Category Archives: Obamacare
Study Shows the ACA Will Not Lead Physicians to REDUCE the Number of Medicaid Recipients, Supply and Demand, and Get Me My Pokemon Cards!
A recent “study” by Lippincott, Williams, and Wilkins is entitled “Doctors Likely to accept New Medicaid Patients as Coverage Expands.” (I may or may not have belly laughed when I read that title). See my blog “Medicaid Expansion: Bad for the Poor.”
The beginning of the article reads, “The upcoming expansion of Medicaid under the Affordable Care Act (ACA) won’t lead physicians to reduce the number of new Medicaid patients they accept, suggests a study in the November issue of Medical Care, published by Lippincott Williams & Wilkins, a part of Wolters Kluwer Health.”
The study was published October 16, 2013. (BTW: From what I can discern from the article, the title actually means that physicians will be forced to accept more Medicaid patients because there will not be additional physicians accepting Medicaid). Odd title.
According to this study, the ACA will not cause doctors to reduce the number of Medicaid patients. What does this study NOT say? Nothing indicates that the ACA, which will allow millions more of Americans to become eligible for Medicaid, will cause MORE physicians to accept Medicaid. Nor does the study state that the ACA will cause physicians to accept MORE Medicaid recipients.
Am I the only person who understands supply and demand?
Anyone remember the 1999 Toys.R.Us.com debacle? On-line shopping was just heating up. I was in law school, and I, as well as millions of others, ordered Christmas presents on-line from Toys R Us. I ordered a bunch of Pokemon trading cards for a nephew…remember those? Me either…I just bought them for my nephew. Toys R Us promised delivery by December 10th.
Toys R Us was, apparently, a very popular store that year, because Toys R Us is unable to package and ship orders in time to meet the December 10th deadline. Nor could Toys R Us meet the deadline of Christmas. Employees were working through the weekends. About two days before Christmas, and just in time to create last-minute havoc during Christmas time, Toys R Us sends out thousands of emails saying, “We’re sorry.”
Obviously, Toys R Us was slammed by the media, and thousands of consumers were highly ticked off…including me.
I had to go to the mall (a place to which I detest going) on Christmas Eve (the worst day to shop of the entire year, except Black Friday, which I also avoid) to get my nephew a present.
Toys R Us learned its lesson. It outsourced its shipping to Amazon.com, which, obviously, has the whole shipping thing down pat.
50 million people are currently eligible for (and receive) Medicaid services (these numbers are purely fictional, as I do not know the real numbers…I basically estimated 1 million per state, which, I am sure, is an underestimation). Say there are 3.5 million physicians that accept Medicaid (70,000/state, which is probably a high estimation, when we are considering only physicians and not health care providers, generally).
Our hypothetical yields 14.28 Medicaid recipients per physician. Or a ratio of 14.28:1.
Media state that, if NC expanded Medicaid, that 587,000 more North Carolinians would be eligible for Medicaid if NC expanded Medicaid.
Using NC as a state average, 29.35 million more people would be eligible for Medicaid if all states expanded Medicaid (obviously not all states are expanding Medicaid, but, in my hypothetical, all states are expanding Medicaid). This equals a total of 79.35 million people in America on Medicaid.
But….no additional physicians….
Because, remember, according to the Lippincott study, the upcoming expansion of Medicaid under the Affordable Care Act (ACA) won’t lead physicians to reduce the number of new Medicaid patients they accept. But the ACA does not lead more physicians to accept Medicaid or physicians to accept more Medicaid patients.
This brings the ratio to 22.67:1. 8 1/2 new patients per one physican…and, BTW, that one physician may not be accepting new Medicaid patients or may not have the capacity to accept more Medicaid patients. It’s a Toys R Us disaster!!! No one is getting their Pokemon trading cards!!!
Why not? Why won’t the ACA lead more physicians to accept Medicaid? Why won’t the ACA lead physicians to accept more Medicaid recipients?
Didn’t the ACA INCREASE Medicaid reimbursement rates? Wouldn’t higher reimbursement rates lead more physicians to accept Medicaid and physicians to accept more Medicaid recipients??? I mean, didn’t you hear Obama tout that Medicaid rates would be increased to Medicare rates? I know I did.
