Category Archives: Medicaid

Canada’s “national shame”: Covid-19 in nursing homes

Posted on by • Posted in 2020 Election Issues, Ageism, Clinical Testing, Core Values, Coronavirus, Cost Management, Cost Reduction, Crisis, Crisis Management, Health Insurance Coverage Adequacy, Health Policy, Health System, Hospital, Hospital Industry, Infection Control, Infection Control Plan, Infectious Virus, Long Term Care, Medicaid, Mortality, National Strategy, Nursing Home, Pandemic, Pandemic Preparedness, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Sexism, Social Distancing, Underinsured, Uninsured, Universal Healthcare System, Vulnerable Populations • Leave a comment

https://www.vox.com/future-perfect/2020/7/7/21300521/canada-covid-19-nursing-homes-long-term-care

Why Canada's coronavirus cases are concentrated in nursing homes - Vox

Nursing homes account for 81 percent of Covid-19 deaths in the country. How did this happen?

Canada’s response to the coronavirus pandemic has generally been viewed as a success, with experts pointing to its political leadership and universal health care system as factors.

But there has been one glaring failure in Canada’s fight against the pandemic: its inability to protect the health of its senior citizens in nursing homes and long-term care facilities.

The situation for these seniors is so dire that the police — and even the military — have been called in to investigate why so many are dying.

In Quebec, some residents have been left for days in soiled diapers, going hungry and thirsty, and 31 residents were found dead at one home in less than a month, leading to accusations of gross negligence. In Ontario, the military found shocking conditions in five homes: cockroaches and rotten food, blatant disregard for infection control measures, and treatment of residents that was deemed “borderline abusive, if not abusive.”

“It’s a national shame,” said Nathan Stall, a geriatrician at Toronto’s Sinai Health System. “I don’t think we’ve done a good job at all in Canada.”

A whopping 81 percent of the country’s coronavirus deaths are linked to nursing homes and long-term care facilities. That means roughly 7,050 out of 8,700 deaths to date have been among residents and workers in these facilities.

In terms of raw numbers, that may not seem like very much. (For comparison, more than 40,000 US coronavirus deaths have been linked to nursing homes.) And, to be clear, Canada is hardly alone in watching tragedy unfold in these facilities. The US and Europe have seen startling numbers of fatalities among nursing home staffers and residents.

But 81 percent is a staggering statistic, especially for Canada, a country that prides itself on its progressive health policies. And it’s higher than the rate in any other country for which we have good data. In European countries, roughly 50 percent of coronavirus deaths are linked to these facilities. In the US, it’s 40 percent.

Experts say a number of factors are probably involved in Canada’s collapse on the nursing home front, like the fact that Canada has done well at controlling community spread outside these facilities (making nursing home deaths account for a greater share of overall deaths) and that residents in Canadian homes tend to be older and frailer than those in US homes (and thus more vulnerable to severe cases of Covid-19). But they say the high death rate in the homes is due, in large part, to egregious problems with the homes themselves.

“I think we have serious issues with long-term care,” said Vivian Stamatopoulos, a professor at Ontario Tech University who specializes in family caregiving. Experts have been warning political leaders about this for years, but, she said, “they’ve all been playing the game of pass the long-term care hot potato.”

Furious over how their elders are being treated, some Canadians have started petitions, protests, lawsuits, and even hunger strikes outside the homes. They say the government’s failure to respond reveals a deeper failure to care about seniors and people with disabilities, and to make that care concrete by sending facilities what they urgently need: more tests, more personal protective equipment (PPE), and more funding to pay staff members so they don’t have to work multiple jobs at different facilities.

Prime Minister Justin Trudeau has acknowledged that the situation in the facilities is “deeply disturbing.” He’s sent hundreds of military troops to help feed and care for the seniors in certain homes, where burnout and fear have prompted some staff members to flee their charges. But to some extent, Trudeau’s hands are tied because the facilities fall under provincial jurisdiction.

That leaves families terrified for their loved ones. They’re asking: Why have things gone so terribly wrong? How could this happen in Canada?

 

Canada’s crisis was a long time in the making

The first thing to understand is that Canada’s universal health care system does not cover nursing homes and long-term care facilities. That means these institutions are not insured by the federal system. Different provinces offer different levels of cost coverage, and even within a given province, you’ll find that some homes are publicly run, others are run by nonprofits, and still others are run by for-profit entities.

“This is the main problem — they don’t fall under the Canada Health Act,” said Stamatopoulos, adding that the same is not true of hospitals. “That’s why you see that the hospitals did so well. They had the resources.”

