Archive for the ‘Hospitals’ Category

Medical Bills Major Cause of Bankruptcies

Wednesday, February 29th, 2012

Most Americans are just one illness away from bankruptcy – even those with healthcare insurance.  Unfortunately, there are millions of other Americans who don’t have the cash to cover their medical bills.  Hospitals expect quick payment and offer insured patients little flexibility if they have difficulty paying bills.  Those unpaid bills are sent to collection agencies, and damage the individual’s credit history for years.  The crisis in American healthcare is not restricted to emergency rooms where uninsured people wait – often for long periods of time — for care.

In fact, a study has estimated that as many as 62.1 percent of all bankruptcies are due – at least in part – to medical expenses that the person simply cannot afford to pay.  And, according to the study’s authors, that might well be a conservative estimate.

“Unless you’re a Warren Buffett or Bill Gates, you’re one illness away from financial ruin in this country,” said Steffie Woolhandler, M.D., of the Harvard Medical School.  “If an illness is long enough and expensive enough, private insurance offers very little protection against medical bankruptcy, and that’s the major finding in our study.”

Yet, 75 percent of the people with a medically-related bankruptcy had health insurance.  “That was actually the predominant problem in patients in our study — 78 percent of them had health insurance, but many of them were bankrupted anyway because there were gaps in their coverage like co-payments and deductibles and uncovered services,” Woolhandler said.  “Other people had private insurance but got so sick that they lost their job and lost their insurance.”

Even patients who have coverage “may not be protected from high out-of-pocket costs when they are diagnosed with cancer,” according to a report by the Kaiser Family Foundation and the American Cancer Society.  In addition to high insurance premiums, those costs may force patients to amass debt as they attempt to pay for the care they need — or postpone or skip lifesaving treatment.  “Having insurance increases people’s ability to access care,” said Mark Rukavina, an expert on medical debt and the executive director of The Access Project, a Boston-based healthcare advocacy group.  “The good news is that they get the care, but the bad news is it’s unaffordable.”

The days of Cadillac health plans are pretty much over,” said Peter Cunningham of the Center for Studying Health System Change in Washington, which found that 20 percent of American families have problems paying medical bills.  More than 44 million Americans currently are paying off medical debt, the Commonwealth Fund said, an increase over the 37 million in 2005.  Two years ago, Congress reported that 30 million Americans of working age had been contacted by a collection agency for unpaid medical bills.  One survey asks how people have been affected by their unpaid medical bills.  “Two-thirds of people say … they’ve had problems paying for some of the basic necessities — food, rent, mortgage, clothes, basic stuff,” Cunningham said. “They’ve put off major purchases.  They’ve taken money out of savings or borrowed money.  An increasing number consider filing for bankruptcy.”

Although it’s not yet known how the Patient Protection and Affordable Care Act (ACA) will impact medical bankruptcies, a study from Massachusetts since its healthcare reform became effective in 2006 offers scant good news. The study, which was published in the American Journal of Medicine, determined that between early 2007 and mid-2009, the share of all Massachusetts bankruptcies with medical grounds fell from 59.3 percent to 52.9 percent, a 6.4 percent decrease.  Because there was a sudden rise in total bankruptcies during that period, medical bankruptcy filings in the state rose from 7,504 in 2007 to 10,093 in 2009.

According to the study’s authors, “Even before the changes in healthcare laws, most medical bankruptcies in Massachusetts – as in other states – afflicted middle-class families with health insurance.  High premium costs and gaps in coverage – co-payments, deductibles and uncovered services – often left insured families liable for substantial out-of-pocket costs.”

“Despite a marked decline in the un-insurance rate in Massachusetts since the implementation of health reform, the proportion of bankruptcies that occurred in the wake of medical problems has not decreased significantly, and the absolute number of medical bankruptcies has actually increased by one third,” said David U. Himmelstein, M.D., from City University of New York School of Public Health, and the study’s lead author.

Survey: Massachusetts Residents Like Their Healthcare Coverage

Tuesday, February 28th, 2012

Despite GOP presidential hopeful Mitt Romney’s wish to distance himself from the law he passed, an overwhelming majority of Massachusetts residents support their state’s landmark universal health insurance program. Even though backing for its central feature — the mandate that most residents have coverage – is not quite as popular, nearly 75 percent of respondents to the Harvard School of Public Health and the Boston Globe poll said they supported the law.  When asked if they wanted changes, more than 50 percent said they did.  Another 24 percent support continuing the law as it is.

