Archive for February, 2012

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Now Available: Roadmaps to Health Community Grants

Wednesday, February 29th, 2012

On February 28th 2012, the Robert Wood Johnson Foundation and Community Catalyst issued a call for proposals for the second round of funding under the Roadmaps to Health Community Grants program. The goal is to issue up to 20 new grants in 2012 to organizations who are working to create positive policy or system changes that address social or economic factors that impact the health of people in their community.

The County Health Rankings and the Roadmaps to Health Community Grants
The Roadmaps to Health Community Grants are part of the County Health Rankings & Roadmaps program that is led by the Robert Wood Johnson Foundation (RWJF) and the University of Wisconsin Population Health Institute (UWPHI). This program builds on the County Health Rankings, which are published online by UWPHI and RWJF. Ranking the health of nearly every county in the nation, the County Health Rankings illustrate the factors that influence the health of our communities. The Roadmaps to Health Community Grants show what communities can do to create healthier places to live, learn, work, and play.

An initial round of Roadmaps to Health Community Grants was awarded in 2011 to 12 organizations. Those organizations are working with diverse coalitions to address social or economic factors – such as education, income and employment, family and social support, and community safety – that we know have a direct influence on the health of their communities.

For example, Rhode Island KIDS COUNT and its partners are using their current Roadmaps to Health Community Grant funding to increase access to high-quality early learning programs and to help Providence youth successfully enroll in and graduate from college—helping to ensure that they lead long, healthy lives. The coalition includes leaders from education, health, other nonprofits, and local elected officials. Their project is using the RWJF funding to engage in non-lobbying education and advocacy to increase funding for public pre-kindergarten, change the state’s education funding formula, expand the availability full-day kindergarten, develop an early warning system to identify students at risk of dropping out of high school, implement a more rigorous high school curriculum, and increase support for students applying to colleges and universities.

Expanding the Roadmaps to Health Community Grants to new communities
Grantees in this program will receive up to $200,000 over two years to demonstrate how a range of partners from multiple sectors in their communities can work together to translate the County Health Rankings into action and work towards improving health. Grantees will be established coalitions or networks that span multiple sectors and may include representatives from business, education, public health, health care, community organizations, community members, policy advocates, foundations, and policymakers. Applicants must engage community members in the planning and implementation of projects, and must collaborate with organizations having expertise in improving the health of the public. Ultimately, these grants will support communities using data and evidence to pursue policy or system changes that address the social and economic factors that most strongly influence health. Applicants must secure 100 percent matching support, including a cash match of at least 50 percent with the balance as in-kind support. Applicants must submit brief proposals by May 2nd using the RWJF online application system.

The call for proposals and more information is now available on the RWJF website. Interested individuals should review the call for proposals, which outlines the goals, selection criteria, and application process for this grant opportunity. On March 20 and April 10, Community Catalyst will host a series of two informational web conferences so that interested individuals can learn more about this grant opportunity and the County Health Rankings & Roadmaps program.

Community Catalyst is excited to be working with the grantees in the Roadmaps to Health Community Grants program. We are providing the grantees with technical assistance and other supports as they work to address the root causes of poor health in their communities. We believe everyone should have a say in the decisions that affect their health – and that includes decisions on issues like education, income and employment, family and social support, and community safety.

– Phillip Gonzalez,  Program Director
Roadmaps to Health Community Grants 

 

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Confronting Our Dirty Little Secret

Wednesday, February 29th, 2012

After a decade of reports and tragedy a lot of progress must be made to improve our oral health

A decade ago, the Surgeon General released a report on oral health that described unmet oral health needs as a “silent epidemic”. Five years ago, a 12 year old Maryland boy, Deamonte Driver, died due to an untreated molar infection which spread to his brain.

Like most dental disease, Deamonte’s cavity could have been treated. His death could have been prevented but he did not have access to care.

Despite a tragic death and a groundbreaking decade old report that chronicles the need for better access to dental care, too many Americans suffer silently and un-served.

Today, Senator Bernard Sanders (I-Vermont) and the Senate Subcommittee on Primary Health and Aging confronted America’s dental crisis with a hearing and report that shined a light on the need to expand access to care.

