Posts Tagged ‘safety net’

ER Visits on the Rise, Thanks to Quick Treatment

Monday, October 24th, 2011

Visits to hospital emergency rooms soared to an all-time high of 136 million in 2009, according to new estimates provided by the Centers for Disease Control and Prevention (CDC).  This represents an approximately 10 percent increase from the 2008 statistic of 123.8 million.  The CDC study is one of three examinations of ER use being released at the American College of Emergency Physicians meeting.  

According to the CDC, patients under the age of 15 accounted for 21 percent of ER visits in 2009; patients between 15 and 24 made up 15 percent; patients between 25 and 44 accounted for 28 percent; patients between 45 and 64, 21 percent; and patients 65 and older, 15 percent.  Breaking visits down by gender, the CDC noted that women visited the ER at a rate of 48 visits per 100, while men had a rate of 42.   

The expected sources of payments for ER visits were private insurance, 39 percent; Medicaid or State Children’s Health Insurance Program, 29 percent; Medicare, 17 percent; other and unknown, five percent each.  Nineteen percent of ER visitors reported that they had no insurance.  The most typical reasons for visiting the ER were stomach and abdominal pain, 9.6 million; fever, 7.4 million; chest pain, 7.2 million; cough, 4.7 million; headache, four million; and shortness of breath and back symptoms, 3.7 million each.  

Physicians attributed the sharp increase to both greater demand for services and improvements that allow ERs to treat patients faster.   “With the economy, people have lost their coverage and, given the fact the emergency department is the safety net, they come to us,” said Dr. Jay Kaplan, an emergency physician at Marin General Hospital who serves on the board of the emergency physicians’ organization.  The physicians contend that it is counterproductive to discourage patients from going to the ER to save money in healthcare costs because they say it doesn’t.  “We’re efficient.  We take care of acute patients and that’s what we do well,” said Dr. Paul Kivela, managing partner of Napa Valley Emergency Medical Group, and a board member of the American College of Emergency Physicians.  

According to Dr. Michael Gerardi, an ACEP board member, he and his colleagues want comprehensive medical liability reform that includes indemnification based on recognized guidelines, caps on non-economic damages and medical courts where providers are judged by medical peers.  “In America, we sue far too often for bad outcomes and not deviations from standard of care,” Gerardi said.  “The overall anxiety of patients and the lack of acceptance that bad outcomes happen are driving costs.”  Because ERs are safety-net providers, they have become increasingly overcrowded.  One factor is the passage in 1986 of the Emergency Medical Treatment and Labor Act, which requires hospitals to provide people with emergency services, despite their inability to pay.  

It has been estimated that 13.7 percent of all emergency room visits could be treated in retail medical clinics, which are typically based in pharmacies or grocery stores.  These facilities are equipped to treat a limited number of minor conditions, such as throat infections or urinary tract infections.  An additional 13.4 percent of emergency room visits could be handled by urgent-care clinics — an independent medical facility that can handle a broader scope of problems, such as minor fractures and more serious injuries.  Urgent-care clinics typically are open on evenings and weekends, fulfilling the need for patients with occurring before or after typical physician office hours.

Commonwealth Fund Tackling Better Care for Uninsured, Minorities

Tuesday, October 18th, 2011

A new strategy report issued by the Commonwealth Fund Commission on a High Performance Health System  has the goal of creating a road map to improve healthcare for the uninsured, minorities and low-income Americans.

The commission, which looks for opportunities to enhance the delivery and financing of healthcare, recommends three broad strategies for achieving that improved care in the report, Ensuring Equity:  A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations.  The recommendations seek to assure the safety net’s stability and stimulate higher performance; strengthen delivery systems for susceptible populations; and coordinate healthcare delivery systems with public health services and community resources.

“Our current economic situation has increased the number and proportion of people who are vulnerable, leaving even more families at risk of suffering from our healthcare system’s inequities,” said Dr. David Blumenthal, chairman of the commission, and Samuel Their, professor of medicine and professor of health care policy at Massachusetts General Hospital/Partners HealthCare System and Harvard Medical School, Boston.

