaffirmed each side's contention that the other was to blame for rising healthcare costs.
"Officials at the antitrust agencies have stated repeatedly that they have been and will remain focused on competition in the healthcare sector. Transactions that these authorities deem to be anticompetitive, in fact, have been challenged," AHA lobbyist Sharis A. Pozen told the Subcommittee on Regulatory Reform, Commercial and Antitrust Law.
"However, despite these activities hospitals' price growth is at a historic low and is not the main driver of higher health insurance premiums," Pozen said.
"The growth in health insurance premiums from 2010-2011 was more than double that of the underlying health costs, including the costs of hospital services. The antitrust authorities should continue to pay as much attention to the health insurance industry as it does to the hospital field and there is no question that the health insurance industry is highly concentrated and is now acquiring hospitals and providers in an effort to replicate the continuum that hospitals are now providing."
AHIP lobbyist Joseph Miller cited several studies showing that hospital consolidations mean higher costs for consumers. He called on the federal government to continue to review hospital mergers that have the potential to harm consumers by consolidating market power and diminishing competition.
"Through the ACA implementation process, AHIP has emphasized that affordability must be a central goal in health reform and that addressing provider market issues is an important part of achieving this goal," Miller said. "Promoting competition and halting harmful consolidation in provider markets are critically important steps toward increasing affordability."
The back-and-forth between the representatives of AHIP and AHA prompted another panelist, Duke University Law professor Barak D. Richman, to note that "both providers and insurers alike seek to exploit different loopholes in the reimbursement system."
"What's funny about the conversation you hear out of AHA and AHIP is sometimes you're hearing both sides of what is really the same coin," Richman told the subcommittee during the question-and-answer period.
"The insurers often lament consolidation among the providers and use that as a justification to consolidate themselves. Providers lament big insurance companies and use that as a justification for their own consolidation. This kabuki dance has gotten us to a large degree in this mess we are in."
Richmond also noted that the market model for providers is "one designed to capture a market and extract maximum dollars from payers."
"There is an alternative business model which really has not been pursued a whole lot among providers and that is to pursue efficiency or value-based models," he said. "It is one reason why business education is so critical to encourage both providers and administrators to really pursue. It involves a very different kind of economic model."
The subcommittee also heard from Thomas P. Miller, resident fellow at the American Enterprise Institute; Thomas L. Greaney, at law professor at St. Louis University School of Law; and consumer rights lobbyist David A. Balto, a former federal antitrust lawyer.
In an attempt to illustrate the impact of losing federal Medicaid funding, the Missouri Hospital Association is using data linking the effects of poverty, poor health, and life expectancy in the state and making comparisons to rates in Third World countries.
When elected officials in Missouri decided last year against expanding their Medicaid program under the Affordable Care Act, the Missouri Hospital Association commissioned a report detailing the economic impact of losing the estimated $1 billion each year in federal funding.
Unfortunately, using common sense to explain an obvious point didn't work.
Now the MHA is trying a new tactic: Shame.
Of course, MHA won't call it a shame campaign. They're much too smart to openly embarrass the state and federal lawmakers they're trying to win over. However, shame is clearly the theme that rings through in MHA's report linking the effects of poverty, poor health and life expectancy in Missouri and comparing them with those of Third World countries such as El Salvador, Vietnam, and Angola.
It would be hard to live in any state with these sorts of health statistics and not be embarrassed. For example, MHA reports that:
Eleven counties in southeast Missouri and the City of St. Louis have average life expectancies less than 74 years. By comparison, Missourians living in these areas can expect to live two years less than the residents of Vietnam and Venezuela, and one year less than Hondurans and Lebanese. On average, they will enjoy the same life span as the population of Iran.
At 71.3 years, Pemiscot County would have the 85th lowest life expectancy in the world if it were a country—just below El Salvador with an average life expectancy of 71.4 years.
In 2011, 75% of Missouri's uninsured adults were in the workforce. However, many low-income blue collar and service industry workers lack access to employer-sponsored insurance, while Medicaid coverage is limited.
In 2013 a single working parent of two can earn no more than $9.59 per day to qualify for Medicaid in Missouri. By contrast, the average daily income in Angola is $13.35. Because of these strict eligibility standards, a large number of Missouri's uninsured are low-income working adults in blue collar and service collar industries.
On average, an uninsured Missourian was treated in a hospital emergency department every minute of every day in 2012. Throughout the last eight years, ED visits by the uninsured have increased 83% in Missouri, from more than 300,000 in 2004 to nearly 560,000 in 2012.
"Sadly, depending on where you live, your community may be part of Missouri's downward spiral in health status," MHA President/CEO Herb B. Kuhn said in prepared remarks. "The gaps in life expectancy between communities with higher incomes and increased access to care, often separated by mere miles, are profound. That's bad for Missouri and the state's economy."
If it's any consolation, Missouri already ranks 42nd in health status according to America's Health Rankings – close enough to the bottom that it wouldn't be a long drop.
