Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at jsimmons@healthleadersmedia.com.
Despite being disproportionately low income and uninsured, many safety net clinic patients in New Orleans had fewer problems paying for care post-Hurricane Katrina. There were also fewer cases of medical debt and inefficient care compared to most American adults, according to a new survey from the Commonwealth Fund.
Overall, the report, Coming Out of Crisis: Patient Experiences In Primary Care In New Orleans, Four Years Post Katrina, found that among all the clinic patients surveyed, only 27% went without needed healthcare because of cost—compared to 41% of adults nationwide.
In 2007, New Orleans' major public hospital and adjacent ambulatory sites were closed, but the Department of Health and Human Service provided a grant to Louisiana to support a network of independent neighborhood primary care centers to increase access to care and develop an organized system of care.
The Commonwealth Fund survey was conducted 18 months after the grant was awarded to assess the impact of the project on patients' access to care and experiences. It also looked at lessons for national and state leaders on the value of strengthening primary care for vulnerable patients.
When the authors compared the 2009 survey of patients in 27 New Orleans health clinics to findings from The Commonwealth Fund's 2007 Biennial Survey, a representative survey of the nation's general population, they found that the clinic patients tended to be less worried about affordability.
Almost half of clinic patients (49%) said they were confident they could afford needed care if they became seriously ill—compared with only 30% of adults in the general population.
In addition, medical debt also seemed to be less of a concern for clinic patients, with 34% reporting medical bills or debt problems compared to 40% nationwide. Unpaid medical bills appeared to be a far greater problem among all U.S. adults than among clinic patients (28% vs. 18%).
Clinic patients also reported receiving care that was more efficient than the US norm. For instance, only 4% of the clinic patients reported duplicate medical tests, or said that medical records or test results were unavailable at their appointment, while 34% of patients nationwide said they experienced those problems.
The clinic patients also said they had more confidence in the healthcare system, with three quarters saying they would be very confident in their ability to get high quality and safe medical care; only 39% of adults nationwide said they were very confident that they could get high quality and safe care.
Other findings from Louisiana included:
88% of patients found it is easy to get same or next day appointments when sick, to access medical advice via telephone or during regular practice hours, or to get after hours care (in the evenings, on weekends or on holidays).
79% patients reported exceptional communication with their doctors and 85% said that their health needs are "very well" met in the clinics. Adults who reported excellent patient experiences, easy access to well coordinated care, and exceptional patient doctor communication were more likely to get recommended preventive services.
Overall, the findings revealed that strengthening primary care could be instrumental in helping to move the nation to a high-performance health system, said Commonwealth Fund Assistant Vice President Melinda Abrams, a co author of the report.
Depending on which bill is examined, 18 million to 23 million people could still remain uninsured under the House and Senate reform bill.
Others could still face financial barriers in obtaining needed healthcare or paying premiums or medical bills—which explains the reasons why Congress will continue Medicare and Medicaid disproportionate share hospital (DSH) payments under healthcare reform legislation.
The catch? The payments will be reduced in most instances to hospitals under proposed reform legislation from both the House and Senate. The reasoning is that more individuals will be covered by insurance. But how much the payments are cut and when that would take place depends on the patient populations served by the hospitals—particularly the safety net hospitals—and which bill language is used.
It is an area that has had hospital groups worried. In a letter sent to Congress and in Capitol Hill testimony last spring, hospital groups—including the American Hospital Association, the Federation of American Hospitals, and the National Association of Children's Hospitals—noted that many urban and rural hospitals were still struggling, even with the DSH payments.
With DSH payments included, the total hospital shortfall has rose from $3.8 billion in 2000 to nearly $32 billion in 2007 (with $21.4 billion for Medicare and $10.4 billion for Medicaid). And, including DSH payments, hospitals received payments of only 91 cents for every dollar spent caring for Medicare patients and only 88 cents for every dollar spent caring for Medicaid patients in 2007 on average, the hospitals said.
The hospital groups are asking Congress to reject reductions in federal support for DSH programs until after coverage expansions are fully implemented, and Medicare and Medicaid payment shortfalls are addressed.
John Bluford, president and CEO of Truman Medical Centers in Kansas City, MO, said at a conference in Washington in the spring that DSH funding was a critical source of support for safety-net providers—which serve a disproportionate share of low-income and minority patients.
These patients were often sicker and more costly to treat. "There was a belief that has been disproved with the Massachusetts experience that coverage for everyone would mean no need for special compensation for safety net providers," he said.