According to the report, there is a significant divide between vulnerable populations and their more secure counterparts in rates of receiving recommended screening and preventive care, control of chronic diseases, and hospital admissions for conditions that may be preventable with good primary care and community health outreach.  By way of example, only four of 10 low-income adults receive all recommended screenings and preventive care, compared with six of 10 higher-income adults.  Approximately three of 10 (29 percent) uninsured adults diagnosed with diabetes do not have it under control, twice the rate of the insured (15 percent).  Black adults are hospitalized for heart failure at rates (959 per 100,000) that are more than twice the rate for Hispanic adults (466 per 100,000); that’s nearly three times the rate for white adults (349 per 100,000).

“This policy framework builds on the great strides we expect to be made for vulnerable populations once the Affordable Care Act takes full effect in 2014,” said Commonwealth Fund Executive Vice President for Programs Anthony Shih, M.D. “By addressing crucial issues like access to care, affordability, quality improvement, and better coordinated care, these recommendations seek to assure that the uninsured, those with low incomes, and racial and ethnic minorities see the full promise of health reform and experience a truly equitable healthcare system.” 

“The Affordable Care Act is a big step forward in terms of addressing the significant needs of vulnerable groups and the healthcare providers who serve them,” said Commonwealth Fund President Karen Davis. “However, the inequity in our healthcare system is significant and” as defined in the Commission’s report, “more work must be done to close that gap and assure that we have a healthcare system that provides all of us with access to high quality healthcare.”

Virginia Appeal Confirms the ACA’s Individual Mandate

Monday, September 19th, 2011

The Obama administration won a round in the legal battle over the Patient Protection and Affordable Care Act (ACA) when a federal appeals court tossed out two lawsuits in Virginia.  The 4th U.S. Circuit Court of Appeals ruled in both lawsuits — one filed by Virginia Attorney General Kenneth Cuccinelli, the second by Liberty University – that the plaintiffs did not have legal standing to sue.  This is a rejection of the first case that ended with a ruling that the healthcare reform law was unconstitutional.  Additional cases remain active, including the lawsuit filed by 26 other states, which means that the issue has by not gone away.

Virginia argued that it had the right to challenge the individual mandate – a key proviso of the law that requires people to buy health insurance by 2014 or pay a tax penalty – because it interferes with a state law that says residents can’t be forced to purchase health insurance.  According to the court, “To permit a state to litigate whenever it enacts a statute declaring its opposition to federal law” would “convert the federal judiciary into a forum for the vindication of a state’s generalized grievances about the conduct of government.”  During oral arguments, a lawyer for the Obama administration said that the case “fails at the outset” because the mandate is applicable to individuals and not the state.  After the decision was handed down, Cuccinelli expressed “disappointment” that the case was thrown out.  According to Cuccinelli, “the Court did not even reach the merits on the key question of Virginia’s lawsuit – whether Congress has a power never before recognized in American history: the power to force one citizen to purchase a good or service from another citizen.”

In the case brought by Liberty University — a private Christian school — the court said in a 2 – 1 ruling that it was blocking the case because a federal tax law stripped it of jurisdiction to decide the issue.  The Court was the first to rule that the individual mandate is essentially a tax.  Because the mandate cannot be enforced until 2014, the Court ruled that the Anti-Injunction Act “strips us of jurisdiction” from hearing a pre-enforcement challenge.  “What the Court said is that the penalty for not complying with the mandate functions as a tax that cannot be challenged until it has been assessed,” said Kevin Walsh, a law professor at the University of Richmond School of Law.

