Posts Tagged ‘Medicaid’
I posted about this last year when I was once again wading through physician credentialing. I recently had occasion to do it again because I’m helping out a friend at a new hospital, and, if anything, the process is even worse.
Everyone wants to be sure their physician is competent and appropriately trained. The way this is done is through credentialing. A new applicant for privileges to practice at a hospital or other healthcare facility fills out an application and submits a curriculum vitae that details when and where a physician trained and the certifications obtained, such as specialty boards, and a work history (if any). Copies of key documents — medical degrees, residency certificates, and the like — accompany the application. The applicant also provides the names of professional references who can attest to competency. Also required are declarations that the applicant has never been fired (or asked to resign) from a medical job for competency issues. The applicant also must also swear to a long list of other things. These include not being a drug addict (who would answer yes to that?), a convicted felon, or to have been disciplined for questionable or illegal activity. A committee then reviews the application and grants (or not) privileges to practice medicine at that facility.
Before the committee grants privileges, however, all the information gets verified. This makes perfect sense because, regrettably, there are more than a few documented instances of people embellishing or even outright lying on their applications. I have been on enough selection committees to know that folks occasionally stretch the truth. Flagrant examples of this occasionally make the news. The job of credentialing departments is to check up on all this. Interestingly, in the example I just linked to, the guy hoodwinked all the verifiers; it was only picked up later by accident.
It gets more complicated because not just hospitals and healthcare facilities want their practitioners credentialed. All of the people who pay the bills, such as insurance companies and the government — Medicare, Medicaid — want to make sure they are paying legitimate costs to legitimate practitioners. So they have their own credentialing departments, all different in how they do things. A typical physician has to be credentialed by every single one of the payers covering every single one of his or her patients. That can mean a dozen payers or more. So, for example, besides having privileges at the hospitals at which I practice, my background is verified by all the people who pay the bills for my patients. And believe me, the requirements of all these entities are not the same and all have their own sheaf of forms to fill out and supporting documents to submit.
This situation cries out for a central clearing house for credentialing information. Some examples of this exist, such as this one, if nothing else because collecting all this information is tedious and expensive. Credentialing departments at many facilities are getting larger all the time. Credentialing is also a major industry, with overwhelmed facility credentialing staffs farming out the process to outside contractors. The problem is that, in our disorganized healthcare “system,” no facility or entity wants to surrender the right to collect their own data in their own way. Attempts to institute a more global process, at least in my experience, have simply added another layer of bureaucracy to slog through. The convenience, or even the sanity, of the physicians wrestling with this unholy mess is not their concern. For physicians like me, who practice at several hospitals in different parts of the country with little overlap in who the regional payers are, the expense and hassle of it all are large. And even when you think you’re done, you’re not: many entities require frequent updates, often meaning a whole new application. One that I deal with demands this every three months.
Okay — rant over. But what prompted this was my agreeing recently to help out some people for a few weeks at a new hospital. I’m now four months into the credentialing “process.” During that time I’ve dealt with three separate organizations, none of which communicate with each other. I’ve worn out my fax machine submitting extraneous document after document. Nearly every day my email inbox has strident demands for still something else IMMEDIATELY! If I hadn’t promised my time to people I like, I think at this point I would just say: no, I’m done — good luck.
I’ve been practicing medicine for over 35 years. For my first job I just showed up for work. People checked that I had graduated from medical school, done a residency, and passed my exams, but that was about it. I realize physicians have to some extent brought all this on ourselves by a few of us scamming the system over the years or just lying. I recall a case some years ago of a physician lying about a five year gap in his work history, a gap that turned out to be because he was serving time in prison for third-degree murder. (I looked for a link to this incident but couldn’t find one — it most likely was pre-Google.)
Anyway, I think this credentialing mess has got to get better organized somehow. We need a central authority of some sort, accepted by all. The current trajectory is unsustainable. Healthcare is expensive enough, and all this adds many millions to the total costs for little benefit.