The report, Dental Crisis in America: The Need to Expand Access, found that:

  • • More than 47 million people live in places where it is difficult to access dental care.
  • • About 17 million low-income children received no dental care in 2009.
  • • One fourth of adults in the U.S. ages 65 and older have lost all of their teeth.
  • • Low-income adults are almost twice as likely as higher-income adults to have gone without a dental check up in the previous year.
  • • Bad dental health impacts overall health and increases the risk for diabetes, heart disease, and poor birth outcomes.
  • • Almost 60 percent of kids ages 5 to 17 have cavities – making tooth decay five times more common than asthma among children of this age.
  • • Nearly 9,500 new dental providers are needed to meet the country’s current oral health needs.
  • • However, there are more dentists retiring each year than there are dental school graduates to replace them.

Senator Sanders recently told The Nation, “We have a real crisis both in terms of access to affordable dental care—and not only for lower-income Americans but for many in the middle-class as well—and the consequences of a lack of treatment.”

The consequences of dental crisis was evident this week as the Pew Center on the States released a report that detailed that lack of access to regular dental care is resulting in costly visits to the emergency room for preventable dental problems.

To address the access problems and public health consequences of poor access to dental care, the report explores potential solutions such as:

  • • expanding the oral health workforce
  • • integrating dental services: federally qualified health centers and school-based health centers as models
  • • expanding coverage and increasing reimbursement rates
  • • focus on prevention and education

In order to ensure that dental access is no longer silently overlooked, Sanders called on community members to, “Go to our website, tell us your views and observations on dental care. And do whatever you can to rally your representatives in the House and the Senate to begin to address this crisis. I think we’ve got to raise the noise and the level of consciousness about the dental crisis, and when we do that we can get some serious Congressional response.”

Speak up, be heard and ensure unmet oral health needs are no longer a silent epidemic.

 – David Jordan, Dental Access Project Director

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Guest Blog: Home Care Workers Need Your Support

Tuesday, February 28th, 2012

On December 15, 2011, President Obama announced that the Department of Labor planned to amend the Fair Labor Standards Act (FLSA) to guarantee minimum wage and overtime protections for 2.5 million home care workers. Since 1974, when Congress amended the FLSA to include domestic workers, home care aides have been subject to the “companionship exemption,” which equated their employment with that of teenage babysitters and denied them the same basic labor protections as other American workers.

Home care workers—90 percent of whom are female, and half of whom are people of color—are the foundation of our system of long-term services and supports. They provide assistance with dressing, bathing, toileting, mobility, and meals for millions of elders and people with disabilities. In some cases, they also provide medical-related assistance, helping to manage medication, taking vital signs, assisting with exercise programs.

Our families rely on home care aides to ensure that our loved ones can remain as independent as possible. That’s why home care is one of our nation’s fastest-growing occupations. With 10,000 baby boomers turning 65 every day, the number of Americans who need assistance is growing rapidly. Within the next decade, the workforce is expected to grow by an additional 800,000 workers.

The outsize demand for home care aides, however, doesn’t guarantee that there will be compassionate, skilled workers to take these jobs in the future. Home care may be one of America’s largest and fastest-growing occupations—but it also among the most poorly paid and supported. Wages average $9.40 per hour, but more than half of workers are part time employees. As a result, annual wages average about $16,600.

These wages reflect the severe undervaluing of the skills and dedication of our home care workforce. These workers play a vital role in our health care system—often reducing overall costs by noticing changes in a client’s appetite, mental clarity, or strength and communicating these changes to a family member or medical professional. With their daily visits to client’s homes, home care workers are the eyes and ears of the health care team.

Yet, for nearly 40 years, as home care has grown into an $84 billion industry, these workers have been denied the most basic labor protections under the FLSA. Home care agencies have used the “companionship exemption,” which was intended to apply to a neighbor who came to sit with grandma for a few hours, to lower labor costs across the board. Confirming this attitude, in a recent article in USA Today, the government relations director for the National Private Duty Association, the industry’s for-profit trade association, said of home care workers, “For them, this isn’t really a job, it’s a lifestyle.”

Tell that to the 2 million women trying to feed their children on poverty-level wages. Though most workers earn above minimum wage, many are not paid for travelling time between clients or for the cost of gas (now nearly $4/gallon). Only fifteen states have wage and hour protections that guarantee time and a half for overtime for home care aides. As a result, at the end of the day, home care workers have so little income that nearly half live in households that rely on public benefits such as Medicaid and food stamps.