One average, Medicaid pays approximately 66% of Medicare reimbursement rates. Obviously, every state differs as to the Medicaid reimbursement rate.
The ACA, however, slashes the Medicare budget by 716 million from 2013 to 2022. The cuts are across-the-board changes in Medicare reimbursement formulas for a variety of Medicare providers, including hospitals, nursing homes, home health agencies, and hospice agencies. Furthermore, the ACA creates the Independent Payment Advisory Board (IPAB), which is intended to determine additional Medicare reimbursement rate cuts. IPAB will be creating a new Medicare spending target; it will be comprised of 15 unelected bureaucrats. The board will be able to make suggestions to Congress to reign in Medicare spending, and one of the biggest tools the IPAB has is cutting physician reimbursement rates.
It’s the old smoke and mirrors trick…We will raise Medicaid rates to Medicare rates…pssst, decrease the Medicare rate so we can meet our own promise!!
While I am extremely happy to hear that, at least according to the Lippincott study, the ACA will not lead physicians to reduce the number of Medicaid patients they accept, I am concerned that the ACA will not lead more physicians to accept Medicaid and physicians to accept more Medicaid recipients.
In fact, the study states that “[t]he data suggested that changes in Medicaid coverage did not significantly affect doctors’ acceptance of new Medicaid patients. “[P]hysicians who were already accepting (or not accepting) Medicaid patients before changes in Medicaid coverage rates continue to do so,” Drs Sabik and Gandhi write. I bet the Drs. did not ask, “Would you continue to accept Medicaid, if you knew that your practice would endure more audits, post-payment reviews, possible prepayment reviews, and, in general, suspensions of reimbursements if anyone alleges Medicaid fraud, irrespective of the truth?”
Which tells me…hello…more Medicaid recipients, not more doctors!! Even if the physicians already accepting Medicaid COULD accept additional Medicaid recipient patients, each physician only has a certain amount of capacity. To my knowledge, the ACA did not increase the number of hours in a day. Supply and demand, people!!
Where are my Pokemon cards???!!!
Representative David Price spoke as the Keynote Speaker at the North Carolina Society of Health Care Attorneys annual meeting yesterday morning. Since Representative Price was actually up in Washington D.C. during the shutdown, it was very interesting to hear him speak. His opinion, as one would expect from his ideology, was that the shutdown was idiotic and unnecessary.
What I found interesting was how he described the relationships between congressmen and women today versus in the 90s. Remember, he has represented NC in Washington for more than one decade. He described the relationships, even across party lines, as more cordial in the 90s than today’s relationships. I wonder why our legislative body has become more segregated.
In the afternoon session, Linwood Jones from the North Carolina Hospital Association spoke about recent legislative action. This legislature was not good to hospitals. As Linwood described the legislative session this year…”It was all about Medicaid.” (I know you were wondering how the NC Society of Health Care Attorneys annual meeting was going to be germane to Medicaid). According to Mr. Jones, the Medicaid budget was the primary factor in almost all budget cuts. And what entities get most of Medicaid funding?
Duh…Hospitals. Hospitals are the biggest providers in the state, and, in some areas, the biggest employers.
Our Medicaid budget is approximately $13 billion.
Remember…36 million a day is what we spend on Medicaid in NC.
How much of that $13 billion Medicaid budget goes to hospitals? According to Kaiser Family Foundation, 25.7% for inpatient care. Or $3.341 billion annually. Or $9.252 million a day!!
Including outpatient care? 38.7% Or $5.031 billion annually. Or $13.932 million a day!!
According to the handy-dandy Wikipedia website, North Carolina has 126 hospitals in 83 counties. For those of you who never went to 6th grade in North Carolina, we have 100 counties in NC. (In the 6th grade, if you grew up here, you learn all about North Carolina geography, which apparently didn’t stick, because I still get lost).
That is $13.932 million dollars a day going to 126 hospitals in NC. That is a lot of money!!!
Does Medicaid matter to hospitals?
Heck, yes!! Remember, a hospital cannot turn anyone away, including Medicaid recipients and uninsured. Add the fact that the mentally ill in NC are not getting medically necessary services because our managed care organizations (MCOs) have monetary incentives to NOT provide the expensive mental health services; PLUS the fact that Medicaid reimbursements are painfully low, which leads to many physicians not accepting Medicaid, and you get the sad sum of Medicaid recipients ending up in emergency rooms of hospitals.