From the standpoint of someone in the US, where more than 132,000 people have died of Covid-19, Canada may seem to be doing well overall: The death toll there is around 8,700. Per capita, Canada’s coronavirus death rate is roughly half that of America’s. It’s clear that the northern neighbor has been doing better at keeping case numbers down, partly because it’s giving safer advice on easing social distancing.

Which makes the dire situation in nursing homes stand out even more. Longstanding problems with Canada’s nursing homes have clearly fueled the tragic situation unfolding there.

These homes are chronically understaffed. They tend to hire part-time workers, underpay them, and not offer them sick leave benefits. That means the workers have to take multiple jobs at different facilities, potentially spreading the virus between them. Many are immigrants or asylum seekers, and they fear putting their precarious employment at risk by, say, taking a sick day when they need it. (These problems aren’t unique to Canada, but as in other countries, they’ve been thrown into stark relief by the pandemic.)

A lot of Canadian homes also have poor infrastructure, built to the outdated design standards of the 1970s. Residents often live four to a room, share a bathroom, and congregate in crowded common spaces. That makes it very difficult to isolate those who get sick.

These problems are even worse in Canada’s for-profit nursing homes. Research shows that these private facilities provide inferior care for seniors compared to the public facilities, in large part because they hire fewer staff members and put fewer resources into upgrading or redesigning their buildings. The for-profit model incentivizes cost-cutting. (Similarly problematic profit motives and poor living conditions persist in US nursing homes, too.)

Canadian experts have been raising the alarm about these issues for more than a decade. So why haven’t they been addressed?

“Frankly, overall, it really reflects ageism in society. We choose not to invest in frail older adults,” Stall said. He added that early on in the pandemic, the public imagination latched onto stories of relatively young people on ventilators in hospitals. The hospitals and their staff got resources, free food, nightly applause. Homes for older people didn’t get the same attention.

“Nursing homes are not something we’re proud of societally. There’s a lot of shame around even having someone in a nursing home,” Stall said.

Stamatopoulos noted there are other forces at play, too. “I’d say it’s a trifecta of ageism, racism, and sexism,” she said. “When you look at this industry, it’s majority female older residents being cared for by majority racialized women.”

Ronnie Cahana, a 66-year-old rabbi who lives with paralysis at the Maimonides Geriatric Centre in Montreal, recently wrote a letter to Quebec’s premier. “I am not a statistic. I am a fully sentient, confident human being, who needs to have my humanity honored,” he wrote, adding that the premier should help the workers who take care of people like him. “Many of them are immigrants, newly beginning their lives in Quebec. … Please give them all the resources they require. Listen to their voices.”

 

How to make nursing homes safer — in Canada and beyond

If you want to keep nursing homes from becoming coronavirus hot spots, look to the strategies that have proven effective elsewhere. For months now, Canadian public health experts and advocates have been begging leaders to do just that.

All residents and workers in nursing homes should be tested regularly, whether they show symptoms or not. Anyone who gets sick should be isolated in a separate part of the building or taken to the hospital. Workers should be given adequate PPE, and universal masking among them should be mandatory. Working at multiple homes during the pandemic should be disallowed.

“Look at South Korea. They’ve had no deaths in long-term care because they treated it like SARS right from the get-go,” Stamatopoulos said. “They did aggressive testing. They were strict in terms of quarantining any infected residents and were quick to move them to hospitals. We’ve done the opposite.” Earlier in the pandemic, some Canadian hospitals sent recovering Covid-19 patients back to their nursing homes too soon; they inadvertently infected others.

“And look at New York state,” Stamatopoulos continued. “Gov. Cuomo signed an executive order on May 10 requiring all staff and residents to be tested twice a week. That aggressive testing helped halt the outbreaks in the homes.” Quebec and Ontario have yet to do this.

British Columbia, a Canadian standout at preventing deaths in nursing homes, adopted several wise measures early on. Way back on March 27, the western province made it illegal to work in more than one home — and topped up workers’ wages so they wouldn’t have to. It gave them full-time jobs and sick leave benefits.

It’s clear that so long as long-term care falls under provincial jurisdiction, nursing home residents will be better off in some provinces than in others. So some Canadian experts, including Stamatopoulos, are arguing that these facilities should be nationalized under the Canada Health Act. Others are not sure that’s the answer; Stall thinks it may make sense to target only for-profit homes, compelling them to improve their poor infrastructure. In the long term, any homes that do not meet modern standards should be redesigned.