The proposed change to the Fair Labor Standards Act, which would narrow the companionship exemption to workers hired by individual households to provide companionship (not personal care), is long overdue. As our nation ages, we need to strengthen and stabilize the home care workforce. Better wages will reduce turnover, which is notoriously high and disruptive to quality care. Moreover, basic labor protections are sign of respect—an acknowledgement that our nation’s 2.5 million home care workers have a true vocation that we value as a society.

The Department of Labor’s proposed rule to provide home care workers minimum wage and overtime protections is open to public comment through March 12. Please add your voice in support of home care workers by visiting www.companionshipexemption.com. Easy instructions and sample comments are available at the website.

– Karen Kahn, director of communication, PHI
– Carol Regan,  director of government affairs, PHI

PHI is a national nonprofit dedicated to transforming eldercare and disability services to ensure dignity, respect, and independence for all who receive care and all who provide it.

 

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Dental Access More Controversial Than Contraceptive Care?

Wednesday, February 22nd, 2012

Late last month as snow enveloped Olympia, Washington, state advocates braved the elements for hearings on two very important yet different issues – improving access to dental care and reproductive rights and contraception coverage. At one point a veteran advocate attending the same hearing for a bill on reproductive rights remarked to our partners at the Children’s Alliance, “When did access to dental care become more controversial than reproductive rights?”

While contraception coverage has been in the national spotlight recently, the debate over access to dental care continues to be just as heated in state capitals as community-driven efforts to add mid-level providers to the dental team are met with resistance from dental associations. Dental therapists, mid-level dental providers, are practicing in Minnesota, Alaska and more than 50 countries. In fact, WBUR explored how dental therapists offer a cost effective way to expand and preserve quality access to dental care for underserved populations during these difficult financial times. Most recently, proposals have been debated in Kansas and Washington. However, 15 other states including Vermont and New Hampshire are also exploring alternative workforce models as a way to extend care to underserved populations. Despite the fact that these new providers would be able to provide care in communities where there are not enough dentists and enhance the dentist-led team’s ability to provide routine and preventive care to vulnerable populations, community driven, multi-stakeholder and consumer efforts are still being met with opposition from dental groups.

This dynamic was on full display in Kansas last month at a House Health Care Committee Roundtable discussion that explored how adding a dental provider to the dental team will improve access to care. A broad coalition of community groups, children’s groups, supportive dentists, safety-net clinics and educators explained the clear need for better access to dental care, especially for children—27.6 percent of Kansas third graders have untreated tooth decay. This is due to the fact that 93 of the 105 counties in Kansas do not have enough dentists to serve their populations, 28 counties do not have a Medicaid dental provider, and only 25 percent of Kansas dentists accept Medicaid patients. Despite the broad-based support for a new way to deliver care, the dental association still opposed the measure.

Unfortunately, lawmakers continue to see the issue as a turf battle. As many know, scope of practice issues typically involve one trade association pitted against another trade association, which legislators do not like refereeing. But this issue is different because it is not about business or about dentists – it is about finding a way to treat untreated tooth decay and helping improve the oral health of underserved communities. As the issue evolves, it is critical to help policymakers and stakeholders elsewhere understand that limited access to dental care disrupts the lives of millions of kids throughout the country. In fact, according to the Pew Center on States state dental policies fail one in five children.

In Washington State, April Ritter’s daughter went without care. She was forced to endure pain and sleepless nights because Ritter could not find a dentist who accepted her Medicaid coverage. In addition to negatively impacting the health of children and adults, the lack of dentists in underserved communities or dentists who will only accept certain types of insurance is also leading to unnecessary costs. According to the Washington Hospital Association, severe toothaches are the number one reason people in Washington without insurance end up in the emergency room.

After taking a closer look at their analysis of ER visits for the time period of January 2008 – June 2009, which found the total number of dental-related ER visits was 54,000, with total charges of $35 million, the Washington Hospital Association joined a community driven coalition organized by the Children’s Alliance, Washington CAN, the American Indian Health Commission, Northwest Portland Area Indian Health Board, the Washington State Dental Hygienists Association, community health centers and supportive dentists who are working to add a dental therapist to the dental team as a way to improve access to care, preserve services and reduce costs – particularly costs incurred through unnecessary ER visits.