Virginia Governor Bob McDonnell reacted to the ruling, saying “Today, a three judge panel, consisting of two judges appointed by President Barack Obama and one by former President Bill Clinton, found that Virginia lacks standing to challenge the individual mandate provision of the federal healthcare law.  We respectfully disagree with the panel’s reasoning.  To conclude that a state has no standing to challenge an expensive and burdensome federal mandate on its citizens that the state has banned in its law, might cause James Madison and George Mason, Virginia’s principal drafters of our nation’s founding documents, to promptly roll in their graves.  To dismiss a Virginia statute as a basis for standing, declaring it to be ‘quintessentially political,’ and asserting that a state cannot be a ‘constitutional watchdog’ undermines our precious principles of federalism.  This decision must be promptly appealed.

“As federal courts across the country continue to come to differing conclusions on the merits of cases arguing the unconstitutionality of the federal healthcare law, today’s decision further exemplifies why these cases should be expedited to the nation’s highest court.  It is the Supreme Court that will ultimately determine whether the federal mandate on every citizen to purchase health insurance violates the U.S. Constitution.  States and businesses continue to expend time and money and languish in uncertainty as they try to come into compliance with a law that may ultimately be ruled unconstitutional.  It is exasperating that the President and the Justice Department oppose a prompt resolution of this case through an expedited appeal.  America needs finality in this case,” according to McDonnell.

Judge Diana Gribbon Motz, who was appointed to the bench by President Clinton, wrote that the only apparent function of the state law was “to declare Virginia’s opposition to a federal insurance mandate.”  The state law was enacted just days after President Obama signed the ACA into law.

Writing in U.S. News & World Report, Scott Galupo says that “Cuccinelli and co. follow a long trail from the 18th century British jurist William Blackstone to the Dred Scott case to the New Deal to the present day.  The conservative team, at first, makes a tight, prudential case against the Obamacare mandate that I, in my nonprofessional capacity, happen to favor.”  Parsing Cuccinelli’s statement about the decision, Galupo notes that “In plainer, get-to-the-point English: We grant you the social safety net established under the ‘Roosevelt Settlement.’  We recognize Congress’s power to regulate interstate commerce.  We even grant that this power could conceivably deliver universal healthcare.  But for Pete’s sake, don’t try to include ‘inactivity’ — that is, not buying a health insurance plan on the private market — under its purview.  Because, once you regulate the act of doing nothing, what’s left to regulate?  Er, nothing.  Thus, does the state’s power to tax and police become theoretically unlimited?  But, later in the body of the piece, Team Cuccinelli begins to play other, more presently familiar cards.  Glenn Beck fans will recognize the faces in the rogue’s gallery: Justice Oliver Wendell Holmes, progressive philosopher John Dewey, and others who, this argument goes, created the post-New Deal legal and philosophical edifice.  Wouldn’t you know it, this welfare-state stuff constitutes a violation of natural law — which, ipso facto, means economic laissez-faire — and a lurch into moral chaos.  Echoing the newly popular Hayek, Cuccinelli’s article asserts the primacy of economic rights while characterizing as relativistic the not-exclusively-liberal jurisprudential argument that personhood and dignity precede the marketplace.  (Last I checked, I’ve never seen an unborn baby sign a contract.)”

The Obama administration remains optimistic about the ACA.  “When it ends, we are confident we will prevail,” White House adviser Stephanie Cutter said.

The Affordable Care Act: A Tale of Two Studies

Monday, May 23rd, 2011

A study of medical bills under the Patient Protection and Affordable Care Act (ACA) determined that most households will be able to afford premiums and related expenses after paying bills for food, child care, transportation and other necessities, according to the Commonwealth Fund. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.

Approximately 8.5 to nine percent of American families living closest to the poverty line could not afford basic necessities and typical medical bills proposed by the health reform law.  The ACA requires individuals to purchase insurance by 2014, although with occasional exceptions.  The ACA restricts household out-of-pocket costs and subsidizes plans available through insurance exchanges to people with low-incomes.  Fewer households in high cost-of-living states could afford healthcare expenses, according to the Commonwealth Fund study.  The report included projections of spending on necessities, premiums and out-of-pocket costs for households between the federal poverty line and 500 percent of the threshold.  Those insured by safety net or state run insurance exchanges were not factored into the study.

