Healthcare Triage News: Infants and the Medicaid Expansion

Healthcare Triage News: Infants and the Medicaid Expansion

Image result for Healthcare Triage News: Infants and the Medicaid Expansion

What can we do about infant mortality and disparities in health care? This week we take a look at a recent study in JAMA that may have an answer.

 

 

Uninsurance of children, parents inched back up in 2017, report finds

https://www.healthcaredive.com/news/uninsurance-of-children-parents-inched-back-up-in-2017-report-finds/554590/

Dive Brief:

  • After improving for several years, insurance gains and participation in Medicaid and the Children’s Health Insurance Program tilted downward in 2017, a new Urban Institute report shows.
  • In the first three years following implementation of the Affordable Care Act, the uninsurance rate dropped from 7% to 4.3% among children and from 17.6% to 11% among parents, or about 40% for both groups. In 2017, however, the children’s uninsurance rate inched back up to 4.6%, or an additional 281,000 uninsured children, and parents’ coverage rate stalled.
  • Uninsurance rates rose both in states with and without the ACA’s Medicaid expansion, but the increase was more pronounced in states without expansion programs.

Dive Insight:

The findings jibe with recent data from the Centers for Disease Control’s National Health Interview Survey, which showed more than 1.1 million Americans lost health coverage in 2018, pushing the total number of uninsured from 29.3 million in 2017 to 30.4 million last year. Among surveyed adults between 18 and 64 years old, 13.3% were uninsured, 19.4% had public health coverage and 68.9% had private coverage.

The trend coincides with Trump administration efforts to weaken the ACA by eliminating several mechanisms meant to stabilize payers participating in ACA exchanges and pushing stripped-down, noncompliant health plans. The result has been rising premiums and a resurgence in the number of uninsured.

Adding to uncertainty about the ACA’s future is the U.S. Department of Justice’s support for a Texas federal district court that ruled the law unconstitutional without its individual mandate penalty, which a Republican-led Congress removed in 2017. A previous Urban Institute report estimated up to 20 million Americans would lose health insurance if the lawsuit prevails — a majority of whom are currently covered through Medicaid expansions and ACA exchanges.

While the ACA remains in legal jeopardy, Democrats and presidential candidates are looking at ways to increase the numbers of insured Americans, from shoring up the ACA to implementing some type of single-payer system or “Medicaid for All.”

According to the Urban Institute, participation in Medicaid/CHIP among children increased from 88.7% in 2013 to 93.7% in 2016, and from 67.6% to 79.9% for parents. Those gains reversed in 2017, however, with Medicaid/CHIP participation dropping to 93.1% among children and remaining unchanged for parents.

Among those who did not enroll in Medicaid/CHIP in 2017, 2 million children and 1.7 million parents were eligible for the programs — versus 1.9 million and a steady 1.7 million, respectively, in 2016.

More than half of the uninsured children and parents who were eligible for the Medicaid/CHIP lived in California, Florida, Georgia, Illinois, Indiana, New York, Pennsylvania and Texas, according to combined 2016-2017 data.

Parents were more than twice as likely to be uninsured as children in 2017. For example, children’s uninsurance rate was less than 5% in most states and under 10% in nearly every state, while parents’ uninsurance was less than 5% in just four states and over 10% in close to half the states, the report says.

The decline in improvement was worse among certain subgroups. “In 2017, the uninsurance rate was nearly 6% or higher among adolescents, Hispanic and American Indian/Alaska Native children, citizen children with noncitizen parents, and noncitizen children,” according to the report. “And consistent with prior years, one in six parents or more who were ages 19 5o 24, Hispanic or American Indian/Alaska Native, below 100 percent of FPL [federal poverty level], receiving SNAP [Supplemental Nutrition Assistance Program] benefits, or noncitizen were uninsured in 2017.”

 

 

 

 

 

 

Number of uninsured adults reaches post-ACA high

https://www.healthcaredive.com/news/number-of-uninsured-adults-reaches-post-aca-high/546653/

Dive Brief:

  • The uninsured rate in the U.S. is at a four-year high, having reached 13.7% in the fourth quarter of 2018, according to a new Gallup poll. That rate is the highest since the Affordable Care Act’s individual mandate was implemented in 2014. 
  • Despite the rise in the uninsured rate, it’s still below the peak of 18%, recorded in the third quarter of 2013. That figure then dropped to an all-time low of 10.9% in 2016. The elimination of the individual mandate penalty, cost-sharing reductions and other policy decisions made under the Trump administration have helped boost the rate back up. 
  • According to Gallup, the uninsured rate has increased most among women, young adults and low-income Americans. Separate research has shown the number of uninsured children in the U.S. has also increased for the first time in over a decade.  