Support for the law has risen from the last time Bay Staters were asked their opinion by the Harvard researchers in 2009.  At that time, overall support was 53 percent.  Since then, it has risen to 63 percent.  That will likely come as a surprise to those who have called the state’s law, which served as a model for the federal Patient Protection and Affordable Care Act (ACA), an abject failure.

“The picture of how the Massachusetts healthcare law is working out is different than many national commentators suggest,” said Harvard’s Robert Blendon.  “Most people in Massachusetts approve of this law, and it hasn’t negatively affected them.  A large share of the audience (outside of Massachusetts) believes that something is terribly wrong because they’ve heard stories about how expensive it is…and people who live in the state just have a very different view of what’s going on here,” he said.

“Even with all the attention the Massachusetts law has gotten nationally, it really hasn’t driven down support among voters here in Massachusetts,” said Steve Koczela, president of the MassINC Polling Group, which conducted the poll.  “Taking that in concert with the level of influence people thought the state law had on the national law, at least it suggests there’s some difficulty distancing yourself from what happened nationally to what happened here at home,” Koczela said.

The myth is that the Massachusetts law failed to significantly reduce the ranks of the uninsured in the state. The fact is that the Massachusetts law dramatically increased the state’s insurance rate over a period when the national health coverage rate declined.  At the end of 2010, 98.1 percent of the state’s residents were insured compared to 87.5 percent in 2006 when the law went into effect.  Almost all children in the state were insured in 2010 (99.8 percent).  By comparison, at the national level the health insurance rate dropped from 85.2 percent in 2006 to 84.6 percent in 2010.

Approximately 77 percent of private companies are providing health insurance to their employees, compared to 70 percent before the law, according to Governor Deval Patrick’s office.  The law requires all employers with more than 11 full-time employees to make a “fair and reasonable” contribution toward their workers’ health plans or face penalties.  The mandate that requires all state residents to carry health insurance has also proved to be effective, with nearly 97 percent of taxpayers in compliance.

The problematic part of the law is its failure to curb rising costs.  Although implementation of the law itself didn’t damage the state’s budget – according to an analysis by the independent Massachusetts Taxpayer Foundation, the increase in net spending for the law was just one percent in 2010 – it hasn’t reduced overall costs for policyholders.  Private spending per member grew an average of 15.5 percent between 2006 and 2008.  Meanwhile, average premiums for full insurance increased 12.2 percent from 2006 to 2008, according to the Massachusetts Division of Health Care Finance and Policy.

Still, two-thirds of adults in the state support the law, while 88 percent of doctors say it improved, or did not affect, the quality of care.

Small Businesses Can Rely on Pooled Exchanges to Cover Employees’ Healthcare Needs

Monday, February 27th, 2012

The Patient Protection and Affordable Care Act (ACA) lets some small businesses avoid buying employee health insurance.  Despite that, a new study from the RAND Corp., said few will qualify.  Starting in 2014, the ACA mandates that the majority of companies provide health insurance for employees or pay to participate in health insurance exchanges.  Companies with fewer than 100 employees can retain their previous policies under a grandfather clause or they have the option to self insure.  The goal, RAND notes, is to spread the financial risk of covering sick or high-cost enrollees across a wider pool of employers.

In 2014, insurance companies will be allowed to set premiums based on enrollees’ age, family size, where they live or tobacco use.  They won’t be allowed to consider enrollees’ gender, overall health or pre-existing conditions.  “Concerns have arisen that such cost sharing could be undermined if small employers with relatively healthy workers and dependents avoid the new regulations by self-insuring or by maintaining grandfathered health insurance plans,” according to RAND.  “Should such a trend develop…premiums offered to all businesses that remain in the exchanges could become unaffordable.”  RAND’s study came to the conclusion that most small employers will opt not to self-insure because of the potential liability and financial risk in case medical expenses rise unexpectedly.  “The self-insure option will reduce enrollment in the small-business insurance exchanges somewhat but it will not have a substantial impact on exchange premiums,” the RAND study said.

“We found that keeping the rules as they are written, particularly the limitations on maintaining a grandfathered plan, will be essential to keeping premiums affordable in small business insurance exchanges,” said Christine Eibner, RAND senior economist and the study’s lead author.  Under the terms of the ACA’s Small Business Health Options Program, or SHOP, the exchanges for individuals have targeted their opening date for January 1, 2014.