Recognizing the benefits of adding a new provider to the dental team would help improve access to care and help control costs, the Washington State Senate Committee on Health and Long Term Care supported the bill and passed it favorably out of their committee on February 2. Despite the bill advancing through the key committee and support from an energetic sponsor, Sen. David Frockt, other legislators did not seize the opportunity this year. However, a great deal of progress was made as lawmakers heard from children and adults in their districts who had unmet oral health needs who came out in support of the Washington Dental Access Campaign.

Last week, the debate regarding access to dental care unfolded in New Hampshire in much the same way – children’s advocates supporting efforts to increase access to care were met with opposition from dentists.

Vermont may be the next state to examine access to dental care. Hopefully, policymakers understand the effort is about the estimated 24,000 children in Vermont enrolled in Medicaid who failed to get the dental care they urgently needed in 2009 or the 10,000 Vermont seniors and 62,000 adults under age 65 who went without care that year, rather than the interests of a trade association. The best solutions begin with listening to the people who need access to care not the businesses and groups who claim they speak for them.

 – David Jordan, Dental Access Project Director

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CMS Releases Guidance on Payment Model to Improve Care for Dual Eligibles

Wednesday, February 22nd, 2012

The issue of improving care for people who are eligible for both Medicaid and Medicare (“dual eligible”) continued to pick up steam with the recent release of a new federal guidance related to payment models. While advocates will not be formally commenting on this new guidance, it is imperative that they keep a close eye on what the guidance says and how this will impact which health plans will be chosen to oversee the care of the dual eligible population.

As readers may recall, the Affordable Care Act created two new offices within CMS to promote long-term systemic improvements for dual eligibles. The Center for Medicare and Medicaid Innovation (Innovation Center) was established to rapidly test, evaluate and replicate innovative models of care. The Medicare- Medicaid Coordination Office (“MMCO”) was created to promote policies and assist states in better integrating care specifically for dual eligibles. As a result, 15 states have planning grants to develop models of care for dual eligibles. In July 2011 MMCO announced a demonstration program to test two new payment models – the “capitated” and “managed fee-for-service” approach – designed to help states improve quality and share in the lower costs that result from better coordination of dual eligibles’ care.

The guidance released last month by the MMCO is directed at health plans or other qualified entities interested in pursuing the capitated financial model. Under this model, CMS, the state, and health plans or qualified entities would enter into a three-way contract, where the participating plans would receive a prospective blended payment to provide comprehensive seamless, coverage to dual eligibles.

Why Focus on the Dually Eligible?
The dual eligible populations (approximately 9 million) are a lot more vulnerable and typically have poorer health status and a greater need for more high-cost services such as inpatient and outpatient hospital, emergency room, and skilled nursing care. Navigating the Medicare and Medicaid programs, which have different sets of rules and requirements, is an added burden for beneficiaries and results in care that is often fragmented and uncoordinated.

Given the uncertainty of today’s political environment, state advocates need to be actively engaged in the decision-making process of any duals-related initiative. Advocates need to keep a close eye on decisions made about: enrollment, provider networks, appeals processes, marketing including how beneficiaries receive information, quality measures, financing, and consumer protections. Without an active voice, we are leaving the decisions to insurers and big providers who do not necessarily have consumers’ best interest in mind. It is important that all states be involved – not just the 15 states who received planning grants or those states that have sent in a letter of intent.

What does this new guidance mean for our work?
The new guidance on pursuing the capitated approach addresses important issues such as payment principles, standards in programmatic areas, key dates, and network adequacy. For each issue, there is a role consumer advocates can play to ensure that the proposed demonstrations keep consumer interests at the forefront. In a previous blog, we shared with you disability-oriented advocacy principles, to help shape the design of the demonstrations. Advocates should use them as guide as well as this fact sheet that highlights the role consumer advocates should play.

The efforts to improve care for the dual eligible population are commendable. However as CMS and states move forward on their aggressive timetable, advocates must ensure that only proposals that maintain or improve beneficiaries’ access to high-quality, comprehensive services make it to the finish line.

 – Leena Sharma, Field  Coordinator
Integrated Care Advocacy Project 

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On Billing and Collections, Some Hospital Groups Out of Tune

Tuesday, February 21st, 2012

Close readers of the Health Policy Hub will note that most of our blogs on hospital issues tend to sound a common refrain: transparency, transparency, transparency. If what’s coming over our wires is any indication, transparency—or the lack thereof—about hospital pricing, financial assistance, and bill collection is resonating these days in many corners of the country.

Why? Why does transparency matter so much—and why is it so hard to come by?