[This is important. It was written by Phil Galewitz and republished (by permission) from Kaiser Health News (KHN), a nonprofit national health policy news service.]
Repealing the federal health law would add an additional 19 million to the ranks of the uninsured in 2016 and increase the federal deficit over the next decade, the Congressional Budget Office said Friday.
The report is the first time CBO has analyzed the costs of the health law using a format favored by congressional Republicans that factors in the effects on the overall economy. It is also the agency’s first analysis on the law under Keith Hall, the new CBO director appointed by Republicans earlier this year.
CBO projected that a repeal would increase the federal deficit by $353 billion over 10 years because of higher direct federal spending on health programs such as Medicare and lower revenues. But when including the broader effects of a repeal on the economy, including slightly higher employment, it estimated that the federal deficit would increase by $137 billion instead.
Both estimates are higher than in 2012, the last time that the CBO scored the cost of a repeal.
The latest report from the nonpartisan congressional watchdog and the Congressional Joint Committee on Taxation comes just days before the Supreme Court is expected to rule on the health law’s premium subsidies in the nearly three dozen states that rely on the federal marketplace. Such a ruling would cut off subsides to more than 6 million people and be a major blow to the Affordable Care Act. It could also boost Republican efforts to repeal the entire 2010 law, which would likely face a presidential veto.
Last week, President Barack Obama said nearly one in three uninsured Americans have been covered by the law—more than 16 million people.
The CBO said repealing the health law would first reduce the federal deficits in the next five years, but increase them steadily from 2021 through 2025. The initial savings would come from a reduction in government spending on the federal subsidies and on an expanded Medicaid program. But repealing the law would also eliminate cuts in Medicare payment rates to hospitals and other providers and new taxes on device makers and pharmaceutical companies.
The CBO projected that repeal would leave 14 million fewer people enrolled in Medicaid over the next decade. Medicaid enrollment has grown by more than 11 million since 2013, with more than half the states agreeing to expand their programs under the law.
By 2024, the number of uninsured would grow by an additional 24 million people if the law is repealed.
In 2012, the CBO projected repealing the health law would increase the federal deficit by $109 billion over 10 years. It said the higher amount in Friday’s report reflected looking at later years when federal spending would be greater.
One of the goals of the Affordable Care Act (aka Obamacare) was to increase access to primary care physicians. The notion is that if people have insurance it would be easier for them to get appointments with primary care physicians. This is because many physicians are unwilling to accept new patients who are uninsured. Further, a key component of the ACA was to increase physician reimbursement for Medicaid because this program was a major mechanism for expanding insurance coverage. Medicaid reimbursement has always been low — significantly lower than Medicare pays for the same encounter — so many physicians would not take it. The ACA drafters hoped higher reimbursement would entice these physicians to accept Medicaid. We don’t know if any of these assumptions are correct, but a recent study published in The New England Journal of Medicine suggests a positive impact.
The authors’ method was a bit sneaky, I suppose. They had trained field staff call physicians’ offices posing as potential patients asking for new appointments. They were divided into two groups; one group said they had private insurance, the other said they had Medicaid. The authors compared two time periods — before and after the early implementation of the ACA. A sample of states were compared to see if the rates of acceptance of new Medicaid patients was associated with a particular state increasing physician Medicaid reimbursement.
The results were not striking, but they suggest a significant positive trend. This is what the results showed, in the authors’ words:
The availability of primary care appointments in the Medicaid group increased by 7.7 percentage points, from 58.7% to 66.4%, between the two time periods. The states with the largest increases in availability tended to be those with the largest increases in reimbursements, with an estimated increase of 1.25 percentage points in availability per 10% increase in Medicaid reimbursements (P=0.03). No such association was observed in the private-insurance group.