Another lesson for the long term comes from Hong Kong, which has managed to totally avoid deaths in its nursing homes. Even before the coronavirus came along, all homes had a trained infection controller who put precautions in place to prevent the spread of infections. (US homes saw a similar system enacted under President Obama, but President Trump has proposed that it be rolled back.) Four times a year, Hong Kong’s homes underwent pandemic preparedness drills so that if an outbreak occurred, they’d be ready with best practices. It did, and they were.

Preparedness clearly saves lives. Hopefully, Canada and other countries will learn that lesson going forward so that no more lives are needlessly lost.

As Cahana, the resident in the Montreal home, said, “Each of us is crying to be heard. We say: More life! Please! We are not afraid of the future. We are afraid that society is forgetting us.”

 

 

 

 

 

340 organizations tell Congress to make telehealth permanent

Posted on by • Posted in 2020 Election Issues, Center for Medicare and Medicaid Services (CMS), Health Policy, Health System, Hospital, Hospital Industry, Medicaid, Medical Group, Medicare, Physician Practice Management, Primary Care, Telemedicine • Leave a comment

https://www.healthcarefinancenews.com/news/340-organizations-tell-congress-make-telehealth-permanent?utm_source=SFMC&utm_medium=email&utm_campaign=NL-HFN-NewsDay-2020-07-01+-+20200629_101004+-+20200630_102918+-+20200630_181109+-+20200701_104543%e2%80%8b

Advocacy and Policy | Primary Care Collaborative

New report finds the growth of telemedicine visits has plateaued and accounts for a relatively small percentage of rebounding ambulatory care.

On Monday, 340 organizations signed a letter urging Congress to make telehealth flexibilities created during the COVID-19 pandemic, permanent. 

Those signing the letter include national and regional organizations representing a range of healthcare stakeholders in all 50 states, the District of Columbia and Puerto Rico.

Congress quickly waived statutory barriers to allow for expanded access to telehealth at the beginning of the COVID-19 pandemic, providing federal agencies with the flexibility to allow healthcare providers to deliver care virtually.

Stakeholders also want Congress to remove restrictions on the location of the patient to ensure that all patients can access care at home, and other appropriate locations; to maintain and enhance HHS authority to determine appropriate providers and services for telehealth; ensure federally qualified health centers and rural health clinics can furnish telehealth services after the public health emergency; and make permanent the Health and Human Services temporary waiver authority for future emergencies.

While federal agencies can address some of these policies going forward, the Centers for Medicare and Medicaid does not have the authority to make changes to Medicare reimbursement policy for telehealth under current law, stakeholders said.

In a statement separate from the letter to Congress, Lux Research Associate Danielle Bradnan said key concerns for legislators are broadband internet access, payer reimbursement and licensure barriers, since, currently, medical licenses are only valid for specific states.

WHY THIS MATTERS

If Congress does not act before the COVID-19 public health emergency expires, current flexibilities will disappear, according to stakeholders.

The PHE is scheduled to expire in July.

In a tweet late yesterday, Michael Caputo, the assistant secretary of the Department of Health and Human Services for public affairs, said HHS is expected to renew the PHE before it expires. It has already been renewed once.

THE LARGER TREND

The use of telehealth has skyrocketed under in-person restrictions under COVID-19.

Private health plans have followed suit, the letter said, resulting in a 4,300% year-over-year increase in claims for March 2020.

However, a new report from the Commonwealth Fund has found that the growth of telemedicine visits has plateaued and account for a relatively small percentage of rebounding ambulatory care services.

As states experiment with reopening – and re-closing – their economies in response to concerns around rising coronavirus cases, the report found that telemedicine visits have actually been declining since April.

 

 

 

 

Oklahoma votes to expand Medicaid

Posted on by • Posted in 2020 Election Issues, ACA, Health Policy, Medicaid, Medicaid Expansion • Leave a comment

https://www.beckershospitalreview.com/payer-issues/oklahoma-votes-to-expand-medicaid.html?utm_medium=email

Oklahoma voters narrowly approve Medicaid expansion | News Break

Oklahoma voters approved a state question to expand Medicaid to more low-income residents, according to The Oklahoman.

The June 30 vote makes Oklahoma the first state to amend its constitution to expand Medicaid. Adding Medicaid expansion to Oklahoma’s constitution effectively limits the state’s GOP-controlled legislature and Republican governor from rolling back the measure.

The vote narrowly passed, with most of Oklahoma’s counties opposing the expansion. Just seven of the state’s 77 counties, including more populated ones such as Oklahoma and Tulsa Counties, voted in favor.