Congress was listening. However, the sections of the House and Senate bills vary in relation to Medicare and Medicaid DSH payments:
In the Medicare section of the Senate bill, DSH payments would be lowered initially by 75% in fiscal 2015; however, these payments would be subsequently increased based on the percentage of the population uninsured and the amount of uncompensated care provided.
In the House bill, beginning in 2017, reducing Medicare DSH payments to hospitals would take into consideration the national rate of uninsurance, based on the Health and Human Secretary's recommendations.
In the Senate bill for Medicaid, a state's DSH allotment (effective in 2011) would be reduced by 50%, or 25% for low DSH states once the state's uninsured rate decreases by at least 45%. DSH allotments would be further reduced—not to fall below 50% of the total allotment in 2012—if states' uninsured rates continue to decrease.
In the House bill, Medicaid DSH allotments would be reduced by a total of $10 billion—$1.5 billion in 2017; $2.5 billion in 2018; and $6 billion in 2019. The largest percentage reductions in state DSH allotments would be made in states with the lowest uninsured rates and those that do not target DSH payments.
One exemption under the Senate bill is Hawaii: the bill would permanently restore Hawaii's Medicaid DSH allotment—because it did not have a permanent DSH allotment in previous years under the structure of its Medicaid program.
A survey from the Institute for Safe Medication Practices (ISMP) has found that the recession may be compromising medication safety—at least according to hospital workers surveyed nationwide.
In an ISMP survey of healthcare professionals made in fall 2009, the economy appears to be putting various pressure on a number of hospitals—particularly through staff cuts—causing them to take steps in response to the economic downturn that could put patients at greater risk.
The 848 respondents to ISMP's survey were largely nurses and pharmacists working at a staff or managerial/director level in hospitals. About one-fifth (20%) of respondents reported that the economic downturn has been a contributing factor to medication errors in the past year.
Among the areas cited were:
Staff reductions. Survey respondents reported staff cuts have had the biggest negative impact. More than two thirds reported that the economy has affected their staffing. About the same percentage reported that the economy was causing low morale—often citing unsafe workloads and inability to provide quality and safe healthcare as the key contributing factors.
Working conditions/technology. Nearly half of the respondents felt the economy had negatively impacted equipment purchases, technology implementation and updating, and facility remodeling. About half also reported that the economy was affecting their ability to participate in education and certification programs.
Culture of safety. According to respondents, organizational culture, staff willingness to report errors, and leadership support for safety had been the least impacted by the economy. However, one-third reported the economy has negatively affected the safety culture with "no time to report near misses" given as the most common example given.
Medication safety officer cutbacks. About 42% of respondents reported that the economy had forced a reduction in dedicated time or total elimination of medication safety officers or quality/risk staff dedicated to medication safety.
Drug purchasing. About a third of respondents reported that current economic conditions have resulted in less safe drug purchasing decisions, such as switching to multiple dose vials instead of using single use vials and prefilled syringes. One-third also reported reduced availability of medications as organizations tried to maintain smaller inventories.
Reduction in pharmacist interaction. More than a third of respondents said the economy had impacted the clinical presence of pharmacists on patient care units.
Missed safety steps. About 33% of respondents reported a reduction in available staff for patient education, and 31% said that staffing changes had led to missed independent double checks of high alert medications before dispensing or administration.
Drug administration shortcuts. About a quarter of nurse respondents reported that staff reductions—due to the weakened economy—has led to hurried drug administration practices during which shortcuts are sometimes taken.
The Medicare Payment Advisory Commission (MedPAC), at its monthly meeting in Washington on Thursday, voted to recommend that Congress give hospitals a fiscal 2011 payment update equal to the rate of change in the marketbasket index (currently projected at 2.4%) for inpatient and outpatient payments. This rate will be concurrent with implementation of a pay-for-performance program.
However, to restore budget neutrality at the federal level, MedPAC called on the Health and Human Services Secretary to reduce the inpatient update by up to 2% in 2011, 2012, and 2013 to recover earlier overpayments that resulted from recent documentation and coding changes in 2008. This could result in an inpatient update of just 0.4% in fiscal 2011.
"We're pleased that MedPAC recommended a full marketbasket update," said Don May, AHA vice president of policy, in a statement. "However, we are disappointed with the commission's coding offset recommendation, since CMS already has authority to apply an offset and has suggested using a less aggressive transition in its 2010 rule."
The Premier healthcare alliance supported MedPAC's recommendations for a full marketbasket update. "Such a recommendation signals to Congress that flat reductions in payment—rather than savings generated from delivery system reform—are imprudent given the poor state of the national economy," it said.