Let’s look at the story that played out in New York last week. Last Monday’s New York Times covered a major report by our partners at the Community Service Society of New York (CSSNY) that investigated how hospitals receiving $1.2 billion in public subsidies from the state’s Indigent Care Pool handle bills for low- and middle-income patients. The findings were alarming: many New York hospitals are using Pool funds to write off patient “bad debt.” Hospitals that tag patient accounts as “bad debt” can, and often will, send the accounts to collections—a decision that can have long-term financial implications for patients. For example, New York hospitals receiving $250 million in Pool funds had collectively placed 4,000 liens on patients’ homes in 2010 in attempts to collect on bad debt. Furthermore, many New York hospitals are falling short of state requirements that they inform patients about financial assistance and other programs before collecting on outstanding bills. Yet, public funds have continued to flow to hospitals flouting these rules.

While New York hospitals may not be feeling the impact of these practices, their patients certainly are. Hope Rubel, a self-described “typical middle-class American,” found herself on the wrong side of one New York hospital’s accounting ledger. Uninsured due to prohibitively high costs, she received emergency hospital services after a stroke—closely followed by an $88,000 hospital bill she couldn’t afford. On Wednesday, Ms. Rubel (along with CSSNY and Community Catalyst staff) talked about her experience with Democracy Now! hosts Amy Goodman and Nermeen Shaikh.

AMY GOODMAN: Did you understand you could get some kind of financial aid?

HOPE RUBEL: No, absolutely not. [...] I had one brief conversation with a social worker while I was in the hospital that was fruitless for me, and then I was on my own. And then the bills started coming from the hospital, and then the phone calls, and then a collection agency, and then the lawyer. I spoke with the lawyers, and I explained to them my situation and that I did not have the money to pay this bill. And they said that we could work out a monthly payment of about $2,000 a month—would be, you know good—

AMY GOODMAN: To the hospital. [...] For how many years?

HOPE RUBEL: —an $88,000—well, ’til the $88,000 was paid off. I said, “Well, I am in no position to pay that kind of money. I cannot do it. I don’t know what to tell you. I can’t do it.” Then the paperwork came: they were suing me.

This is why consumer advocates stress the importance of hospital transparency. Far too often, the burden of navigating the complex maze of hospital pricing, or of asking the right questions about financial assistance or a fair payment plan, falls to patients who do not know such programs exist. For these patients, any miscommunication or misstep carries long-term financial consequences with little possibility for relief. And if this happens in New York—where, it bears noting, the laws around hospital transparency are comparatively robust—consider the burden that falls on patients in states without any such laws at all.

The policy solutions to the problem are pretty simple, actually, but they’re all rooted in one thing: transparency. We need hospitals to provide patients and the public with information about financial assistance and billing programs. We need policymakers to gather and share this data in a way that enables comparisons of hospitals’ policies. That’s how we’ll know where the trouble spots are.

Yet some hospital groups are adamant that things are working fine the way they are, thankyouverymuch. But for whom? When trade associations block national initiatives to make information about financial assistance programs publicly available, or frame Coloradans’ efforts to limit charges to low-income uninsured patients as “unnecessary administrative requirements, which would in turn increase the cost of health care and impede access,” we have to wonder who they’ve been talking to.

Because it certainly isn’t Hope Rubel, or the millions of Americans who are in her shoes.

If it were, hospitals would be singing a different tune.

 – Jessica Curtis, Director
Hospital Accountability Project 

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Deal on Medicare Physician Pay Leaves Clues to Future Debates

Tuesday, February 21st, 2012

Last Friday, Congress reached an agreement on how to prevent a payroll tax increase on 160 million working Americans, preserve unemployment benefits for laid-off workers and also extend a number of expiring health care provisions, most visibly, deferring a scheduled 27 percent cut in Medicare physician pay (the so called Sustainable Growth Rate Formula, or SGR). The agreement also preserves programs that help low-wage workers and low-income Medicare beneficiaries with their health care costs.

