Category Archives: Medicaid

The Stressed and Strained Health Care Workforce

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The Institute of Medicine put out a report yesterday titled “Retooling for an Aging America: Building the Health Care Workforce.” The report discusses how the aging of the baby-boom generation will create greater needs for health care providers (of all types) who are trained in caring for the elderly with chronic conditions. The report’s recommendations fall into three categories: training, system transformation and financing. Like many reports about health system improvement, their recommendations all make sense – particularly within the context of the three categories. However, like many IOM reports, the writing by Committee process is a bit evident in that, (at least from the Executive Summary), it doesn’t seem to describe a complete plan, nor does it prioritize any of its recommendations – either in terms of funding or which actions should be done first.

In addition, while the report recognizes that the elderly in the coming decades will be healthier than those of 20 or 30 years ago, it doesn’t seem to fully address how this will change the healthcare services needed by the future elderly.

It seems to me, that one of the major challenges facing the healthcare system of the future is how to better manage chronic conditions – regardless of the patient’s age. Thus, rather than retrain clinicians (or train more caregivers) in geriatrics, there needs to be more across the board efforts in chronic care management and coordination among all levels of caregivers. This would benefit the growing elderly population – many, but not all of whom will have multiple chronic conditions – as well as the non-elderly with chronic diseases like diabetes, and the many neuromuscular degenerative diseases like MS or rheumatoid arthritis. This type of system-wide transformation seems like a better use of resources than segmental/specialized retraining and recruitment.

What are your thoughts?

Costs & Access

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Today’s Boston Globe has a lead article about the higher than expected costs for Massachusetts’ healthcare program implemented to create near universal insurance coverage. The costs of this program have been greater than expected due primarily to more people joining the subsidized health insurance program. (This greater than expected number has been attributed to underestimates of the actual number of uninsured in Massachusetts prior to the start of the Commonwealth Care program.)

The higher costs are certainly a problem for the state’s budget – although almost 50% of these costs may be paid for by the Federal government under the state’s Medicaid waiver. However, concerns about these cost overruns are in contrast to the Medicare Part D prescription drug benefit, which has been costing less than originally expected…… In part because fewer than the expected number of people have enrolled in Part D plans. Despite this, Medicare Part D has come under attack for it’s high costs – among other reasons.

The compare & contrast lesson here is that costs and access are like twin suns circling each other. One or the other can be dominant, but the two effect each other. Policy makers and pundits can praise or pummel each of these plans for their high costs or failure to cover more people, but the reality is more access will – at least initially – require additional spending. While cost containment can certainly be part of any acess expansion plan, it often requires reduced benefits or cutting reimbursements (or their growth rate) for specific clinicians, services or products, but these actions often have negative consequences down the road. Paraphrasing what the head of a national healthcare foundation stated a few months ago: “Lousy insurance can be provided inexpensively.” (And the inverse is true too – Inexpensive insurance can be lousy.)

What do you think?

US Healthcare Costs & The Economist

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The January 26th issue of The Economist had a short article about growing healthcare costs in the US. It pointed out (referencing CMS as a source), that healthcare costs had increased 6.7% from 2005-2006, but that Medicare spending had increased 18.7% What these numbers reflect, (but the Economist article only implies), is that because Medicare Part D started in 2006, spending growth shifted from private spending (and Medicaid) to Medicare. Looking at the actual data shows this to be the case:

  • Public sector healthcare spending increased 8.2% in 2006 compared to 2005; Greater than the 7.1% the previous year
  • Private sector healthcare spending o increased 5.4% in 2006 compared to 2005; Less than the 6.1% the previous year

Looking closer at the data is even more interesting. For 2006 compared to 2005:

  • Medicare spending increased 18.7% compared to the prior year’s 9.3%
  • Medicaid spending declined by 0.9% (the first decline in the history of the program) compared to a 7.3% increase the prior year
  • Spending on private health insurance increased 5.5% (the slowest rate of growth since 1997) compared to 6.2% the prior year
  • Out-of-pocket payments increased 3.8% compared to 5.2% the prior year

However, although total Medicare spending has increased, Part D spending has been tens of billions of dollars per year lower than originally projected.

What do you think this all mean for:

  • Longer term spending within the US healthcare system?
  • The political fighting over Part D?
  • Changes to Part D’s structure (e.g. donut hole), and financing?
  • Medicare’s contracting with managed care plans in Medicare Advantage (formerly Medicare+Choice)?