medicaid

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Audit Questions $35M In State Medicaid Payments

A state audit has identified $35 million of what were called “questionable and unallowable” payments by the state’s Medicaid program.

Massachusetts State Auditor Suzanne M. Bump (Josh Reynolds/AP)

Massachusetts State Auditor Suzanne M. Bump (Josh Reynolds/AP)

Auditor Suzanne Bump said Wednesday that her office and MassHealth disagree in their interpretations of federal and state rules that govern the program.

The audit focused on MassHealth’s Limited Program, which covers eligible non-citizens.

While federal land state rules are supposed to restrict coverage under the program to emergency medical services, Bump says auditors found that MassHealth often paid claims even when a provider indicated that a service was not of an emergency nature.

She says MassHealth “regularly substituted its own judgment for that of the medical profession.”

State officials strongly disputed the findings, saying they disagreed with the auditor’s definition of emergency medical services.

Mass. Health Insurers Report Losses; Many Premiums To Rise By 3 Percent

Health insurance rate changes for the small group market in Mass. The Q1 rates also apply to individual coverage for 2015. (Source: Mass. Office of Consumer Affairs and Business Regulation)

Health insurance rate changes for the last quarter of 2014 for the small group market in Mass. The Q1 rates also apply to individual coverage for 2015. (Source: Mass. Office of Consumer Affairs and Business Regulation)

Premiums for Massachusetts small businesses and residents who buy insurance on their own are going up.

The average increase for Jan. 1 is 3.1 percent. But this is just the base rate. Your rates could be higher or lower, depending on how much you or your fellow employees have spent on health care this year.

Insurers say premiums are going up because residents are using more care. What’s known as “utilization” in the insurance world dropped during the recession, but appears to be creeping up again. Then, say insurers, there’s the cost of some expensive new drugs, such as Sovaldi to treat Hepatitis C; taxes related to the Affordable Care Act; and the expense of dealing with the Health Connector’s failed website.

Although the average increase for Jan. 1 is just over three percent, there’s quite a range.

Shop carefully. Many of the cheaper plans will have a high deductible, so if you have a chronic disease or lots of young children, you may not want this option. You can save money by choosing a plan that limits where you seek care, but check to see if your doctor(s) are in the covered network.

Also today, the state’s three largest health plans reported that they’ve lost money so far this year.

Blue Cross Blue Shield posted a net loss of $32.2 million for the second quarter and $91.4 million loss for the first six months of the year.

“Our second quarter results reflect our continued commitment to delivering more affordable premiums to our members while we absorb costs associated with complying the ACA,” said Allen Maltz, Blue Cross CFO.

Harvard Pilgrim’s net loss through June is $10.4 million. Continue reading

Report: In Mass. Health Care, System Skewed So Rich Get Richer

A report released today by the Healthcare Equality and Affordability League (H.E.A.L.) — a partnership between the for-profit Steward Health Care System and the union, 1199 SEIU United Healthcare Workers East — finds that disparities in hospital costs and financing across the state are driving “a vicious cycle” of inequality in health care.

The result, according to this analysis, is that medical care is becoming less affordable for lower-and middle-income families in Massachusetts, and the disparities in hospital financing are “compromising the viability of community hospitals.”

The group is calling for new, and what they call more “fair” reimbursement rates so that poorer, community hospitals (with a greater proportion of Medicare and Medicaid patients compared to the higher-cost Boston teaching hospitals) can continue to serve the lower-income patients, among other financial recommendations.

David Williams, president of the Boston consulting firm Health Business Group, who was paid by H.E.A.L to research and co-author the report, says: “What hasn’t been demonstrated before is what impact these financing disparities have on communities and community hospitals.”

He notes: “The hospitals that have the highest percentage of publicly funded patients, they get paid less, but in addition to that, those hospitals also get the lowest commercial rates — because they’re not in as strong a position to negotiate — so that means that they’re doubly disadvantaged…it means that the hospitals serving middle-class and lower income communities don’t have the resources to compete effectively with those hospitals that get higher reimbursements.”

Clearly, the group’s recommendations would benefit the Steward-owned hospitals, Williams acknowledges, but, he adds: “it would also help with the state’s overall approach to cost containment.