MHA spokesman David M. Dillon says the state's hospitals are hopeful that state legislators and the general public will be motivated to change the status quo once they understand that Missouri health statistics rival those of Third World countries.
"One of the important parts of this report versus a lot of the more academic stuff we have done in the past is that it shines a pretty bright light on comparatives and gives individuals an opportunity to understand it in a way they might not otherwise," he says.
"If you look at the state of the state, there is this preconception about what Medicaid covers and who it covers and you'd think we have two metros so it's an urban problem. Well, not so much. It is very much a rural problem."
Dillon is picking his words carefully. That's because Missouri's hospitals did not create this "preconception" that they now have to overcome. In coarser terms, the report shows that refusing Medicaid expansion dollars hurts rural whites as much if not more than it hurts urban blacks.
The data also show that most of these blacks and whites who could be served by the Medicaid expansion are holding down jobs that provide no health benefits. These people are not the "moochers" and "takers" that some would have us believe. Their common denominator is poverty.
"The low Medicaid eligibility level being $9.59 a day for income just tells you that even adults with children would have a very hard time being eligible," Dillon says.
There is some hope that Missouri elected officials are coming around. The Missouri House and Senate have each formed interim committees to examine the Medicaid expansion to see if they can find a compromise proposal during the 2014 session. Dillon says many lawmakers understand what is at stake.
"There are a lot of them in public who would say 'no' but there are also a lot who would acknowledge what the economic benefit of it is and the impact on their constituents. They want to say 'yes' but there has to be a program that is very Missouri-specific," he says. "That is what you are seeing in other states and last week and this week we have seen governors in other states talk about this issue and create plans that were very tailored to the politics and the needs of their states."
"We are hoping that reports like this help shape the public perception of the problem because frankly, as a community, we get really wrapped up in things like discussing the federal poverty level and most people don't have any connection to that term in their lives," Dillon says.
"That is why we were making an effort this time to talk about what those numbers means and make comparatives to what they might mean. Life expectancy was a good benchmark, so it was going to be easier to show comparatives on [that metric]. Talking about the negative health implications and what they mean is vital."
"It is one thing to talk about what happens in Jefferson City," he said. "It's another thing to put it into the context of how people live their lives."
While data shows there's been an uptick in hospital employment for physicians, more than half still work for themselves, an AMA survey finds. The number of physicians in solo practice, however, has dropped.
Conventional wisdom says physicians in private practice are a dying breed.
The narrative says physicians are flocking to employed arrangements with hospitals and larger physician practices as health reform and compensation models push the healthcare industry away from fee-for-service and toward economies of scale, quality outcomes and population health.
An American Medical Association report released this week, however, suggests that the demise of private practice physicians may be overstated [PDF]. "To paraphrase Mark Twain, the reports of the death of private practice medicine have been greatly exaggerated," AMA President Ardis Dee Hoven, MD, said in prepared remarks.
"This new data shows that while there has been an increase in hospital employment, more than half of physicians (53.2%) were self-employed in 2012, and 60% worked in practices wholly owned by physicians. Needed innovation in payment and delivery reform must recognize the wide range of practice types and sizes that exist today so all physicians can participate in the move to a more patient-centered system that rewards high-quality care and reduces costs."
Of course, the report also shows that conventional wisdom is not completely wrong. There has been a trend toward hospital employment over the past five years. In 2012, 29% of physicians worked either directly for a hospital (5.6%) or for a practice that was at least partially owned by a hospital (23.4%). The last AMA survey taken in 2007–2008 did not distinguish between direct hospital employment and employment in a hospital-owned practice, but found that 16.3% of physicians worked in one of the two settings.
Phil Miller, vice president of communications at Merritt Hawkins, says the AMA findings are consistent with what the Irving, TX-based physician recruiting specialists find in their annual recruiting assignments.
"I was a little surprised to see they indicated that a little over 50% of physicians are still self employed. That contradicts a little some of the other things I have seen out there," he said. "In the great majority of settings that we are recruiting into it's an employed setting, mostly hospital employed. But it could be a community health center or a larger medical group, with the doctor coming in as an employee and not a practice owner."
Miller says that in 2004 only 11% of the physician search assignments Merritt Hawkins conducted were hospital employed physicians. This year, that figure went up to 64%.
"Of the physicians who are being recruited and newly hired by various entities, they are overwhelmingly going to employed settings. If a doctor is coming out of residency for example, the ones who are switching practice locations and are being recruited by people like us they are going into employed settings," Miller says.
It is also becoming increasingly uncommon for independent physicians to be recruited into other independent practices. "We recruit that doctor not for another independent setting. They are going into an employed setting," Miller says.
"That gradually siphons off the numbers of independent doctors. Even in the AMA survey they're showing that the percentage of hospital employed doctors is growing. Today it's a little unusual for a doctor to go from one independent practice to another."
