Showing posts from July, 2016

The Mystique of Medicaid Expansion

Imagine 100% of Americans covered by insurance across private insurance and Medicare and an expanded Medicaid across all US locations. Would this be a great boost to health care in the US or not?

Many would jump for joy at 100% insurance coverage. But the reality for health policy always remains the same. There are always winners and losers. Rather than a blatant promotion of expansion, more important is to understand who would win and who would lose?

The current situation in Medicaid makes the answer quite obvious. Those providing the lowest paid services at the current time would remain the lowest paid - primary care, geriatric primary care, mental health care, basic services, cognitive services, office services. Despite 100% insurance coverage, the payments for these services would be insufficient to hire the team members and support the care needed, because payments are below the cost of delivery.
Expansion Requires Expansion and Subtraction Is Contraction

A decent business executi…

A Few Hundred Million More is 8 Billion Less for Primary Care

A few hundred million more dollars for primary care is small change compared to 8 billion dollar annual increases in the cost of delivery.

The various ACA and CMS proponents have been feasting on JAMA articles by CMS and President Obama. Primary care advocates hoping for any good news also pass around these pieces despite what the real message is about. It is important to read the fine print. Rather than the promotion of the new math, we need more who can calculate the damage being done to access and to primary care delivery capacity year after year for decades.

Primary care is about people taking care of people. The main cost of delivery of primary care should always be the cost of the employees that deliver the care. The design of primary care should add more support for the team members that deliver primary care. The innovative designs have found ways to subtract from care delivery.

Primary care delivery capacity is about the magnitude of support specific to primary care team members…

Readmissions Better from ACA or Preexistingly Worse from DRG?

In 1983 after a very short period of testing on a very atypical state (New Jersey) and because there were no other existing options for cost cutting, the hospital payment method known as DRG or Diagnosis Related Groups was implemented. Bundling under a disease or condition or treatment remains a very popular method of cutting costs and is now being implemented with physician payments. What are the benefits and what are the consequences? Should we implement methods that have long term consequences when we fail to consider or study these issues?

If there is any consolation for President Obama and CMS, may well be that Readmission Penalties took away some of the "poor quality" result of the Bundling Bungling that preceded it (DRGs). This may be the only evidence for Accountable Care working. Of course Readmissions focus has consequences also.

Is the Change in Readmission Rates an Indication of Poor Quality from DRGs?

This is an interesting question. As noted previously by th…

President Obama Stretches Readmission Gains

The medical literature is apparently not immune to promotions and marketing. Graphics can be powerful at a time when few read between the lines - or read the lines at all. The following graphic was prepared for the President by CMS.

Note the use of only 2 points of change from 17.5 to 19.5 to enhance the apparent effect.The change from 19% readmissions to 18% across this 2 percentage point difference generations a much steeper slope. Truncated graph - from wiki  A truncated graph (also known as a torn graph) has a y axis that does not start at 0. These graphs can create the impression of important change where there is relatively little change. The other graphics presented by the President are more reasonable. For example the % uninsured has the full 0% to 25% represented graphically.

The big question arising from the claim of improvement with readmissions penalties is whether the previous payment system resulted in worsening of readmissions and perhaps other quality measures. Perhaps t…