Native Amercan Healthcare Alliance

Friday, July 27, 2012

Kaiser News Article "Maine's Efforts To Pare Medicaid May Put It On Collision Course With Administration"

Maine's Efforts To Pare Medicaid May Put It On Collision Course With Administration
Phil Galewitz
July 12, 2012 — In what is shaping up as the first state-federal showdown on Medicaid following the Supreme Court's ruling on President Barack Obama's health law, Maine is moving ahead with plans to cut thousands of people from its rolls to balance its state budget.

Maine Gov. Paul LePage speaks at a Dec. 2011 news conference in Augusta, Maine, to defend proposed cuts to Medicaid. (AP Photo/Robert F. Bukaty)

Advocates and health experts contend some of those cuts, affecting about 26,000 people, violate a provision of the law barring states from making it harder for people to join the government health insurance program for the poor.

Among those who would lose health care coverage as early as September are nearly 15,000 Maine parents with incomes between the federal poverty level ($23,050 for a family of four) and 133 percent of the poverty level ($30,657), as well as 6,000 19- and 20-year-olds who have been covered up to 150 percent of the poverty level ($34,575 for a family of four).

The dispute stems in part from different interpretations of the Supreme Court's ruling, which upheld the health law but made its 2014 expansion of Medicaid effectively optional for states.

Maine Gov. Paul LePage, a Republican, and Attorney General William Schneider said the recent court ruling means the state no longer needs to seek a special waiver from the federal government to enact cuts to Medicaid. They say the provision of the law known as "maintenance of effort," which prohibits states from cutting eligibility for Medicaid, is no longer valid.

However, in a letter to governors Tuesday, Health and Human Services Secretary Kathleen Sebelius strongly suggested otherwise. She asserted the high court's ruling leaves every provision of the law standing except the one that would have penalized states for not expanding Medicaid. The expansion is intended to provide 17 million additional Americans with health coverage.

Whether Maine officials will strike a deal with the federal government is unclear. LePage, in a letter to Sebelius on Wednesday, said the state will send more information to her agency as part of a "state plan amendment," meaning a permanent change to the program.

"I know you take your duty to uphold the Constitution and laws of the United States seriously and will reserve judgment until the law and facts are fully presented," he wrote.

The Obama administration has shown flexibility in permitting some eligibility rollbacks by other cash-strapped states such as Wisconsin, Illinois and Hawaii. To date, however, the administration has not permitted any state to drop eligibility below 133 percent of the federal poverty program, as many (though not all) of Maine's cuts would do.

Under the health law, starting in 2014, everyone making below that level will qualify for the program. Today, states set different eligibility levels, and few offer coverage to childless adults.
LePage has been an outspoken opponent of the health care law, recently criticizing the Supreme Court’s decision to uphold most of its provisions as an erosion of freedom that would give individuals no choice but to buy health insurance or "pay the new Gestapo — the IRS."

He subsequently apologized for using the word "Gestapo," saying the word had clouded his message.
Advocates for the poor in Maine say the state’s plans go further than the federal government has allowed other states.

"We really want the state to hold off and not move forward," said Ana Hicks, senior policy analyst for Maine Equal Justice Partners, an advocacy group.

Jocelyn Guyer, co-executive director of the Georgetown University Center for Children and Families, said the plan "very clearly violates the maintenance-of-effort requirement. Maine is asking for trouble by pursuing this path."

States and the federal government share the cost of Medicaid, with the federal government paying on average 63 percent of expenses in Maine. The state has about 350,000 people enrolled in the program.

Under the law, the federal government would pay the full cost of the expansion from 2014 until 2017, after which states would pay a portion that cannot exceed 10 percent.

Article from Kaiser Health News Medicaid Expansion

KaiserHealth News – July 25, 2012

“Capsules”blog – Short Takes on News & Events

MedicaidExpansion Reduces Mortality, Study Finds

By Matthew Fleming

As states decide whether to expand theirMedicaid programs to cover low-income childless adults, the impact of theirchoices became clearer today in a study showing areduction of mortality in states that have already made that move.