Oklahoma has until July 1, 2021, to expand Medicaid under the ACA. The expansion is expected to affect about 200,000 Oklahomans and cost about $164 million annually. The cost was a sticking point for Gov. Kevin Stitt, as the state may face a $1 billion shortfall in 2022. The Oklahoma Hospital Association supports the expansion.

 

 

As Americans lose job-based coverage, ACA marketplace sets record with near 500K signups

Posted on by • Posted in 2020 Election Issues, ACA, Coronavirus, Employer-Based Health Insurance, Health Insurance Coverage Adequacy, Health Policy, Medicaid, Medicaid Expansion, Pandemic, Supreme Court, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

https://www.healthcaredive.com/news/as-americans-lose-job-based-coverage-aca-marketplace-sets-record-with-near/580623/

Dive Brief:

  • Millions of individuals have lost their jobs as a result of the pandemic, allowing them to enroll in Affordable Care Act marketplace coverage via Healthcare.gov due to their special circumstances. CMS said this week that this special enrollment coverage due to job loss specifically has reached a record, with about 487,000 consumers gaining coverage, a 46% increase compared with the same time last year.
  • April saw the biggest jump in enrollment following job loss, an increase of 139% compared to April of last year.
  • Due to a number of factors, CMS said it “remains unclear how many people will eventually look to Exchanges using HealthCare.gov to replace job-based coverage.”

Dive Insight:

The pandemic has battered the economy, causing historic levels of unemployment. For many Americans, healthcare coverage is tethered to their jobs. As such, the pandemic is not only a threat to Americans’ health but their ability to pay for the care they need, sick with COVID-19 or not.

As many as 27 million Americans may have lost job-based coverage between March and May of this year, according to a recent analysis from the Kaiser Family Foundation. 

Of the newly uninsured, about half (12.7 million) would be eligible for Medicaid coverage, according to Kaiser’s estimates. There are a few options for workers out of a job and insurance. They can opt to extend their coverage through COBRA, enroll in coverage through the exchanges, or check to see if they qualify for Medicaid.

This week, CMS attempted to quantify just how many out-of-work Americans were turning to the exchanges.

About 500,000 out-of-work consumers enrolled in coverage so far this year. However, there are other life events that qualify a consumer to shop for coverage during a special enrollment period. Overall, special enrollment period sign-ups garnered more than 890,000 enrollees, dwarfing other periods. 

If the trend continues, it may fuel a significant shift in health insurance. For years, a majority have received commercial coverage through work. Even health insurers recognize disruption is on the horizon.

Many of the nation’s largest insurers are bracing for a shift from their commercial book of business to covering more Medicaid enrollees through their contracts with states. Earlier this year, Molina, Centene and Anthem all said they expect upticks in their Medicaid membership and exchange products.

Molina executives said in April they already saw 30,000 more Medicaid members from the prior-year period.

 

 

 

 

ACA enrollment up 46%

Posted on by • Posted in 2020 Election Issues, ACA, Coronavirus, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Policy, Medicaid, Medicaid Expansion, Out of Pocket Expenses, Preexisting Conditions, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

https://www.axios.com/newsletters/axios-vitals-59e9ac1a-ab86-4f8a-917a-8c9d52f5835f.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Obamacare Coverage Spikes After Covid-Related Job Losses

The number of people who lost jobs and related health coverage and then signed up for Affordable Care Act health plans on the federal website was up 46% this year compared with 2019, representing an increase of 154,000 people, the federal government said in a new report.

The bottom line: The government said the rush of people going to HealthCare.gov was tied to “job losses due to COVID-19,” Bob writes.

Yes, but: Medicaid enrollment due to coronavirus-related job losses appears to be growing even faster than enrollment in ACA plans, according to the Georgetown University Health Policy Institute.

Go deeper: Medicaid will be a coronavirus lifeline

 

 

 

 

White House set to ask Supreme Court this week to overturn ACA: 4 things to know

Posted on by • Posted in 2020 Election Issues, ACA, Employer-Based Health Insurance, Essential Health Benefits, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Health System, Hospital, Hospital Industry, Individual Mandate, Medicaid, Medicaid Expansion, Medical Loss Ratio (MLR), Out of Pocket Expenses, Preexisting Conditions, Supreme Court, Texas v. United States, Underinsured, Uninsured • Leave a comment

https://www.beckershospitalreview.com/hospital-management-administration/white-house-to-ask-supreme-court-this-week-to-overturn-aca-4-things-to-know.html?utm_medium=email

New rules for Supreme Court justices as they plan their first-ever ...

The White House is expected to file legal briefs with the Supreme Court this week that will ask the justices to end the ACA, according to The New York Times. 

