Uninsured face delays, increased risks en route to long-term care
Writing for Heart & Soul, Yanick Rice Lamb offers up a comprehensive take on the special challenges patients and hospitals face when it comes to long-term care for the uninsured.
… a growing number of uninsured people … need long-term care after hospital stays. They lack insurance because they can’t afford it, their employers don’t offer it or they were dropped by private carriers after taking out policies on their own. Consequently, these patients experience delays in moving on to the next step in their care once they are medically ready for discharge. They are stuck in the hospital, because it’s hard to place patients in long-term care facilities or send them home with a nurse when they have no coverage, especially when there are complications. Hospitals end up picking up the tab — sometimes even after patients leave. Those costs are ultimately passed on to everyone who pays taxes and anyone who has a medical bill.
Rice Lamb fleshes out this scenario not only with anecdotes, but with a raft of statistics and studies showing that the ranks of such patients are swelling rapidly, as is the financial toll they’re taking on the system. She ties it in with the hospital “frequent flyer” and charity care issues that have received so much ink in recent years. At the same time, she takes a deeper look at the issues faced by the patients themselves, from the difficulty of spending days and weeks away from family, to the lower levels of attention they may receive from hospital staff as their stays drag on, to the increased risk of hospital-acquired infections and lack of specialized rehab.
Some of the most surprising observations came in relation to undocumented immigrants, who present major challenges despite being a small part of the patient population.
In some cases, when community support can’t be found, Rice Lamb writes that hospitals “Often pay to transport immigrants back to their countries — if the patients agree — and sometimes cover medical bills in their homelands. This often costs less than absorbing the expense of continuous care in the United States.”
Furthermore, she says, “Even with U.S. citizenship, language barriers can contribute to discharge delays. When caregivers spoke little English, the length of stay increased to 6.1 days, compared to four days for the control group, according to a study published recently in the Archives of Pediatrics & Adolescent Medicine.”
Throughout her work, Rice Lamb takes advantage of sources which reporters around the country should find useful when localizing similar topics.
Rice Lamb completed this project while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund.
Kenen suggests topics for regional, local Medicaid stories
My last blog post was on coverage of Medicaid, and we’ve just posted a tip sheet about it, pointing out that if you think the story is going in several incompatible directions simultaneously (expand, contract, blow up, salvage, reform) you are right. As it’s an undercovered but extremely important topic, I thought I’d stick with it for this post too.
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Looking at coverage nationally, I’m still finding a lot of legislative process stories, or bits and pieces stories. I’m still on the lookout for good regional and local stories on Medicaid – I’d love to see some good ones about delivery system reform in Medicaid and, for those of you in states with Republican governors endorsing block grants, some tough questions about exactly what the state would do with all that flexibility and not all that much money. In the meantime, here are a few stories that I think shed some light on current Medicaid issues.
There were a couple of pieces about the Rhode Island “global waiver,” which has become the equivalent of a poster child for the block grants favored by Republicans – even though the savings may be far more modest than touted and the state was getting MORE money than it would have without the waiver, not less as it would under block grants. (I wish the latter point had been made higher up in Phil Marcelo’s very good story.)
• Janet Roberts, on May 15 in The New York Times: Rhode Island’s Medicaid Experiment Becomes a Talking Point for Budget Cutters
• Philip Marcelo, on May 16 in The (R.I.) Providence Journal: R.I. Medicaid agreement admired in other states
• A few earlier stories tracking developments in Rhode Island include Felice Freyer’s April 11 story in The (R.I.) Providence Journal, State looking to maintain Medicaid coverage level, and, for a focused look at how hard it is to define and compare Medicaid savings even in neighboring states, see Confusion over Medicaid numbers in The (R.I.) Providence Journal by Randal Edgar and Philip Marcelo.
• In Fla. Pilot program to cut Medicaid costs raises new questions, N.C. Aizenman in The Washington Post on May 11 looks at whether 1)the cost savings are real 2)whether quality of care is being damaged.
• Phil Galewitz at Kaiser Health News writes about Florida’s proposal to charge poor people on Medicaid monthly premiums and $100 for nonurgent ER visits (some advocates point out that it could be a dangerous deterrent for people who may have symptoms like chest pains that could be a true emergency or could turn out to be less serious)
• This May 2 story – just a short really but packs in some good information in a small space – by Carrie Ghose of Columbia Business First, Feds mull ‘mystery shoppers’ to gauge Medicaid access to doctors.
Health reform battle entering a new phase
As I try to figure out what AHCJ members most need as they cover health reform in year two of the Affordable Care Act, I tried to see if I could detect themes at the AHCJ conference in Philadelphia. That unified theory of health reporting plan went out the door as I heard questions ranging from very basic queries about pre-existing conditions to far more technical inquiries about accountable care organizations.