The need for SHOP exchanges is very real.  Small businesses tend to struggle to pay for health insurance for their employees, and they have much less bargaining power with insurers than big business.  According to Timothy Jost of the Washington and Lee University law school, to succeed, the SHOP exchanges will have to provide small employers with an attractive alternative to the options currently available; keep costs affordable; regulate the insurance burden; administer the program; manage enrollment periods; and protect against poor selection, which would lead to a top-heavy number of sicker individuals in the exchanges.

It is estimated that the ACA’s state health insurance exchanges for small businesses will cover nearly 10 million employees, in addition to the 15.3 million individuals who gain coverage through the individual exchanges when the law is fully implemented.  According to Fredric Blavin and colleagues at The Urban Institute and The Commonwealth Fund, SHOP has the potential to provide affordable insurance for small employers who face high premiums and administrative costs.

The reform law grants states considerable flexibility in designing their exchanges, such as allowing them to combine their small business and individual exchanges, limiting enrollment to companies with 50 or fewer employees or opening to firms of up to 100 employees through 2015, or reducing the ability of insurers in the exchange to charge premiums on the basis of age beyond what the law allows.  When they examined all options, the researchers found that merging the small business and individual market exchanges would bring two million additional people into the exchanges, for a total of nearly 27 million.  This would reduce premiums by an average of $600 per person every year, and would cut federal spending on premium subsidies by $4 billion.  Few of the other options significantly impacted coverage or costs.  The authors conclude that “these results suggest that states can make these design choices based on local support and preferences without fear of dramatic repercussions for overall coverage and cost outcomes.

“SHOP exchanges have the potential to transform the experience of small businesses and their employees when shopping for and administering health insurance,” said Sara Collins, vice president for Affordable Health Insurance at The Commonwealth Fund.

Hedging Their Bets, Insurers Setting Up Health Insurance Exchanges

Wednesday, February 22nd, 2012

Health insurance companies are trying to play an important role in healthcare reform as the Patient Protection and Affordable Care Act (ACA) threatens to upend their marketplace in 2014 by creating their own exchanges. Health plans are trying to lock in business before government-sponsored health insurance exchanges go online in 2014.  According to Kaiser Health News and reported by Minnesota Public Radio, the largest insurers are creating their own private insurance exchanges to protect themselves against competition from the public exchanges.

The implementation of the ACA is the most significant change to healthcare since Medicare and Medicaid came on line in the 1960s – and the impact for health insurers is virtually unfathomable.  Less than two years from today, the federal healthcare law will bring more restrictions on premium increases, millions of new customers, and the ability for consumers to comparison shop online for the best deal on their health insurance.

According to Sabrina Corlette, research professor at Georgetown’s Health Policy Institute, these are just some of the changes coming in 2014. Just how insurance markets will shake out is anyone’s guess, she said.  “Insurance companies are grappling with the uncertainty like everybody else and trying to look two years down the road and how to position themselves,” Corlette said.  “(What) also needs to be watched closely (is) that it’s working for the consumer.”

According to the Obama administration, 28 states are in the process of establishing insurance exchanges under the ACA, despite multiple lawsuits and a spring date with the Supreme Court.  Fourteen states, including some with Republican governors, have passed legislation or have the authority in place to set up the regulated insurance markets, according to a report by the Department of Health and Human Services (HHS).  Other states have passed executive orders or authorized studies to demonstrate the value of exchanges.  The goal is to bring coverage to 16 million uninsured Americans in 50 states and the District of Columbia.

In their most recent demonstration of progress in health reform, administration officials promised to provide assistance to states that miss the 2013 deadline to ensure their participation.  “We’re going to meet states where they are, and…we’re going to work with them to get them as far down the path as we can,” said an anonymous administration official.

According to the report, some states such as Nevada, Alabama, Mississippi, all with Republican governors, and others are making significant progress.  The irony is that many of these “red” states are also suing the administration over the ACA’s constitutionality.