Don Dalton, a spokesman for the Hospital Association, said that statewide about 46 percent of hospitals’ revenue comes from Medicaid. (See Rose Hoban’s article).
But, hospitals don’t make a huge profit. Especially on Medicaid recipients.
On average, Medicaid reimburses hospitals 80% of the actual cost for hospital services.
But this year, the General Assembly created a budget in which the 80% will be reduced to 70%.
Medicaid reimbursements were already bad. But now, the Medicaid reimbursements will be 10% worse. Subtract 10% from the $13.932 million dollars a day…
This is not a good thing for hospitals nor Medicaid recipients.
When Representative Price was speaking, a woman raised her hand with a question/vignette. She said that she and her friends had gotten on the health care exchange (Obamacare) (Healthcare.gov) website and “shopped” for health insurance. She said that all the people who signed up for health care exchange (because it is mandated and there is a penalty for not having insurance) had their premiums increase anywhere from 300%-800%. Although Rep. Price made a good point, that they all should have contacted Blue Cross Blue Shield (BCBS) and asked why BCBS dropped that particular insurance plan. Nonetheless, the woman harped on the fact that Obama had promised, “You like your insurance? You can keep it! You like your doctor? You can keep him/her!” (I added the “her.”)
So, here we are…with low Medicaid reimbursements to begin with, high medical costs, and the General Assembly reducing the Medicaid rates for hospitals by 10%.
Incentive to accept Medicaid recipients? I think not…but hospitals have no choice.
Physicians and other Medicaid providers have the choice as to whether to accept Medicaid patients, but hospitals? No choice there. Hospitals must accept Medicaid recipients. Mandatory!!!
In my opinion, the very first step toward fixing the Medicaid system is RAISING Medicaid reimbursement rates.
Sound counterintuitive? Yes, I agree it sounds counterintuitive. But think about Medicaid like this:
If you agree with me that Medicaid is an entitlement and that the Medicaid budget is way too high, but that all Medicaid recipients deserve quality health care…if you agree with all that…
And you also agree with me that it is drastically more expensive for Medicaid recipients to go to the emergency room (ER) for health issues that could be solved in a family physicians’ office…if you agree with all that…
Then we would save Medicaid dollars by increasing (drastically) the Medicaid reimbursements. If doctors had a monetary incentive to accept Medicaid, then more doctors would accept Medicaid (Logic 101). If more doctors accept Medicaid, then more Medicaid recipients have the ability to go see a doctor. If more recipients have more office visits then ER visits drop. If more unnecessary ER visits drop, then the State pays less money to the hospitals, which is an extremely higher rate (even with the 10% reduction) than a higher Medicaid reimbursement to physicians. Cut the $13.932 million a day to hospitals, not by decreasing the reimbursement rate, but by fewer Medicaid recipient going to the ER…instead have the recipients receive quality care outside the hospital, thus saving money…
By reducing the Medicaid reimbursements to hospitals, the legislature did decrease the Medicaid budget, but not in a way that intelligently attempts to fix the system. The same amount of Medicaid recipients will be going to hospitals. Since the hospitals cannot turn anyone away, reducing reimbursements to hospitals merely hurts the hospitals.
Want to decrease the Medicaid budget? Increase Medicaid reimbursements (drastically) to Medicaid providers. More providers accepting Medicaid means more recipients receiving quality care and NOT checking into the ER….
Money saved intelligently. Too bad the legislature didn’t ask my opinion prior to slashing Medicaid reimbursement rates.
On September 27, 2013, the Centers for Medicare and Medicaid (CMS) approved Arkansas’ request to begin a Private Option demonstration. Arkansas is the first state to receive approval for a “private option” as an alternative to Medicaid expansion.
Remember my “A Modest Proposal?” Providing Medicaid recipients with private insurance….
Basically, Arkansas will accept federal money for Medicaid expansion, but instead of expanding Medicaid, Arkansas will purchase private insurance for these “newly eligible” Medicaid recipients, adults who make $15,280 or less. Those individuals who earn up to 138 percent of the poverty line — or $15,415 per year — would purchase subsidized private insurance through the state’s insurance exchange. From my understanding, the federal funds will cover the newly eligible recipients’ premiums and any co-pays above the co-pays set by statute.