Four things to know:

1. The filings are in relation to Texas v. United States, the latest legal challenge to the ACA. Arguments around the case center on whether the ACA’s individual mandate was rendered unconstitutional when the penalty associated with it was erased by the 2017 tax law. Whether that decision invalidates the entire law or only certain parts of it is at question.

2. The White House is set to ask the Supreme Court June 25 to invalidate the law. The filings come at a time when the COVID-19 pandemic has caused millions of Americans to lose their jobs and their employer-based health coverage.

3. Republicans have said they want to “repeal and replace” the ACA, but there is no agreed upon alternative, according to The New York Times. Party strategists told the publication that Republicans will be in a tricky spot if they try to overturn the ACA ahead of the November elections and amid a pandemic. 

4. In addition to the filings, Democratic House speaker Nancy Pelosi is expected to reveal a bill this week that would boost the ACA. Proposals include more subsidies for healthcare premiums, expanding Medicaid coverage for uninsured pregnant women and offering states incentives to expand Medicaid.

Read the full report here. 

 

 

Moody’s: Patient volume recovered a bit in May, but providers face long road to recovery

Posted on by • Posted in ACA, Bad Debt Expense, Cash, Cash Reserves, Coronavirus, Credit Quality, Credit Ratings, Crisis, Crisis Management, Deferred Healthcare, Economic Crisis, Economic Recovery, Elective Procedures, Elective Surgery, Emergency Care, Federation of American Hospitals, Health Policy, Health System, Hospital, Hospital Industry, Infection Control, Infection Control Plan, Infectious Virus, Liquidity, Market Outlook, Market Trends, Market Uncertainty, Medicaid, Medicare Advance Payments, Mortality, Office Visit, Pandemic, Payor Mix, Personal Protective Equipment (PPE), Physician, Public Health, Public Safety, Quarantine, Rev Cycle Management, Revenue Cycle, Social Distancing, Supply Chain, The CARES Act • Leave a comment

https://www.fiercehealthcare.com/hospitals/moody-s-patient-volume-recovering-may-but-providers-face-long-road-to-recovery?mkt_tok=eyJpIjoiWmpjeVlXVTRZV0l5T1RndyIsInQiOiJLWWxjamNKK2lkZmNjcXV4dm0rdjZNS2lOanZtYTFoenViQjMzWnF0RGNlY1pkcjVGcFwvZFY4VjFaUUlZaFRBT1NRMGE5eWhGK1ZmR01ZSWVZWGMxOHRzTkptZVZXZmc5UnNvM3pVM2VIWDh6VllldFc3OGNZTTMxTDJrXC8wbzN1In0%3D&mrkid=959610

Moody's: Patient volume recovered a bit in May, but providers face ...

Patient volumes at hospitals, doctors’ and dentists’ offices recovered slightly in May but lagged well behind pre-pandemic levels, according to a new analysis from Moody’s Investors Service.

In all, the ratings agency estimated total surgeries at rated for-profit hospitals declined by 55% to 70% in April compared with the same period in 2019. States required hospitals to cancel or delay elective procedures, which are vital to hospitals’ bottom lines.

“Patients that had been under the care of physicians before the pandemic will return first in order to address known health needs,” officials from the ratings agency said in a statement. “Physicians and surgeons will be motivated to extend office or surgical hours in order to accommodate these patients.”

Those declines narrowed to 20% to 40% in May when compared to 2019.

Emergency room and urgent care volumes were still down 35% to 50% in May.

“This could reflect the prevalence of working-from-home arrangements and people generally staying home, which is leading to a decrease in automobile and other accidents outside the home,” the analysis said. “Weak ER volumes also suggest that many people remain apprehensive to enter a hospital, particularly for lower acuity care.”

The good news:  The analysis estimated it is unlikely there will be a return to the nationwide decline of volume experienced in late March and April because healthcare facilities are more prepared for COVID-19.

For instance, hospitals have enough personal protective equipment for staff and have expanded testing, the analysis said.

For-profit hospitals also have “unusually strong liquidity to help them weather the effects of the revenue loss associated with canceled or postponed procedures,” Moody’s added. “That is largely due to the CARES Act and other government financial relief programs that have caused hospital cash balances to swell.”

However, the bill for one of those sources of relief is coming due soon.

Hospitals and other providers will have to start repaying Medicare for advance payments starting this summer. The Centers for Medicare & Medicaid Services doled out more than $100 billion in advance payments to providers before suspending the program in late April.