While employees are one of the largest costs for most hospitals, they’re also critical to the success of health systems. Our Trendline covers everything you need to know about labor in the healthcare industry

Dive Insight:

The Affordable Care Act helped the U.S. reach historical lows for the rate of uninsured adults, but that figure has continued to tick back up as the Trump administration has undermined the law.

In all, the 2.8 percentage point increase since 2016’s low point represents about 7 million more uninsured Americans. Most of those 7 million became uninsured in 2017, which experienced the largest single-year increase (1.3 percentage points) since Gallup began polling Americans on the question in 2008.

The continued rise in the uninsured rate is reversing the gains made under the Affordable Care Act.

The ACA ushered in a time when people could buy insurance not tied to a job — without having to worry about being denied for having a pre-existing condition such as diabetes or cancer. Plus, it allowed states to expand Medicaid to low-income residents who otherwise could not afford to purchase private coverage on their own.

During that time of record-low uninsured rates, many Americans were required to have health insurance or risked incurring a financial penalty.

But once President Donald Trump was elected he began working to overturn the law. In December 2017, the GOP’s tax bill eliminated the financial penalty for not having insurance. 

A separate Commonwealth Fund report found that the uninsured rate was up significantly among working adults in states that did not expand Medicaid.

 

 

 

Ballad Health Relies on Partnerships to Excel With Difficult Payer Mix

https://www.healthleadersmedia.com/finance/ballad-health-relies-partnerships-excel-difficult-payer-mix?spMailingID=15495934&spUserID=MTg2ODM1MDE3NTU1S0&spJobID=1621203648&spReportId=MTYyMTIwMzY0OAS2

Ballad CFO Lynn Krutak said the health system faces significant financial challenges but has the discipline and leadership to navigate obstacles ahead.


KEY TAKEAWAYS

CFO Lynn Krutak said the system’s most significant challenge is its payer mix.

Luckily, she says, Virginia’s decision to expand Medicaid will help somewhat in terms of recouping from years of cuts.

Ballad Health also has a $308 million, 10-year spending plan in the works.

Last year, Mountain States Health Alliance (MSHA) and Wellmont Health System, merged to form Ballad Health. The fact that the two rural systems merged was not typical because it formed under a certificate of public advantage (COPA).

This legal agreement governs the merger through joint oversight from both the state of Tennessee and Virginia and also includes “enforceable commitments” to invest in population health, expand patient access, and boost research and education opportunities.

According to the Millbak Memorial Fund, the COPA acts as a “state-monitored monopoly—or a public utility model of healthcare delivery.”

Related: Ballad Health Launches Changes Across Newly Merged Hospital Network

Lynn Krutak, who served as CFO for both MSHA and its corporate parent Blue Ridge Medical Management, was elevated as CFO at Ballad Health. In an interview with HealthLeaders, Krutak emphasized how she implemented effective cost-cutting strategies within a challenging payer mix and low-wage index area.

This transcript has been lightly edited for brevity and clarity.

HealthLeaders: Can you describe the challenges and opportunities for Ballad Health in its provider market?

Krutak: The majority of our hospitals are either in southwest Virginia or northeast Tennessee, so we have high-use rates. From the payer standpoint, as more people move into managed Medicare and managed Medicaid, we know those use rates are going to fall.

Our population growth is flat to even declining; a lot of our counties in southwest Virginia are coal counties that have been hit hard by the [employment] reductions. So, with the use-rates decline, population decline, and the reimbursement decline that we’re all faced with, we know that there are going to be issues going forward.

As far as our payer mix, we’re heavily governmental. Over 70% of our payer mix is Medicare, Medicaid, or self-pay. We can continue to see the payer mix decline as well. We are also faced with high-deductible health plans out there now, with the patient portion of those deductibles being so high our bad debt has increased over 30%.