I asked Nancy Turnbull, an associate dean at the Harvard School of Public Health, to take a look at the report and here’s what she had to say:

…This report looks to be raising critical issues regarding payment disparities. We’ve known for years, from the work of the [Attorney General], [Center for Health Information and Analysis] and others that these disparities exist and are, in many cases, getting worse. So far, we’ve done little to address them, and the effect these disparities have on lower paid providers and the patients for whom they care. However, I don’t think the solution is, in most cases, to just increase the rates of payment for poorly paid providers, although that is a needed action for some. We also need to talk about reallocation of existing payments, and about costs. I am supportive, to some extent, of giving consumers reasonable financial incentives, based on their income, to use lower cost providers—although lower paid is not the same as lower cost–but we also need approaches that are systemic. Consumers in tiered and high deductible health plans aren’t going to solve this problem without tough action by state government and other payers, including, in my opinion some regulation of rates of payment. And most tiered networks available so far are regressive — they impose higher costs on lower-and moderate-income people. They address one form of inequality by creating another.

Among the findings, according to the H.E.A.L press release:

“The rich get richer as highest cost hospitals attract a greater proportion of patients with commercial insurance, which have higher reimbursement rates than Medicare and Medicaid.”

(H.E.A.L report)

(H.E.A.L report)

–“Patient migration for routine care from community hospitals to high cost Boston teaching hospitals increases total medical costs and contributes to higher premiums for all individuals and families with commercial insurance (non-Medicare nor Medicaid). Additionally, low-income patients, forced to travel greater distances to receive routine care are more likely to forgo treatment until conditions become acute and require more expensive interventions.”  Continue reading

Study: The Deadly Toll Of Opting Out Of The New Medicaid Expansion

TexasImpact/flickr

TexasImpact/flickr

Here are some serious numbers from Harvard researchers regarding the 25 states that have opted out of expanding Medicaid coverage under the Affordable Care Act:

We estimate that due to the opt-outs 7.78 million people who would have gained coverage will remain uninsured. This will result in between 7,115 and 17,104 more deaths than had all states opted-in.

Writing for the journal Health Affairs blog, researchers led by Samuel Dickman, a medical student at Harvard Medical School/Cambridge Health Alliance, estimate further severe health woes linked to states’ decisions to forgo expanded Medicaid, including:

•712,037 more persons diagnosed with depression
•240,700 more persons suffering catastrophic medical expenses
•422,533 fewer diabetics receiving medication
•195,492 fewer women receiving mammograms
•443,677 fewer women receiving pap smears

 

Here’s more from the Cambridge Health Alliance news release (and for full disclosure, all of the study authors are members of the national group, Physicians For a National Health Program, which advocates that the U.S. adopt a Canadian-style single payer health system. PNHP did not pay for any part of this research, according to a spokesperson):

Dickman and his colleagues, longtime health researchers at Harvard Medical School and the City University of New York drew on demographic data from the Census Bureau’s 2013 Current Population Survey and estimates on Medicaid take-up rates from the Congressional Budget Office and elsewhere to characterize those who would remain uninsured in states opting out of Medicaid expansion.

They developed estimates of the health effects of remaining uninsured based on previous studies that used state-level data on Medicaid expansions and death rates, the National Health and Nutrition Examination Survey Mortality Follow-up, and the Oregon Health Insurance Experiment.

In addition to arriving at national estimates, the researchers were able to break the findings down by state.

For example, in Texas, the largest state opting out of the Medicaid expansion, approximately 2 million people who would otherwise have been insured will remain uninsured as a result of the state’s action.

“Texas’ refusal to accept federal money to expand Medicaid will result in 184,192 more people experiencing depression, 62,610 more people suffering catastrophic medical expenses, and as many as 3,035 avoidable deaths,” said Dr. Steffie Woolhandler, a professor of public health at the City University of New York who is also on the faculty at Harvard Medical School. Continue reading

When Nursing Homes Are No Longer The Last Stop For Patients

Two years ago, Dorothy Holmes, then 75, was in the cozy pink bathroom of her mobile home getting ready to shower when she fell. It’s the type of accident that’s pervasive among older Americans — and it’s often the very thing that triggers the end of independence.

“I got a big spot on my head, it almost conked me out,” Holmes said in her soft voice.

She heard her husband come down the hall, “and when he turned the corner all I heard was, ‘Oh God, honey, what did you do now?’ After that I don’t know anything cause I passed out,” Holmes recalled.