Key takeaways:

Who killed a long-term SGR fix? (Hint: It wasn’t Colonel Mustard)

Although they reached a short-term (ten month) agreement, Congress passed up a chance to put an end to the annual exercise by using unspent war funds. Their decision not to do so makes you wonder in whose interest is the recurrent debate over physician pay? No one wants their fingerprints on the knife, but the evidence does point in a particular direction. Congress’s failure to address the payment formula means physicians are less happy with the Medicare program. It also means physicians are less well disposed toward the Affordable Care Act (ACA) because they thought that they had a commitment that SGR would be addressed in the context of broader health reform. Finally, failure to fix SGR also leaves in place a device for forcing additional spending cuts either in health care or elsewhere in the federal budget. Now, let’s see…who wants to undermine support for Medicare and the ACA and force additional cuts in federal health spending? (If you really can’t figure it out, check out this post).

An eroding commitment to public health?

We sometimes criticize corporate CEOs for being too focused on the next quarterly profit statement and their unwillingness to think long term. However, there is plenty of short-term thinking in Washington as Congress just proved with their decision to cut funding from the Prevention and Public Health Fund (PPHF) as a partial offset to the cost of blocking the scheduled cut in Medicare physician pay. As we argue here, a successful strategy to reduce health care spending must include a commitment to improving the underlying health of the American public.

To their credit, the drafters of the ACA recognized this simple truth and included new investments in public health as part of the legislation. Unfortunately, that moment of clarity appears to all too short lived. Almost immediately, public health resources were diverted for the worthy, but different, purpose of training more primary care providers. Pre-existing commitments to public health have since been scaled back with the assumption that the funding gap would be filled by the PPHF, resulting in less of a net gain in funding. Now Congress has diverted $5 billion from the fund to avoid the physician pay cut.

The problem is that while the case for public health investment is compelling, there are not enough powerful champions to defend the fund, especially since cutting it means taking away funds that are to be allocated in the future. As a result, in the short run, no one actually experiences a current funding reduction.

The shape of things to come?

As we said in our blog last week even though President Obama’s budget will not be enacted, it contains important signals for the direction of future action. Hardly 48 hours after its release, health programs the President indicated a willingness to cut showed up as offsets for yet another short-term SGR patch. This means we need to take very seriously other cuts President Obama has indicated he would support because these items are sure to reappear in future debates over cuts in health spending.

Those debates are likely to occur in the context of the 2012 elections, and will resume in Congress immediately thereafter since the delay in the physician pay cut is only for ten months. Many other issues—such as the scheduled expiration of the Bush tax cuts, the recently extended payroll tax reduction, the debt ceiling agreement and more—will also need to be addressed at that time, setting the stage for a high stakes debate over both taxes and spending, including (perhaps especially) Medicare and Medicaid.

We can guarantee that Congress will be looking for spending cuts yet again, and if we don’t want to see costs shifted onto Medicare and Medicaid beneficiaries or more raids on the Prevention Fund, advocates will have to start working with Congress and the Administration now to protect those programs.

– Michael Miller, Director of Strategic Policy

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Obama’s Budget: An Imperfect Reminder That We Can Cut Costs Without Undermining Care

Tuesday, February 14th, 2012

President Obama released his 2013 budget proposal yesterday. In the short run, it’s a mere formality. With a divided Congress in an election year, Obama’s budget is dead on arrival. But our national conversation about entitlement reform is far from over, and the health care cost-containment approach in Obama’s budget will inform that debate.

Obama’s budget reduces Medicare spending by $300 billion, and cuts another $55 billion from Medicaid. The good news is that Obama achieves many (but unfortunately not all) of these savings by weeding out wasteful spending rather than by pushing costs onto beneficiaries. For example, his budget:

  • • reduces overspending on prescription drugs by requiring drug manufacturers to pay the same rebates for low-income Medicare recipients as they do for Medicaid beneficiaries
  • • improves access to low-cost generic drugs by ending “pay for delay” agreements, a practice that allows brand-name drug manufacturers to pay generic drugmakers to keep their products off the market
  • • creates incentives for nursing homes to avoid needless and costly hospitalizations by providing better primary care to residents

The President proposes that the savings outlined in his budget replace the $1.2 trillion in across-the-board cuts scheduled to go into effect in January 2013 (“the sequester,” triggered by the failure of the Super Committee.) As far as the health care budget is concerned, the policies outlined above represent a marked improvement over the across-the-board cuts: they target the waste in our system rather than indiscriminately cutting good health care spending along with the bad. These policies not only save federal dollars, they actually strengthen Medicaid and Medicare.

