The Medicaid Gap

The Hospitalist. 2010 December;2010(12):

December 1, 2010 | The Hospitalist

Another unresolved issue is how to pay for the long-term care of chronically ill patients, which in New York accounts for nearly half of its Medicaid spending. Kugler says the high incidence of chronic conditions, including mental illness, among patients in urban settings can contribute to the high readmission rates the new law is set to begin penalizing in 2012. Other studies have found that among Medicaid patients at high risk for frequent hospital admissions, substance abuse can be a major contributor.²

The difficult task, then, is to ensure that the hospitals serving these populations don’t lose even more resources through penalties due to subpar quality metrics. “Do the legwork now. Get your IT systems in place to be able to provide the coordinated care,” Kugler advises. Identifying efficiencies while maintaining the appropriate level of care will be key, whether in appropriate reductions in length of stay or in increased focus on communication with outpatient providers and other forms of outreach.

Dr. Lopez and his colleagues found that among patients with chest pain admitted to EDs, blacks, Hispanics, and those who lacked insurance or were on Medicare were less likely to receive urgent triage care.

Hope for the Safety Net

Despite the financial and logistical challenges, Lenny Lopez, MD, MPH, a hospitalist at Brigham and Women’s Hospital and an assistant in health policy at Massachusetts General Hospital, both in Boston, says the situation is far from hopeless for safety-net hospitals. “The idea that if you’re a DSH hospital you’re somehow pegged and destined to provide low-quality care—that does not have to be the case,” he says. Nor do problems such as disparities in how patients are treated necessarily require expensive solutions.

In a recent paper in Academic Emergency Medicine, Dr. Lopez and his colleagues found that among patients with chest pain admitted to EDs, blacks, Hispanics, and those who lacked insurance or were on Medicare were less likely to receive urgent triage care.³ “These are problems that are fixable in a low-cost way,” he argues. “We don’t need another fancy machine to diagnose chest pain.” Rather, he suggests, the problem is really one of quality improvement that centers on boosting guidelines, not buying more equipment or involving more personnel.

Properly defining the problem, Dr. Lopez says, can lead to effective measures to boost quality. Amid the continuing budget crunch, pinpointing where interventions could provide the biggest bang for the buck also might prove enormously helpful.

Of the roughly 4,200 acute-care hospitals in the country, Dr. Lopez and his colleagues found that less than 10% care for the bulk of minority patients, and those on Medicaid or lacking insurance. That means such care is concentrated in about 400 hospitals, “which is a huge opportunity for intervention options for this kind of an issue,” he says. TH

Bryn Nelson is a freelance medical writer based in Seattle.

References

1. Benefits and burdens of Medicaid. The New York Times website. Available at: www.nytimes.com/2010/09/22/opinion/22wed2.html?_r=2&hp. Accessed Oct. 23, 2010.
2. Raven MC, Billings JC, Goldfrank LR, Manheimer ED, Gourevitch MN. Medicaid patients at high risk for frequent hospital admission: real-time identification and remediable risks. J Urban Health. 2009;86(2):230-241.
3. López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med. 2010:17 (8):801-810.

The Fight Over Child-Only Insurance Plans

In another unresolved skirmish over healthcare insurance, the federal government and major insurers are continuing their feud over covering children with pre-existing conditions. In September, on the eve of new regulations that would prohibit insurers from denying coverage to such children, several major companies, including Aetna and Cigna, announced they would no longer offer standalone policies for children in some states. Department of Health and Human Services Secretary Kathleen Sebelius hit back in mid-October in a letter to the National Association of Insurance Commissioners, saying insurers “reneged on their commitment.”

Acknowledging that they can’t compel insurers to offer specific policies, federal and state officials have instead tried an assortment of carrots and sticks. In California, Gov. Arnold Schwarzenegger signed a bill that would punish companies that refuse to sell child-only policies by barring them from selling any individual plans for five years. Sebelius also has suggested incentives to encourage workers to enroll their children in employer-sponsored insurance plans rather than standalone child policies.

Insurers say they fear parents will enroll their children only when a child becomes ill, thus unfairly raising costs. The industry has proposed year-round enrollment for healthy children, based on questionnaires, but a more limited open-enrollment period for those with pre-existing conditions. Sebelius rejected that proposal as incompatible with the intent of healthcare reform but pointed out that charging higher premiums based on health status—as long as the practice adheres to state law—is still permissible.—BN