How does a red state that has taken a lead in lawsuits against the ACA reconcile these differences?  Writing in the Richmond Times Dispatch, Michael Martz says that “Six bills have been filed in the legislature proposing varying ways to set up a benefits exchange, which is required under the federal healthcare reform law that (Governor Bob) McDonnell opposes and the state hopes to overturn in the U.S. Supreme Court.  But the governor is discouraging legislators from approving any of the bills during this session, despite looming federal deadlines that some lawmakers and insurers fear will leave Virginia with a less-competitive federal exchange for individuals and small businesses to buy health benefits.  The state would have to submit a plan for the exchange this year to the U.S. Department of Health and Human Services (HHS) no later than January 1, 2013, to ensure that the entity can begin operating a year later.”

“There is plenty of time to act,” the McDonnell administration said in a series of “talking points” on why legislation is not currently needed.  “There is no need for members of the General Assembly to make untimely and unnecessary decisions surrounding creation of an exchange during the 2012 session.”

States Want Feds to Move Faster on ACA Rules

Tuesday, February 21st, 2012

Although the Patient Protection and Affordable Care Act’s (ACA) major provisions don’t go into effect until 2014, states and insurers must be prepared to enroll some 32 million Americans who currently lack insurance coverage into Medicaid or private insurance programs.  According to Kaiser Health News, the fly in the ointment is that to successfully unveil their individual programs in just two years, the states must make important crucial decisions and take actions this year.

It will be difficult for many states to meet fast-approaching deadlines, and some may not make it, said Brett Graham, managing director at Leavitt Partners, a consulting firm.  Two years is surprisingly brief and many states need information from the federal government detailing the various insurance exchange options and precisely which benefits must be included in health plans.  Complicating the situation is the fact that states are competing for a limited pool of information technology vendors to give them the help they need.  “It’s a pressure cooker,” said Graham. States are “in a position where they have to act with imperfect information.”

Next New Year’s Day, the Department of Health and Human Services (HHS) will certify which states are ready to run their own exchanges.  To earn certification, a state must put in place laws to fund the exchanges’ continuing operations.  While the federal government is providing financial help up front for the creation of exchanges, states will assume the cost once they are underway.  HHS can issue a conditional certification for those states that are making progress but need more time.

Only 14 states and the District of Columbia have made significant legislative progress toward creating exchanges, according to a Robert Wood Johnson Foundation report prepared by the Urban Institute. The study’s authors reach the conclusion that because of the ACA, the percentage of the population that is uninsured will decline in all 50 states and Washington, D.C.

While some states are aggressively moving forward, “at the other end are states that say, ‘no way, no how, we’re not doing it.’  Montana, Texas, Louisiana, Florida, they are not going to build it and they’re playing a game of chicken,” said Graham.  “They’re waiting for the Supreme Court,” hoping it will declare the ACA unconstitutional in June.

The majority of states cannot make up their minds about whether to build their own exchanges and or participate in the proposed federal model. It’s ironic that some states that are participating in the Supreme Court challenge have taken action: Colorado, Washington and Nevada have set up exchanges.

According to the Robert Wood Johnson/Urban Institute report, “Without action by these states, their populations will still benefit from health reform through the expansion of Medicaid/CHIP, but will have to rely on the federal government to create exchanges, as called for under the ACA.  This creation will be dependent on adequate federal resources and political support.”

According to the Robert Wood Johnson Foundation and the Urban Institute, 15 states have made “little or no progress” implementing insurance exchanges where individuals and small businesses can buy private insurance.  The states that haven’t started working on creating exchanges are among the states with the most residents eligible for federal subsidies to help buy insurance.  According to the analysis, the federal government has the ability to establish and run a substitute in any state that does not establish its own exchange.

Creating a full or partial federal exchange also could be a problem, although some healthcare analysts are unsure whether it will be any easier for the federal government.  It faces the same brief timeline as the states.  While Obama administration officials say they have the money to fund exchanges, many healthcare analysts aren’t so certain.  Most state legislatures will adjourn for the year by March or April — before the Supreme Court hands down its ruling — according to the National Conference of State Legislatures.  Special sessions after the ruling would be virtually impossible in an election year.

New York Controversy Emerges Over Food Portion Size Campaign

Monday, February 20th, 2012

The New York City Department of Health recently launched a campaign to get New Yorkers to make their waistlines smaller by controlling their portion sizes when ordering food and beverages. “Consuming too many calories can lead to weight gain,” said city Health Commissioner Thomas Farley.  “If New Yorkers cut their portions, they can cut their risk.”  The “Cut your portions. Cut your risk” campaign is billed as “hard-hitting” and has the purpose of making certain that people understand that large meals cause obesity.  Even worse, obesity can cause diseases like diabetes.  In one city poster, a man whose leg has been amputated because of Type 2 diabetes sits behind a graphic showing how soft drink portions have grown over the years.