Even with implementation of the ACA, some families across all income levels would continue to struggle to afford coverage because of steep out-of-pocket costs.  According to the report, 17 percent of families of four earning up to $44,700; approximately 25 percent of families earning between $44,700 and $67,050, would struggle with healthcare costs.  The data examines costs in 2014, the first year the ACA will be fully implemented and the start of state-based health insurance exchanges.  The law provides federal subsidies for the lowest-income people to buy insurance.  Americans with incomes between 133 and 399 percent of the poverty level are eligible for income-based tax credits.  Some low-income people will be eligible for subsidies to make up for out-of-pocket costs.  Americans who make less than 133 percent of the poverty level are eligible for Medicaid.

“The Affordable Care Act is very good news for millions of Americans who are struggling to afford health care, going without health insurance, or skipping the care they need because they can’t afford it,” said Commonwealth Fund President Karen Davis. “The new law makes health insurance and health care affordable for nearly all families, and introduces delivery system reforms that have the potential to greatly improve quality and efficiency.  If implemented well, new entities like accountable care organizations may bring even greater savings and affordability than this report predicts.”

Although the Commonwealth report is positive about the likelihood that more families will be able to afford health insurance, Craig Pollack, M.D., M.H.S., assistant professor of medicine at Johns Hopkins, and Katrina Armstrong, M.D., from the University of Pennsylvania, are not as upbeat about the ACA.  The physicians warn that as a result of certain provisions in the ACA, wealthy hospitals and physician practices might “cherry-pick” similar institutions and create Accountable Care Organizations (ACOs).  In this way, they can avoid poor and minority-heavy patient populations who will be treated elsewhere to cut costs.  ACOs encourage patients to seek care within their own network, which highlights the disparities between networks.

According to Pollack, hospitals and physician practices that treat too many minorities may be unable to join ACOs and will fall further behind in the cost and quality of care that is likely to occur in such networks.  “There is ample evidence of racial and ethnic disparities in healthcare,” Pollack said.  “Hospitals and private practices that care for greater numbers of minorities tend to have larger populations of Medicaid and uninsured patients.  These patients have less access to specialists, and their hospitals and practices tend to have fewer institutional resources than their counterparts.”

New York Public Hospital Facing a $1 Billion Loss

Tuesday, March 23rd, 2010

New York City public hospitals demonstrate difficulties of staying afloat.  That fact that New York City’s public hospitals could lose $1 billion illustrates the difficulty that healthcare systems face in their efforts to stay afloat.  New York City Health and Hospitals Corporation has projected a billion dollar loss through June 30, 2011, despite an expected infusion of “hundreds of millions of dollars” in retroactive Medicaid payments.

The Medicaid payout, as well as cost-cutting efforts and improvements to efficiency will help the 12-hospital system achieve an operating gain as of June 30.  Operations, however, will “burn through that at a pretty torrid rate,” notes system president Alan Aviles.  The growing demand for subsidized and free care during the recession, as well as cuts to Medicaid – which covers approximately two-thirds of the system’s patients – makes balancing the budget problematical.

New York’s public hospitals saw the number of uninsured patients grow by 4,000 in 2009, 36,000 in 2008 and 17,000 in 2007.  According to Aviles, the growth among the uninsured is leveling, but his system has limited capacity to accept new patients.  The $1 billion doesn’t include approximately $70 million in payment cuts and tax increases contained in the New York state budget for the fiscal year that begins in April.  The gloomy forecast assumes a $300 million cut to the system’s disproportionate-share payments, which are financial assistance given to hospitals that serve low-income patients.  Aviles is lobbying New York legislators to reinstate these by prioritizing such spending in the public health system’s favor.

“This highlights that as this economic downturn continues, that public hospitals and other safety net systems that serve a great number of Medicaid and uninsured patients are going to be increasingly reliant on disproportionate-share payments to keep their systems afloat and solvent,” Aviles said.