Tuesday, January 20, 2009

What Medicaid Tells Us About Government Health Care

Why would Obama want to build on a system with poor outcomes?

Medicaid provides coverage to poor and disabled Americans, many of whom face the highest burden of chronic disease owing to cultural and socioeconomic challenges. The program beats being uninsured, but it often relegates the poor to inferior care.

Reimbursement rates are so low, and billing the program so complicated, that it is hard for internists like me to get beneficiaries access to specialized care or timely interventions. For my patients as well, many of whom are uneducated or don't speak English, Medicaid is replete with paperwork, regulations and rejections that make the program hard to navigate.

Now Medicaid is to receive a bolus of federal money, probably as part of the fiscal stimulus plan -- the figure whispered in Washington is $100 billion -- with no obligation that the program does anything to reverse its decline.

Accumulating medical data shows that Medicaid recipients' poor health outcomes aren't just a function of their underlying medical problems, but a more direct consequence of the program's shortcomings. Take the treatment of serious heart conditions, which are among the most closely evaluated Medicaid services.

One study published in the Journal of the American College of Cardiology (2005) found that Medicaid patients were almost 50% more likely to die after coronary artery bypass surgery than patients with private coverage or Medicare. The authors suggest this may be a result of poorer long-term, follow-up care. Like other similar studies, this one tried to control for the other social and medical factors that are believed to influence patients' clinical outcomes.

Another study in the journal Ethnicity and Disease (2006) showed that elderly Medicaid patients with unstable angina had worse care, partly because they were less likely to get timely interventions or be treated at higher quality hospitals. Three other recent studies showed that Medicaid patients presenting with heart attacks or unstable angina received cardiac catheterization less often than Medicare or private paying patients. This procedure to open blocked heart arteries has become standard care, with ample evidence showing it improves outcomes.

The same trends can be observed in other diseases. For example, a study of adults with cancer published in the journal Cancer (2005) found that patients on Medicaid were two to three times more likely to die from the disease even after researchers corrected for differences in the location of the tumor and its stage when diagnosed.

The federal and state governments are equally culpable for the program's troubles. The federal government matches state Medicaid spending, paying an average of 57% of costs. States expand enrollment in order to qualify for more federal aid. Insurance coverage has become the end itself, with states spreading resources widely but thinly -- without enough attention to the quality of care, accessibility, or whether coverage was actually improving health. States have no obligation to rigorously measure health outcomes in order to qualify for more federal money.

A government survey in 2002 for the Medicare Payment Advisory Committee found that "approximately 40% of physicians restricted access for Medicaid patients" because reimbursement rates are so low. Only about half of U.S. physicians accept new Medicaid patients, compared with more than 70% who accept new Medicare patients. Several recent studies trace the difficulty in getting Medicaid patients seen by specialists to low fees and payment delays. Technologies are also restricted. Many expensive but important drugs aren't paid for under various state drug formularies.

There's also a fair degree of fraud in the program. James Mehmet, New York's former chief Medicaid investigator, was quoted in the New York Times as believing that at least 10% of state Medicaid dollars were spent on fraudulent claims, while 20% or 30% more was siphoned off by what he termed "abuse." Even if the federal government wanted to hold states more accountable for peoples' ?185 health, Medicaid claims data is poorly gathered in most states, making meaningful oversight hard.

Barack Obama's team and Democratic leaders plan to change the federal matching rate to reduce the amount of state funding that is required for maintaining a given level of federal Medicaid spending. Mr. Obama would give Medicaid tens of billions more in federal dollars as part of the fiscal stimulus bill. And he wants to extend Medicaid to some unemployed workers, with the federal government paying the entire cost -- a watershed expansion of the program. New money alone won't fix the program's woes. It will simply allow states to siphon off more of what they would have spent on Medicaid to other uses.

For its part, the federal government has often prevented the states from taking steps to fix their own Medicaid programs, such as by devising outcome-based standards for evaluating performance, and de-emphasizing the goal of growing the number of covered people to focus more on improving the health of those served.

Among a handful of states that have received "special permission" from federal regulators to take incremental steps to improve their Medicaid programs, North Carolina has created a primary care-based program that pays doctors more to improve coordination of care, and gives patients more choice by getting new doctors to participate in the program. Indiana is incorporating personal accounts that allow patients greater choice of providers.

Another idea being tried in some states allows patients to choose coverage tailored to specific health needs like pregnancy or certain disabilities. In Louisiana, Gov. Bobby Jindal wants to provide tailored Medicaid services through managed-care networks run by private and competing companies that would be held accountable for showing better health results.

