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Improving Medicare and Medicaid – An Imperative
Group 2Sara, Dave, Paul, William
Agenda
Background
Quality Issues
Cost Issues
Access Issues
Conclusion
An Introduction
National Health Care Spending In 2005, US health care expenditures:
Reached $2 trillion Projected to reach $4 trillion by 2015. 4.3 x the amount spent on national defense.
Gross domestic product (GDP) in 2005: 16% of GDP in the United States 10.9% of GDP in Switzerland 10.7% in Germany 9.7% in Canada 9.5% in France
Nearly 47 million Americans are uninsured.
The Impact of Rising Health Care Costs on Access to Health Care
Primary reason people are uninsured is the high cost of health insurance coverage. 60% - get health care through their employer. 27% - covered by government sponsored health care. 13% - self employed or working for companies which do
not provide health insurance benefits - purchase coverage directly through private health insurance companies.
Any high risk factors, health insurance companies may be unwilling to insure him at any price.
The Impact of Rising Health Care Costs on Access to Health Care
Currently 34 states offer some form of risk pool, covering about 183,000 people.
That leaves a large chunk of the population without any sort of health care coverage whatsoever.
48% of insured working-age adults whose insurance does not include prescription drug coverage reported medical bill or debt, compared to 33% with prescription drug coverage.
65% of working-age adults who reached the limit of what their insurance plan would pay for a specific treatment or illness experienced medical bill problems, medical debt, or both.
The Impact of Rising Health Care Costs on Access to Health Care
Having an Accessible Primary Care Provider, by Age Group,Family Income, and Insurance Status, 2002
69
82 8480
66
74
53
74
54
38
0
50
100
Total 65+ years 400%+ ofpoverty
<200% ofpoverty
19–64years
400%+ ofpoverty
<200% ofpoverty
Insured all year
Uninsuredpart year
Uninsuredall year
Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Percent of adults with a usual source of care who provides preventive care, care for new and ongoing health problems, and referrals, and who is easy to get to
Elderly adults Nonelderly adults
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: COORDINATED CARE
23
The Impact of Rising Health Care Costs on Quality of Health Care
Receipt of Recommended Screening and Preventive Care for Adults,by Family Income and Insurance Status, 2002
31
46
52
39
48
56
49
0 50 100
Uninsured all year
Uninsured part year
Insured all year
<200% of poverty
200%–399% of poverty
400%+ of poverty
National
Percent of adults (ages 18+) who received all recommended screening andpreventive care within a specific time frame given their age and sex*
* Recommended care includes seven key screening and preventive services: blood pressure,cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
QUALITY: THE RIGHT CARE
13
Medicare Medicaid: Quality Problems
System centered, not patient centeredFragmented and uncoordinated careSafety - Medicaid alleged to be less safe Lack of effectiveness measurements Inefficient, long waits for service, wasteNot equitable, inconsistent from state to
state
Medicare Medicaid: Quality Solutions
Patient as “source of control” System adaptable to patients desires, New forms of communication and care availability. Transparency for informed decisions
Improve collaboration and communication among clinicians and institutions
Monitor threats to patient safety Structural issues
Medicare Medicaid: Quality Solutions
Introduce Evidenced-based practice Compare care against other
benchmarks and organizations Nurture continuing care
relationships Eliminate duplication or lack of
service Ensure that all mandatory services
are obtainable (e.g. dental coverage)
Leverage Electronic Medical Record and Informatics systems
Medicare / Medicaid: Cost Problem
Medicaid Funding Structure Sources / Growth
Medicare Funding Structure Sources / Growth
Fundamental Problems Aging population Cost of service increases
(2019 solvency) Fraud
Improving Cost: MedicaidMedicaid Maximization
Ensure all eligible state programs are reimbursed
Cost Sharing Private Insurers, Estate, Employers
Reconfigure Long Term Care Services Emphasize home / community care
Selective Contracting
Improving Cost: Medicare
Mimic successful private payer initiatives Pay for Performance Managed Care
Clinical Care Teams Prescription Drug
Management Formulary Eliminate Drug
Negotiation Barrier
M/M: Access Problems
3 Key MeasuresProviders accepting new M/M patients
Declined to 71%; varies by specialty
Patients delayed or did not receive care For Seniors, this increased to 11% in 2001
Lack of timely appointments Check-up delay > 3 weeks – 37% Illness appointment wait > 1 week – 40%
Medicaid Access Crises
Homeless 2 Million homeless any night Only 30% qualify for Medicaid Dropped due to address issues
Gaps Leaving prison or mental health
facility Immigrants with <5 years in US
Undocumented New rule – must prove citizenship Original or certified documents
required Florida, Iowa, Kansas, Louisiana,
New Mexico & Ohio attributed declines to the rule
Improving Access: Increasing Supply
Improve the availability of timely, coordinated services for M/M patients Pilot opening M/M clinics
Staffed by physicians, nurses, therapists, PAs & NPs• w/o the burden of practice start-up costs
Salaried positions – not based on reimbursement Loan forgiveness program (% of loan by year)
• 20% of total amount for Year 1, increasing by year Scholarships in exchange for commitment
Clinics target areas & specialties with worst access stats.