Fortunately, Virginia has implemented a Medicaid expansion program, so we will get some relief. However, we’ve had years of ACA cuts and this is a small portion. With the cuts that we’ve had versus what we’re going to gain back from Medicaid expansion, we’ll still be in the red.

Our wage index with Medicare is another hurdle we have. We are in the fourth-lowest wage index area in the country; we’re getting about half of what other [systems] are getting. We’ve done a good job of controlling our costs because we have to.

We’re excited about the potential with some of the things that we’re going to be able to do as a merged organization. We have $308 million in spending commitments over the next 10 years, but we have about twice as much in estimated savings. We’ve been able to achieve a lot of that already and we’re working hard on our continued integration.

This merger’s unique and what we’re going to be able to do is take costs out of the system, as far as redundant and duplicative costs go, and then reinvest them back.

HL: Can you describe some initiatives Ballad is looking to pursue in the next few years?

Krutak: As far as the labor costs, we’ve done a great job controlling our labor by not using contract labor for nursing. During the nursing shortage, other systems were using contract labor, it was something that MSHA did not have to do.

We have East Tennessee State University right in our backyard in Johnson City, where we work with them to develop nursing programs and offer scholarships to students in return for a work commitment.

Of the investments through COPA, where we have committed $308 million over a 10-year period, [is] $75 million is going to common health issues facing children. We’ve made a commitment to bring on specialists—specifically pediatrics—and be able to keep these patients and their families in the region and not have to send them elsewhere.

We’ve also committed $140 million to mental health, addiction, or rural health [initiatives] with $85 million going to behavioral health. That’s an issue for our service area in northeast Tennessee and southwest Virginia.

Finally, we have $8 million set for clinical effectiveness and patient engagement mainly related to health information exchange. Wellmont was on Epic, MSHA was on Cerner, so we agreed to convert the whole system to Epic, which will happen in April 2020.

HL: How is Ballad best positioned to navigate the direction healthcare is going while still providing the best quality service to its patients?

Krutak: We’ve been working with our state representatives to craft a fair wage index bill, where Ballad would get some relief and revamp how those calculations are done. In other words, you would not be penalized if you do a good job controlling your costs.

Our CEO, Alan Levine was secretary of health in Florida and secretary of health in Louisiana. We have Tony Keck, who is the executive vice president of our development, innovation, and population health improvement, who was secretary of health in South Carolina. We have a lot of insight on the [governmental] side of things from them.

We’re positioning ourselves to take costs out of the system but also to switch over from fee-for-service plans to looking at risk-based contracts. How do we get paid more for showing better patient outcomes? We’re looking over the next five years to transition into more of that than your traditional payments.

HL: What advice would you give to CFOs from rural systems to make the most of what are sometimes challenging financial situations?

Krutak: As a result of the merger, I’m relieved that we’re going to be able to have these savings to reinvest in rural areas. The largest issue we face with the payer mix shift is that it’s hard to get physicians in rural areas.

My advice to them is just make sure that you are controlling your costs as much as you possibly can and look to partner with other systems that may be near you that could provide physician-sharing arrangements.

For the reimbursement side, it’s always actively looking at how you’re being paid and what you’re being paid. Work with your government officials and partner with your hospital associations, to say, ‘Hey, if we’re going to continue to keep these rural hospitals and provide access, then there’s going to have to be changes as far as how that reimbursement is calculated and how those facilities are compensated.’

On the cost side, make sure that that you’ve situated yourself appropriately and then as things transition to outpatient, be sure the investments that you’re making are being made in the right places.

 

 

 

 

Red states’ Medicaid gamble: Paying more to cover fewer people

https://www.axios.com/republicans-medicaid-affordable-care-act-expensive-d7057a8e-0a55-4f0d-906e-e42aa3f00ba9.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Illustration of a price tag hanging from an IV stand

Red states are getting creative as they look for new ways to limit the growth of Medicaid. But in the process those states are taking legal, political and practical risks that could ultimately leave them paying far more, to cover far fewer people.

Why it matters: Medicaid and the Children’s Health Insurance Program cover more than 72 million Americans, thanks in part to the Affordable Care Act’s Medicaid expansion. Rolling back the program is a high priority for the Trump administration, and it needs states’ help to get there.

