MA: Those nasty costs snarling health insurance brainstorm

And it's only just beginning. Wait until it gets more and more bureaucratized. Costs grow in such systems; they don't decline

Soaring healthcare costs, combined with the recession, are threatening to undermine the gains from Massachusetts' 2006 healthcare overhaul, according to the third annual "Update on Health Reform in Massachusetts" published today. The survey of roughly 4,000 adults found that, after seeing initial gains in affordability, an increasing percentage of residents are now reporting problems paying medical bills. It also found that a rising number of residents, especially those with lower incomes, are reporting that they did not get needed care because of costs, which are rising faster than inflation.

The cost factor is likely to be central to a discussion today as healthcare leaders come to Boston, in part for a briefing on the findings. Massachusetts' pioneering experiment is being closely watched as a potential model for a national health insurance mandate. "You can see Massachusetts as a kind of crystal ball for what some of the implementation challenges might look like in national health reform . . .," said Drew Altman, chief executive of the Kaiser Family Foundation, a California-based nonprofit that researches healthcare trends.

While the state is facing cost challenges, he said, implementation of near-universal coverage in 2006 still put consumers here in a better position than in other states. "We should be lucky enough to have those problems [nationally]," Altman said of the challenges outlined in the Urban Institute survey. "If we get to a point where everyone is insured, then we can move on to worry about the affordability of care."

The survey was conducted by the Urban Institute, a social policy think tank, and funded by the Blue Cross and Blue Shield of Massachusetts Foundation, Robert Wood Johnson Foundation, and the Commonwealth Fund. It found that public support for the state's healthcare initiative is holding strong. Overall, about 70 percent of those surveyed in 2006 through 2008 said they back the first-of-its-kind law.

The survey, published in the health policy journal Health Affairs, identified many bright spots in the state's massive new system, which requires nearly everyone to have health insurance or pay a hefty tax penalty. In the United States, Massachusetts now has the lowest percentage of uninsured residents, less than 3 percent, compared with an average of about 15 percent elsewhere. That coverage helped fuel a significant boost in the percentage of people who have been able to visit doctors and dentists, the study found.

Roughly 91 percent of residents said they have a regular healthcare provider, compared with 86 percent in 2006, when the health law went into effect. And three quarters of those surveyed said they had been to a dentist in the past year, up substantially from 68 percent just three years ago. The study compares results from 2006, when many of the key elements of reform were just getting underway, to the fall of 2007 and 2008. Overall, it reveals striking gains in access to care and affordability in the first year of the state's near-universal coverage plan.

But by the fall of 2008 - when the recession started taking a toll in Massachusetts - the gains began to erode. The latest survey shows that 17.9 percent of residents reported that they had medical bill problems in 2008, up from 16.5 percent in 2007. Still, access to care is "generally good in Massachusetts and health reform made it better," said study author Sharon Long.

The affordability problems that have started to resurface, she said, can not be blamed on the state's overhaul, but on a much larger and troubling national trend. "Healthcare costs, in general, are increasing faster than inflation," Long said.

One number that remained unchanged, the report found, was the roughly 15 percent of Massachusetts residents who reported throughout the surveys that they used hospital emergency rooms for nonurgent care. One key goal of the state's initiative was to drive down ER use - which can be expensive - by extending insurance to nearly everyone, so they could regularly visit their family physicians. When asked why they used ERs for nonemergency conditions, roughly 55 percent of the adults reported going because they were "unable to get an appointment as soon as one was needed," the report found.

Difficulties finding a physician were much more common for low-income than higher-income residents. And adults with state-subsidized health insurance were much more likely to be told that a physician was not taking their type of insurance - 24 percent - compared with those with private insurance, 7 percent. [Isn't that precisely what the whole scheme was supposed to eliminate?]

But cost remained the overarching concern. A special state commission, created last year, is racing to identify ways to slow soaring healthcare costs in Massachusetts, where spending is growing by more than 8 percent annually, driven largely by the high price and heavy use of hospitals.

The high price of healthcare is a hurdle the Boston-based Access Project hears about daily from families who increasingly find that medical bills are eating larger portions of their budget. Yet the project's executive director, Mark Rukavina, said that while the percentage of Massachusetts residents reporting problems is creeping up toward 20 percent, again, that figure is closer to 28 percent nationally. "We have a much more generous safety net here in Massachusetts than is the case in most other states," he said.

That safety net, expanded during the state's healthcare overhaul, extended help paying insurance to more working poor families and also provided more money to community health centers and, until recently, urban hospitals that typically serve poorer neighborhoods.

"At the same time," Rukavina said, "the fact that nearly one in five people in Massachusetts are accruing medical debt in such a large, insured population is unacceptable. [Isn't that precisely what the whole scheme was supposed to eliminate?] It certainly is a measure that policy makers in Massachusetts should pay attention to, to ensure those medical debt numbers are declining and not increasing."