Over the last 40 years, according to the Health Department, serving sizes for sugary soft drinks have grown four times, and the amount of French fries in a single order has tripled.  As a result, “a single meal could balloon to contain many more calories than the amount an adult needs for an entire day” – roughly 2,000.

Writing on the friendseat.com blog, Spence Cooper takes a more cynical attitude. “The number of New Yorkers motivated to make healthier choices and forgo that next order of large fries because of ad nauseam public service ads is equal to the number of New York smokers who pay attention to the warnings on cigarette packs. You can count them on one hand.”

The new posters, available in both English and Spanish, bear the message “Cut your portions. Cut your risk,” providing New Yorkers with a clear strategy for preventing obesity and its health penalties.  While the City has made strides in combating the nationwide trend of growing obesity, the majority of adult New Yorkers (nearly 57 percent) and two out of every five New York City elementary school children remain overweight or obese and the health consequences are dire, ranging from hypertension to type 2 diabetes.  Nearly 10 percent of New Yorkers have been told they have type 2 diabetes, which can lead to blindness, kidney failure and amputations. In 2006, nearly 3,000 New Yorkers with diabetes were hospitalized for amputations. Obese children and adolescents also are more likely to become obese adults. Even while young, they are more likely to develop obesity-related conditions such as high cholesterol, high blood pressure, and type 2 diabetes.”

Not all are in agreement with Farley’s campaign. The New York ads create an “inaccurate picture” of the impact of soft drinks, argues Stefan Friedman, a spokesman for the American Beverage Association.  “Portion control is indeed an important piece of the solution to obesity,” he said. “Instead of utilizing scare tactics, the beverage industry is offering real solutions like smaller portioned containers and new calorie labels that show the number of calories in the full container, right up front, to help people chose products and sizes that are right for them and their families,” he said.

The posters are appearing on subway stops around the city for the next three months. Mayor Bloomberg dismissed his critics who claim that the ads were too graphic and disturbing:  “What do you want to do? Do you want to have people lose their legs or do you want to show them what happens so that they won’t lose their legs? Take your poison. Which do you want?” said Bloomberg.

Many healthcare experts agree with Bloomberg. “Obesity rates in adults rose to 35.7 percent from 30.5 percent between 1999 and 2010, compared with rates that nearly doubled in the two previous decades, the Centers for Disease Control and Prevention (CDC) reported . The rate among boys climbed 29 percent, surpassing girls for the first time, according to the CDC.

More than 78 million American adults — as much as  one third of the population, and about 12.5 million children were considered obese in 2009- 2010, according to a series of studies reported in the Journal of the American Medical Association. The studies are part of a continuing CDC effort to track obesity rates with new numbers every two years.

Planned Parenthood, Susan G. Komen For the Cure Disagree, Then Make Up

Tuesday, February 14th, 2012

After setting off a firestorm by threatening to cut funding to Planned Parenthood, the founder and CEO of Susan G. Komen For the Cure — the nation’s largest breast-cancer advocacy agency — backtracked and promised to amend the criteria.  “We will continue to fund existing grants, including those of Planned Parenthood, and preserve their eligibility to apply for future grants,” Nancy G. Brinker said.  “We want to apologize to the American public for recent decisions that cast doubt upon our commitment to our mission of saving women’s lives.”  According to Brinker, the decision was not “done for political reasons, or specifically to penalize Planned Parenthood.”

Planned Parenthood president Cecile Richards expressed gratitude and said her agency could resume longstanding relations with Komen and that she anticipated continuing to receive ongoing funding.  “I really take them at their word that this is behind us,” according to Richards.  She gave credit to an outpouring of support, especially on social media sites, with forcing the reversal.  In just three days, Planned Parenthood raised $3 million and acquired 10,000 new Facebook supporters, Richards said.

Komen executives insisted that their decision was not compelled by pressure from anti-abortion groups.  Planned Parenthood said its national network of health centers performed more than four million breast exams over the last five years, including nearly 170,000 paid for by Komen grants.  The grants totaled $680,000 in 2011.  As the controversy developed, Planned Parenthood received $400,000 in smaller donations from 6,000 people, as well as a $250,000 pledge from New York Mayor Michael Bloomberg to match future donations.  Komen was flooded with negative emails and Facebook posts, accusing it of bowing to pressure from anti-abortion groups.