My next plan was to blog about the “reporting on health reform” session. A conference fellow beat me to that - (also see the tip sheets Covering health reform issues, Health care reform: Litigation update, Three health reform issues to watch in the states).
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The repeal and replace stage of the health wars isn’t over. But I think we are entering another phase. The dominant national discussion topic is the deficit and the debt – and that leads into Medicare, Medicaid and other entitlements. I’ve done a tip sheet on Medicare and “premium support.” Medicaid is next up.
The proposals in the House-passed version of the budget are not brand new; Medicaid block-grant proposals have been around since at least the Reagan years, and they were definitely part of the Gingrich era. I remember hearing about variants of premium support and/or Medicare vouchers in the late 1990s, and I suspect they were around before that.
We don’t know every detail of what the Ryan plan would do; the budget plan is a federal framework, and the details aren’t filled in. And of course the Ryan budget won’t be accepted by the Democratic-controlled Senate or President Obama. But this idea isn’t going to go away. We need to watch how it plays into reforms being considered at the state level, and see what kind of steam it picks up (or loses) after 2012.
If your governor or state legislature favors block granting Medicaid, it’s time to start asking questions.
- What would Medicaid look like under a block grant?
- Who would still get it?
- Would there be enrollment caps and waiting lists?
- How much of the costs would be shifted to the beneficiaries and families?
- Would providers get paid less?
States can already get waivers for Medicaid, and that can allow for innovation in red and blue states alike. States will have a lot more flexibility under some of the ACA provisions in the next few years, including ways of doing a better job caring for people with chronic disease and the “dual eligibles” on Medicaid and Medicare.
Here are a few articles I’ve seen recently that describe some of what the states are already doing – or considering – as they confront rising Medicaid costs today.
Looking at the coverage
Carol M. Ostrom of The Seattle Times had an April 17 piece: “Doctors: State plan to limit Medicaid ER trips risks lives.”
Several of the Florida papers have had pretty good coverage of Gov. Rick Scott’s plans to transform Medicaid. But a solid hour of Googling didn’t net me one good big clear step-back story (it may be out there somewhere … send it if you see it) that tells out-of-state readers the whole story. But I still found work by John Kennedy and Stacey Singer at The Palm Beach Post (here’s one) and Marc Caputo of The Miami Herald (click here - you have to read down a bit to get the state overview) helpful.
The Oregonian has been taking a look at some of Gov. John Kitzhaber’s agenda, which should be worth watching as he has a track record as an innovator (and knows CMS administrator Don Berwick quite well). And of course we’ve all heard a lot about Arizona.
A lot of the stories I looked at from around the states were written by state capitol reporters, not health beat folks, so they were heavy on process and “Republican said X, Democrat said Y” kind of coverage. They didn’t always do a great job of getting beyond a fusillade of quotes. I guess if I’ve been Googling for more than an hour and can’t find a really solid health overview story, I should stop here and invite you to send me any you’ve seen (or written).
Don’t forget about Medicaid
Medicare is getting an awful lot of ink – after all, old people vote, and most of us expect to get old someday and need Medicare. We’ve got to look harder at Medicaid which covers poor kids and their parents, some of the disabled and mentally ill, some of the HIV population, and lots of the residents of nursing homes. That isn’t who votes. That isn’t who decides what reporters cover. And it’s certainly not a benefit most of us hope to use someday.
Last comment for today - and you’ll probably hear me return to this theme frequently because, to me, it’s some of the most interesting reporting we’ll be able to do in the coming years: Remember the Affordable Care Act, the health reform law, isn’t only about coverage and insurance exchanges. It makes countless changes to Medicare and Medicaid - changes that will affect the current fee for service model, changes that affect the private managed care sections of it and changes that will add new dimensions as we explore new ways of delivering care (medical homes, ACOs, a number of Medicaid programs aimed at getting people care in the community, not just nursing homes).
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Four states refuse to name hyper-prescribing docs
As part of his war against overprescription and fraud, Sen. Charles Grassley asked states to share data on doctors who write colossal amounts of prescriptions for drugs covered by Medicaid. At this point, at least four states are holding out, and Pharmalot’s Ed Silverman is naming names. Montana, Alabama, Wisconsin and New Jersey have declined Grassley’s request, and a commenter says Michigan, which didn’t name names, belongs on the list as well.
Silverman attempted to contact the four holdouts he listed and gleaned what other information he could from other published sources. The reasons officials gave are, for the most part, well-worn: The data’s too expensive to collect, it doesn’t have enough context and, according to Alabama, might wrongly pinpoint physicians with legitimate reasons for prescribing all those drugs.