Hospital group Federation of American Hospitals asked Congress to change the repayment terms for such advance payments, including giving providers at least a year to start repaying the loans.

Another risk for providers is the change in payer mix as people lose jobs and commercial coverage, shifting them onto Medicaid or the Affordable Care Act’s (ACA’s) insurance exchanges.

“This will lead to rising bad debt expense and a higher percentage of revenue generated from Medicaid or [ACA] insurance exchange products, which typically pay considerably lower rates than commercial insurance,” Moody’s said.

 

 

 

COVID-19 Implications for pharma: US payer insights

Posted on by • Posted in Coronavirus, Health Insurance Benefit Design, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Medicaid, Medicare, Pharmaceutical Industry, Pharmacy Benefits Management, Telemedicine, Value-Based Contracting, Value-Based Insurance Design (VBID) • Leave a comment

https://www.healtheconomics.com/resource/covid-19-implications-for-pharma-us-payer-insights

What are the implications for pharma as COVID-19 forces fundamental change in US payer practice and policy?

The COVID-19 pandemic has created a unique set of challenges for US payers. In the short-term emergency healthcare packages have included increasing patient access to medicines, waiving co-pays, relaxing prior approval requirements and increasing telemedicine services. But longer term? The commercial healthcare market is likely to contract and demand for Medicare/Medicaid will increase. Payers are looking at a very different post-COVID-19 world and the impact on drug prices, formulary coverage, generic use and plan coverage will present significant hurdles to drug manufacturers.

Pharma needs to plan for a new long-term reality. To explore current thinking we interviewed, in COVID-19 implications for pharma: US payer insights, experienced US payers to give you a clear perspective of the immediate actions being taken and the emerging issues and trends that will shape pharma/payer relations.

Payers explore key issues

  • What emergency measures are in place to ensure the health plans address customers’ medical needs and will these need to be reconsidered on an ongoing basis?
  • What precautions are currently being taken to negate the impact of costs directly related to COVID-19 such as screening, hospital admissions and long-term treatment of COVID-related health issues?
  • What impact could COVID-19 have on private healthcare plans and Medicare/Medicaid and their formulary coverage, market access to medicines and the role of telemedicine services in the future?
  • How might COVID-19 impact policy on co-payments, premiums and patient selection criteria for treatments in the future?
  • What impact could COVID-19 have on pricing and reimbursement of drugs and the role of value-based contracting?

Click here for more information about this report.

 

 

 

 

Re-examining the delivery of high-value care through COVID-19

Posted on by • Posted in 2020 Election Issues, Access, Access & Quality of Healthcare, Affordability, Chronic Care Management, Chronic Conditions, Clinical Unmet Needs, Dept of Health and Human Services (HHS), Emergency Care, Evidence, Evidence-Based Care, Evidence-Based Plan, Health Insurance Benefit Design, Health Insurance Coverage Adequacy, Health Policy, Health System, High Deductible Health Plans, High Drug Prices, High Prices, High Value Care, Infection Control, Infection Control Plan, Infectious Virus, Low-Value Care, Medicaid, Medicare, Non-Essential Care, Out of Pocket Expenses, Pandemic, Population Health, Primary Care, Quality, Quality of Care, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Unnecessary Care, Vaccination • Leave a comment

https://thehill.com/opinion/healthcare/502851-examining-the-delivery-of-high-value-care-through-covid-19#bottom-story-socials

Re-examining the delivery of high-value care through COVID-19 ...

Over the past months, the country and the economy have radically shifted to unchartered territory. Now more than ever, we must reexamine how we spend health care dollars. 

While the COVID-19 pandemic has exposed challenges with health care in America, we see two overarching opportunities for change:

1) the under-delivery of evidence-based care that materially improves the lives and well-being of Americans and

2) the over-delivery of unnecessary and, sometimes, harmful care.

The implications of reallocating our health care spending to high-value services are far-ranging, from improving health to economic recovery. 

To prepare for coronavirus patients and preserve protective equipment, clinicians and hospitals across the country halted non-urgent visits and procedures. This has led to a substantial reduction in high-value care: emergency care for strokes or heart attacks, childhood vaccinations, and routine chronic disease management. However, one silver lining to this near shutdown is that a similarly dramatic reduction in the use of low-value services has also ensued.

As offices and hospitals re-open, we have a once in a century opportunity to align incentives for providers and consumers, so patients get more high-value services in high-value settings, while minimizing the resurgence of low-value care. For example, the use of pre-operative testing in low-risk patients should not accompany the return of elective procedures such as cataract removal. Conversely, benefit designs should permanently remove barriers to high-value settings and services, like patients receiving dialysis at home or phone calls with mental health providers.   

