Fewer Access Problems, More Uninsured

by Clive Riddle, August 26, 2011

That is the title to the opening section of a new study released from the Center for Studying Health System Change:  Mixed Signals: Trends in Americans' Access to Medical Care, 2007-2010, Tracking Report No. 25, August 2011 by Ellyn R. Boukus and Peter J. Cunningham.

In a statement, the Center commented on this paradox by noting “about 9 million fewer people had health insurance in 2010 compared with 2007, and logically such a large increase in the uninsured population would be accompanied by an increase in access problems. However, approximately 17 percent of the U.S. population in 2010—about one in six people—reported not getting or delaying needed medical in the previous 12 months, down from 20 percent—one in five—in 2007, the study found.”

So how can that be? The statement goes on to answer this question: “the decline in access problems was driven primarily by fewer problems for insured people, likely reflecting recession-related decreases in the demand for medical care and subsequent easing of health system capacity constraints.”

The study authors also say that access for the insured improved much more than for the uninsured.  Ellyn R. Boukus, M.A., health research analyst with the Center, and coauthor of the study tells us “while overall access problems declined, the access gap between insured and uninsured people widened in 2010, especially for lower-income people and those with health problems.”

Here’s some key findings from the study:

  • The proportion of insured people reporting an unmet medical need declined from 6.2% to 4.5% between 2007 and 2010.
  • 17.5% of the uninsured reported an unmet need in 2010 compared to 16.6% in 2007
  • 75.2% of the 52 million people reporting access problems identified cost as an obstacle to needed care in 2010 compared with 69.0% percent in 2007.
  • 95.3% of the uninsured cite cost as a barrier compared to 65.9% of the insured in 2010
  • In 2010, 9.3% of people with incomes below 200 percent of poverty ($44,100 for a family of four) reported an unmet need compared to 3.0% for those with incomes at or above 400 percent of poverty
  • This 2010 ratio of 3.1 (9.3%/3.0%) for low incomes peoples unmet needs/higher income unmet needs compares to a ration of 2.2 in 2007
  • 16.9% of those in fair or poor health reported forgoing needed medical care in 2010 compared with 4.6% of those in good, very good or excellent health (16.9% vs. 4.6%)
  • 30% of uninsured people in poor or fair health reported they went without needed care in 2010
  • Among all people citing a health-system obstacle, the biggest declines were associated with the following reasons: inability to get an appointment soon enough (10.2 percentage point decrease); takes too long to get to the provider (6 percentage point decrease); inability to get to provider when the office was open (5.7 percentage point decrease); and inability to get through on the telephone (5.5 percentage point decrease)

Kaiser Permanente by the Numbers -2nd Qtr 2011

By Clive Riddle, August 19, 2011

Kaiser Permanente earlier this month released highlights from their quarterly financial operating results.  Not being a for-profit publicly held plan, Kaiser’s numbers don’t always get the same level of attention as their national counterparts. Here’s some selected figures worth reviewing. Please note as an integrated system, they are combined results for Kaiser Foundation Hospitals, the Health Plan, and various subsidiaries.

  • Combined operating revenue was $11.9 billion for the second quarter 2011, compared to $11.0 billion in 2Q 2010. For the six months ending June 30, 2011, total operating revenue was $23.9 billion, compared to $22.0 billion for the six months in 2010.
  • Operating income was $390 million in the second quarter of 2011, compared to $313 million in the same quarter last year.  Year-to-date (thru June) operating income was $1.0 billion, compared to $794 million for the same period in 2010.
  • Net non-operating income was $273 million in the second quarter of 2011, compared to $91 million in the same quarter last year.  Net non-operating income was $564 million in the first six months of the year, compared to $316 million in the same period last year.
  • Net income for the second quarter was $663 million versus net income of $404 million in the same period last year.  Year-to-date net income (thru June) was approximately $1.6 billion, compared to $1.1 billion for the same period in 2010.
  • Capital spending in the second quarter of 2011 was $735 million, versus $576 million in the same quarter of last year. Capital spending for the first six months of 2011 was approximately $1.4 billion, compared to $1.0 billion in the same period last year.  Kaiser notes they have opened 13 new and replacement hospitals and 86 medical office buildings in California over the last five years.
  • Kaiser Permanente membership increased 208,000 members during the first six months of 2011, now totaling more than 8.8 million overall.
  • Currently, serves over 100 million visitors each year. Year-to-date in 2011, members have securely viewed 34.8 million laboratory results, exchanged 6.2 million emails with their Kaiser Permanente caregivers and refilled 4.6 million prescriptions online.

Not a bad showing. Operating revenue for the first half year is $1.9 billion more than the first half of 2010;  net income is $0.5 billion more over last year for the first six month, and membership went up, not down.