The research published in the New EnglandJournal of Medicine found a 6.1 percent reduction in mortality among low-incomeadults between the ages of 20 and 64 in Maine, New York and Arizona — threestates that expanded coverage since 2000, compared with similar adults in NewHampshire, Pennsylvania, Nevada and New Mexico, neighboring states that did notdo so.

The decline in mortality, by an overall 19.6deaths per 100,000 adults, was especially pronounced among older individuals,minorities and residents of the poorest counties. The researchers analyzed dataspanning five-year periods before and after the three states extended theirMedicaid coverage to poor, childless adults.

The study also found “improved coverage,access to care and self-reported health” among the newly covered adults.

“It seems intuitive, but there’s beensurprisingly little evidence so far,” said lead researcher Benjamin D. Sommers,M.D., Ph.D., an assistant professor of health policy and economics at theHarvard School of Public Health. “There’s been some [research] on pregnantwomen and children, but much less on adults. And right now there are asignificant number of people arguing that Medicaid is worsethan nothing at all.”

The Supreme Court onJune 28 struckdown as unduly coercive a provision of the 2010 federal health care lawthat sought to force all states to extend Medicaid coverage to everyone withincomes up to 133 percent of the federal poverty level — currently $14,856 forindividuals and $25,390 for a family of three. Although the federal governmentwill pay the full cost of the expanded coverage for three years starting in2014, and at least 90 percent thereafter, a number of state governors have saidthey will not approve the wider coverage.

The study’s authors — Sommers, KatherineBaicker, Ph.D. and Arnold M. Epstein, M.D. — said their research results areconsistent with previous analyses finding an 8.5 percent reduction in infantmortality and a 5.1 percent drop in child mortality as a result of Medicaidexpansions in the 1980s.

The authors cautioned that their study“cannot definitively show causality,” because other factors might havecontributed to the reduction in death rates in the population newly covered byMedicaid. Among those factors, they said, was the possibility that “expandingcoverage had positive spillover effects through increased funding to providers,particularly safety-net hospitals and clinics.” But they said they were notaware of any large-scale changes in health policy in the three states theystudied.
“This answers the question of what happenswhen you give people Medicaid who didn’t already have coverage, as opposed tocomparing people who have Medicaid with people who have something else,” saidSommers. “The latter is not apples to apples, because Medicaid recipients areusually sicker and with worse socioeconomic conditions.”

NY Times article regarding alaska native model

A Formula for Cutting Health Costs

No matter what happens to President Obama’s health care reforms after the November elections, the disjointed, costly American health care system must find ways to slow the rate of spending while delivering quality care. There is widespread pessimism that anything much can be achieved quickly, but innovative solutions are emerging in unexpected places. A health care system owned and managed by Alaska’s native people has achieved astonishing results in improving the health of its enrollees while cutting the costs of treating them.

At a recent conference for health leaders from the United States and abroad at the native-owned Southcentral Foundation in Anchorage, the Alaskans described techniques that could be adopted by almost any health care organization willing to transform its culture. Such a transformation would require upfront financing for training, data processing and the like, but the investment should rapidly pay off in reduced costs.

The foundation, established in 1982, provides primary outpatient care to Alaska natives and American Indians who had previously been the responsibility of the federal government’s Indian Health Service. It serves 45,000 enrollees in the Anchorage area and 10,000 more scattered in remote villages, most reachable only by air, on an annual budget of $200 million. It also jointly owns and manages (with a consortium of native tribes) a small hospital, and has built a modern campus of outpatient clinics with the help of loans, grants, bonds and retained earnings.

About 45 percent of its revenue comes in what amounts to an annual block grant from the Indian Health Service, a source unavailable to most health systems; another 45 percent comes from Medicaid, Medicare and private insurers, and the rest from philanthropy and grants.