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Patients forced to wait hours in ambulances parked outside British hospital emergency departments

Ambulance chiefs have warned that lives are being put at risk "on a daily basis" by long delays allowing patients into Accident and Emergency units

An investigation by The Sunday Telegraph has found that thousands of 999 [emergency] patients are being left to wait in ambulances in car parks and holding bays, or in hospital corridors – in some cases for more than five hours – before they can even join the queue for urgent treatment. Experts warn that hospitals are deliberately delaying when they accept patients – or are diverting them to different sites – in order to meet Government targets to treat people within fours hours of admitting them.

The extent of the problems have been revealed in correspondence between senior health officials, obtained under the Freedom of Information Act, which also show their serious concerns about the dangers the delays pose to patients. A letter by Sir Graham Meldrum, chairman of West Midlands Ambulance Service, sent to hospital chief executives last November warns that patients are "being put at risk on a daily basis", with 7,600 patients a month facing delays of more than 30 minutes – a situation which has since deteriorated, with more than 8,000 such delays in March.

The documents also reveal an investigation into the death of a patient who waited three hours to be seen by A&E staff after being taken by ambulance to The Royal Wolverhampton Hospitals Trust.

On two occasions in January, ambulances took more than five hours to unload patients at Queen's Hospital in Romford, Essex. In the same month, journeys to Weston-super-Mare hospital in Somerset were repeatedly held up, with more than a dozen waits of two hours, including delays of four and five hours.

Dozens of A&E units refused all 999 arrivals for periods of several hours, on hundreds of occasions, forcing crews to take desperately sick patients on lengthy journeys, and shifting pressures to other hospitals, the documents show. In the course of six months, hospitals in the West Midlands ordered a "divert" on more than 450 occasions, closing A&E units to all 999 arrivals for hours at a time. During a six-week period last autumn, hospital chiefs in the north east of England closed casualty units to 999 arrivals on 34 occasions, for up to 19 hours at a time.

Internal documents from the London Ambulance Service reports of extensive delays throughout December: "Ambulances have queued in large numbers for up to five hours to unload, and two hour delays were relatively common," it says.

The briefing note, written in January, says hospitals were so short-staffed that ambulance staff were regularly forced to look after multiple patients simultaneously, so that colleagues could respond to 999 calls.

Delays to patients arriving to A&E by ambulance are increasing in many parts of the country as hospitals struggle to cope with a massive increase in the number of emergency hospital admissions since family doctors stopped providing routine out-of-hours care. Since the changes were made five years ago, the number of emergency hospital admissions has risen by 30 per cent, while the number of beds fell by more than 20,000. More than 100,000 ambulance journeys were delayed at casualty units by more than 30 minutes in the month of March alone – an increase of 18 per cent in 12 months.

Mike Penning, the shadow health minister, said: "Labour's tick box culture is forcing staff to prioritise the four hour target ahead of ensuring patient get the treatment they need. "It is madness that all of this has happened at a time when the number of people being admitted to A&E units is soaring."

Ambulance staff and patients groups said hospitals were routinely ignoring NHS guidance which says the "clock" for the A&E four hour wait should start 15 minutes after an ambulance arrives on site. Katherine Murphy, from the Patients Association, said: "We are hearing increasing numbers of stories of seriously-ill patients lying in pain in ambulances, worried out of their mind, while others are taken on long journeys because casualty units have been closed. "The guidance may say they should not be delayed, but the A&E target is the one that comes with financial penalties attached, and it is the one hospitals care about."

Most ambulance trusts measure delays by "turnaround time" – the time between the ambulance's arrival at A&E and its availability for the next call. It includes any time cleaning or restocking the vehicle, which should take no more than a few minutes. Research by one ambulance trust found three quarters of delays occurred before the patient was handed over to staff, and that 84 per cent of those cases were connected to bed shortages.

Sam Oestricher, ambulance representative for trade union Unison, said ambulances were being treated "as mobile waiting rooms". He said: "Our members are spending hours effectively babysitting patients, who have been rushed to A&E departments because they need to be seen urgently. "It leaves patients and crews in a terribly anxious, frustrating situation, and it greatly increases the risks."

Jim Wardrope, A&E consultant at Sheffield Northern Hospital and past president of the College of Emergency Medicine said: "The whole system is running hot, so that when the pressure comes, it backs up quickly and we end up desperately searching for trolleys."

Health Minister Ben Bradshaw said "severe action" would be taken against any hospitals found to be keeping patients in ambulances in an attempt to cheat on the A&E targets. He added: "The vast majority of hospitals up and down the country are meeting the four hour target without keeping people waiting in ambulances."

More than 4,800 people have backed The Sunday Telegraph's Heal Our Hospitals campaign, which is calling for a review of hospital targets to make sure they work to improve quality of care.

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