The big picture: The Centers for Medicare & Medicaid Services, under the leadership of Administrator Seema Verma, has made clear that it wants to say “yes” to new limits on Medicaid eligibility, and has invited states to ask for those limits.

  • But CMS hasn’t actually said “yes” yet to some of the most significant limits states have asked for.
  • In the meantime, states are left either with vague ambitions they’re not sure how to implement, or with risky plans that put their own budgets on the line.

What we’re watching: State-level Republicans are waiting for CMS to resolve two related issues: how much federal funding their versions of Medicaid can receive, and the extent to which they’re able to cap enrollment in the program.

  • “These issues are going to continue to be intertwined,” said Joan Alker, the executive director of Georgetown University’s Center for Children and Families.

Verma has reportedly told state officials that she wants to use her regulatory power to convert Medicaid funding into a system of block grants — which would be an enormous rightward shift and probably a big cut in total funding.

  • CMS probably cannot do that on its own, experts said, but it could achieve something similar by approving caps on either enrollment or spending.

Where it stands: GOP lawmakers in a handful of states are looking to Utah, which has bet big on Verma’s authority, for signals about what’s possible.

  • Utah voters approved the full ACA expansion last year, but the state legislature overruled them to pass a more limited version.
  • By foregoing the full expansion, Utah passed up enhanced federal funding. It’s still asking for that extra money — a request CMS has never previously approved.
  • Utah will also ask CMS to impose a per-person cap on Medicaid spending — a steep cut that was part of congressional Republicans’ failed repeal-and-replace bill, and which may strain CMS’ legal authority.
  • If Utah doesn’t get those two requests, its backup plan is simply to adopt the full expansion.

What’s next: Utah is not the only red state leaning into Verma’s agenda, but it’s further out on a limb than any other.

  • Idaho, like Utah, overruled its voters to pass a narrower Medicaid bill. But it preserved an option for people to buy into the ACA’s expansion.
  • Alaska Gov. Mike Dunleavy has said he wants to take Verma up on her offer of block grants; so have legislators in Tennessee and Georgia. But in the absence of any detail about what that means, or what CMS will approve, that’s all pretty vague right now.

If CMS does move forward on any of this, it could face the same threat of lawsuits that have stymied its first big Medicaid overhaul — work requirements.

  • Those rules are on ice in two states because a judge said they contravene Medicaid’s statutory structure and goals. The same argument could await a partial expansion or tough spending caps.

“There’s a clear agenda here to get a handful of states to take up these waivers, which fundamentally undermine the central tenets of the Medicaid program — which [are] that it is a guarantee of coverage, and a guarantee of federal funding,” Alker said.

 

 

 

ECONOMIC RIPPLES: HOSPITAL CLOSURE HURTS A TOWN’S ABILITY TO ATTRACT RETIREES

https://www.healthleadersmedia.com/finance/economic-ripples-hospital-closure-hurts-towns-ability-attract-retirees?utm_source=silverpop&utm_medium=email&utm_campaign=ENL_190410_LDR_BRIEFING%20(1)&spMailingID=15444335&spUserID=MTY3ODg4NTg1MzQ4S0&spJobID=1620658993&spReportId=MTYyMDY1ODk5MwS2

The epidemic of rural hospital closures is threatening small towns such as Celina, Tenn. The town of 1,500 has been trying to position itself as a retiree destination but that task has grown more difficult since the March 1 closure of 25-bed Cumberland River Hospital.


KEY TAKEAWAYS

Celina became the 11th rural hospital in Tennessee to close in recent years — more than in any state but Texas. Both states have refused to expand Medicaid in a way that covers more of the working poor.

The closest hospital is now 18 miles away. That adds another 30 minutes through mountain roads for those who need an X-ray or bloodwork. For those in the back of an ambulance, that bit of time could mean the difference between life or death.

When a rural community loses its hospital, health care becomes harder to come by in an instant. But a hospital closure also shocks a small town’s economy. It shuts down one of its largest employers. It scares off heavy industry that needs an emergency room nearby. And in one Tennessee town, a lost hospital means lost hope of attracting more retirees.

Seniors, and their retirement accounts, have been viewed as potential saviors for many rural economies trying to make up for lost jobs. But the epidemic of rural hospital closures is threatening those dreams in places like Celina, Tenn. The town of 1,500, whose 25-bed hospital closed March 1, has been trying to position itself as a retiree destination.