Coverage is to begin January 2014, although enrollment opened today.
Arkansas estimates that 225,000 individuals will be eligible for the demonstration project. Iowa has submitted a similar request for a “private option” program. CMS has not yet ruled on Iowa’s request. Likewise, Pennsylvania Governor Corbett submitted a request to CMS based of the Arkansas model.
It seems that some Republican governors are thinking outside the box to provide health care coverage for additional Medicaid recipients without merely providing the newly eligible simply a Medicaid card. Because, remember, receiving health care is completely different from receiving health insurance. Having insurance does not always allow Medicaid recipients to receive health care. Obviously, many provider refuse to accept Medicaid. But these newly eligible Medicaid recipients will have health care…with private insurance…just like I have…or you have….
And I ask you…What is more important….handing a person a Medicaid card?…Or providing that person with quality health care?
Who likes a tie (or a draw) in sports? Not me!
In the last few years, I have noticed that, increasingly, parents of young children in sports are not keeping score. You can go to a ten-year-old’s soccer game and ask the score, only to hear, “Oh, we don’t keep score. We believe that everyone is a winner.”
Without stepping up onto my soapbox, let me just say I think “scoreless games” are as worthless as the nonexistent scores themselves. I mean, come on, our country was founded on doing your best, working hard and receiving just compensation for hard work. (Not to mention that I grew up participating in competitive sports (gymnastics), and I truly believe that my participation in a competitive sport has contributed to my work ethic today).
Even Ashton Kutcher, during a recent Teen Choice Awards speech, surprised many with a speech about hard work and that opportunity looks a lot like hard work.
But, it is a different story when the teams actually keep score and the end result is still a draw. When you keep score and the result is a draw, generally, that means that two teams with similar ability played and both played hard and both kept one another at bay.
Like the 1996 hockey game between Colorado Avalanche and Buffalo Sabres…both teams bragged it had the best goalie. They played (and kept score) and recorded a shutout (0-0) tie game. Apparently, both goalies were equally great.
Going to Medicaid expansion. That’s an old topic for North Carolina, right? But not for the U.S…
Yes, Governor McCrory nixed NC Medicaid expansion in NC. Which, BTW, in my humble opinion, was a smart choice. But, before everyone starts screaming cuss words at the computer screen, read my blog: Medicaid Expansion: Bad for the Poor.
But, remember, other states are still wrestling with the idea of Medicaid expansion.
Decisions are being made every day. Just yesterday, Wyoming lawmakers announced that they were considering an alternative to Medicaid expansion. (As in, it would pretty much be Medicaid expansion, but named something else to avoid the appearance of concurring with the Affordable Care Act (ACA)).
So what is each state’s stance on Medicaid expansion?
Go figure….close to a tie.
Here is each state’s stance on Medicaid expansion as of July 26, 2013:
So the score is 28-22 (counting those states “leaning” as decided). Not exactly a tie, but pretty close.
The tie is especially interesting when you consider that the “score” of Republican to Democrat governors in the U.S. is 30-20.
The red states denote Republican governors; the blue states elected Democratic governors.
Although, remember, 18 states still have not decided whether to expand. Which means, the score could be 46-4 or 10-40. Whew….neither of those scores is a tie!
So what does this “close to a tie” in Medicaid expansion mean? Especially with the majority of governors nationwide affiliated as Republicans…Anything?
But, at least, we are keeping score. At least both teams are playing to the best of its ability. In the end, there will be a winner.
As there should be.
Hopefully, in the end, the winners will be the Medicaid recipients. (One can hope).
For anyone interested, the Triangle Business Journal, is hosting a Health Care symposium discussion, which will mainly revolve around the issues affecting employers, health care providers, insurance and benefits consulting companies as everyone gets ready for the implementation of federal health care law in 2014. I am sitting as a panelist for the discussion.
Here is the link: http://www.bizjournals.com/triangle/event/87901#eventDetails
Here is a description:
2013 Health Care Today
How will the upcoming health care changes affect small businesses and their employees? Join us to find out!