Dorothy Holmes shortly after her fall. (Courtesy)

Dorothy Holmes shortly after her fall. (Courtesy)

Holmes spent almost three months in a hospital near her home in Belchertown, Mass. Her heart stopped a few times, she had breathing and memory problems, and doctors removed an ulcer as big as a grapefruit. Even with continuous nursing care, the wound wouldn’t heal.

“Every day the girls came in and changed it and cleaned it. Then I had to take,” Holmes paused, “what do you call it when they help you learn to walk and everything?”

Physical therapy — which continued for more than a year in a nursing home. These days, patients are often transferred from a hospital to a nursing home to recover. But some never leave.

“The only thing I worried about was not getting out. I kept saying to him and one of my daughters, ‘You’re not going to keep me here are you?’ ”

Holmes worried her children and her husband wouldn’t be able to handle her care at home. Continue reading

Medicaid Study: First 2 Years, Mental Health Improves, Not Physical

Co-author Amy Finkelstein (Courtesy)

Prof. Amy Finkelstein of MIT (Courtesy)

Prof. Katherine Baicker of Harvard (Courtesy)

Prof. Katherine Baicker of Harvard (Courtesy)

Just out here in the New England Journal of Medicine: The latest, mixed but important findings about how health and life change for uninsured people when they gain Medicaid coverage.

It’s a nuanced look at what most changes — mental health — and what doesn’t — physical health — in the recipients’ first two years on Medicaid, the government health insurance mainly for low-income and disabled people.

That “mixed message,” in fact, is the bottom line, says lead author Katherine Baicker, a health economics professor at the Harvard School of Public Health.

“There are substantial benefits, but they’re not uniform across all outcomes,” she said. “It’s too easy to have a black or white view of the program.”

If you’re a big Medicaid fan, the study’s findings may well disappoint you. Among winners in Oregon’s Medicaid lottery, after about two years with coverage, it found no measurable improvement on several important health measures: high blood pressure, cholesterol, blood sugar control in people with diabetes.

On the other hand, the study did find a dramatic drop in depression among people newly covered by Medicaid, and — not surprisingly — a great easing of the financial strain caused by medical expenses. In the two years it followed the lottery winners, it also found an increase in diagnoses of diabetes and in the use of medication for diabetes.

Prof. Baicker says the findings contradict “two extreme and opposing points of view” about Medicaid. One holds that Medicaid is “a terrible program that has huge costs and does nothing for beneficiaries” — yet the study clearly found improved well-being among recipients, from reduced depression to increased visits to the doctor.

(From "The Oregon Experiment -- Effects of Medicaid on Clinical Outcomes," courtesy of the New England Journal of Medicine.)

(From “The Oregon Experiment — Effects of Medicaid on Clinical Outcomes,” courtesy of the New England Journal of Medicine.)

The opposite view holds that Medicaid is “a fantastic program” that so improves care for chronic disease that it will quickly save money. In fact, she said, the study found that people tended to incur $1200 in additional health costs once they were covered, and it’s clear that “at least within the first two years, expanding Medicaid does not pay for itself. It costs money.”

Highlights of the paper from Prof. Baicker and Prof. Amy Finkelstein of MIT: Continue reading

Citing Shifting Landscape, Medicaid Insurer Jumps Into Commercial Market

A comparison of monthly premiums for a single 35-year-old (Source: The Connector)

A comparison of monthly premiums for a single 35-year-old (Source: The Connector)

Citing the fast-shifting, post-Affordable Care Act health insurance landscape, Network Health, a nonprofit Medicaid health plan, is branching out into the commercial market. That means individuals, families and small businesses will be able to purchase Network’s less expensive plans — which don’t include hospitals in the state’s most expensive hospital network, Partners Healthcare — through the state’s Health Connector, and through Network Health directly.

Why now?

Well, first of all, the other Medicaid plans in the state — such as Boston Medical Center’s plan — have already done it. Moreover, with the ACA kicking in in earnest next year, all of the insurers are scrambling for market share.

