Posts Tagged Medicaid
ER doctors never ask the question but often think: “Why did you call an ambulance for a sore throat?!” The trip costs at least $1000 and stands a chance of not being covered by insurance. The ambulance crew feels bad they don’t have a more appropriate option but if you call an ambulance — you get an ambulance.
Kaiser Health News reports the South Metro ambulance company in a suburb of Denver Colorado is trying a new service. An ambulance that is basically an ER in a box. Equipped with lab tests, bandages, sutures and a few medications they go to a home to treat a problem rather than transport a person to the ER. It costs about $500 — at this point, it is something insurance will not cover.
Here are two extremes:
- A single parent picks up their child from a family member after working 2 jobs at fast food restaurants. The parent just got the jobs after 3 months of being unemployed. The primary care doctor’s office is closed and the parent is expected at work in about 7 hours. But, the child has a fever and a sore throat. The bus they usually catch to go to the hospital does not run after 8 PM. The parent calls an ambulance.
- A woman drops a martini glass and cuts her finger. Her husband thinks she needs stitches but he has some after hours stock trading to do before bed. He tells the butler to call an ambulance and get the problem resolved.
The first case is common for Medicaid families. No resources, no car, and not much to lose by calling an ambulance. But, something to gain by not missing time at a new job and it helps the child on both counts. The ambulance and ER visit may cost Medicaid over $1000. But, during the day a visit to primary care might only cost $50.
The second case is crying for concierge care. The family has the cash to pay for someone to come to the house and put a few stitches in a finger. But, instead the problem clogs up the ER that should be dealing with heart attacks and car wrecks. Again, if the problem happened earlier in the day a primary care office or urgent care clinic could have solved the problem.
One could see Medicaid having a fleet of mobile treatment units just to limit the financial losses in the ER. Actually, a good idea. Both cases might have solved their problems by taking a taxi to an urgent care clinic — if one was open.
Will the “ER in a box” find a place? — at least a place where someone will pay them? The idea leans toward the concierge model. No insurance is going to pay for an ambulance when a taxi will work. No insurance company will pay extra just for the convenience of one patient.
Nice idea, but it’s not likely to fly financially.
Death can be caused by not having a car. If a sick person does not have transportation the effects can be serious. And, lack of insurance makes the problem worse.
A new study reported in Health Affairs finds closure of inner-city ER facilities causes more deaths. Poverty, advanced age, immigrant status, and lack of insurance were correlated with the increased mortality.
Poor people count on the ER as the clinic of last resort — our health system is designed that way — call an urgent care clinic and ask what services are available — “it depends on your insurance” is the answer — “you better go to the ER” is the advice if you have Medicaid or don’t have insurance.
Why wait until the last minute? Because, there is always hope the health problem will get better, the chest pain will subside, the blood in the stool will stop or the arm weakness will vanish. Once the heart attack hits, the bleeding is worse, or the whole side of the body is paralyzed the chances of death are much higher.
If you don’t have money one of the greatest concerns is NOT getting admitted — how do you get home, how do you pay for outpatient medications and how do you pay for the ambulance ride ($1000)? The logic is simple: wait until you are REALLY sick.
The ambulance-to ER-to-operating-room is usually a very profitable supply-line of patients, so lots of resources have been lavished to make the system work. If the ambulance-to-ER system brings diabetes, pressure ulcers and urine infections it drains a hospital’s resources, and finally leads to ER closure.
A good health system would provide transportation, guaranteed urgent care, medications and transportation home for a low-cost package price. The unloading of the ER might actually save the ER, save patients with true emergencies, and save poor patients who get care earlier. Wow — and what if that urgent care center was right next to the ER so if there really was an emergency it could be handled.
But no, all that would require planning and a health system where hospitalization was an overhead expense, not a profit center. So, the only viable solution in the US: include vouchers for ER visits with Cadillac purchases or golf club memberships.
Wishful thinking is not sound public policy. (Bjorn Lomborg) The South, unlike the rest of the US, has rising numbers of the uninsured. The “Health Reform Monitoring Study” from the Urban Institute is disturbing . Why? Because insurance subsidies were supposed to insure more people. The problem seems to be the money is not reaching the people who can’t afford insurance. The original ACA plan was for Medicaid to cover the very lowest income people then at some higher income level the ACA insurance subsides would take over. Many states in the South did not elect to expand Medicaid so there is a gap between Medicaid and the income level at which ACA subsidies are available. According to the study, the most frequent reason given by uninsured people for not having insurance is: “it costs too much” and second “it might affect immigration status”. The following is a graph is a comparison of each region between 2013 and 2014: The South has a huge problem with health literacy — many residents have no idea how to approach health insurance. About 11% of Southern uninsured people say they do not want insurance — it’s like asking someone if they want a kumquat — if you don’t understand what it is or what it costs you might not want one.