People with low incomes and multiple chronic conditions are of particular concern as unemployment rises and more Americans lose their health care coverage. Suboptimal access and affordability to high-value chronic disease care prior to the COVID-19 pandemic was well documented  As financially distressed providers re-open to a new normal, hopeful to regain their financial footing, highly profitable services are likely to be prioritized.

Unfortunately, clinical impact and profitability are frequently not linked. The post-COVID reopening should build on existing quality-driven payment models and increase reimbursement for high-value care to ensure that compensation better aligns with patient-centered outcomes.

At the same time, the dramatic fall in “non-essential care” included a significant reduction in services that we know to be harmful or useless. Billions are spent annually in the US on routinely delivered care that does not improve health; a recent study from 4 states reports that patients pay a substantial proportion (>10 percent) of this tab out-of-pocket. This type of low-value care can lead to direct harm to patients — physically or financially or both — as well as cascading iatrogenic harm, which can amplify the total cost of just one low-value service by up to 10 fold. Health care leaders, through the Smarter Health Care Coalition, have hence called on the Department of Health and Human Services Secretary Azar to halt Medicare payments for services deemed low-value or harmful by the USPSTF. 

As offices and hospitals reopen with unprecedented clinical unmet needs, we have a unique opportunity to rebuild a flawed system. Payment policies should drive incentives to improve individual and population health, not the volume of services delivered. We emphasize that no given service is inherently high- or low-value, but that it depends heavily on the individual context. Thus, the implementation of new financial incentives for providers and patients needs to be nuanced and flexible to allow for patient-level variability. The added expenditures required for higher reimbursement rates for highly valuable services can be fully paid for by reducing the use of and reimbursement for low-value services.  

The delivery of evidence-based care should be the foundation of the new normal. We all agree that there is more than enough money in U.S. health care; it’s time that we start spending it on services that will make us a healthier nation.

 

 

 

Why People Are Still Avoiding the Doctor (It’s Not the Virus)

Posted on by • Posted in 2020 Election Issues, ACA, Centers for Disease Control & Prevention (CDC), Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Debt Collection, Debt Collection Agency, Deferred Healthcare, Economic Crisis, Employee Benefits, Employee Furlough, Employee Hiring Freeze, Employee Layoffs, Employee Pay Cuts, Employer-Based Health Insurance, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Drug Prices, High Prices, Infection Control, Infection Control Plan, Infectious Virus, Job, Job Market, Job Search, Job Security, Medicaid, Medicare, Out of Pocket Expenses, Pandemic, Preexisting Conditions, Rev Cycle Management, Revenue Cycle, Telemedicine, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

Why People Are Still Avoiding the Doctor (It's Not the Virus ...

At first, people delayed medical care for fear of catching Covid. But as the pandemic caused staggering unemployment, medical care has become unaffordable for many.

At first, Kristina Hartman put off getting medical care out of concern about the coronavirus. But then she lost her job as an administrator at a truck manufacturer in McKinney, Texas.

While she still has health insurance, she worries about whether she will have coverage beyond July, when her unemployment is expected to run out.

“It started out as a total fear of going to the doctor,” she said.

“I definitely am avoiding appointments.”

Ms. Hartman, who is 58, skipped a regular visit with her kidney doctor, and has delayed going to the endocrinologist to follow up on some abnormal lab results.

While hospitals and doctors across the country say many patients are still shunning their services out of fear of contagion — especially with new cases spiking — Americans who lost their jobs or have a significant drop in income during the pandemic are now citing costs as the overriding reason they do not seek the health care they need.

“We are seeing the financial pressure hit,” said Dr. Bijoy Telivala, a cancer specialist in Jacksonville, Fla. “This is a real worry,” he added, explaining that people are weighing putting food on the table against their need for care. “You don’t want a 5-year-old going hungry.”

Among those delaying care, he said, was a patient with metastatic cancer who was laid off while undergoing chemotherapy. He plans to stop treatments while he sorts out what to do when his health insurance coverage ends in a month.

The twin risks in this crisis — potential infection and the cost of medical care — have become daunting realities for the millions of workers who were furloughed, laid off or caught in the economic downturn. It echoes the scenarios that played out after the 2008 recession, when millions of Americans were unemployed and unable to afford even routine visits to the doctor for themselves or their children.

Almon Castor’s hours were cut at the steel distribution warehouse in Houston where he works about a month ago. Worried that a dentist might not take all the precautions necessary, he had been avoiding a root canal.