Although the dispute between the two sides appears to have reached an amicable solution, the debate continued as Carol Tobias, president of National Right to Life Committee, said Komen’s decision to reverse its decision will almost certainly cost the group contributions.  “I think right now pro-lifers are going to be reluctant to support them because the money may go to the country’s largest abortion provider,” Tobias said.

According to Mike Paul, president of MGP & Associates, a reputation management firm, Komen will have to “build up trust” following the commotion.  Komen was the world’s most valuable non-profit brand, according to a 2010 report by market-research firm Harris Interactive.  Now, the Komen brand could become a subject for political debate, Paul said.  “People wanted to be associated with every single thing they did,” he said.  “And now we hear politics and policy has influence.  The same affinity people had on the positive side became the same affinity they’ve having on the negative perspective,” he said.

“Politics should never come between women and their healthcare, and I am very glad that Komen did the right thing and reversed their misguided and deeply damaging decision,” Senator Patty Murray (D-WA), said.  Taking an opposite position was Senator David Vitter (R-LA), who originally applauded the move.  Commenting on Friday’s announcement, Vitter said that “While Komen now claims that they don’t want their mission to be ‘marred by politics,’ unfortunately it seems that Komen caved to political pressure from the pro-abortion movement and its enforcers in the media.”

The backlash is still adversely affecting the Susan G. Komen organization. Many long-time donors, irked by the foundation’s decision to pull their funding from Planned Parenthood, have said they’ll no longer give to the organization.  Others, disappointed that the decision was reversed, also will no longer provide financial support.  Melissa Berman, president and CEO of Rockefeller Philanthropy Advisors, is optimistic that the foundation will eventually recover.  “They changed their mind pretty quickly, and so they’re going to be able to make a recovery here,” Berman said.  “Susan G. Komen will have to tell the story of how many women they reach, how many women get access to care, how many women participate in their events, how much research they’re funding.  They’ll just have to continue to tell that story clearly and concisely,” according to Berman.

Writing in Forbes, contributor Davia Temin says that “In one of the more bizarre series of actions I have ever witnessed, Susan G. Komen for the Cure completely compromised its sterling reputation by first caving in to one set of political pressures, and then another.  And in the process, they left us all wondering who these people really are, and what they stand for.”

“Although, in their somewhat grudging apology requesting that ‘everyone who has participated in this conversation…help us move past this issue,’ they clearly want to put the past week behind them, it will never happen.  At least not for a good, long time.  I bet the folks at Komen wish they could have a do-over.  Or that in true Groundhog Day movie fashion, they could replay the week over and over again until they got it right.  Reputational suicide is not too extreme to call it.  Because no one is happy with them now.  And the questioning from all sides will continue, and spill over to their every action.  On this one, I predict our memories will be long.”

Hospitals, CMS Butt Heads Over Too Many Readmissions

Tuesday, February 14th, 2012

Medicare has plans to penalize hospitals that frequently readmit patients who really don’t need hospitalization. According to one estimate, this practice costs the federal government $12 billion every year.  Medicare’s goal is to persuade hospitals to be certain that patients get the care they need following their discharge.  This new policy is likely to excessively impact hospitals, particularly those that treat low-income patients, according to a Kaiser Health News analysis of data provided by the Centers for Medicare & Medicaid Services.  Hospitals that admitted the most underprivileged Medicare patients were approximately 60 percent as likely to have significantly higher readmission rates for heart failure.  At these hospitals, lower-income people comprise a larger share of the patients than they do at 80 percent of hospitals.

“When some of our patients get home, their lights and gas are shut off,” said Roland Abellera, vice president of quality and corporate compliance at St. Bernard Hospital in Chicago’s blighted Englewood neighborhood.  “So what ends up happening is that the ambulance brings them back to us and we have to house them until our staff can help them get the utilities turned on.  We have a community in need.”

Within 30 days of discharge, 25 percent of Medicare patients with heart failure are readmitted to the hospital.  The Patient Protection and Affordable Care Act (ACA) has ruled that beginning next October, Medicare will fine hospitals whose patients who have had heart attacks, heart failure or pneumonia return to the hospital too soon.  By 2014, hospitals with high readmission rates can potentially lose up to three percent of their Medicare reimbursements.