 Executive Vice President and Chief Financial Officer Kathy Lancaster shared in a statement that “our year-to-date operating margin of 4.3 percent was in line with our financial plan. Our operating results, coupled with a sound investment strategy, enable us to reinvest in health care facilities, technology and programs that are essential in continuing to meet the needs of our members, patients and the communities we serve.” 

Should you want to check out how the major publicly held health plans performed in the second quarter of 2011, listen to the MCOL Quarterly Reports Podcast (August 2011) featuring Doug Sherlock, of Sherlock Company.


Big Bump in Emergency Department Use of CT Scans

By Clive Riddle, August 11, 2011

Keith Kocher, M.D., M.P.H., a clinical lecturer in U-M Department of Emergency Medicine, was lead author for a 14 page paper just published in the August issue of Annals of Emergency Medicine:  “National Trends in Use of Computed Tomography in the Emergency Department” [doi:10.1016/j.annemergmed.2011.05.020]. They examined national data for CT Scan use in EDs from 1996 to 2007, using CDC’s National Hospital Ambulatory Medical Care Survey, that involved 1.29 billion weighted records of emergency visits , 97.1 million of which included patients who received a CT scan.

Kocher’s team found that the “rate of CT use grew 11 times faster than the rate of ED visits during the study period. The study also showed that the use of CT scans was less common early in the study period, but rose significantly over time. Just 3.2 percent of emergency patients received CT scans in 1996, while 13.9 percent of emergency patients seen in 2007 received them.”

Doctor Kocher tells us "this means that by 2007, 1 in 7 ED patients got a CT scan. It also means that about 25 percent of all the CT scans done in the United States are performed in the ED. There are risks to overuse of CT scans, because each scan involves radiation -- so if they’re done for marginal reasons you have to question why. For example, patients who complained of flank pain [pain in the side] had an almost 1 in 2 chance of getting a CT scan by the end of the study period. Usually most physicians are doing that to look for a kidney stone, but it’s not clear if it’s necessary to use a CT scan for that purpose. I think a lot of the increase is related to changes in how doctors practice medicine and the availability of CT scanners. They provide lots of information quickly and so doctors and patients see CTs as a means of arriving at diagnoses efficiently and conveniently. Couple that with the fact that CT scanners are commonly housed in or near the ED itself, and the barriers to getting the test done are lower than in the past."

On the other hand, they note that “patients who received a CT scan in the beginning of the study had a 25 percent chance of being admitted to the hospital directly from the ED, while by 2007, this rate had been cut in half…[and that] this difference suggests that CT use may also prevent ICU admissions, perhaps shifting these hospitalizations toward a non-ICU bed. In general, however, the effect of CT use in the ED and hospitalization or transfer appeared to diminish after 2003 when the adjusted rate flattened and stabilized between 10.8% and 12.8% despite a continuing increase in overall CT use.”

They also note that “for all of the 20 most common reasons patients came to the ER for treatment, the study found that CT use increased during the study period. However, CT use was particularly high for the following complaints” [% of visits with CT scans indicated] impairments of nerve, spinal cord or brain function (50.7%); flank pain (43.3%); convulsions (38.9%); vertigo, dizziness or light-headedness (36.3%); headache (32.5%); abdominal pain (31.7%); and general weakness (25.6%).


AcCOUNTable Care? Engagement Is Not Required, Just Send Dollars

By Cyndy Nayer, August 4, 2011

It's been a long few weeks, and temperatures have not subsided.  The AC needed--the cooling off that would come with accountability throughout the stakeholders of consumers, patients, physicians, health plans, health services, pharma-device-biospecialties, etc.-- is not on the horizon.    Today, the heated up consumers have shown they have lost confidence in our economy, and the stockmarket dropped 350 points already today. The Congress is worn out from its weary negotiations, and members have recessed for 5 weeks, leaving less than 90 days for negotiations by the SuperCommittee, who will, in turn, "solve" the money crisis, we hope.  But, the money counting has begun. Does this matter to health care, employee engagement, and accountable care?  It sure does, as it reflects the impact that loss of revenue and loss of taxes will have on our ability to get health care coverage for more citizens.

Then, another stunning blow:  In an overlooked clause in the PPACA legislation, Massachusetts hospitals will recoup $275M in Medicare reimbursements, and 7 other states will also be receiving new Medicare dollars, while the rest of the states get hit for these dollar transfers.  The article, in the Associated Press, explains it this way:

Hospitals in Massachusetts will reap an annual windfall of $275 million through a loophole enshrined in the new health care law. Hospitals in most other states will get less money as a result.

Hospital association executives in other states are up in arms over the news, buried in a Medicare regulation issued Monday. It comes at a time when hospitals face more cuts under the newly signed federal debt deal.

"If I could think of a better word than outrageous, I would come up with it," said Steve Brenton, president of the Wisconsin Hospital Association.