The Centers for Medicare and Medicaid Services, which regulates the program, recently gave states the flexibility to redesign their Medicaid benefits by modeling the programs after popular private-sector plans already being offered in a particular state. But creating enduring incentives for broader state accountability probably means ending Medicaid's open-ended funding. Even the auto makers are being held accountable to certain outcomes as a condition for getting federal loans.

The troubling evidence about the quality of Medicaid patients' services is a cautionary tale for Mr. Obama as he sets about to administer more of our health care inside government agencies. Turning Medicaid around should be the least we demand before turning over more of our private health-care market to similar government management.


Slow ambulances in Canada too

Very reminiscent of the Australian and British experience

She was so miserable, she prayed she would live. She was so miserable, she prayed she would die. "Couldn't decide," her husband said later. On Jan. 4, three days after her emergency appendectomy, Jessica Baker, the morning traffic reporter for CFRB and EZRock, began experiencing excruciating abdominal pain - far worse than the pain she had in the hours before her appendix was removed - and vomiting repeatedly. At around 7:20 p.m., with Baker in the fetal position, her husband, Adam Dolgin, called 911. The ambulance, he said, arrived at their Toronto apartment more than 30 minutes later.

"It was awful. It was horrible. Probably the worst experience of my life," said Baker, who was hospitalized with a surgery-related infection. "I assume if anybody calls an ambulance, regardless of what it is - because who knows what it could have been, right - that 10, 15 minutes would be the longest it would take."

In all GTA municipalities, ambulances do respond to almost all "Code 4" 911 calls, those classified as the most urgent, within 15 minutes. But responses have become progressively slower over time - nowhere more than in Toronto. In 2007, Toronto responded to 90 per cent of Code 4 calls within 11 minutes, 58 seconds - 3:38 longer than its response time in 1996, according to Ministry of Health figures released upon request. Peel Region's response time increased by 2:38, from 9:32 to 12:10; York Region's increased by 1:26, from 11:38 to 13:04. With the exception of Durham Region, responses slowed throughout the GTA after Ontario downloaded ambulance service to municipalities in 2001.

Responses got faster in 27 of 50 Ontario ambulance jurisdictions between 2001 and 2007. But while numerous small towns and rural areas improved, the most populated urban areas generally regressed. The widespread increase in urban response times, said Emergency Medical Services officials, hospital doctors and the province, is largely the result of systemic problems outside EMS's control. Demand for ambulance care has boomed as cities have both grown and aged, far outpacing increases in EMS budgets.

Increasingly overburdened emergency rooms, unable to quickly find hospital beds for admitted patients, have become slower to take responsibility for people brought in by ambulance, forcing paramedics to continue to provide care instead of returning to the streets to respond to new calls. "Really, the ambulance response time problem is a symptom of the underlying problem: not enough capacity within the whole system. And it's predictable," said Dr. Dante Morra, medical director of the University Health Network's Centre for Innovation in Complex Care.

"The EMS group, and how they respond, is captive to how the hospitals act. The main problem here is that we do not have enough in-patient beds to take care of sick patients. ... These EMS people, who should just walk into the emergency, drop their patient off, and then leave, are frozen in the emerg for a long period of time, because there aren't enough resources there. But the problem isn't even an emerg problem. It's a flow problem."

Growth in the use of cellular and Internet phones, which do not provide automatic location information to ambulance dispatchers, has further contributed to a slower response times. While American cellular companies were forced to adopt location technology by 2005, Canadian regulators only this month imposed a 2010 deadline.

Norm Lambert, Toronto EMS deputy chief, said some of the worsening in Toronto's times - which increased by 44 per cent since 1996, 4 per cent since 2001 - is the result of a change in philosophy that emphasizes "a smarter response" as opposed to just a rapid response. For calls about heart attacks or choking, Toronto ambulances will scream to the scene. For reports of chest pain, however, the city will attempt to dispatch a team of expert paramedics equipped with cardiogram machines, even if that team is minutes farther from the victim than another ambulance. "In the past, we sort of always looked at it that if somebody phones in and it's considered an emergency, we want to run lights-and-siren to the call and get there as quickly as possible," Lambert said. "But that's not always the case. It's not a road race."

As elsewhere, he said, "off-load delay" - the time paramedics spend waiting to hand over patients in emergency rooms - plagues the city's response system. It cost EMS approximately 180 ambulance hours per day in December 2007. The Liberal provincial government has identified emergency room wait times as a priority. The province began in 2008 to provide funding to busy hospitals to devote nurses to the reception of ambulance patients - an "interim solution," the Ministry of Health said in an email. As a result, in December 2008 Toronto EMS lost 60 fewer hours per day to off-load delays. But the demand problem continues to escalate. In York Region, calls for ambulances are up 60 per cent since the municipality took over the service in 2000, said EMS general manager Norm Barrette.

