The “Take Me To Your Leader – Egads!” edition of the Health Wonk Review is up at Peggy Salvatore’s Health Talent Transformation blog.
You are currently browsing the monthly archive for September 2010.
Tags: HWR
Fraudulent providers can rob taxpayers of money due to Medicaid beneficiaries. Fraudulent offenses include:
- billing Medicaid for services provided to patients ineligible for Medicaid;
- billing for services not rendered;
- upcoding (i.e., charging for more expensive services or equipment that the patient received);
- providing inappropriate, risky or unncessrary treatments;
- requesting reimubrsement for care provided by unlicensed or untrained workers;
- engaging in kickback arrangements , bribes or other illegal marketing practices;
- forging prescriptions;
- promoting off-label drug use; and
- offering flawed or non-existent testing; and illegally adding tests or services that were not requested (bundling);
Should Medicaid sanction fraudulent providers? The answer seems obvious. Policymakers, however, are often loathe to sanction Medicaid providers, especially those who care for the beneficiaries most in need.
“Local policymakers also proved reluctant to enact regulations or impose sanctions that would improve patient care. In place where there were acute bed shortages, officials were particularly unwilling to take on the industry. Even where there were egregious conditions, they would not shut down a facility because its inhabitants had no other place to live. Thus, the owners could hold elected leaders hostage because ‘throwing old people out of nursing homes was scarcely politically acceptable, unless organized alternatives were available–and they were not.’ ”
- Laura Katz Olson. The Politics of Medicaid. Columbia University Press, p. 48, 172; June 7, 2010.
Tags: Medicaid
In the third post using information from The Politics of Medicaid series, we will discuss how States often try to reduce Medicaid spending. From a fiscal point of few, Medicaid spending is often attractive since it is accompanied by matching federal dollars. On the other hand, Medicaid trails only elementary and secondary education in terms of state outlays. [According to this study, States spent more on Medicaid (21.5%) than education (21.4%) using total dollars, since the State often spends a large amount of money received from the Feds. Counting just state expenditures, States spent more on education (34.8%) than Medicaid (16.8%)] Regardless of how the numbers are computed, States spend a large share of their budgets on Medicaid.
States generally pursue 4 types of policies to reduce Medicaid costs. These include:
- Restrict beneficiary eligibility,
- reduce provider reimbursements,
- Prevent fraud and abuse, and
- Eliminate certain benefits.
Tags: Medicaid
The MacArthur Foundation named 23 fellows, recipients of the so-called “genius” grant. The full list of winners is available here. The fellows receive the fellows will receive $500,000 in “no strings attached” support over the next five years. Some people whose work piqued my interest:
- Drew Berry is a biomedical animator whose scientifically accurate and aesthetically rich visualizations are elucidating cellular and molecular processes for a wide range of audiences.
- Carlos D. Bustamante mines DNA sequence data for insights into the dynamics and migration of populations and the mechanisms of evolution and natural selection.
- John Dabiri is a biophysicist studying fluid dynamics in jellyfish. The results of these studies can be applied to better understand from blood flow in the human heart.
- Carol Padden, a UCSD alum, focuses her research on the unique structure and evolution of sign languages—how they differ from spoken language and from each other—and on the specific social implications of signed communication.
- Emmanuel Saez is the only economist on this list. His work examines how taxation affects income and savings.
- David Simon is the screenwriter/producer for the best television series of all-time.
Tags: Genius Grants, MacArthur Grants
In the 1990s, State Medicaid programs turned to Managed Care Organizations (MCOs) to reduce costs. States such as Florida, Indiana, Kentucky, Louisiana, Missouri, Ohio, South Carolina and Texas attempted to turn over their entire Medicaid programs to MCOs through waivers. For instance, in 2007 MO HealthNet mandated managed care for all participants by 2013.
Some of the larger Medicaid MCOs are subsidiaries of large insurance groups. Two examples include WellPoint Health Networks and AmeriChoice (a Medicaid-only subsidiary of United Health Group, Inc.).
Do MCOs offer better care at lower costs than State governments? Laura Katz Olson believes not. Many Medicaid MCOs instituted “gag rules” which controlled what physicians could disclose to their patients about treatment options. Other MCOs gave bonuses to physicians who limited services to their patients.
A study by Mark Duggan (2004) found that “the resulting switch from fee-for-service to managed care was associated with a substantial increase in government spending but no corresponding improvement in infant health outcomes. The findings cast doubt on the hypothesis that HMO contracting has reduced the strain on government budgets.”
Another study by Landon et al. (2007) found that “the performance for the commercial population exceeded the performance for the Medicaid population on all measures except 1, ranging from a difference of 4.9% for controlling hypertension (58.4% for commercial vs 53.5% for Medicaid; P = .002) to 24.5% for rates of appropriate postpartum care (77.2% for commercial vs 52.7% for Medicaid; P = .001). Differences of similar magnitude were observed for commercial and Medicaid populations treated within the same health plan.”