Medicare has set aside funds so hospitals can more effectively plan patients’ post-discharge care.  According to Patrick Conway, Medicare’s chief medical officer, some funds will be targeted to hospitals that serve significant numbers of poorer people.  “We especially are concerned about safety-net hospitals that take care of a high portion of patients in poverty and racial and ethnic minorities,” he said.  At the same time, his agency is committed to the readmission penalties, in part because it is the law and because it believes the penalties will persuade hospitals to be certain that patients get the follow-up care they need.

Some hospital administrators are concerned that the new policy is too harsh.  “In essence, they are penalizing those hospitals and areas that need the most help and the most money to address these issues because we have the sickest, most noncompliant and vulnerable patient population,” said Guy Alton, chief financial officer at St. Bernard.  According to Abellera, St. Bernard’s heart failure patients usually have more than one serious conditions, such as kidney failure, hypertension and diabetes.  “A patient does not come here for heart failure alone,” he said.  “They have no less than six or seven diagnoses — we’ve had many with more than that.”

Dr. Ashish Jha, in the latest New England Journal of Medicine, makes the case that readmissions aren’t the best gauge of unnecessary care — even though they’re a natural target for budget-cutters.  The Harvard University professor points out that many hospitals with the highest readmission rates serve the poorest areas with the biggest health problems.  “Readmissions are caused by what hospitals do, who the patients are, and what’s happening in the community,” he says. “You want hospitals to fix the things they can, but you don’t want to punish them for taking care of poor people, and you don’t want to punish them for being located in a poor area.”

Two of the most frequent reasons for hospital readmissions are medication errors and failure to see a physician – both of which could be reduced if patients were supervised through home care visits following discharge.

New HHS Program Seeks to Cure Alzheimer’s in 13 Years

Monday, February 13th, 2012

A national Alzheimer’s disease advisory council has set  preliminary goals and  recommendations for a national strategic plan to slow — or even bring to an end to — the expected rise in new cases as the baby boomer generation ages. The plan’s goal is to prevent and successfully treat the disease as soon as 2025. The objectives include enhancing care quality and efficiency, expanding patient and family support, enhancing public awareness and engagement, and improving data to track disease progress.

The plan is part of the National Alzheimer’s Project Act that was signed into law on recently by President Barack Obama. The law created the Advisory Council on Alzheimer’s Research, Care, and Services. The new law requires the secretary of the Department of Health and Human Services (HHS) and the advisory council to create and maintain a national plan to defeat Alzheimer’s.  Members of the council’s subgroups on long-term services and supports (LTSS), clinical care, and research are meeting to comment on and provide recommendations to formulate the plan’s draft framework.

The council’s members support alternatives to Medicare coverage and physician reimbursement to encourage the diagnosis of Alzheimer’s and provide care planning to individuals diagnosed with the disease and their caregivers. Additionally, quality indicators for the care and treatment of individuals with Alzheimer’s need to be formulated. The group proposed medical home pilot projects specifically designed to improve medical management for Alzheimer’s patients using grants from the Center for Medicare and Medicaid Innovation (CMMI).

More than five million Americans have been diagnosed with Alzheimer’s, a brain disease that causes dementia and affects primarily elderly people.  Some experts estimate that treating the disease costs the United States more than $170 billion annually.  Australia, France and South Korea already have comprehensive Alzheimer’s plans, and worldwide experts have been urging the United States to assume a leadership role.

“We want to demonstrate that as a country we are committed to addressing this issue,” Dr. Howard Koh, assistant secretary for health at HHS, said.  “We know the projected number of patients is expected to rise in the future.  We know there are far too many patients who are suffering from this devastating condition and it is affecting them and their caregivers,” Koh said.

Other experts believe that the 2025 deadline is too close and unrealistic.  “No one set a deadline for the ‘War on cancer’ or in the fight against HIV/AIDS.  We make progress and we keep fighting.  The same should be true for Alzheimer’s,” said Dr. Sam Gandy, an Alzheimer’s researcher at Mount Sinai School of Medicine.  “In my mind, that provides the unfortunate sense that we will have ‘failed’ if we don’t have a cure by 2025.”  The National Alzheimer’s Project Act provides no new funding for research.  Although some drug companies have compounds in clinical trials, researchers say they are just beginning to understand the complex disease, which develops without any symptoms for 15 to 20 years before any memory problems begin to show.  “This means that if we had, today, already in hand, the funding, recruitment and the perfect drug, the trial would still take 15 to 20 years,” Gandy said.