- When: Thursday, May 2, 2013,7:30am-9:30am Add to my calendar
- Where: Sheraton Imperial4700 Emperor Blvd. Durham NC 27703
- Suggested Dress: Business
Triangle Business Journal subscribers save up to 10% per ticket
|Ticket Type||Seats per ticket||Price per ticket||Quantity|
|1 2 3 4 5 6 7 8 9 10||Register|
2013 Health Care Today: Your Impact, Your Dollars
How will the upcoming changes affect small businesses and their employees?
The symposium discussion will mainly revolve around the issues affecting employers, health care providers, insurance and benefits consulting companies as everyone gets ready for the implementation of federal health care law in 2014.
Moderator: Triangle Business Journal Health Care Reporter Jason deBruyn
- Dr. Allen Dobson, President and CEO of Community Care of North Carolina
- Rick Kelly, Senior Vice President of Progressive Benefit Solutions
- Adam Searing, Director of Health Access Coalition for the North Carolina Justice Center
- Brad Wilson, President and CEO of Blue Cross and Blue Shield of North Carolina
- And me:) Knicole C. Emanuel, Medicaid Attorney
More panelists to be announced soon…
Join Triangle Business Journal as a panel of experts discuss these very important changes in the health care rules that could have a profound impact on our economy.
One week has passed since the infamous federal sequester deadline. Let’s re-assess: Does the Sequester Affect Medicaid?
Remember, according to the federal government, the Medicaid budget was exempt from the across the board slashes in budgets.
However, the following sequester cuts will have a direct effect on Medicaid:
- $44 million cut from the Centers for Medicare and Medicaid Affordable Insurance Exchange grants;
- $168 million cut from Substance Abuse and Mental Health Services Administration;
- $75 million cut from the Aging and Disability Services Programs;
- $17 million cut from Housing Opportunities for Persons with AIDS;
- $19 million cut from Housing for the Elderly;
- $57 million cut from the Health Care Fraud and Abuse Control;
- $51 million cut from the Prevention and Public Health Fund; and
- $27 million cut from the State Grants and Demonstrations.
Let’s analyze the first cut: $44 million from the Affordable Insurance Exchange. The Affordable Insurance Exchange grants is an intregal part of the Affordable Care Act (ACA). The ACA directs the U.S. Department of Health and Human Services (“HHS”) to provide states with funding to support planning, implementation and operation of state exchanges. Already every state except Alaska received an initial allotment of up to $1 million in planning grants in the fall of 2010. North Carolina already received $86,357,315.
As I am sure everyone is aware, NC has opted out of Medicaid expansion. However, the ACA requires an insurance exchange program. On February 12, 2012, Gov. McCrory announced NC’s intent to allow the federal government to operate the exchange.
So, now, our health care exchange program will be only as good as the federal government makes it, which is a scary prospect in my mind, especially in light of the near certain fact that the federal government is in such financial stress that it will not be able to uphold its end of the bargains under the ACA. Already?
I wonder if the states accepting the federal dollars for Medicaid expansion are re-thinking those decisions.
Last week, Charles P. Blahous, III, who has served as a public trustee for Social Security and Medicare since 2009, said there was a “near certainty” that the federal government would not provide the full level of Medicaid funding now scheduled under law.
Blahous also stated that “to return the federal budget to sustainable historical norms in the absence of any cuts in the growth of Medicaid and the new health exchanges would require all other non- interest spending to be cut by nearly one-quarter by 2037 relative to projected levels, and by roughly 15 percent relative to current levels in relation to GDP.”
And: “This is probably unrealistic.”
Despite the budget cuts due to the sequester, the federal government is STILL in severe financial stress.
So as to, the ultimate question posed in the beginning: “Does the Sequester Affect Medicaid?”
The answer: A resounding yes.
Summary: (Please note: The word “impact” should carry a pejorative connotation. When reading, feel free to add in “negatively” each time you read “impact.”)
The sequester impacts health care. Medicaid is health care. The sequester impacts Medicaid.
The sequester impacts the health care exchange program. The federal government is in financial stress. The federal government will control NC’s health care exchange. NC’s health care exchange will be in financial stress.
I randomly picked up Wednesday’s copy of “Indy” in a coffee shop. The title caught my eye, “The Legislature’s Disgraceful Two Weeks.” I mean, Wow. That’s quite a title! So, of course, I had to pick it up.