One alternative to compelling beneficiaries to enroll in MCOs is to allow them to choose which MCO they want. In 2006, Florida Governor Jeb Bush began an “empowered care” pilot which gives Medicaid beneficiaries a subsidy based on their health status and prior use of health services. Beneficiaries could use the subsidy to buy their own health insurance if they wished. Because of limited government oversight, low physician participation rates, and a lack of clarity of the benefits which were covered, the Florida inspector general found that MCOs have “too few specialist, untimely access to care, inaccurate information about resources and patient needs, and inaccessible drug coverage information and consumer service phone numbers.”
Although I am in favor of additional patient choice, additional transparency is needed in order for patient choice to work. Even if beneficiary choice improve satisfaction, one must still worry that risk adjustment will be imperfect and MCOs will “select” the healthiest beneficiaries to enroll in their plan.
- Laura Katz Olson. The Politics of Medicaid. Columbia University Press, 416 pages, June 7, 2010.
Tags: Managed Care, Medicaid
Most people don’t think so. This is not a phenomenon specific to the United States. According to a BBC survey:
“The figures vary from nation to nation, but the general picture is that people do not feel their taxes are well spent. In Columbia and Pakistan, the average estimate of the amount of tax not spent in the public interest was more than two-thirds.
In not country was it less than one-third. Spain, at 34%, was the only one that came close to that.“
The Robert Wood Johnson Foundation has put together a series of briefs which explain how Health Reform will affect various types of consumers. These briefs include:
Although are a lot of these types of guides out there, the RWJ briefs are generally fairly comprehensive yet also easy to read. There is even a brief on how health reform will affect health outcomes, even though I believe the ability to predict whether outcomes will improve or not will depend a lot on how health reform is implemented.
Tags: Health Reform
Health Reform (a.k.a. Patient Protection and Affordable Care Act [PPACA]) provides two small provisions that will affect malpractice costs. Randall Bobvjerg explains:
“As enacted, PPACA contained only two, quite limited malpractice provisions. Section 10607 authorized malpractice demonstrations by states, and section 10608 extended federal malpractice protections to free clinics’ nonmedical personnel.
The demonstration authority comes with many conditions that are much more limiting than the demonstrations grants already implemented by the Obama administration. Under PPACA, only states may be funded; funding levels are too low to backstop alternative compensation systems; even those funds are unappropriated; and any patient in a demonstration can, at any time, bring a conventional tort claim instead. The free-clinic provision extends the scope of the Federal Tort Claims Act (FTCA). The act had previously been modified to cover health professionals‘ volunteered services at free clinics, as well as care at federally qualified community health centers, as though the caregivers were federal employees, such as Veterans Administration physicians. The FTCA does not alter state rules of tort law, which govern any claims made; but claims resolution follows federal processes, any trials occur in federal courts, and payouts come from federal funds.”
In short, not much has changed.
- Randall R. Bovbjerg “Will the Patient Protection and Affordable Care Act Address the Problems Associated with Medical Malpractice?“, Timely Analysis of Immediate Health Policy Issues, Urban Institute and RWJ Foundation, August 2010.
Tags: Health Reform, Malpractice
As part of Health Reform, the government created the a center to study clinical effectiveness of different health treatments. This center, known as the Patient-Centered Outcomes Research Institute (PCORI), “does not have the power to mandate or even endorse coverage rules or reimbursement for any particular treatment.” What leverage does the Institute have? Not too much. “Medicare may take the institute’s research into account when deciding what procedures it will cover, so long as the new research is not the sole justification and the agency allows for public input.” Basically, PCORI is supposed to be like the UK’s NICE but without any teeth.
Who is running PCORI? The answer was revealed today. The PCORI Board of Governors includes:
- Associate Executive Director for the Permanente Medical Group of Northern California,
- CEO of Empower, LLC,
- Chairperson of Friends of Cancer Research,
- Chief Medical Officer of the Pfizer Medical Division,
- Chief Science and Technology Officer for Johnson & Johnson,
- Director of Strategic Partnerships and Alliances at the Xerox Corporation,
- Executive Vice President of The Regence Group
- President and CEO of the American Association of People with Disabilities
- President of BJC Health Care,
- Program Director for the Health Technology Assessment program at the Washington State Health Care Authority.
- Principal Deputy Under Secretary for Health and National Program Director for Cardiology, Department of Veterans Affairs
- Researchers from the following universities: Dartmouth, Harvard, Mississippi, North Carolina, UCLA, and Yale.
- Senior Vice President of Medtronic, Inc.
Tags: Comparative Effectiveness, Comparative Effectiveness Research, Health Reform
Medicaid Overview
September 26, 2010 in Books, Medicaid | 2 comments
“If you’ve seen one Medicaid program, you’ve seen one Medicaid program.”
This week, I will review some of the findings from a wonderful book titled The Politics of Medicaid. Author Laura Katz Olson writes a well-researched book that evaluates Medicaid from the points of view of its various stakeholders including beneficiaries, providers (esp., physicians and nursing home), managed care organizations (MCOs), and the state and federal governments. This post provides a general overview of the Medicaid program.
Enrollment
Spending
CHIP
Popularity
Benefits
Laura Katz Olson admits at the end of the book that she believes that “a single payer is a necessary component of any restructuring of medical insurance, including Medicaid itself.” Despite this admission, the book is thoroughly research and well-written. For anyone interested in what really happens in the Medicaid program, I highly recommend The Politics of Medicaid.
Source:
Tags: Medicaid