Posts Tagged ‘Reimbursement’

Is Getting People on Medicaid Doing More Harm Than Good?

Tuesday, July 19th, 2011

To control soaring Medicaid costs,  several states have started the new fiscal year by cutting payments to doctors, hospitals and other healthcare providers that treat the poor.  Some experts say the cuts could add to a shortage of physicians and other providers participating in Medicaid.  “Further depressing payment rates can only worsen the situation,” said Sara Rosenbaum, chair of the health policy department at George Washington University.  She says some states cutting rates — South Carolina, for example — already have acute Medicaid physician shortages.

Insurers and employers believe that cutting the rates will prompt providers to raise their prices for patients who have private insurance.  “It’s always a concern that when providers get less from Medicaid, that they will shift the costs to private insurance so families and employers pay more,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans (AHIP), the healthcare industry’s lobbyist group.

States reducing Medicaid payments to physicians are Colorado, Nebraska, Oregon and South Dakota.  Arizona, which cut rates in April, will impose another cut in October.  States reducing payments to hospitals include Colorado, Connecticut, Florida, Nebraska, New Hampshire, North Carolina, Oregon, Pennsylvania, South Carolina, Texas, Virginia and Washington.  New York cut hospital payment rates in April.  In March, California okayed a 10 percent Medicaid cut to doctors and hospitals; those reductions are pending because of a lawsuit that has not yet been resolved.

The payment cuts, which require federal approval, are part of an effort by states to cut Medicaid costs, typically the largest- or second-largest expense after education.  A joint state-federal program, Medicaid serves more than 50 million low-income and disabled Americans.  Under the provisions of the Patient Protection and Affordable Care Act (ACA), more than 16 million more people will become eligible 2014, with the federal government picking up the majority of the cost.  To lure more physicians to accept Medicaid patients, the law raises rates for primary-care physicians in 2013 and 2014 to match those paid by Medicare.  On average, states currently pay Medicaid providers approximately 72 percent of what Medicare pays.

Federal-state Medicaid costs totaled $366 billion in fiscal 2009.  The federal stimulus package gave states $100 billion to help pay their share, but that funding ended June 30, and “states are struggling,” said Laura Tobler, a policy analyst at the National Conference of State Legislatures.  The ACA does not allow states to restrict eligibility for the program.

Because of cuts in reimbursement, the Government Accounting Office (GAO) has found that fewer physicians are accepting children on Medicaid as patients.  More than 75 percent of 932 doctors surveyed by the GAO reported difficulty when referring children with public insurance for specialty care, citing an overall shortage of specialists, and different waiting lists for children receiving Medicaid or Children’s Health Insurance Program (CHIP) benefits than children covered by private insurance.  In 2010, more than 40 million children in the country received healthcare through one of the two programs which cost $79 billion in federal and state funds.  Physicians serving rural areas are more likely to accept new patients with Medicaid and CHIP than doctors in urban areas.  Rural primary-care doctors reported greater difficulty referring their Medicaid and CHIP patients to specialists than urban physicians.

Writing in Forbes, Avik Roy says that “The real problem, however, is that many physicians don’t accept Medicaid patients, primarily because Medicaid underpays them for their time and costs.  The Health Tracking Study Physician Survey found that internists are 8.5 times as likely to reject all Medicaid patients versus those with private insurance.  The New England Journal of Medicine recently published a study showing that 66 percent of Medicaid children were denied an appointment with a specialist for an urgent medical condition — such as uncontrolled asthma or seizures — compared to only 11 percent for the privately insured.  What makes this even more appalling is that we’re spending billions of dollars to take millions of children away from high-quality private insurance, and shoving them in Medicaid instead.  As Peter Suderman notes, the Congressional Budget Office has estimated that of the children who have been added to Medicaid’s sibling, the State Children’s’ Health Insurance Program (CHIP), one-quarter to one-half were adequately covered by private insurance beforehand.”

Why Aren’t Physicians Paid For Talking To Their Patients?

Tuesday, July 5th, 2011

One possible reason that more physicians do not choose family practice as their specialty could be the fact that an essential part of the job is spent talking with patients – an activity that pays less than does performing procedures.   According to a recent study published by the Journal of the American Medical Association, just two percent of medical students plan a career in general internal medicine, pediatrics or ob/gyn.

Writing on the KevinMD.com website, Jennifer Adaeze Anyaegbunam says that “Family doctors spend more time talking to patients than performing procedures, but these doctors don’t get paid much to chat.  According to Dr. Sameer Badlani, a professor at the University of Chicago School of Medicine, when physicians are paid on a fee-for-service basis, specialists have the opportunity to make four to five times as much as a family physician.  Given the increasing debt of medical students, it is no surprise that the overwhelming majority choose to specialize.  In order to increase the supply of primary-care providers and meet the anticipated demand, family physicians need to be reimbursed more for their services.  Congress is looking into legislation that includes provisions for loan forgiveness and increased Medicare/Medicaid payments to primary-care providers.  Additionally, there have been talks of expanding the National Health Service Corps, program that utilizes scholarships and loan repayment to recruit primary care professionals to work in underserved areas.”