I turned to page 7 and read the “Block Obamacare” paragraph and almost choked when I read the paragraph. The statements written were patently untrue. Forgive my naivety, but isn’t there some sort of oath for journalists to at least attempt to state the truth?
I felt obligated to explain how the Indy failed to publish the correct facts.
First sentence: “The Affordable Health Care Act would extend Medicaid (government health insurance for poor people) to 500,000 North Carolinians who don’t currently qualify – at essentially no cost to the State.”
No cost to the State??? Seriously? Where did these facts come from??? Reality: According to an economic study in the New York Times, should North Carolina expand Medicaid, between 2014-2019, North Carolina would have to contribute approximately $1.029 Billion. Yes, Billion!!! If you think $1.029 billion is “essentially no cost,” please send me a check for a few million. Make it out to my name please.
Second sentence: “Nonetheless, Senate and House Republicans have said they don’t want the money.”
What? They don’t want the money? The sentence makes it sounds like the federal government is passing around a basket full of money and asking the states to take what they want. Not only is this sentence incorrect, it is misleading. There is no free basket full of money for everyone. And no one in the General Assembly (I feel confident this is correct, although it has not been corroborated) is refusing free money.
The choice to not expand Medicaid is predicated on a plethora of reasons. One reason off the top of my head, is that, according to the recent audit conducted on DMA, yearly, DMA spent approximately $648.8 million on administration costs. Proponents of Medicaid expansion have said that Medicaid expansion would create jobs. Guess where? DMA. Let’s ADD to the administration costs instead of reeling them in….Really???? This is similar to the mentality I had as a teenager: I know I’m doing something wrong, but unless my parents find out, so what?
Third sentence: “The bill to block the expansion is en route to the House with the backing of Gov. Pat McCrory.”
Ok, that was the only sentence somewhat true with one large difference. In reality, Gov. McCrory has been extremely hesitant to rush the decision of whether to expand Medicaid. He urged lawmakers not to rush.
So after reading the paragraph preceding the article, I was terrified to actually read the article. But much like a train wreck happening in front of you, I couldn’t resist.
My favorite line: “It’s long been apparent that Republicans should have no credibility on the question of fiscal prudence.”
Once I read that sentence, I laughed out loud. Obviously, this journalist suffers from extreme parochial vision and has made the topic a “Republicans v. Democrats” debate. People, who cares what political side you are on? Medicaid recipients deserve quality care and enough health care providers to care for the entire Medicaid population (currently around 1.5 million in North Carolina). Right now, in North Carolina, Medicaid recipients cannot find physicians, psychologists, dentists, or specialty physicians willing to accept Medicaid patients.
Enable the 1.5 million North Carolinians, to whom we owe a duty to provide health care, to receive quality health care. Personally, if I were on the cusp of receiving Medicaid, and I knew that, through Medicaid expansion, I could get the Medicaid card, but not find a doctor willing to accept me (or if I found one to accept me that I wouldn’t get all the tests or procedures that someone with private insurance would undergo), I would choose to say, “No, to unequal health care.”
Medicaid eligibility. Just the phrase itself raises so many questions:
The Medicaid system, like our tax system, is esoteric. So, the purpose of today’s blog is set out some much-needed facts.
First, Medicaid eligibility, as of today, can be found in an extremely detailed, yet hard to understand, chart on the Department of Health and Human Services‘ (DHHS) website. Click here. But don’t say I didn’t warn you.
Under the federal health care law, should NC choose to accept the federal dollars, eligibility for government-backed Medicaid may be expanded in 2014 to anyone making below 138 percent of the federal poverty level. Here’s who would qualify:
Family size: Income level
1 person: $15,414
2 people: $20,879
3 people: $26,344
4 people: $31,809
So there is it: The Medicaid eligibility requirements currently and if NC accepts federal dollars.
It is important to note that, on Tuesday, February 12, 2013, Governor McCrory endorsed a measure to prevent major components of the federal health care law from taking effect in North Carolina. Merely hours after McCrory’s announcement, the measure won easy approval in a House committee. The full House will consider the legislation quickly.
I will devote another blog to the effects of reform versus expansion. Today, I only wanted to get the eligibility requirements out.