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Part One – The Problem with the Status Quo   

   

From the New York Times to KevinMD.com blog, every news publication you pick up (or click on) seems to have at least one headline concerning primary care and with terms like “uncompensated pressures,” “collapsing system” and “crisis point” thrown around, it ain’t lookin’ good.  The May edition of Health Affairs entirely dedicated to primary care issued warnings with only glimpses of optimism…but at least we’ve been warned.   

One of an ever-growing list of problems with primary care is a lack of time, or at least an inefficient and inadequately compensated use of physicians’ time.  In 2008, an internist’s practice, highlighted recently in the New England Journal of Medicine, took 23.7 calls per physician per day, with nearly 80 percent of such calls handled directly by physicians, on top of receiving 16.8 e-mails per day.   

As Lawrence Casalino, MD describes in a Health Affairs article, more and more of physicians’ time is devoted to patient education on chronic conditions like diabetes, heart disease, cancer and asthma, which directly contribute to the nation’s astronomically high health care costs.  Consultations not only with patients but also with specialists take up an increasingly amount of this precious resource – but with what consequence?   

Quality of care suffers During longer visits, Casalino says, PCPs can “take the time to reflect, investigate, and learn when faced with puzzling problems, or when potentially critical diagnostic and therapeutic decisions had to be made. They would engage in many telephone and e-mail communications with patients, specialist physicians, and other health care workers, such as home health nurses.”  Patients’ whole-person and long-term health needs often take a backseat to quick decisions, pressured by a waiting room full of other patients.   

Access issues become exacerbated How many times have you been in a waiting room an hour after your appointment time?  With 40 million individuals gaining coverage under federal health reform, conditions are expected to only worsen without change.   

Physicians’ burn out and experience job dissatisfaction According to an Annals of Internal Medicine article, almost half of primary care physicians report moderately or highly stressful jobs, more than a quarter report burnout, and nearly a third were at least moderately likely to leave their practices within two years.   

Not surprisingly, primary care does not appeal to students Given that less than 10 percent of med school graduates go into primary care, as the New York Times wrote, the current health care system is reaching a “crisis point.”   

Parts 2 and 3, to be posted separately over the next two weeks, will consider possible solutions states are exploring.

(Image from the Kaiser Commission on Medicaid and the Uninsured presentation)

June 18, 2010 – UPDATE: According to American Medical News, the federal government pays for 57 percent of Medicaid costs on average, varying by state. The 2009 economic stimulus package increased this average by at least six percentage points through December 31, 2010, which helped prevent significant program cuts, including reductions in physician pay.

The National Conference of State Legislatures says at least 33 states as of late April 2010 proposed or adopted budgets that included the expected (not yet passed by Congress) additional federal dollars. The Senate version of the American Jobs and Closing Tax Loopholes Act would continue enhanced Medicaid stimulus funding through June 30, 2011.

California Governor Arnold Schwarzenegger is attempting to address the state’s $18 billion fiscal 2010-11 deficit by proposing to end the state’s welfare program and require co-pays for Medicaid enrollees.

(Image from American Medical News based on Kaiser Family Foundation report)

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Original post — May 20, 2010

All states, with the exception of Vermont, are legally required to balance their budgets annually or biennially.  To accomplish this, states attempt a variety of approaches to cut spending and increase savings — and Medicaid is often one of the first state programs on the chopping block. Governor Rick Perry (R) recently released a plan to save $1.2 billion in the current Texas FY 2010-2011 budget.  With the state Medicaid program reduced by $64 million, provider reimbursement rates were not spared.  Although a two percent cut was a possiblity, some are concerned the one percent reduction taking effect September 1 will discourage providers from accepting new patients enrolled in the program.

In Missouri, the 2011 state budget approved by lawmakers assumes: (1) Medicaid costs will grow by less than originally projected; (2) savings as a result of several bills that have yet to pass the Legislature; and (3) additional savings by shuffling money among earmarked accounts.  Also in an effort to close a $350 million budget gap, lawmakers considered taxing insurance premiums for Medicaid managed care plans, but ultimately removed this provision from the final version of the bill.  Currently, only California has such a tax.

Arizona Governor Jan Brewer (R) recently signed legislation to restore $385 million to the state’s Medicaid program. The funding cut approved by the Governor in March as part of the state’s FY 2011 budget would have dropped more than 310,000 people from the program effective January 1.  The new law also reauthorizes and finances the state’s Children’s Health Insurance Program, which covers 47,000 low-income children.  The shift in state policy follows the enactment of the federal health care legislation, which requires states to continue funding health care programs at current levels or risk forfeiting all future federal funding.  Voters recently approved a ballot measure to institute a temporary one percent sales tax increase to raise state revenue.

Despite pressure from a Democratic-controlled legislature, Minnesota Governor Tim Pawlenty (R) would not approve an expansion to the state’s Medicaid program during budget negotiations.  The new health reform law enhances federal matching funds, sweetening the deal for states to enroll more participants in medical assistance programs.  Some speculation as to whether the Governor—who is not seeking reelection—is opposing “Obamacare” to boost his chances in becoming the Republican presidential candidate in 2012.