The Bad News
Unfortunately, not all of the President’s cost-containment proposals are preferable to the across-the-board cuts. The sequester exempts Medicaid from cuts, but the President’s budget shifts billions in Medicaid costs onto states by: 1) reducing federal Medicaid matching rates, 2) limiting states’ ability to use provider taxes to finance Medicaid, and 3) increasing Medicare cost-sharing requirements (which would increase state Medicaid costs since Medicaid pays the Medicare cost-sharing requirements for the “dually-eligible”).

Shifting Medicaid costs onto states is not much better than shifting those costs directly onto vulnerable beneficiaries. Experience tells us that states are likely to compensate for their lost funds by scaling back on benefits like prescription drugs or dental care, raising premiums and co-pays, or cutting already-low provider reimbursement rates – all of which create barriers to needed care for the millions of seniors, children and people with disabilities who rely on Medicaid.

President Obama’s budget also cuts the Prevention and Public Health Fund by $4 billion over ten years. Since slowing our nation’s’ health care costs depends on our success at reducing the incidence of chronic illness, cutting prevention funding is a particularly short-sighted strategy.

We’ll Take More of “The Good”, Please
There is far more we can do to save money in our health care system without resorting to policies that would harm access to care for our nation’s most vulnerable citizens or undermine efforts to improve the health of Americans. For example, we should:

  • • Incentivize hospitals to reduce harmful care. The Affordable Care Act began adjusting Medicare payments to provide a stronger incentive to hospitals to prevent complications, such as hospital-borne infections and readmissions. As we outline in this paper, Medicare can do much more to reduce these harmful events. Doing so would not only save the federal government over $100 billion dollars, it would reduce deaths and suffering caused by avoidable infections, other preventable conditions, and needless hospitalizations.
  • • Tax sugar-sweetened beverages. This would bring in over $100 billion dollars in needed revenue over the next 10 years. And by lowering the consumption of sodas, a tax on sugary drinks would reduce the burden of obesity, diabetes, and heart disease on Americans’ lives and our health care costs.

As they debate entitlement reform, politicians will try to convince us that we have no choice – that slowing health care spending necessitates scaling back on our promise to care for our seniors, people with disabilities, and low-income families. By building off of the strengths in President Obama’s cost-containment approach, we can prove them wrong. We can – and we must — reduce our health care spending while strengthening Medicaid and Medicare.

-Katherine Howitt, Senior Policy Analyst
-Michael Miller, Policy Director

 

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Contraception Coverage: A Compromise That Protects Women

Monday, February 13th, 2012

In the immortal words of “Say Anything’s” Lloyd Dobler, “I gave her my heart, she gave me a pen.” We were worried women were going to get pens this Valentine’s Day instead of a key improvement to health care they are set to receive under the Affordable Care Act. Under the ACA, women can receive many preventive services – including contraception – without a co-pay. However, some religious leaders and policymakers objected that some religious-affiliated employers (e.g. universities and hospitals) would be required to cover contraception as part of their insurance plans.

The recommended list of preventive services was based on a report by the Institute of Medicine and includes services such as annual physicals, screening for gestational diabetes, breast feeding support and FDA-approved contraceptive methods and counseling.

In the face of that strong opposition, we were heartened when the Secretary of Health and Human Services announced in January that all employers, except churches and religious organizations that primarily serve members of their own faith, would be required to provide insurance coverage that included contraceptive services. And despite all the hot air from opponents of these critical improvements to women’s health, recent polling shows the majority of Catholics support inclusion of contraceptive services.

Friday morning the Administration announced it was making changes to the rule, and we worried women would be getting pens this Valentine’s Day.

Fortunately, our fears were assuaged when President Obama announced a change to the rule that still supports women and their health care needs. Under the President’s new proposal, insurers will directly offer contraceptive coverage to those who work at religious affiliated institutions, which means institutions won’t have to include or pay for this benefit as part of the coverage they provide to their employees. As a result, women will continue to be able to get access to these important services at no cost, no matter where they work. The amended rule has the support of women’s health organizations and the Catholic Health Association (a critic of the earlier rule), as well as support from Catholic voters.

If the Administration had allowed some of these large, religious-affiliated employers to opt-out of providing birth control, hundreds of thousands of women (of varying faiths) would not have access to these important preventive services and would face additional financial costs. The President’s proposal is a fair compromise: women who work at these institutions will get the services they need from their insurance companies directly, and employers will be exempt for providing services they oppose. As Jack Lew, President’s Obama Chief of Staff, explained on the Sunday news shows, the Administration can’t make everyone happy, but they were able to create a compromise that has the support from various groups on both sides of the issue.