In reply, Silverman lets the already disclosed data speak for itself:
… in Florida, the top Zyprexa provider wrote 1,356 scrips for 309 patients in 2008 and 1,238 for 236 last year, compared to the 10th-highest prescriber each year who wrote 256 for 55 patients and 192 scrips for 30 people, respectively (more here). In Texas, one doc authorized 13,596 filled scrips for Xanax in 2008, and increased that to 14,170 filled in 2009. The doc who occupied the lowest ranking in the top 10 prescribers wrote just 1,444 and 1,696, respectively. The list goes on…
Related
AHCJ members can read more about getting Medicaid prescribing data from states in this article by Christina Jewett. Jewett, now at CaliforniaWatch, requested Medicaid data from a number of states for an investigation for ProPublica.
NPR explores the right to at-home care for disabled patients
When it comes to summarizing the NPR news investigation “Home or Nursing Home,” you really can’t do much better than its tagline: “America’s empty promise to give the elderly and disabled a choice.”
The package is anchored by Joseph Shapiro’s wonderfully written profile of the family of a young woman who lives at home, despite the need for 24-hour intensive care. She’s 20, and Illinois Medicaid will stop covering her care as soon as she hits 21. Why?
It’s expensive to care for Olivia at home: nurses cost about $220,000 a year. Still, that’s less than half the cost of what the state counts as the alternative — having her live in a hospital. The Welters figure they’ve saved the state millions of dollars by keeping her at home.
But when she turns 21, the state changes how it measures cost. For an adult, the state says the alternative is no longer a hospital — it’s a less expensive nursing home.
At 21, Olivia and thousands like her around the country enter an uncomfortable gray area rife with lawsuits, acts of government and supreme court decisions. In fact, families like hers have lately been suing states – and winning. Shapiro explains how.
In 1999, the U.S. Supreme Court ruled, in Olmstead v. L.C., that under the ADA, people with disabilities often have the right to live in the community rather than in institutions. Since then, other federal laws and policies have said that states have an obligation to provide more home-based care. The new health reform law is filled with incentives for the states to spend more.
But federal law is contradictory. An older federal law, the 1965 law that created Medicaid and Medicare, says states have an obligation to provide nursing home care. Home care programs are still optional.
Also not to be missed: Shapiro’s profile of a patient advocate that doubles as a seamless history of how the system reached this point. A timeline and interactive graphic round out the package.
Drugs send more of the 45-plus crowd to hospitals
At a time when overall prescription drug use is climbing across the board, the AHRQ reports that the number of medication- and drug-related hospital visits for Americans over the age of 45 doubled between 1997 and 2008. Abuse is also on the rise in that age group, and the cost burden for the increase has fallen heavily upon Medicare and Medicaid. The numbers come from the AHRQ’s Healthcare Cost and Utilization Project, a wonderfully deep well of cost-related statistics from 2008.
A few numbers from the release:
Hospital admissions among those 45 years and older were driven by growth in discharges for three types of medication and drug-related conditions – drug-induced delirium; “poisoning” or overdose by codeine, meperidine and other opiate-based pain medicines; and withdrawal from narcotic or non-narcotic drugs.
Admissions for all medication and drug-related conditions grew by 117 percent – from 30,100 to 65,400 – for 45- to 64-year-olds between 1997 and 2008. The rate of admissions for people ages 65 to 84 closely followed, growing by 96 percent, and for people ages 85 and older, the rate grew by 87 percent. By comparison, the number of hospital admissions for these conditions among adults ages 18 to 44 declined slightly by 11 percent.
Beyond the headline-making news involving drugs, AHRQ’s report includes data on other types of medical conditions treated in hospitals, surgical procedures and costs in 2008.
Mass. reform, cost-cutting crush safety net hospital
Filed under: Government, Health care reform, Health policy, Hospitals
Boston Medical Center has been pushed to the financial brink by a mix of politics, economics and expanded health coverage. In Boston Magazine, Eileen McNamara examines the forces that are dragging down the commonwealth’s largest safety net hospital, in the process painting a cautionary tale of what happens when universal health care and cost-cutting collide. If it keeps eating through its financial reserves at the current rate, the hospital will become insolvent next year.
Photo by Wade Roush via Flickr
BMC is in a unique position, thanks to a legal mandate (not shared by its wealthier, Harvard-affiliated competitors) that it “consistently provide excellent and accessible health care services to all in need of care, regardless of status or ability to pay,” McNamara writes. In return, the state is supposed to compensate for its disproportionate load of low-income patients. Instead, the state’s clamping down on Medicare reimbursement.
BMC is locked in a battle with the Patrick administration over dramatic cuts in how the state pays for treating the poor. Barring a last-minute settlement, a Suffolk Superior Court hearing on September 29 will consider the state’s motion to dismiss a BMC lawsuit that challenges Massachusetts’ reimbursement rate. (The state currently pays the hospital 64 cents for every dollar it spends on patients with Medicaid.)