Improving Access: Outreach
Increase the promotion of healthy behaviors, preventative care, and M/M clinics Leverage technology – easy website
Provide tailored information Ask questions Find a M/M clinic Find a community screening activity
Leverage existing groups to promote Meals on Wheels Senior Centers, Community Centers State & local Departments of Health
Improving Access: Removing Barriers
Streamline documentation Accept affidavits
Involve States Wash state sued on behalf
of immigrant children
Coordinate transitions From jails From mental health
facilities
ConclusionWhy is the number of uninsured people increasing?
1/3 of firms in the U.S. did not offer coverage in 2005.
38% of workers are employed in smaller businesses, Rapidly rising premiums cited for not offering coverage.
The employees can't always afford their portion of the premium Coverage is unstable during life's transitions
Losing a job or quitting can mean losing affordable health coverage Employer-sponsored coverage cut by a change from FT to PT work, or self-employment, retirement or divorce. COBRA continuation out of reach
Conclusion
How does being uninsured harm individuals and families?
Less preventive care Diagnosed at more advanced disease stages, Once diagnosed
Receive less therapeutic care Higher mortality rates than insured individuals.
Nearly 50% of uninsured children did not receive a checkup in 2003, almost twice the rate (26%) for insured children.
Conclusion For about 20% of the uninsured (vs. 3% of those with coverage) - usual source of care is the emergency room.
Nearly $100 billion per year is spent to provide uninsured residents with health services - Hospitals provide about $34 billion worth of uncompensated care a year.
Preventable deaths among uninsured adults age 25-64 is in the range of 18,000 a year.
Uninsured are 30 to 50% more likely to be hospitalized for an avoidable condition.
Over 1/3 of the uninsured have problems paying medical bills.
Call to ActionGetting Everyone Covered through Medicare and Medicaid will Save Lives and Money
The impacts of going uninsured are clear and severe.
Many uninsured individuals postpone needed medical care: Resulting in increased mortality Resulting in billions of dollars lost in productivity Resulting in increased expenses to the health care system.
We are all vulnerable to the potential loss of health insurance.
Every American should have health care coverage, participation should be mandatory, and everyone should have basic benefits.
Improving Medicare and Medicaid - Conclusion
Improving cost of care, access to care and quality of care to beneficiaries of Medicaid and Medicaid becomes not just important, but imperative.
Contact your legislators; grill the presidential candidates; be the change you want to see.
References Physician Shortage Areas: Medicare Incentive Payments not an Effective Approach
to Improve Access, United States General Accounting Office “Date raise concerns about Medicaid access”, aapnews.org, Volum 18, number 4 “Lacking Papers, Citizens are Cut from Medicaid”, New York Times, March 12, 2007 “Poverty in the United States: A Snapshot: One out of Eight people in the USA are
living in poverty”, www.nclej.org “Washington state sues over Medicaid access for immigrant children”, the Jurist Legal
News and Research, March 6, 2007 “Low pay hurts Medicaid access to specialists”, Joel Finkelstein, AMNews, July 26,
2004 "Insurance Coverage and Care of Patients with Non-ST Segment Elevation Acute
Coronary Syndrome," James E. Calvin, Matthew T. Roe, Anita Y. Chen, et al, Annals of Internal Medicine, (Nov. 21, 2006) 145 (10): 739-748
"Study Says Uninsured Lack Follow-Up Care," Lindsey Tanner, Associated Press, September 13, 2005
“The Business Case For Quality: Case Studies And An Analysis”, Sheila Leatherman, Donald Berwick, Debra Iles, Lawrence S. Lewin, Frank Davidoff, Thomas Nolan and Maureen Bisognano, Health Affairs, 22, no. 2 (2003): 17-30
“The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care”, Elliott S. Fisher, MD, MPH; David E. Wennberg, MD, MPH; Thérèse A. Stukel, PhD; Daniel J. Gottlieb, MS; F. L. Lucas, PhD; and É toile L. Pinder, MS