We are grateful that this Valentine’s Day the Administration, in the face of intense political pressure, put women’s health care needs first.

The ACA is a huge victory for women. This Valentine’s Day, let’s make sure women and the Administration receive hearts and not pens. Let the Administration know you support their decision that insurance should cover a woman’s basic preventive health care needs, including contraception, no matter where she works.

– Reena Singh, Associate Director of State Health Advocacy

 

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The New Boom in Managed Care: Long-term Services and Supports

Monday, February 13th, 2012

A new report from AARP captures the changes coming for people who depend on Medicaid for services that help them live with chronic illnesses and disabilities. The number of states that actively manage long-term services and supports in Medicaid will nearly double by 2013, from 12 to 23, with many states folding in services previously only offered through special arrangements with the federal government, called waivers. Long-term services and supports include everything from nursing home care to community-based supports such as help with chores, personal care, transportation, and maintaining a home.

Will this mean more seniors and people with disabilities get the services they need to live in the community and better coordination of those services with medical care? Or will it destroy the fragile network of supports and community-based organizations that millions of often vulnerable people rely on for their everyday needs?

AARP is sponsoring a webinar tomorrow on their report, which is the latest of a string of papers on the transformation of Medicaid-supported long-term services and supports.

The reason for this boom in managed care is no surprise if you look at the numbers: More than one-third of Medicaid spending is for long-term supports and services. But only 6 percent of that is delivered through capitated managed care where plans are paid a fixed sum to provide services. Demand is rising for these services as the population ages, and the lingering recession makes more people eligible for Medicaid to pay for them. Facing fiscal crises, more states are turning to managed care – and making participation mandatory – in the hope of controlling spending. States are also looking to shift more long-term care from nursing homes into the community, largely in response to consumer demand. And the federal government is offering incentives and flexibility to states that make one or both of these moves.

But only a dozen states and relatively few managed care companies have experience with Medicaid managed long-term services and supports. There is little evidence on whether managing long-term services improves outcomes or cuts costs, which may in part be because many of the states are managing these services in a vacuum, separate from medical services, according to a report last fall from the Kaiser Family Foundation. Adding to the challenge, AARP reports that many states have gutted their staffs who work on aging and disability issues.

Meanwhile, the biggest users of these services in Medicaid are low-income seniors and people with severe disabilities who also qualify for Medicare, often referred to as “dual eligibles.” Making things even more complicated, three-quarters of the states are pursuing separate, but related initiatives to integrate all care for these folks, from hospital and doctor’s visits to long-term services, and many plan to actively manage that care.

If there ever was a time for consumer watchdogs to start barking, this is it.

Getting it right will take time, but states are rushing forward. Making it robust will require trained home care workers, but there is a shortage. Making it responsive to consumer needs will take listening to consumers and leaning on the community-based agencies that know this stuff cold, but the for-profit national companies are moving in.

Advocates would do well to focus on these 10 questions:

  1. Are consumers, and consumer advocates, actively involved in planning the changes?
  2. Will services be patient-centered and consumer-directed whenever possible?
  3. Will consumers have as much choice as possible – of participating, of plans, of providers?
  4. Will a full range of services be available, without bias toward nursing home care, and without medicalizing what are primarily social services?
  5. Will long-term services and supports be integrated with medical and behavioral health services, with the right services offered in the right setting at the right time?
  6. Will community-based organizations, such as Independent Living Centers, Recovery Learning Communities, Aging Services Agencies, and Aging and Disability Resource Centers have the opportunity to be providers, or even managed care organizations?
  7. Will there be a single point of entry for consumers to obtain long-term services and supports?
  8. Will there be continuity of care for consumers with long-standing relationships with specific providers?
  9. Is the emphasis on improving quality of care as strong as the emphasis on cutting costs?
  10. Will the state exercise strong oversight over managed care plans?

There are some small programs across the country that can serve as examples, as well as aspects of state managed LTSS plans that are particularly responsive to consumers or creative in serving their needs effectively and efficiently. Some are described in the Kaiser report, some in a State Long-Term Services and Supports Scorecard published by AARP last September, and some in a “Roadmap” put out by the Center for Health Care Strategies in 2010. Watch for additional resources on best practices from Community Catalyst in the coming months as well.

– Alice Dembner, project director

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