“I’d say, look elsewhere,” said Susan Scovel, a Seattle transplant who arrived with her husband in 2015.

Scovel’s despondence is especially noteworthy given she leads the local chamber of commerce effort to attract retirees like herself. She considers the wooded hills and secluded lake to hold scenic beauty comparable to the Washington coast — with dramatically lower costs of living; she and a small committee plan getaway weekends for prospects to visit.

When she first toured the region before moving in 2015, Scovel and her husband, who had Parkinson’s, made sure to scope out the hospital, on a hill overlooking the sleepy town square. And she has rushed to the hospital four times since he died in 2017.

“I have very high blood pressure, and they’re able to do the IVs to get it down,” Scovel said. “This is an anxiety thing since my husband died. So now — I don’t know.”

She can’t in good conscience advise a senior with health problems to come join her in Celina, she said.

When Seconds Count, Delays In Care

Celina’s Cumberland River Hospital had been on life support for years, operated by the city-owned medical center an hour away in Cookeville, which decided in late January to cut its losses after trying to find a buyer. Cookeville Regional Medical Center executives explain that the facility faced the grim reality for many rural providers.

“Unfortunately, many rural hospitals across the country are having a difficult time and facing the same challenges, like declining reimbursements and lower patient volumes, that Cumberland River Hospital has experienced,” CEO Paul Korth said in a written statement.

Celina became the 11th rural hospital in Tennessee to close in recent years — more than in any state but Texas. Both states have refused to expand Medicaid in a way that covers more of the working poor. Even some Republicans now say the decision to not expand Medicaid has added to the struggles of rural health care providers.

The closest hospital is now 18 miles away. That adds another 30 minutes through mountain roads for those who need an X-ray or bloodwork. For those in the back of an ambulance, that bit of time could mean the difference between life or death.

“We have the capability of doing a lot of advanced life support, but we’re not a hospital,” said Natalie Boone, Clay County’s emergency management director.

The area is already limited in its ambulance service, with two of its four trucks out of service.

Once a crew is dispatched, Boone said, it’s committed to that call. Adding an hour to the turnaround time means someone else could likely call with an emergency and be told — essentially — to wait in line.

“What happens when you have that patient that doesn’t have that extra time?” Boone asked. “I can think of at least a minimum of two patients [in the last month] that did not have that time.”

Residents are bracing for cascading effects. Susan Bailey hasn’t retired yet, but she’s close. She has spent nearly 40 years as a registered nurse, including her early career at Cumberland River.

“People say, ‘You probably just need to move or find another place to go,'” she said.

Bailey and others are concerned that losing the hospital will soon mean losing the only three physicians in town. The doctors say they plan to keep their practices going, but for how long? And what about when they retire?

“That’s a big problem,” Bailey said. “The doctors aren’t going to want to come in and open an office and have to drive 20 or 30 minutes to see their patients every single day.”

Closure of the hospital means 147 nurses, aides and clerical staff have to find new jobs. Some employees come to tears at the prospect of having to find work outside the county and are deeply sad that their hometown is losing one of its largest employers — second only to the local school system.

Dr. John McMichen is an emergency physician who would travel to Celina to work weekends at the ER and give the local doctors a break.

“I thought of Celina as maybe the ‘Andy Griffith Show’ of healthcare,” he said.

McMichen, who also worked at the now-shuttered Copper Basin Medical Center, on the other side of the state, said people at Cumberland River knew just about anyone who would walk through the door. That’s why it was attractive to retirees.

“It reminded me of a time long ago that has seemingly passed. I can’t say that it will ever come back,” he said. “I have hopes that there’s still some hope for small hospitals in that type of community. But I think the chances are becoming less of those community hospitals surviving.”

 

“UNFORTUNATELY, RURAL HOSPITALS ACROSS THE COUNTRY ARE HAVING A DIFFICULT TIME AND FACE THE SAME CHALLENGES, LIKE DECLINING REIMBURSEMENTS AND LOWER PATIENT VOLUMES THAT CUMBERLAND RIVER HOSPITAL HAS EXPERIENCED.”