Again, these are data from the early days of ACA implementation. But they are encouraging. One of the most important components of slowing the seemingly inexorable rise in healthcare costs is getting people good primary and preventative care. This keeps people with a chronic, manageable condition out of the emergency room and, one hopes, out of the hospital. This is particularly the case with common conditions like diabetes and asthma. For both of those disorders regular care by a primary care physician can spare patients much suffering and save many thousands of dollars.
I hope this kind of research continues as the ACA matures. It’s a good way to see if the overall goals are being met. Of course it raises a new challenge: making sure we have enough primary care physicians. Right now we don’t.
The CHIP program (Children’s Health Insurance Program) has just been reauthorized by Congress. This is a program that provides health insurance for children of lower income families who still make too much income to qualify for Medicaid. Both CHIP and Medicaid provide essential, even life-saving healthcare for kids. That’s a good thing. A recent research study asked a deeper question: What are the long-term economic effects of providing this care, of keeping children healthy into adulthood? Their study doesn’t address the humanitarian aspects, which are huge, but rather the cold, hard economic ones.
The authors used the expansion of Medicaid and the implementation of CHIP that occurred in the 1990s to follow children who had obtained healthcare via those programs and were now adults. The bottom line is that well over half of those healthcare dollars spent were recouped in the form of taxes over the working lifetime of the subjects. Again, this doesn’t even take into account the global benefit to society of keeping people from suffering. In the words of the authors:
The government will recoup 56 cents of each dollar spent on childhood Medicaid by the time these children reach age 60. This return on investment does not take into account other benefits that accrue directly to the children, including estimated decreases in mortality and increases in college attendance.
There were several, less measurable multiplier effects that pushed the return even higher than that. One of these was the probability of the subjects collecting Earned Income Tax Credits in the future. They conclude:
We find that by expanding Medicaid to children, the government recoups much of its investment over time in the form of higher future tax payments. Moreover, children exposed to Medicaid collect less money from the government in the form of the Earned Income Tax Credit, and the women have higher cumulative earnings by age 28. Aside from the positive return on the government investment, the eligible children themselves also experience decreases in mortality and increases in college attendance.
To me it seems pretty intuitive that keeping children healthy makes them more likely to be healthy adults, and healthy adults are more likely to become able-bodied, working taxpayers. They also have longer lifespans. This study gives important, long-term data to support that intuition. Plus, it’s the right thing to do.
Everyone wants to be sure their physician is competent and appropriately trained. The way this is done is through credentialing. A new applicant for privileges to practice at a hospital or other healthcare facility fills out an application and submits a curriculum vitae that details when and where a physician trained and the certifications obtained, such as specialty boards, and a work history (if any). Copies of key documents — medical degrees, residency certificates, and the like — accompany the application. The applicant also provides the names of professional references who can attest to competency. Also required are declarations that the applicant has never been fired (or asked to resign) from a medical job for competency issues. The applicant also must also swear to a long list of other things. These include not being a drug addict (who would answer yes to that?), a convicted felon, or to have been disciplined for questionable or illegal activity. A committee then reviews the application and grants (or not) privileges to practice medicine at that facility.
Before the committee grants privileges, however, all the information gets verified. This makes perfect sense because, regrettably, there are more than a few documented instances of people embellishing or even outright lying on their applications. I have been on enough selection committees to know that folks occasionally stretch the truth. Flagrant examples of this occasionally make the news. The job of credentialing departments is to check up on all this. Interestingly, in the example I just linked to, the guy hoodwinked all the verifiers; it was only picked up later by accident.
It gets more complicated because not just hospitals and healthcare facilities want their practitioners credentialed. All of the people who pay the bills, such as insurance companies and the government — Medicare, Medicaid — want to make sure they are paying legitimate costs to legitimate practitioners. So they have their own credentialing departments, all different in how they do things. A typical physician has to be credentialed by every single one of the payers covering every single one of his or her patients. That can mean a dozen payers or more. So, for example, besides having privileges at the hospitals at which I practice, my background is verified by all the people who pay the bills for my patients. And believe me, the requirements of all these entities are not the same and all have their own sheaf of forms to fill out and supporting documents to submit.