The AMA study also found that:
The percentage of physicians who were practice owners in 2012 decreased eight percentage points from 2007/2008.
18% of physicians were in solo practice, down 6% points over five years.
Single specialty practice was the most common practice type in 2012, accounting for 45.5% of physicians.
Miller says every trend is pointing towards the employed model.
"The number of solo settings that we recruit into 10 years ago was close to 20%. Last year it was 1%. It was the same thing with partnerships," he says. "Solo practices and partnerships were the classic independent settings and now we do next to none of those anymore. Pretty much 90% or more of the settings we recruit into now feature employment of one kind or another."
In an online event Monday, the nation's three largest hospital associations expressed their unified support for the Patient Protection and Affordable Care Act in the face of withering and relentless criticism that appears to be sapping public support.
Leaders from the nation's three largest hospital associations met on Monday to reaffirm their support for the Affordable Care Act and encourage hospitals to help patients understand their health insurance options when open enrollment begins on Oct. 1.
"This is going forward. This is going to happen. I don't think there is anything between now and the near future that I could imagine would derail it," Chip Kahn, president/CEO of the Federation of American Hospitals, said at the Monday afternoon webcast sponsored by the American Hospital Association.
"And over the next six months you are going to have the opportunity to work with your communities and your patients to help your patients get the health coverage they need."
Joining Kahn at the hour-long webcast were: AHA CEO/President Rich Umbdenstock; Sister Carol Keehan, president and CEO of the Catholic Health Association;Mandy Cohen, MD, senior advisor to the administrator of the Centers for Medicare & Medicaid Services; and Cynthia Taueg, vice president, ambulatory and community health services at Detroit-based St. John Providence Health System.
The event was open to anyone with online access, but billed as an opportunity for hospital leaders to submit questions about the looming six-month open enrollment period for individual coverage on the health insurance exchanges, or marketplaces, as they are known. Cohen and Taueg provided suggestions to help hospitals with the transition.
"One thing [hospitals] might want to do is think about the patients that they already serve that are perhaps uninsured and how they can reach out to give them some information, be that through a mailing or some sort of a drive or health fair on the campus. But reach out to them. Don't wait for them to call you," Taueg said.
"Secondly, don't forget about your employees or your associates. They too are ambassadors in your community. They need to be informed, and many of them have family members who need to go to the marketplace. So take the time to look at your own employees and work with them."
"The third thing is I can't emphasize the partnerships enough. They are very important. You need to know who the navigator grantees are in your area and build on the partnerships that you already have. While it is not necessarily innovative, these are things that work. We just have to make sure that we work them."
Cohen was asked by Umbdenstock if the exchanges would be operational on Oct. 1.
"We are going to be ready on Oct. 1," Cohen replied. "We are not moving that deadline. Oct. 1 is coming and we will be open for business. The important thing is the context. Oct. 1 being open for business [means] it is the first time that folks will largely be seeing a lot of the plans in their states, their rates, and they really need to think through those options and that is why this enrollment period is six months long. It is not Election Day on Oct. 1. It is just a beginning."
The webcast, however, clearly provided a public platform for the nation's three largest hospital associations to reaffirm their unified support for the Patient Protection and Affordable Care Act in the face of withering and relentless criticism that appears to be sapping public support.
A Pew Research poll released Monday found that 53% of Americans disapprove of the PPACA. The same poll also found that only 25% of respondents said they understood how the law will affect them.
"People will only enroll if they know that this coverage is available and if they understand how to access these new coverage options," Umbdenstock said. "That is where we can help. It is critical that community stakeholders, certainly hospitals, faith groups, civic organizations and others come together to help make the enrollment process straight forward and widely available."
Keehan called access to healthcare "a matter of human dignity" and said hospitals will play a vital role "as a credible source of information in our communities." Keehan encouraged hospital administrators to "watch closely what is happening in your state with regard to marketplaces and Medicaid expansion."
"While the Affordable Care Act is not perfect, it is a great step toward the healthcare system all Americans deserve. To make the coverage provisions of the law readily available we need to focus now on enrollment, educating the public, signing people up, learning what we as hospitals can to do contribute," Keehan said.
"No matter who does the study, 75% to 85% of the people that this Act is supposed to help in this open enrollment believe there is nothing in the Act for them and that is largely because of massive misinformation. A good number of people don't even believe the Affordable Care Act is still the law and that it offers assistance and helps them pay for coverage."
The CHA leader also sought to tamp down the apocalyptic predictions of ACA critics.
"Try to have a historical perspective," Keehan said. "Look at the beginnings of our Medicare program. There were lots and lots of ups and downs in that and today not having the Medicare program is unthinkable. There will be bumps in the road, unintended consequences, things we didn't think of. But they are all worth getting beyond. We have the talent and commitment at CMS and (Health and Human Services) and in the Administration and Congress and get beyond them and give us a healthcare system that is worthy of our nation."