In a survey prepared by MedPAC staff, they noted that 218 top-performance hospitals from 2005-2007 they were evaluated had a 0.2% Medicare earnings margin. Other hospitals (1,991) showed an 8.3% decline.
Also on Thursday, MedPAC recommended that Congress provide physicians a 1% payment update in fiscal 2011. It also called for raising fee for service payments for practitioners who focus on primary care.
MedPAC additionally called for Congress to provide no payment update in fiscal 2011 for inpatient rehabilitation facilities, long term care hospitals, skilled nursing facilities or home health providers.
The MedPAC recommendations will be included in the report submitted to Congress in March.
White House and Congressional leaders passed another important signpost Thursday on the road to completing the healthcare reform bill. Following marathon negotiations with labor union leaders all week, a new deal was reportedly hammered out over the issue of taxing employees' high-cost or "Cadillac plans."
The provision, which originated in the Senate bill, will remain, but the threshold at which the 40% tax would kick-in with the high-cost plans would change. The threshold would now be for families whose plans' value reach $24,000—up from $23,000; for individuals, the $8,500 threshold is likely to remain the same.
Also under the agreement, healthcare plans negotiated under collective bargaining would be exempt until 2018—five years after nonunion health plans. The tax was originally projected by the Congressional Budget Office to raise $149 billion over 10 years; the changes could lower that number around $60 billion to $80 billion, which now must be made up.
As of Thursday, no specific plan had been announced of where lawmakers would find that funding. Some reports have indicated that Democrats may target two industries that had offered to contribute to the health reform effort last summer—the hospital industry and the pharmaceutical manufacturers—for additional funding.
This issue of higher cost plans proved to be a troubling point to the labor unions who had been strong supporters of national healthcare reform legislation. Oftentimes, employees had bargained for higher cost policies and benefits instead of higher wages.
Rep. Joe Courtney (D CT), though, cautioned that the proposed deal was struck between labor leaders and the White House—and not members of Congress who need to evaluate the agreement.
Courtney, who had collected more than 119 House member signatures opposing the tax, had a briefing on Wednesday in which he released a Watson Wyatt study that showed that the tax would put a higher burden on employers located in higher-cost areas of the U.S.
The House and Senate still have a number of issues to resolve, such as the structure of the insurance exchanges and abortion language. Negotiations will continue today.
When House Speaker Nancy Pelosi (D-CA) was asked where they were in the negotiations, she responded: "We are close."
As a part of healthcare reform, interest has been high on the concept of patient-centered care. But sometimes, an important presence may be overlooked in providing quality patient-centered care to that patient: the family caregiver. Today, more than 30 million family caregivers play major roles in overseeing and promoting the health and quality of life of individuals with acute and chronic illnesses.
This month, the American College of Physicians (ACP) issued a position paper that provides ethical guidance in addressing the role of the family caregiver whom patients depend on for assistance with daily activities, managing complex care, navigating the healthcare system, or communicating with healthcare professionals.
Although hospice and palliative care programs address the impact of illness on patients and families, the patient physician relationship historically has focused on the patient and his or her rights and interests. Less attention has been paid to the patient's experience within the context of his or her family and social relationships, the paper's authors state.
"I think that as healthcare is moving more and more towards teams of people taking care of patients, we have to look at the composition of those teams—including more and more family members," says one of those authors, Virginia Hood, MD, chair of ACP's Ethics, Professionalism and Human Rights Committee. "That includes, of course, friends as well as direct family members."
Physician recognition of the value of the caregiver role may contribute "to a positive caregiving experience and decrease rates of patient hospitalization and institutionalization," says Hood, a nephrologist and professor of medicine at the University of Vermont in Burlington.
It's important to examine the roles of caregivers in the provider-patient-caregiver relationship, as well, she says. "We should think about what the ethical issues are that come up when you add a new person to the team."
The paper, which was endorsed by 10 other professional medical societies, outlines four primary principles for physicians or providers, who may face ethical challenges collaborating with patients and caregivers in a variety of situations while preserving the primacy of the patient physician relationship:
1. Respect for the patient's dignity, rights, and values should guide all patient physician caregiver interactions. As part of this, the authors note that physicians routinely should assess a patient's wishes regarding the degree of caregiver participation in a clinical encounter—striving to provide the patient's desired level of privacy.
According to the Health Insurance Portability and Accountability Act (HIPAA), health professionals can share relevant healthcare information with a family caregiver—if the patient agrees or does not object to the disclosure.