But the expense has become more pressing. He also works as a musician. “It’s not feasible to be able to pay for procedures with the lack of hours,” he said.

Nearly half of all Americans say they or someone they live with has delayed care since the onslaught of coronavirus, according to a survey last month from the Kaiser Family Foundation. While most of those individuals expected to receive care within the next three months, about a third said they planned to wait longer or not seek it at all.

While the survey didn’t ask people why they were putting off care, there is ample evidence that medical bills can be a powerful deterrent. “We know historically we have always seen large shares of people who have put off care for cost reasons,” said Liz Hamel, the director of public opinion and survey research at Kaiser.

And, just as the Great Recession led people to seek less hospital care, the current downturn is likely to have a significant impact, said Sara Collins, an executive at the Commonwealth Fund, who studies access to care. “This is a major economic recession,” she said. “It’s going to have an effect on people’s demand for health care.”

The inability to afford care is “going to be a bigger and bigger issue moving forward,” said Chas Roades, the co-founder of Gist Healthcare, which advises hospitals and doctors. Hospital executives say their patient volumes will remain at about 20 percent lower than before the pandemic.

“It’s going to be a jerky start back,” said Dr. Gary LeRoy, a physician in Dayton, Ohio, who is the president of the American Academy of Family Physicians. While some of his patients have returned, others are staying away.

But the consequences of these delays can be troubling. In a recent analysis of the sharp decline in emergency room visits during the pandemic, officials from the Centers for Disease Control and Prevention said there were worrisome signs that people who had heart attacks waited until their conditions worsened before going to the hospital.

Without income, many people feel they have no choice. Thomas Chapman stopped getting paid in March and ultimately lost his job as a director of sales. Even though he has high blood pressure and diabetes, Mr. Chapman, 64, didn’t refill any prescriptions for two months. “I stopped taking everything when I just couldn’t pay anymore,” he said.

After his legs began to swell, and he felt “very, very lethargic,” he contacted his doctor at Catalyst Health Network, a Texas group of primary care doctors, to ask about less expensive alternatives. A pharmacist helped, but Mr. Chapman no longer has insurance, and is not sure what he will do until he is eligible for Medicare later this year.

“We’re all having those conversations on a daily basis,” said Dr. Christopher Crow, the president of Catalyst, who said it was particularly tough in states, like Texas, that did not expand Medicaid. While some of those who are unemployed qualify for coverage under the Affordable Care Act, they may fall in the coverage gap where they do not receive subsidies to help them afford coverage.

Even those who are not concerned about losing their insurance are fearful of large medical bills, given how aggressively hospitals and doctors pursue people through debt collections, said Elisabeth Benjamin, a vice president at Community Service Society of New York, which works with people to get care.

“Americans are really very aware that their health care coverage is not as comprehensive as it should be, and it’s gotten worse over the past decade,” Ms. Benjamin said. After the last recession, they learned to forgo care rather than incur bills they can’t pay.

Geralyn Cerveny, who runs a day care in Kansas City, Mo., said she had Covid-19 in early April and is recovering. But her income has dropped as some families withdrew their children. Although her daughter is urging her to get some follow-up testing because she has some lingering symptoms from the virus, she is holding off because she does not want to end up with more medical bills if her health plan will not cover all of the care she needs. She said she would dread “a fight with the insurance company if you don’t meet their guidelines.”

Others are weighing what illness or condition merits the expense of a doctor or tests and other services. Eli Fels, a swim instructor and personal trainer who is pregnant, has been careful to stay up-to-date with her prenatal appointments in Cambridge, Mass. She and her doctor have relied on telemedicine appointments to reduce the risk of infection.

But Ms. Fels, who also lost her jobs but remains insured, has chosen not to receive care for her injured wrist in spite of concern over lasting damage. “I’ve put off medical care that doesn’t involve the baby,” she said, noting that her out-of-pocket cost for an M.R.I. to find out what was wrong “is not insubstantial.”

At Maimonides Medical Center in Brooklyn, doctors have already seen the impact of delaying care. During the height of the pandemic, people who had heart attacks and serious fractures avoided the emergency room. “It was as if they disappeared, but they didn’t disappear,” said Dr. Jack Choueka, the chair of orthopedics. “People were dying in home; they just weren’t coming into the hospital.”

In recent weeks, people have begun to return, but with conditions worsened because of the time they had avoided care. A baby with a club foot will now need a more complicated treatment because it was not addressed immediately after birth.

Another child who did not have imaging promptly was found to have a tumor. “That tumor may have been growing for months unchecked,” Dr. Choueka said.