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Wednesday, January 29, 2014

"There is no way to survive the coming rise in Medicaid recipients, aging boomers, still-uninsured and underinsured without a lean, efficient organization." - Joe Flower

One of the clearest thinkers in the health care space is Joe Flower. His latest blog post "What about the poor?" is a tour de force. An excerpt:
What can we expect in the coming years?

The Future of Medicaid, the Uninsured and the Underinsured

Medicaid numbers are astonishing if you are not used to them. Even before the projected expansion, at some time during an average year about 72 million people, close to a quarter of all Americans, are on Medicaid. At any given moment, it’s over 50 million. Medicaid is an open-ended program: When more people are eligible, or sick, or have more complex diseases, the states and the federal government pay more. By law, states have to provide certain minimum benefits for certain defined poor populations, such as children, pregnant women, the disabled and the elderly. The only control states have over Medicaid costs is to cut reimbursements and to control utilization by making health care massively inconvenient to access.

The economy. The economy appears to have undergone real structural change. In this new economy a lower proportion of the working age population is able to find work with a living wage or start a sustaining business. Income inequality is still growing, with almost all of the new wealth created in the slowly recovering economy going to those few who are already well off. So we can expect more Medicaid-eligible people every year.

Expansion. In over half the states, Medicaid eligibility has been expanded by the Affordable Care Act (ACA) to include all adults with income below 138 percent of the federal poverty level (FPL). More states will likely accept the expansion. Turning away federal money that would benefit your citizens and pay for thousands of jobs (as studies show) may be ideologically pure, but politically and economically it is a very shaky stance. It will become shakier as people in neighboring states reap the benefits, while yours do not.

Will those newly covered individuals use more health care or less? Contrary to a common assumption, studies show that just getting people covered does not in itself improve their health, and those newly insured patients will likely use the emergency department (ED) 40 percent more than they did when uninsured, unless the system finds some less expensive way to serve their needs. The “system,” in this case, is you.

. The ACA will actually expand the ranks of the underinsured (those whose insurance is weak enough that they will often act as if they are uninsured). The “bronze” plans cover only 60 percent of most expenses; the “silver” only 70 percent, well below the 80 percent typical of corporate plans, with much higher deductibles. The feds also allow, in fact encourage, states to add deductibles and co-pay requirements to Medicaid even for the poorest. And many states that are expanding eligibility are actively cutting reimbursements, narrowing networks and reducing benefits.

Out-of-luck demographics
. At the same time many people, especially in the just pre-Medicare demographic, will not want to accept Medicaid, because they still have some assets, typically equity in a house, that Medicaid would require them to liquidate and “spend down.” In the states that do not expand Medicaid eligibility, the uninsured non-disabled adult below 138 percent of the FPL is just plain out of luck, with no ACA subsidies for insurance, but is still hit with the ACA tax penalty.

So expect still substantial numbers of uninsured — 26 million by 2016 by Congressional Budget Office estimates — as well as growing Medicaid rolls in all states, even those that do not expand eligibility.

? “Deficit hawk” politicians focus on Medicaid because it is growing and open ended. Proposals to reform Medicaid largely would make it into block grants to the states, which Congress could then throttle downward. No proposed reforms contemplate putting more money into Medicaid. Under any reasonably expectable political scenario we can expect ever-narrowing reimbursements.

Health care execs can be forgiven for feeling that they are in some zombie movie, pursued by teeming masses of people with Medicaid coverage, or no coverage at all. But it’s time to stop hiding. It’s time to leave behind the old tactics of divert, dump and deny once and for all, and to push instead for radical new ways of providing health care — good, quality care — to those who can least afford it...
Click the link above. Read the entire piece. I've forwarded it on to Dr. John Toussaint of the ThedaCare Center.

I began this blog nearly four years ago touting the utility of "Lean" right in my first post. See also one of my workflow slide decks (pdf).

apropos of the title of Joe's post, "What about the poor?" recall my prior post When it comes to health, your zip code matters more than your genetic code.”

See also Danielle Ofri's latest:
When Doctors Give Patients Money

Recently a few of my colleagues were sitting together and one asked if any of us had ever given money to a patient. There was an awkward pause, and then the stories starting coming out — a few dollars for a co-pay, or to help a frail patient take a cab instead of a bus; a bag of food or an extra meal. “How could I not,” one doctor said, “when my patient’s immediate need could be solved by the small change in my coat pocket?”

A physician recently wrote in JAMA about giving a patient $30 to help pay for a medication after a two-hour phone battle with the insurance company came to naught. He was cited by his institution for unprofessional behavior, but was also deluged with letters from doctors and nurses who have been in the same position and done the same thing.

We hear daily about “health care costs,” a lumbering behemoth that dominates the news and the economy. But it is the smaller amounts, literally the pocket money, that often has the most profound and palpable effect on the concrete currency of health.

Caregivers on the front lines fully recognize that giving patients a few dollars isn’t ultimately the way to solve the problems of society. But the starkness of our patients’ immediate needs are hard to ignore...
Even though overall health care costs have been falling slightly, and some aspects of the economy appear to be improving, economic realities are playing an increasing role in the day-to-day health of many patients. The dollar amounts in question are usually small — bundled together they would hardly rise to a rounding error of a distant decimal of “health care costs.” The impact, however, is anything but small. Medications skipped, antibiotics delayed, procedures avoided, diet skimped — the morbidities rack up quickly.

A recent study in Health Affairs confirmed what most physicians and nurses see in their daily practice — lack of small amounts of money wreaks outsize damage on health. This particular analysis showed that in low-income neighborhoods there was a 27 percent increase in hospital admission for hypoglycemia, or low blood sugar, at the end of the month compared with the beginning of the month.

This end-of-the-month disparity, unsurprisingly, was not noted in high-income neighborhoods, where households do not run out of money and food at the end of the month...
Yeah. See also
Millions Are Now Realizing They're Too Poor For Obamacare

Thanks to a Supreme Court ruling and staunch Republican resistance, Marc Alphonse, an unemployed 40-year-old Marine veteran who is essentially homeless, cannot get health insurance under Obamacare.

Three years ago, Alphonse learned he has a kidney disorder that will deteriorate into kidney failure, and possibly prove fatal, if left untreated. As it stands now, he suffers from bouts of nausea caused by his dysfunctional kidneys, and he's dogged by an old knee injury that limits his job prospects. He gets by on $400 a month in unemployment benefits, and his family can no longer afford housing in their home city of Miami. Alphonse's 28-year-old wife, Danielle, and three young children are staying with relatives while Alphonse couch surfs.

"I live from family to family until I'm able to get myself situated," he told The Huffington Post.

Alphonse is one of nearly 5 million uninsured Americans caught in a cruel gap that renders some Americans "too poor for Obamacare."

Broken Promise
Obamacare was supposed to make health coverage affordable, or even free, for low-income Americans. The law's official name is the Affordable Care Act. However, the Supreme Court tossed a huge obstacle in the path of that goal in 2012, ruling that the states could opt out of one of Obamacare's crucial provisions: The expansion of Medicaid coverage to anyone making less than 133 percent of the federal poverty level, or about $15,300 a year for a single person. Since the court's ruling, 24 states, including Florida, chose not to expand the program...
Indeed. "What about the poor?"

More to come...

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