As the Commerce Department noted when it gave Southcentral a national quality award in 2011, known as the Malcolm Baldrige award, the foundation has achieved startling efficiencies: emergency room use has been reduced by 50 percent, hospital admissions by 53 percent, specialty care visits by 65 percent and visits to primary care doctors by 36 percent. These efficiencies, in turn, have clearly saved money. Between 2004 and 2009, Southcentral’s annual per-capita spending on hospital services grew by a tiny 7 percent and its spending on primary care, which picked up the slack, by 30 percent, still well below the 40 percent increase posted in a national index issued by the Medical Group Management Association.

Patients have not been shortchanged; in fact, care and access to services have improved greatly. Patients are virtually guaranteed a doctor’s appointment on the day they request it, and their calls are answered quickly, usually within 30 seconds. The percentage of children receiving high-quality care for asthma has soared from 35 percent to 85 percent, the percentage of infants receiving needed immunizations by age 2 has risen above 90 percent, the percentage of diabetics with blood sugar under control ranks in the top 10 percentile of a standard national benchmark, and customer and employee satisfaction rates top 90 percent.

The staff is trained to treat patients courteously, not with the disdain often reserved for the poor or ethnic minorities. The atmosphere is so welcoming that natives routinely congregate in waiting areas to swap stories and meet old friends even when they do not need medical care.

Although Southcentral has unique attributes (it even refers cases to traditional tribal healers if doctors agree), here are some of its techniques that almost any health care system can adopt:

¶Assigning small teams — consisting of a doctor, a nurse, and various medical, behavioral and administrative assistants — to be responsible for groups of 1,400 or so patients. The team members sit in the same small work area and communicate easily. When a patient calls, the nurse decides whether a face-to-face visit with a doctor or other health care provider is required or whether counseling by phone is sufficient. The doctors are left free to deal with only the most complicated cases. They have no private offices and the nurses have no nursing stations to which they can retreat.

¶Integrating a wide range of data to measure medical and financial performance. Southcentral’s “data mall” coughs up easily understood graphics showing how well doctors and the teams they lead are doing to improve health outcomes and cut costs compared with their colleagues, their past performance and national benchmarks, and it provides them with action lists of what they can do to improve and mentors to guide them. That almost always spurs the laggards. One doctor whose team ranked well behind 10 others in scheduling annual eye exams for diabetics jumped to first place within two months once she became aware of how poorly her team was performing.

¶Focusing on the needs and convenience of the patients rather than of the institution or the providers. The facilities feature rooms where providers and families can chat as equals on comfortable chairs, in sharp contrast to examination rooms where a doctor looms over a patient. Every patient visit is carefully planned so the patient can get in and out quickly without being delayed because, say, a needed lab test result is not available.

¶Building trust and long-term relationships between the patients and providers.

¶Changing from a reactive system in which a sick patient seeks medical care to a proactive system that reaches out to patients through special events, written and broadcast communications, and telephone calls to keep them healthy or at least out of the hospital and clinics.

Visionary health care systems elsewhere are already adopting Southcentral’s techniques, usually after visits to Anchorage to observe them in action.

CareOregon, a small Medicaid managed-care plan in Portland, sent not only its own people but also delegations from the clinics that serve its patients. It then paid the clinics a subsidy to get started and found that, within two years, Southcentral’s tactics greatly reduced the use of costly emergency departments and hospital admissions while improving health outcomes. Dr. David Labby, CareOregon’s medical director, said in an e-mail that the example set by Southcentral was “hugely inspirational” and “remains the model that guides us.”

Similarly, Maxine Jones, the service manager of a primary care practice in the county of Fife, Scotland, is supervising a pilot study for the National Health Service using techniques adapted from Southcentral that almost immediately produced a sharp decline in visits to the practice because many problems could be handled by an integrated team of doctors and nurses by phone. “I can see that this model has the potential to transform the face of primary care in Scotland,” she said in an interview at the conference.

Many other health care organizations in the United States and elsewhere have consulted with Southcentral on how to make their delivery of care more efficient and less costly while maintaining or improving quality. If enough of them summon the energy to transform their operations, their combined impact could help slow the rising curve of health care costs, or even bend it downward.

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This is part of a continuing examination of ways to cut the costs of medical care while improving quality.