Primary-care physicians spend more time talking to patients and helping them avoid health crises to cope with chronic and incurable diseases than they spend performing tests and procedures. These doctors ask relevant questions, about health and life circumstances, and listen carefully to their patients.  These are physicians who know their patients and the circumstances and beliefs that can make health problems worse or hamper effective treatment.  The problem is that reimbursements are dictated by Medicare and other insurers.  As a result, physicians are not compensated well for taking the time to talk to patients.  They are primarily paid for procedures – such as blood tests and surgery — and for the number of patients they see.  Most spend long hours doing paperwork and negotiating treatment options with insurers.  The payments they receive have not increased along with increases in the costs of running a modern medical practice.  To earn a reasonable income of $150,000 a year, many primary-care doctors squeeze more and more patients into the workday.  “If you have only six to eight minutes per patient, which is the average under managed care, you’re forced to concentrate on the acute problem and ignore all the rest,” said Dr. Byron M. Thomashow, medical director of the Center for Chest Diseases at New York-Presbyterian Columbia Medical Center.  In a study of more than 3,000 patients with chronic obstructive pulmonary disease, 50 to 60 percent had one or more other illnesses, and 20 percent had more than 11 other conditions that required medical attention.  “There just isn’t the time to address them all,” Thomashow said.

Dr. Alan J. Stein, an infectious disease specialist in private practice in Brooklyn who treats many patients with HIV, described his practice as “heavily cognitive.  I spend a lot of time talking to patients — listening to them, examining them, interpreting tests and figuring out what’s wrong,” he said.  “I don’t do procedures in the office.  Over the last 10 or 15 years, the income of procedure-based physicians like cardiologists has increased significantly, whereas for those in primary care it has remained the same.”

Despite this, many physicians are reluctant to talk to their patients via e-mail.  Suzanne Kreuziger, a Milwaukee registered nurse, said.  “It makes sense to me to have the words laid out, to be able to re-read, to go back to it at a convenient time,  If I were able to ask my physician questions this way, it would make my own health care much easier.”  Her experience is shared by the majority of Americans: They want the convenience of e-mail for non-urgent medical issues, but fewer than 33 percent of doctors use e-mail to communicate with patients, according to surveys.

“People are able to file their taxes online, buy and sell household goods, and manage their financial accounts,” said Susannah Fox of the Pew Internet & American Life Project.  “The health care industry seems to be lagging behind other industries.”  Physicians have good reasons for avoiding e-mail exchanges with their patients.  Some are concerned that it will increase their workload.  Others worry about hackers compromising patient privacy.

Mixed Verdict on Level of RN Staffing and Better Patient Outcomes

Wednesday, April 20th, 2011

Elevated levels of nurse staffing can lead to better patient outcomes, though not necessarily in safety net hospitals – which provide healthcare to low-income, vulnerable and uninsured persons — according to a report published by the American Public Health Association. According to a study funded by the Robert Woods Johnson Foundation’s Interdisciplinary Nursing Quality Research Initiative, researchers examined discharge records for 1.1 million patients in 872 units — including 285 intensive-care units — at 54 University HealthSystem Consortium hospitals and found relationships between patient outcomes and the length of time that nursing care patients received.

Although staffing levels were similar, outcomes were enhanced in non-safety net facilities, where more registered nurses were associated with lower mortality rates from congestive heart failure, infections and bedsores, as well as shorter stays. There were also fewer “failure to rescue” deaths, where nurses did not note or initiate treatment in life-threatening situations.   “Higher levels of nursing skill and more nurses providing more hours of care, overall, are correlated with better care — shorter hospital stays, fewer infections and lower rates of failure to rescue,” said Mary Blegen, RN, PhD, FAAN, professor in Community Health Systems and director of the Center for Patient Safety at the University of California San Francisco School of Nursing.  “We suspect that the increase in mortality rates due to congestive heart failure in safety-net hospitals are a function of patients’ overall health, rather than staffing rates, but more research needs to be done.  We also need to know more about how non-RNs affect patient care.”

There’s another side to this issue, however.  A study published in the New England Journal of Medicine found that a lack of adequate nurses has a direct correlation to higher patient morality rates.  A study of nearly 200,000 nursing shifts determined that staffing of “RNs below target levels” is linked to increase patient deaths.  Some of the under-staffing is a result of efforts to control costs.  In one finding, when inadequate numbers of nurses were on duty, inappropriate and dangers levels of patient transfers and discharges occurred.  Shortages also lead to higher turnover rates.  According to the study, the risk of death increased two percent for patients cared for by shifts staffed by too few RNs.  The typical patient was exposed to three nursing shifts, which created a six percent increased risk of death.  Elevated levels of shift turnovers resulted in four percent more deaths.  The American Nursing Association believes that policymakers must focus on reimbursement systems that reward hospitals for maintaining adequate nurse staffing.