 

 

 

 

COMMUNITY HEALTH CENTERS MORE FINANCIALLY STABLE UNDER MEDICAID EXPANSION

https://www.healthleadersmedia.com/finance/community-health-centers-more-financially-stable-under-medicaid-expansion?source=EHLM8&effort=B&utm_source=HealthLeaders&utm_medium=email&utm_campaign=MeritWelcomeB&emailid=&utm_source=silverpop&utm_medium=email&utm_campaign=Warming-Merit-Finance-040319%20(1)&spMailingID=15443417&spUserID=Mzc4MjM1NTY0ODgyS0&spJobID=1620654151&spReportId=MTYyMDY1NDE1MQS2

Facilities are faring better in states that expanded Medicaid, according to a new Commonwealth Fund report.


KEY TAKEAWAYS

A year after facing a federal funding cliff, CHCs in expansion states are thriving. 

CHCs provide care to 27 million patients each year, according to the Health Resources and Services Administration.

The financial stability of CHCs, which serve medically vulnerable communities, is a benefit for health systems.

Community health centers (CHC) operating in states that expanded Medicaid under the ACA are 28% more likely to report improvements to their financial stability, according to a Commonwealth Fund report released Thursday morning.

CHCs in Medicaid expansion states reported were more likely to report improvements in their ability to provide affordable care to patients, 76%, than their counterparts in non-expansion states, 52%.

More than 60% of CHCs in expansion states reported improved ability to fund service or site expansions and upgrades for facilities, while only 46% of CHCs in non-expansion states said the same.

These facilities reported higher levels of unfilled job openings for mental health professional and social workers, while also implying a greater openness to operating under a value-based payment model.

The success and viability of CHCs are essential for larger health systems, according to Melinda K. Abrams, M.S., vice president and director of the Commonwealth Fund’s Health Care Delivery System Reform program, adding that CHCs act as a strong foundation for providing primary care to medically vulnerable populations in rural communities.

Abrams said that by making sure patients are insured and receiving care up front, rather than delaying treatment and exacerbating their condition, they are less likely to end up in a hospital emergency room and contribute to a rise in uncompensated care for hospitals.

She also told HealthLeaders that populations with higher enrollment rates make it easier for CHCs to innovate, invest in technology, hire new staff, train existing the workforce, and adopt new models of care.

“[Medicaid expansion] makes it a lot easier to provide high-quality comprehensive care when [a CHC’s] patients have health insurance,” Abrams said. “In this particular instance, it’s a lot easier to innovate and have financial stability when you have more paying patients, which means that it is easier if you are [a CHC] in a state that has expanded Medicaid.”

The Commonwealth Fund report provides a welcome note of positivity for CHCs, which serve vulnerable populations primarily composed by the uninsured, but have faced funding challenges in the past.

During the budget battles that produced multiple government shutdowns throughout the early portion of 2018, advocates wondered anxiously whether Congress would provide long term funding to the nearly 1,400 CHCs operating at nearly 12,000 service delivery sites across the country.

According to the Health Resources and Services Administration, CHCs provide care to more than 27 million patients annually.

The Community Health Center Fund (CHCF), created in 2010 as a result of the ACA, is the largest source of comprehensive primary care for medically underserved communities, according to the Kaiser Family Foundation.

However, Abrams said that Medicaid expansion has also been a beneficial tool for CHCs, as they have begun to see more insured patients while also benefiting from Medicaid reimbursements, even though they are low compared to other reimbursement rates.

CHCs in states that expanded Medicaid have been able to grow the services that are offered while assisting in the ongoing fight against the opioid epidemic, according to the Commonwealth Fund report.

Abrams said that one downside to the growing success of CHCs have been the unfilled positions, mostly for mental health providers, that are falling behind rising demand levels, though she added that this finding is not surprising.

“I think it’s in part because the supply of the workforce is lagging a little bit behind the demand,” Abrams said. “There’s no reason to think that over time that this gap wouldn’t be closed. But we did find that as a challenge, that [CHCs] have a lot of positions open [yet] they’re hiring. A number of these CHCs are in economically depressed areas, so the good news is that there are some jobs available.”

CHCs are much more likely to participate in value-based payment models as a result of Medicaid expansion, with Abrams explaining that changes in payments and delivery models are common during insurance expansions.

She sees the continued progress made on the value-based front by CHCs as a way to “promote better healthcare and save money” over time.