Network Health President Christina Severin said through a spokesperson that despite its history as a Medicaid plan, “we wanted to offer the same high-quality affordable coverage to an even larger percentage of Massachusetts residents, both individuals and through the business communities, and in doing so, expand on our mission to improve the health and wellness of the diverse communities we serve. We are also preparing for changes that will inevitably occur in our market when federal health care reform takes full effect. The Affordable Care Act is changing the country’s health care system, and seeking to make Exchanges more dynamic marketplaces. We very much believe that Network Health’s value proposition is an excellent match with this evolving market place.”

Network Health was purchased by Tufts Health Plan in November 2011, but the decision to enter the commercial market wasn’t a condition of the sale, a Network Health spokesperson said. Rather, it was just a business reality. WBUR’s Martha Bebinger had a few more questions about the deal and here are some answers:

Q: Will Network Health be underpricing Tufts Health Plan and if so, how?

A: NH compared its relationship with Tufts Health Plan to “The Gap and Banana Republic.” Continue reading

State Auditor: MassHealth Needs Better Checks On Income, Residency

Mass. state auditor Suzanne Bump

WBUR’s news staff reports on findings released today by state auditor Suzanne Bump. She found shortcomings in the state’s $12-billion MassHealth program, the government insurance for lower-income residents:

State auditor Suzanne Bump is auditing the MassHealth program, saying it lacks safety measures to verify applicants’ income, or that they live in Massachusetts.

The audit says MassHealth, which provides care to low-income residents, cost the state $6.5 million in 2010 alone by treating patients who may have lived outside Massachusetts. It also does not verify an applicant’s supplemental income, such as lottery winnings.

And State House News reports:

Income verification shortcomings in the state’s massive MassHealth program make it possible for ineligible applicants to receive health insurance benefits for a year before being removed from the program, according to an audit released Wednesday. Continue reading

Snapshot Of Obama, Romney Care From Guys Who Were There

(Updated at 3:50 pm with additional material.)

Let’s just get this out in the open: Jon Gruber has an agenda.

He really likes President Obama’s Patient Protection and Affordable Care Act. Heck, Gruber, the MIT economist, even wrote an entire comic book about the law (and served as an advisor to the president in developing the national plan). So, when he joins forces with Stuart Altman, professor of national health policy at Brandeis and John McDonough, director of the Harvard School of Public Health’s Center for Public Health Leadership to compare the “impacts of ObamaCare, RomneyCare, and RomneyCandidateCare on health care consumers in every state,” you’ve kind of got an idea of where they’re coming from.

Still, the comparison is useful in reinforcing their message with some numbers.

What the analysts found in comparing the president’s approach to candidate Romney’s “composite” set of health care proposals — which includes repealing the ACA — is this: ObamaCare is better all around because it helps more people gain access to health insurance and pay for their care.

As Gruber put it in a conference call with reporters today, ObamaCare and RomneyCandidateCare offer two “completely different” visions. “Rather than fixing the problem, RomneyCandidateCare will make things worse,” he said.

The full report is here. (Even the cover underscores the authors’ perspective with a photo of Obama next to two pictures of Romney, each facing a different direction. To me it screams “flip-flopper.” Am I alone here?)

(Families USA)

Still, there is serious content inside. Continue reading

Klein On Clinton: Medicaid Bit Was Most Important Part Of The Speech

If you missed Bill Clinton’s excellent, entertaining, arithmetic-laden and “muscular” sales pitch for Obama last night, here’s the full transcript from The Washington Post.

Also, read Ezra Klein’s smart analysis in which he concludes that the most important part of Clinton’s speech was the bit about Medicaid:

“…it’s arguably the most important and concrete policy difference between the two campaigns. The Medicare changes get more attention on both sides, but Romney and Ryan don’t intend to touch Medicare for 10 years, they swear they’ll honor the Medicare guarantee, and at least in Ryan’s most recent budget, he envisions the exact same long-term spending path as Obama does. By contrast, Romney and Ryan intend to begin cutting Medicaid immediately, and independent analyses suggest that their cuts could throw as many as 30 million people off the program. If you want to see the difference between Obama and Romney’s vision for American policy, it’s probably the single starkest example.

Which is, no doubt, why Clinton chose to highlight it. Tonight, his role was wonk-in-chief, and he was trying to persuade the public of an old idea: That the best way to understand this election is to simply do the arithmetic. And so, for 48 minutes, that’s pretty much what he did. The question now is whether the Romney campaign can persuade voters that there’s a mistake in Clinton’s math.”