In Toronto, now the 11th-fastest responder in Ontario, calls are up 23 per cent since 2002. Over the same period, Lambert said, the number of paramedics has increased only 1 per cent. "It gets back to resources and vehicle availability ... a 1 per cent increase in paramedics with a 23 per cent increase in demand is quite a difference." Ontario's 50 ambulance providers have been required by provincial law to match their 1996 response time for Code 4 calls - less than a third of which generally turn out to be actual life-threatening emergencies - in 90 per cent of cases. In 2007, only 17 of them met their targets, which the province considers "no longer relevant" to modern realities and which municipal governments have ignored to such an extent that some of them use different targets than the Ministry of Health. Toronto officials, for example, have long used a target of 8:59; the province lists it as 8:20.

As of 2011, municipalities will be permitted to set their own response-time targets for non-life-threatening problems, which will be made public. Municipalities will be urged, but not required, to meet ministry response guidelines for life-threatening problems. Richard Armstrong, director of Durham EMS, and Lambert both said the elimination of legislated targets would not reduce the incentive to improve response times. Voters, Armstrong said, would punish local politicians who set low standards in order to claim success in meeting them. "Through the combined accountability of municipalities to the ministry and to its residents, we believe the risk of such action - the filing of `easy-win' targets - is extremely low," the health ministry said.


An Alzheimer's patient lies in a grubby hospital bathroom because of a shortage of beds. Will the elderly EVER be treated with dignity in Britain?

This is the picture that shames the NHS. An elderly Alzheimer's patient is treated in a squalid bathroom due to a chronic shortage of beds at a hospital. In what her family describe as 'an affront to human dignity', Gladys Joynes, 79, was shunted into the bathroom for several hours. The grandmother was left next to an overflowing bin, a commode and a foulsmelling walk-in bath. And with no power point in which to plug in her saline drip equipment, she swiftly became dehydrated and unresponsive.

Mrs Joynes was taken to the Royal Liverpool University Hospital last Friday after falling ill with pneumonia-like symptoms at the nursing home where she is a resident. She arrived at the hospital's emergency department in the early hours but was not examined by a doctor until around 7am. Medical staff were unable to find a bed for her and at 10am she was placed in the bathroom. At 2pm her family arrived and were led to the bathroom. One of her three daughters, Sharon Huxley, 55, a company director, said: 'I was so shocked. It was a smelly bathroom with an overflowing bin and we had to put a tray of food on the floor and feed her ourselves from that. 'I just can't believe that staff are so desensitised and complacent that they didn't think it would be a problem.'

Mrs Joynes's eldest daughter, psychologist Kathleen Huxley, 57, said: 'It is a total affront to human dignity for her to be treated this way and the Government should ensure it does not happen again. 'We believe she was cynically chosen because she is an Alzheimer's sufferer and as such would not complain. 'What if an elderly patient or Alzheimer's sufferer hasn't got a family to stand up for them?'

Shadow Health Secretary Andrew Lansley said: 'It is extremely concerning if patients are not being treated with the respect and dignity they deserve. 'I know that the hard-working staff of the NHS will do everything they can to stop this from happening, but unfortunately their hands have been tied by Labour's complacent approach to the extreme pressures placed on our hospitals during winter. Years of bungling by Labour ministers have created a terrible legacy for NHS patients.'

The Daily Mail has consistently highlighted the plight of the older generation through its Dignity for the Elderly campaign. In recent weeks, our readers have also raised tens of thousands of pounds for Alzheimer's sufferers.

Mrs Joynes, 79, ran a milliner's shop in Liverpool before marrying Merchant Navy seaman Frank Huxley. After his death in 2002 she married Stewart Joynes, a musician, who also later died. She developed Alzheimer's symptoms about four years ago.

Last night Tony Bell, chief executive of Royal Liverpool University Hospital, said the hospital was dealing with an ' unprecedented' number of cases and said an extra ward with 17 beds had been opened to cope with the strain. Mr Bell said: 'I would like to offer the patient and her family our sincere apology. It is not acceptable for a patient to be put into a bathroom. 'We are now conducting a full investigation and will identify measures to prevent it happening to other patients.' The hospital denied that Mrs Joynes had been 'earmarked' for the bathroom because her condition meant she was less likely to complain.

Mrs Joynes was last night feeling a lot better and was about to be discharged. She was diagnosed with a chest infection.


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