In order to maintain funding levels and increase Medicaid recipients, the Alabama Legislature tapped state funds — by transfering from other state agencies, state drug rebates, tobacco settlement funds and provider specific assessments — and utilizing available federal matching funds.  The state also is pursuing means to save money within Medicaid by using new technology to aggressively address fraud and abuse.

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Additional resources on Medicaid

Kaiser report on Medicaid funding under Health Care Reform

Other KFF Medicaid / CHIP resources

May 10, 2010 — UPDATE: Image from State Net Capitol Journal:

Friday, April 30 was one of the first deadlines established under the federal health care reform legislation.  States were required to decide whether they would work with the federal government to establish a health insurance pool for high risk individuals.

Much of the debate amounted to mere partisan ties.  Of the 29 states that agreed to create a pool, Alaska, California, Connecticut, New Jersey, South Dakota and Vermont have Republican governors.

Participating states didn’t want their residents’ health care left up to the federal government.  A spokesperson from Michigan Governor Jennifer Granholm’s office (D) says, “We know our market. We are connected to our consumers, and we can properly respond to them.”

In Connecticut, Governor M. Jodi Rell’s (R) response to Secretary Sebelius seeks a partnership between the state’s existing pool, which Connecticut formed in 1976, and the requirements of the federal legislation.   According to the Governor, “[Connecticut’s] participation will depend on the state not being forced to pick up any additional financial burdens as a result of the new venture.”

According to the Washington Post, 19 states will not join HHS in creating a state pool:

  • Alabama 
  • Arizona 
  • Delaware*
  • Florida 
  • Georgia 
  • Hawaii 
  • Idaho 
  • Indiana 
  • Louisiana 
  • Minnesota 
  • Mississippi 
  • Nebraska
  • Nevada
  • North Dakota
  • South Carolina
  • Tennessee*
  • Texas
  • Virginia
  • Wyoming*

* the 3 states with Democratic governors

Arizona Governor Jan Brewer (R) explained her decision not to participate by saying, “In light of Arizona’s existing fiscal challenges, I cannot commit the state to a program without confidence that there is funding available to sustain it.”

Expressing similar concerns in a recent press release, Wyoming Governor Dave Freudenthal (D) says, “The state’s involvement would be an unnecessary addition to the process that would result in redundant administrative costs and unnecessary delays in the implementation process.”

Always the rebels, Rhode Island and Utah—both with Republican governors—are undecided.

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Additional resources on:

38 states with established high risk pools

State and federal pools 

HHS available funding for the pools by state

HealthCare.gov’s High Risk pool site

June 2, 2010 — UPDATE: In a recent statement, Vermont Governor James H. Douglas (R) laid out his conflicting opinions—on the state’s 2010 universal health care legislation—which lead to the ultimate decision not to sign or veto the measure.  Included in the letter, SB 88:

+ Shows promise for quality improvement and cost reduction – representing the culmination of years of work by revising the state’s existing program, Blueprint for Health.

+ Articulates the components of the integrated medical home and community health team payment reform model.

+ Requires insurance carriers to participate in the statewide expansion of the Blueprint as a condition of doing business in the state.

+ Establishes interoperable connectivity through the state Health Information Exchange and a one-year primary care work force development committee.

+ Charges the Department of Banking, Insurance, Securities and Health Care Administration with limiting the rate of growth in hospital spending and insurance premiums.

– Has caused concerns among health care professionals regarding low-income residents’ access to free prescription samples.

– Mandates studies that are a “wasteful expense of time and scare resources, as Vermont would be prevented by the federal health care reform law from implementing any of the new ‘designs’ until 2017 at the earliest.”

– Jeopardizes Vermont’s participation in the CMS Advanced Primary Care Practice Medicare demo.

May 17, 2010 — UPDATE: Image from the Kaiser Commission on Medicaid and the Uninsured:

In Vermont, a state with more than 90 percent of residents insured and ranked #1 in the Commonwealth Fund’s most recent State Scorecard on Health System Performance, the legislature is close to adopting a change to the health care delivery system not accomplished by Congress—universal coverage.   Both chambers of the state’s Democratic-controlled General Assembly passed different versions of SB 88—the original version of the bill, passed by the Senate, would establish a single-payer system.  The House amended the legislation, replacing single-payer with a public option, which would allow the state to create a health insurance program to compete with private payers.

Legislators currently are working out the details in a conference committee.  Governor Jim Douglas (R) has not yet indicated whether he will sign either version of the bill if it reaches his desk.  The governor supports certain cost-containing provisions of the legislation but does not approve of either bill in its entirety.  The state could not pursue such plans until 2017 as required by the new federal health care law.

Vermont, however, isn’t alone in its efforts.  Minnesota SF 118 was introduced in 2009 but has received little attention from the Legislature in 2010.  During the current legislative session, HB 767 and SB 682 were considered by the Maryland General Assembly but ultimately were reported as unfavorable by their respective initial committees of referral.

California also is considering a single payer bill, SB 810, which passed the state Senate and is under consideration in the Assembly.  In a recent press release concerning federal health reform, Governor Arnold Schwarzenegger (R) indicated that he supports reform and expanding coverage.  However, given the state’s current economic condition, adoption in 2010 seems unlikely.

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Additional resources on universal health care in Vermont

History of Health Care Reform Legislation in Vermont

Details of Vermont’s Premium Assistance Program & Buy-In Option


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--Robin

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