This situation cries out for a central clearing house for credentialing information. Some examples of this exist, such as this one, if nothing else because collecting all this information is tedious and expensive. Credentialing departments at many facilities are getting larger all the time. Credentialing is also a major industry, with overwhelmed facility credentialing staffs farming out the process to outside contractors. The problem is that, in our disorganized healthcare “system,” no facility or entity wants to surrender the right to collect their own data in their own way. Attempts to institute a more global process, at least in my experience, have simply added another layer of bureaucracy to slog through. The convenience, or even the sanity, of the physicians wrestling with this unholy mess is not their concern. For physicians like me, who practice at several hospitals in different parts of the country with little overlap in who the regional payers are, the expense and hassle of it all are large. And even when you think you’re done, you’re not: many entities require frequent updates, often meaning a whole new application. One that I deal with demands this every three months.
Okay — rant over. But what prompted this was my agreeing recently to help out some people for a few weeks at a new hospital. I’m now four months into the credentialing “process.” During that time I’ve dealt with three separate organizations, none of which communicate with each other. I’ve worn out my fax machine submitting extraneous document after document. Nearly every day my email inbox has strident demands for still something else IMMEDIATELY! If I hadn’t promised my time to people I like, I think at this point I would just say: no, I’m done — good luck.
I’ve been practicing medicine for over 35 years. For my first job I just showed up for work. People checked that I had graduated from medical school, done a residency, and passed my exams, but that was about it. I realize physicians have to some extent brought all this on ourselves by a few of us scamming the system over the years or just lying. I recall a case some years ago of a physician lying about a five year gap in his work history, a gap that turned out to be because he was serving time in prison for third-degree murder. (I looked for a link to this incident but couldn’t find one — it most likely was pre-Google.)
Anyway, I think this credentialing mess has got to get better organized somehow. We need a central authority of some sort, accepted by all. The current trajectory is unsustainable. Healthcare is expensive enough, and all this adds many millions to the total costs for little benefit.
There is one aspect of our relentlessly rising healthcare costs that seems particularly out of control — administrative costs. An interesting recent editorial in the New England Journal of Medicine provides some sobering details.
Every physician confronts daily the burden of dealing with healthcare bureaucrats of various sorts. The average doctor personally spends 43 minutes each day at it, and behind every physician there is an army of coders. They all communicate (inefficiently) with another army of insurance company employees and Medicare and Medicaid workers. What is the added cost of all this baked into the system? Do we have any idea? Can we do anything about it?
The Institute of Medicine, a component of the National Academy of Sciences, estimates the yearly administrative costs to be 361 billion dollars. This is a staggering sum — twice the amount of money we spend on heart disease and three times what we spend on treating cancer. Can we do anything about this?
Many have suggested that a single payer system would be the obvious answer, since providers would not be dealing with dozens of insurance and governmental entities. Although this is my view, I realize that right now it is just not politically feasible. It is the standardization of methods and procedures that matters most. The question, as well laid out by the editorial authors, is if we can reap some of the benefits of standardization without a single payer system? The authors think we can, and I agree.
One issue that really, really needs better standardization is physician credentialing. Each healthcare entity, be it a hospital or a payer, has its own way and standards of reviewing the credentials of physicians. And believe me, it’s a mess that just gets worse and worse. I have practice privileges at several hospitals and medical licenses in several states. Each one of these has its own, often idiosyncratic, standards for credentialing physicians, and these credentials need to be redone every couple of years. The process takes many hours and causes many headaches. There are national databases that keep relevant information about physicians — medical school and residency information, medical license information, information on disciplinary actions. You might think this would have made the process faster, but it just added another layer to the mess. Hospitals spend millions of dollars duplicating work that has already been done. It’s crazy.