2. Effective communication and physician accessibility are fundamental to supporting the patient and family caregiver. Here, physicians or providers should strive to ensure that the patient, caregiver and other family members have "a common, accurate understanding of the patient's condition and prognosis," the authors say.
Sometimes, physicians believe they provide far more information to caregivers than caregivers believe they receive: Physicians' use, for instance, of medical jargon and technical terminology can be confusing to family members.
3. The physician should recognize the value of family caregivers as a source of continuity regarding the patient's medical and psychosocial history. Sometimes caregivers can find themselves in the shadows, Hood notes.
In a care setting, for instance, caregivers may be treated as if they are in the way. "That's something as providers that we have to change—if it's ever there," Hood says.
"These are incredibly valuable people. They often know more about a patient's history . . . than do some of the other providers because they've been there," she says.
4. When the caregiver is a health care professional, the physician should draw appropriate boundaries to ensure that the caregiver is not expected to function in a professional capacity in relation to the patient.
When the family caregiver is a health professional, caregiving may bring added or unique pressures and ethical challenges, the authors say. The treating physician should assist in setting reasonable patient and family expectations regarding the caregiver's role in interpreting disease processes, prescribing medications, or dealing with new symptoms.
Note: You can sign up to receiveQualityLeaders, a free weekly e-newsletter that provides strategic information on the business of healthcare management from around the globe.
While it may have dual names in the healthcare reform debate—such as the Independent Payment Advisory Board or the Independent Medicare Advisory Board—the possibility of its existence has created a firestorm of controversy in the healthcare community because of its perceived restrictions. However, the provision—now included in the Senate bill—may not be totally out in the cold.
Earlier this month, President Barack Obama expressed support for an independent federal board that would, in his words, improve the long term solvency of Medicare, while strengthening the quality of care and reducing unnecessary or inefficient spending. The board concept itself recently has received support from groups of economists and other healthcare groups—encouraging oversight of not just Medicare but to the private sector.
Whether the House will be sold on the board idea remains to be seen. It was excluded from the House reform bill, but recent closed-door discussions indicate that a board, with appointed members, could be part of the final compromise bill.
The board proposal has seen a number of different changes since Sen. Jay Rockefeller (D-WV) introduced the idea in May, with the most recent occurring during the Senate reform debate. Under the current Senate bill, it is proposed that the board would be made up of 15 members appointed by the president, with advice from the Senate. This membership would include physicians, employers, third-party payers, experts in outcomes research, experts in pharmaco-economics, and pharmacy.
Last month, amendments were proposed and approved by Rockefeller, and Senators Joseph Lieberman (I-CT) and Gordon Whitehouse (D-RI) that call for tightening the provision by:
Eliminating the carve out for hospitals and hospices. No one provider type or group of providers would be given special treatment.
Changes the savings targets. This amendment would replace the phase in approach to the 1.5% savings target in 2018 with an immediate savings target of 1.5% beginning in 2015.
Accelerates timeline for congressional consideration. This amendment moves up the implementation date for the board's recommendations (or a congressional alternative) from August 15 to June 15.
Provides board recommendations in years of controlled cost growth in Medicare. Fast track consideration of board recommendations would be made even in years where no spending reductions are required.
Requires recommendations to contain costs in the private sector. The board would be required to submit a report to Congress and the Secretary of Health and Human Services regarding the Medicare recommendations that are also applicable to the private sector. In years where there are no Medicare spending targets to achieve, the commission could offer recommendations to the private sector that are outside of the scope of Medicare.
Congress will likely resume looking into the issue of rapidly rising drug costs following release of a Government Accountability Office (GAO) report that prices of more than 400 brand name drugs increased by at least 100% between 2000 and 2008. These 416 brand name drug products represented 321 different drug brands.
More than half of the brand name drug products that had large price increases were in three therapeutic classes: central nervous system, anti infective, and cardiovascular. These therapeutic classes include drugs used to treat conditions, such as fungal or viral infections, and heart disease.
Almost half of the price increases were for brand name drug products purchased from drug manufacturers or wholesalers, repackaged, and resold in smaller packages to healthcare providers. In 2008, the prices for 71 drug products increased by 100%, but in 2000, only 28 drug product prices increased by that amount.
However, some drug repackagers serve a niche in the drug market—claiming a small share of the market in a therapeutic class. Some of the higher price increases were for drugs priced less than $25 per unit. A full course of treatment for some of these drugs could total several thousand dollars, GAO said.