BMC says the new reimbursement formula violates state and federal law, and will sound the death knell for the state’s largest safety-net hospital. The commonwealth says it has the power to set any rate it wants; if BMC finds the payments inadequate, it can simply stop taking Medicaid patients. The state’s argument might have some merit in the case of doctors being free to choose their patients, but it’s a ludicrous posture to adopt toward an inner-city hospital that is required — by state law — to serve all comers.
On MedpageToday, Kevin “@kevinMD” Pho, who trained at BMC, pulls no punches as he riffs on McNamara’s article.
Universal coverage makes great headlines, helps get politicians elected, and, to be fair, is something that needed happen. But doing so without adequately addressing its cost is going to bankrupt hospitals, especially inner-city ones like BMC. That will hurt the Medicaid and Medicare patients dependent on them.
And that’s a goddamn shame.
How reform will affect America, group by group
Filed under: Health care reform, Health policy, Hot Health Headline, Studies
In Health Affairs (AHCJ members get free access), economist Joseph Newhouse considers how health care reform will affect four major groups. They’re summarized below.
- Uninsured or on Medicaid or CHIP (30 percent)
- Insured individually or through a small business (10 percent)
- Insured through a mid-size or large business (45 percent)
- Recipient of Medicare (15 percent)
Medicaid expansion and broader subsidies are “major gains.”
This group will undergo the most change, with the individual mandate expanding their ranks to as much as 50 million people (16 percent of Americans). Health reform should “repair” this now-broken sector of the market.
A wash, as an insurance tax is balanced out by a reduced need to cover uncompensated care for the uninsured.
Complicated. The doughnut hole will close, but future financing sources are murky. Newhouse goes pretty deep into just how murky.
His conclusion is relatively upbeat. Newhouse writes that while reform “addressed many issues in health care financing, it left many others unresolved.” The system will need to be revised and updated throughout the foreseeable future, Newhouse writes, and effective implementation will “require persistence for many years to come.”
Reform may worsen ER crowding
Filed under: Health care reform, Health data, Health journalism, Health policy, Hospitals, Hot Health Headline, Member news, Studies
Associated Press medical reporter Carla K. Johnson has found that, contrary to common assumptions, emergency rooms could become even more crowded with the passage and implementation of health care reform. Popular wisdom has it that, with more access to insurance thus to primary care, folks will be less likely to go to the emergency room for minor complaints or to allow illness to progress to the point where an emergency visit is necessary. Johnson, an AHCJ board member, gives three big reasons why it’s not that simple:
- There are not (will not) be enough primary care physicians in America to deliver that preventative care.
- At present, the uninsured are no more likely to use the ER than patients with insurance coverage.
- “The biggest users of emergency rooms by far are Medicaid recipients,” Johnson writes. “And the new health insurance law will increase their ranks by about 16 million.”
ERs are crowded, Johnson writes, not only because of a lack of insurance but also because of obstacles inherent in their structure and mission, such as an aging population, more people with chronic illnesses, the closures of many ERs in the 1990s and the demand for beds for both emergency patients and patients scheduled for elective surgeries that bring more money.
AHCJ Immediate Past President Trudy Lieberman praised Johnson’s story and linked it to reporting by The Boston Globe on the impact of that state’s reform law upon emergency room use. So far, events in Massachusetts reinforce Johnson’s predictions.
The Boston Globe revisited Massachusetts’s ER conundrum last week, and reported pretty much what it did last year—that despite the state’s reform law, which mandated everyone have coverage beginning in July 2007, emergency room use is rising. Last year, the state’s Division of Health Care Finance and Policy cautioned that it was too early to draw any conclusions from the seven percent rise in ER visits between 2005 and 2007. Now the agency is saying that expanded coverage may be one reason for the 9 percent rise from 2004 to 2008. According to commissioner David Morales, many studies have shown that expanding coverage does not reduce emergency room visits. That’s because the uninsured “are not really responsible for significant ER use,” he told the Globe.
We have public options now. Are they any good?
Filed under: Government, Health care reform, Hot Health Headline
ProPublica’s Sabrina Shankman reviews America’s existing “public options” for health care, finding mixed results and limited utility. In addition to Medicare and Medicaid, Shankman reviews a few less prominent institutions:
- The armed forces Tricare plan: Covers all active members of the military, retirees and their families, regardless of preexisting conditions. If you stick to military treatment facilities, it’s cheap.
- Veterans Health Administration: Veterans who meet its standards are guaranteed high quality care, but funding is tight at the VA right now.
- Indian Health Service: Allows American Indians and Alaska Natives free access to reservation clinics… until the service’s funding runs out, as it does about halfway through each year.
- Healthcare Group of Arizona: It was founded to provide afforable insurance to certain small businesses, but a lack of funds and climbing deductibles mean that many employers will be better off looking to the private market anyway.
Reuters has a handy summary of the key provisions of the latest bill likely to be considered by the House of Representatives.
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