Even Medicare says it is concerned about "manipulation" of its inpatient payment rules to create big rewards for one state at the expense of others.

Hospitals in 41 states will lose money as result of the change. The biggest loser: New York, which is out $47.5 million.

Seven states come out ahead, though none do as well as Massachusetts. Runner-up New Jersey stands to gain $54 million, or about 20 percent of the Massachusetts windfall.

President Barack Obama's health care overhaul was supposed to lead to reforms in Medicare's byzantine payment system. Critics say this latest twist will encourage hospitals and other big players to game the system in a scramble for increasingly scarce taxpayer dollars.

Hospitals are paid under a complex set of formulas for their services for Medicare recipients.  When these kinds of shifts are made, the hospitals, of course, must take the hit--unless they are in the "lucky" states.  But, as you may imagine, these less-fortunate hospitals have bills to pay, too.  So, they often raise pricing on the other national payers of health care:  the employers.  This means we can expect to see the employer-provided costs of health insurance to go up, which means employers have one of 3 alternatives:

1/ pay the increase.  But their sales are down (witness the plunging consumer spends) and their insured population (workers, families) have already absorbed100%+ increases in insurance costs over the past 10 years;

2/ pass the increase to their covered lives.  See #1 above, and note that recently Kaiser Family Foundation published research that showed that 61% of the uninsured in America are part of a family with a fulltime employee who is offered affordable health care and chooses to not take it. Passing costs to employees who choose not to take it does not make a healthier employee nor a healthier corporation.

3/ do not offer insurance.  Well, it will sure save dollars for America's employers (up to $13,700 per family in 2010).  But it certainly will not increase employee engagement in their health or performance, and it will not add to the total health improvement for employers, who are experiencing the aging and sicker workforces that have been documented over and over again.

So, Turning on the AC, as noted in my previous blog, hasn't quite worked so well in the past few weeks.  Accountable Care may well have become AcCOUNTable care, emphasis on the count.  I hope that those that received the reimbursed dollars will be able to support the only reasonable outcome:  send people to those states for the coverage they will not find in their own. Another reason for Medical Travel, but, alas, it's not about improved health.  It's about improved reimbursement, just as many have feared.


Milliman: More Room in the Medicaid Inn Needed in 2014

By Clive Riddle, July 29, 2011

Milliman’s Robert Damler and Paul Houchens have just released a white paper:  “Social Security and modified adjusted gross income: Estimated impact to Medicaid enrollment under the PPACA.”

Their abstract states “The Patient Protection and Affordable Care Act (PPACA) provides for an expansion of Medicaid eligibility for individuals who have an annual household income at or below 138% (including the 5% income exclusion) of the federal poverty level (FPL). Recent discussion has turned to individuals who may qualify for Medicaid even though their households have significant Social Security or Supplemental Security Income (SSI). Using the 2009 American Community Survey (ACS) data published by the U.S. Census Bureau, this paper explores the potential number of individuals receiving Social Security or SSI and other family members within the household who may have been excluded from the Medicaid population expansion analyses because of the differences between defining household income under the public surveys and the modified adjusted gross income (MAGI). The MAGI methodology will be used to determine eligibility for Medicaid and exchange subsidies under the PPACA.”

What this all means is Damler and Houchens have identified and quantified an additional source of potential Medicaid enrollment that had not figured into most Medicaid projections currently in use. They do caution that while their results are based on the 2009 American Community Survey, “results using other publicly available survey data or internal government resources may differ significantly.” Hence the different numbers currently in use.

But what if Damler and Houchens are right?  They conclude that “based on calculating household income with and without non-taxable Social Security and Supplemental Security Income included, we estimate from the ACS data that approximately 2.3 million additional individuals nationwide will be eligible for Medicaid beginning in 2014, because of the exclusion or partial exclusion of these income sources.”

However, Damler and Houchens note, these 2.3 million bodies didn’t just appear from nowhere.  They would have largely qualified for subsidies anyway under the state health insurance exchanges. The added cost implications are in who pays for them (state vs. federal-  and their Medicaid eligibility increases state costs according to the authors) as well as benefit design (Medicaid benefits are richer, thus the costs will be higher under the Medicaid program.)

The authors also point out that not all 2.3 million newly Medicaid eligible persons will “take up” Medicaid enrollment. They estimate 897,000 (as of 2009) currently have employer coverage and many will elect to remain under those plans. Another 86,000 have military coverage who may also retain current coverage. Less likely to stay put would be 329,000 paying for their own individual coverage or the 698,000 uninsured (these numbers add up to less than 2.3 million as they reflect the 2009 actual ACS data, before adjustment to 2014 numbers.)

Regardless,  states, HIX and Medicaid stakeholders should pay attention to the implications. The authors do provide state by state estimates in their analysis.