Based on interviews with experts and industry representatives, a lack of therapeutically equivalent drugs—both generics and other brand name drugs used to treat the same condition—plus limited competition may contribute to the high price increases. Also, the limited availability of therapeutically equivalent drugs may result from patent protection and market exclusivity, along with the size of the market for a given drug.
"It is hard to find a good faith explanation for price increases that are this severe, said Sen. Charles Schumer (D-NY), who along with Sen. Amy Klobuchar (D-MN), had requested the GAO investigation following a 1998 hearing. "This report will lead to a strong demand for action by Congress. We should make sure Medicare is allowed to negotiate drug prices in the final version of the healthcare bill."
Pharmaceutical Research and Manufacturers of America Senior Vice President Ken Johnson said in a statement that the GAO report focused "only on a small number of selected brand medicines rather than the entire prescription drug market." When looking at recently released national healthcare spending data for 2008, a sharp decline in retail prescription drug spending growth occurred—"leaving medicines as one of the slower growing areas of healthcare expenditures," he said.
Last month, Health and Human Services Inspector General Daniel Levinson agreed to a request from Sen. Bill Nelson (D-FL) to look into charges that 96% of wholesale prices of brand name prescription drugs were sharply increased in anticipation of healthcare reform. The investigation will look at how high prices are impacting Medicare and Medicaid.
Several major primary care physician groups, plus the AFL-CIO and Consumers Union, are among the 118 groups that sent a letter Tuesday to congressional leaders in the House and Senate urging them to support "equality of Medicaid and Medicare rates" for primary care services.
The groups are calling for the lawmakers to "ensure meaningful access to care under the proposed Medicaid expansion" by adopting in the reconciled House Senate health reform agreement the initial House provision that would bring Medicaid reimbursement rates for primary care "in line with comparable Medicare rates within four years."
They added that Medicaid rates, which average 66% of Medicare rates for primary care services, have been "woefully inadequate" in covering the cost of providing care. Among those who rely on Medicaid to meet their healthcare needs are millions of low income women, children, minorities, and individuals with disabilities.
Medicaid rates are "woefully inadequate" to cover the cost of providing care. If the Medicaid reimbursement levels are not addressed in conjunction with the Medicaid expansion, the U.S. may face the prospect of leaving poor and medically vulnerable residents behind "despite the promise offered by healthcare reform,” according to the groups.
"We are very concerned that failure to address reimbursement disparities will weaken an already fragile network of Medicaid providers at a time when the demand for their services will be growing," ACP President Joseph W. Stubbs, MD, FACP, said in a statement. "It is critical that while we provide access to care for so many more low income Americans, we also adjust payments for primary care services so they are equal to Medicare rates."
Nearly 75 healthcare organizations—including the American Hospital Association, the Medical Group Management Association, the Association of American Medical Colleges, the American College of Surgeons, and the California Medical Association—called for Congress to drop the proposed Independent Payment Advisory Board (IPAB) from consideration in the reconciled healthcare reform bill.
If established, the board, which is now included in the Senate-passed reform bill, would "essentially assume authority" over the Medicare program—with the purpose of reducing the "per capita rate of growth in Medicare spending indefinitely," the groups said in a letter to Senate Majority Leader Harry Reid (D-NV) and House Speaker Nancy Pelosi (D-CA).
Since Medicare's growth rate has been "below or equal to growth in the private sector," any reductions by the board would be in addition to the $400 billion to $500 billion savings in provider payments already included in the healthcare reform legislation, they said. This could "jeopardize both access for Medicare beneficiaries and even infrastructures" for the healthcare system, they added.
It was last summer that the White House expressed support for what it called the Independent Payment Advisory Council, which would have the authority to make recommendations to the President on annual Medicare payment rates and other reforms. The President could either approve or disapprove the recommendations, and Congress could intervene within a 30-day period if it disagreed.
In that July letter from White House Office of Management and Budget Director Peter Orszag to Pelosi, he said that approach was similar to a recommendation from Sen. Jay Rockefeller (D-WV) to make the Medicare Payment Advisory Commission (MedPAC) an independent executive branch agency that was designed to improve the efficiency of the Medicare system. The council would feature physicians and other health experts appointed for five-year terms.
The board proposed in the Senate bill would have officials appointed by the president to make decisions. However, replacing elected officials "with political appointments from the President does not remove 'politics' from the equation," the healthcare organizations said.
In addition, the proposal "usurps congressional authority over the Medicare program," they said. This would "greatly limit" the ability of Medicare beneficiaries to improve the program—making it difficult "to include coverage of new and better treatments, procedures, and technologies," they added.