Credentialing and other systems that are used to establish contracts between providers and health plans are riddled with redundancy, with many organizations collecting virtually identical information from providers. The typical physician spends more than 3 hours annually submitting nearly 18 different credentialing forms, with staff spending an additional 20 hours.
This sort of craziness is found all through the system (which really isn’t a system at all) that we have. The editorial’s authors go on to suggest several useful things which, if implemented in the context of the Affordable Care Act, would save billions:
The possibilities for reducing administrative complexity are immense. The reforms we describe could save as much as $20 billion annually for providers (roughly $29,000 per physician), or $40 billion annually for all stakeholders. And $2 billion of these savings would accrue to the federal government — a relatively small but valuable contribution to reducing the deficit. For the individual physician, these savings could translate into more time and resources for direct patient care — and therefore into improved professional satisfaction.
As we look for ways to make our healthcare system more efficient, this sort of thing truly is low-hanging fruit. It wastes resources we should be putting toward patient care.
It’s pretty well known that emergency room use is on the increase. This recent study summarized the trend over the past decade (the complete article is behind a paywall — let me know if anybody wants a complete copy). The authors compared 1997 with 2007, looking at the number of ED visits per 1000 population. They found that the total number of visits had increased from 353 per 1000 persons in 1997 to 390 per 1000 persons. The total increase in number of visits was about double what you would predict just from population growth. So more folks have been going to the ED over the past decade. How many of these were children?
It turns out that the rate among children has not changed significantly over the past decade — it’s stable at 362 per 1000 population. So the past decade’s growth in ED use has come from other age groups. The study found all adults between 18 and 64 years of age increased their rate of use. Interestingly, older people, those over 65, did not.
ED use by insurance status confirmed what all of us have known for quite some time: the uninsured and those with Medicaid have the highest rate of ED use. A patient with Medicaid was roughly twice likely as a patient with insurance to go to the ED for care, and someone with no insurance was half again as likely to go to the ED as an insured person. The reason for this is most likely little or no access to regular primary care, care which would keep them out of the ED. It’s getting harder and harder for kids on Medicaid to find a doctor, largely because the reimbursement rate is so bad. In my state, for example, a pediatrician gets paid less to see a child with complicated health problems than it costs to change the oil in your car.
Another recent study, this one just involving children, examines the issue of inappropriate ED use. After all, if children can get care from a regular doctor, they are less likely to use the ED to get routine care. (Unfortunately there’s a paywall on this article, too.)
The authors examined the characteristics of what they called “inappropriate” use of the ED — essentially things for which, if the child had a regular doctor, they would not have come to the ED. Their findings also confirmed what we would have suspected: poor kids, kids on Medicaid, and uninsured kids — those who had trouble finding a regular doctor — were more likely to use the ED for routine care. ED care is extremely expensive care: the same visit for asthma, for example, is far cheaper in the office than in the ED. But if you’re a parent whose child is without regular healthcare, where are you supposed to go, if not the ED? From the article:
“Specifically, patients identified access barriers in the primary care clinic as the major reason for choosing the ED instead of the clinic. They reported a cumbersome scheduling system, long waiting times for appointments, and no availability of walk-in care.”
All this seems obvious. But sometimes we need actual research studies to confirm the intuitively obvious. And excessive ED use is one of the engines in our ever-increasing healthcare bills.
A recent editorial in the New England Journal of Medicine makes an interesting contrast between the approaches public and private health plans have taken in controlling costs. It points out how governmental health programs — Medicare and Medicaid — have long focused on controlling costs by focusing on the unit cost of things. So they have paid less attention to how many of something, say a surgical procedure, gets done and more attention to the cost of each one. What can happen in this approach is that doctors do more and more of whatever it is in order to make up the lost revenue. This can be quite bad for patients. Overutilization of health services is already a huge problem; some estimates are that a quarter to a third of medical care provided in America is unnecessary. More care is not better care, although that notion in some way seems to go against our national ethic.