The Governors of the Southern States are hurting people, not something expected. Somehow they thought by not expanding Medicaid and ignoring the ACA the health care problems in the South would go away or get better by magic. Wishful thinking is not a strategy for success.
Here is the list:
- Pay doctors more
- Let the government pay subsidies to families not covered by the employee’s health insurance.
- Get rid of fee-for-service payments
- Smooth the transition from Medicaid to subsidized health insurance
- Transparent pricing
There are obviously some problems with this “consensus”. To begin with, who is part of the consensus? And who benefits from the 5 suggestions? On the face the ideas seem OK but where is overall cost reduction — the real crux of our health care problem?
So, to address each point:
- Pay doctors more — if the payment is not tied to reducing health care costs and increasing quality then it is money down the drain.
- Covering families — seems simple enough but why should business be exempt from doing what they have traditionally done? Employer insurance needs to cover the whole family — that’s simple.
- Get rid of fee-for-service. Yes that payment method is a problem but there must be an incentive for health care providers to provide a high volume of work and an incentive to do quality work. The simple solution is to pay a health care system (an accountable care organization) to provide care for a large group of people for a yearly fee. The organization must meet quality and budget constraints as opposed to our current “the sky is the limit” fee model.
- Smooth the the transition away from Medicaid. At this point Medicaid is less expensive than standard indemnity plans — why think about a change? If the person enters the workforce the employer just pays the cost — simple. Changing providers is not easy but if quality is uniformly better there would not be such concern.
- Transparent pricing. This is presented to suggest people could decide on what tests and treatments to buy if only they knew the prices — patients have never had the knowledge to make that decision and never will. The transparency of pricing should be the price for ALL the healthcare a person needs per year. Market forces may be helpful on the macro level (like for a healthcare system) but there is no free market for healthcare on the micro level — imagine a person being asked to choose between various methods of treating diabetes or the best way to remove an appendix (the decision is either random or biased by what the very person asking the question tells them).
The U.S. is experiencing something its citizens have not witnessed before: the transition away from population healthcare decisions being made behind closed doors at insurance companies to those decisions being made in the political arena. Other countries experience this all the time — just look at newspaper headlines in the UK or France over the past 20 years!
The IOM is a government organization that studies medical care and issues reports. The reports are scholarly and well regarded. Below is an excerpt from a recent 380 page report.
The full report is available online and worth reading.
What is the bottom line?
There are numerous areas where US health care wastes money and delivers poor care. The wasted money is estimated at over $750 billion dollars each year. The IOM opines an environment where everybody has the attitude of gladly improving health care so each problem could be addressed and by an evolutionary process the US would end up with a great health care system.
Frankly, it ignores working health care systems in other countries and fails to outline a structure for management of US health care. All great quality improvement ideas fail without a structure . From a political standpoint the question will be “what am I buying”? The answer “the cost will evolve” is just not adequate.
So, in the absence of structural suggestions here is a place to start:
This system replaces all existing government health care agencies with an insurance system covering “basic care benefits”. All private insurance would offer the basic care benefit with insurance add-on products as desired.
Top level: Administrator
Department: United States Health Care (USHC)
Funded by: Congress (has a budget each year)
- Office of budget compliance with regional offices (comptroller)
- State divisions of quality improvement
- National drug and equipment evaluation and approval (formulary)
- Office of hospital, specialist, device and prosthetic payments
- Office of primary care and drug payments
- National patient registry
- Office of basic care benefits
- Office of national health records (System wide EMR)
- Office of health research integration
- Office of manpower training (free training in exchange for service)
Now we are getting somewhere. An administrative structure and a payment structure. There is huge efficiency by consolidating current US agencies like Medicare, Medicaid, Veterans Health System, Indian Health Service and all others. Private insurance is encouraged for those items not covered by basic care benefits (e.g. heart transplants, cosmetic surgery, fertility services, extremely expensive chemotherapy etc).
You may say the forgoing is just not possible for the US. But, consider the idea as restructuring, a management technique used by large companies all the time. The IOM says change is needed but we need that change NOW — we need to think like a large company and get the job done.