According to P.J. Skerrett, Editor of Harvard Health, “Like a powerful wave, the Alzheimer’s epidemic is expected to crest in 2050. At that time an estimated 16 million Americans will be living with this mind-robbing disease. (About 5.4 million Americans have Alzheimer’s Disease today.)  In an effort to head off the explosion, President Obama has signed into law the National Alzheimer’s Project Act.

This ambitious project aims to attack Alzheimer’s on several fronts:

  • Improving early diagnosis.  The brain changes that lead to Alzheimer’s disease probably begin years before memory loss and other problems appear. Earlier diagnosis could help families better plan for the future, and could be especially important if better treatments become available.
  • Finding effective prevention and treatment strategies.  Today’s treatments relieve symptoms for only a short time; none prevent or stop Alzheimer’s-related mental decline. New treatments that are more durable would be a huge boon to current and future Alzheimer’s sufferers.
  • Providing more family support.  Spouses and adult children are the primary caregivers for many people with Alzheimer’s disease. The day-to-day challenges of caring for someone with Alzheimer’s can be daunting. Many caregivers have no training and don’t know what resources are available to them. The project would provide better education and support for caregivers.” Skerrett said.

Healthcare Providers Must Innovate to Trim Costs

Wednesday, February 8th, 2012

A top official from the Centers for Medicare and Medicaid Services (CMS) recommended that providers — including hospital executives — should research technology-driven changes in their systems with the goal of improving care and reducing costs.  “We need to decide now whether to make the commitment to adopt innovation that will fundamentally change the way we operate, change the way we deliver care, change the way we think about these organizations that we run,” Dr. Richard Gilfillan, acting director of the CMS’ Center for Medicare and Medicaid Innovation, said.  “This is not an abstract notion; this is a very concrete question that each of us will have to answer.”

Healthcare leaders who join in such an overhaul in their care delivery will likely find that the main obstacle is in changing how they are paid, Gilfillan said.  “We can ask people to keep folks from going back to the hospital, but if we pay health systems for putting more people in the hospital, we’ll get what we have today: a lot of hospital care,” he said.  Medicare will encourage private payers to change payment approaches by undertaking its own changes.  Specifically, Gilfillan said, once his office identifies payment practices that result in improved clinical outcomes and reduced spending, the HHS secretary will implement those throughout Medicare administratively.  “As you can see, this is a powerful tool for changing the way we deliver care,” Gilfillan said.

The large number of senior citizens covered by Medicare and low-income Americans covered by Medicaid suggests that any changes that serve those patients could soon be adopted throughout the system.  “The reality is that over the years, the private sector has by and large followed Medicare’s lead in payment systems,” Gilfillan said.  “Medicare has been the most innovative payer if you look back over the last 30 years.”  With $10 billion in funding through the end of 2019, Gilfillan anticipates rolling out additional initiatives before too long.  These could encompass ideas that emerge at an “innovation summit”.

Created by the Patient Protection and Affordable Care Act (ACA), the Innovation Center works to test and support innovative new healthcare models that reduce costs and strengthen the quality of care.  “The Affordable Care Act gives us tremendous new tools to innovate and improve our health care system,” said Health and Human Services Secretary Kathleen Sebelius.  “We discussed how we can work together to make innovative ideas a reality in communities across the country.”

“The level of real excitement surrounding this conference shows not only that people who know healthcare recognize the urgent need for better health and better care at lower cost, they also are ready to move forward with solutions,” said CMS Acting Administrator Marilyn Tavenner.  “The fact that all of these disparate interests share the aim of better healthcare and are willing to work for it not only means that we’re going to have the best ideas on the table, but also that we’re going to have the expertise and the resources that will ultimately ensure better health at a lower cost will be within the reach of every American,” Gilfillan said.

In the meantime, the Obama Administration also released a new report highlighting the success of the Center for Medicare and Medicaid Innovation.  The Center for Medicare and Medicaid Innovation’s role is limited to testing payment incentives and healthcare delivery methods within Medicare and Medicaid, as well as the Children’s Health Insurance Program.