Private insurers have generally tended to take another approach: instead of largely focusing on the unit cost of providing a service, they have tried to control the number of times the service is provided, using such things as preauthorization requirements. The result has been predictable — the gap between the unit cost paid by private insurers, always more than public programs paid, has been getting steadily larger. In 2000, providers on average billed private payers about 15% more than public ones for the same procedure; by 2009, the difference was 30-40% more for the private ones. In the same period, public payers on average cut by 10-15% what they would pay for the procedure. So if you add up the math, you can see what has happened: in order to maintain revenues, providers are shifting the costs to the private payers. This cost shifting has been known in the healthcare world for years, but it is getting worse and worse. It represents a sort of hidden tax on all of us, and it is one of the things driving healthcare costs even higher.
I recommend the editorial. It’s short and easy to understand. It’s also eye-opening as to the magnitude of the cost-shifting phenomenon.
I’ve written before about how children from poor families have a higher chance of needing PICU care than do children from more affluent families. Eligibility for Medicaid is a good marker for this; nearly half the population of most urban PICUs is made up of children on Medicaid, even though the national average (it varies a little from state to state) for children on Medicaid is about 25%. So poor kids are more likely to become critically ill.
A report from the Robert Wood Johnson foundation, a renowned health policy organization, lays out how poverty correlates so closely to poor health. This chart is the most telling. It measures a somewhat vague quantity, something they call “children in less than very good health.” They obtain this value by surveying parents, so you could quibble about the validity of whatever it is the term measures. That quibble would make sense to me if the numbers weren’t so striking.
But they are striking. For example, among white, non-Hispanic children, 20% of poor children have “less than very good health,” compared with 6% of well-off children. The differences among black and Hispanic children are much more dramatic. Nearly 50% of poor, Hispanic children are not in optimal health.
What this means to me is fairly obvious, and it has been obvious for a long time — health status is linked to socio-economic status. We shouldn’t need a study to tell us that, but it is helpful to have such a graphic demonstration of the effect. I’m sure it’s partly because poor families can’t afford health insurance. But that isn’t the whole story — all of these poorest children, the group with the most severe health problems, would qualify for Medicaid, even in the states with the most stringent requirements.
Thus whatever we do about healthcare reform will be closely linked to what is happening in the economy. Perhaps the best thing we can do for healthcare is reduce poverty.
I’ve written before about how poor children and children without health insurance are far more likely to need PICU care than are more affluent children. For example, although children on Medicaid account for 20 – 25% (depending upon the state) of children in America, about half of all children in America’s PICUs are on Medicaid. Once in the PICU, though, do the poorer kids have worse outcomes than the richer kids? Does their chronically disadvantaged situation set them up for being more difficult to treat and cure?
I’ve been looking for information about this crucial question for some time and recently found some disturbing data about it, in the form of an article in the journal Pediatric Critical Care Medicine (volume 7, pages 2-6, 2006). You need a subscription to the journal to get the article, but I’ll summarize its important findings for you.
First, the study confirmed that children without insurance are far more likely to suffer critical illness: ” . . . far more serious illness and injuries were associated with uninsured children admitted to the PICU.” But did that make it more likely that these children would suffer worse outcomes, or even make it more likely for them to die?
Unfortunately, uninsured children did have poorer chances of survival. In fact, they were three to four times more likely to die in the PICU. Why was that? The answer was not that they received different care in the PICU once they got there; the answer was that they were much sicker to start with. Compared to children with either private insurance or public assistance (Medicaid), the uninsured children came into the PICU in much worse shape, with far worse derangements in their physiological state. Most likely their parents, fearful of the cost, delayed bringing them to the hospital until sometimes it was too late to save them.
What can we learn from this? Lack of health insurance kills children. That is both a tragedy and a terrible indictment of how we presently care for America’s children.
Sachin on 