Coalition Demands an End to Public Health Budget Cuts

Recent budget cuts to the already-dwindling fund devoted to public health initiatives are resulting in “dire consequences” for many programs, health providers, and patients according to a new report issued by the Coalition for Health Funding (CHF). The report, entitled “Faces of Austerity: How Budget Cuts Hurt America’s Health,” emphasizes the lasting and widespread impacts that the past budget cuts catalyzed and includes a call on Congress to stop the cuts and, instead, to invest in public health more vigorously.

The demand to Congress to end budget cuts is grounded in the findings outlined in the CHF report. Specifically, the CHF highlights what it calls “deep cuts to public health programs in recent years” that “undermine our ability to prevent and respond to a variety of health emergencies, from outbreaks of measles, Chikungunya, and MERS, to the steady drumbeat of school shootings at the hands of mentally ill gunmen, to an epidemic of heroin abuse.” A CHF press release also argues that Congressional cuts affect programs on state and local levels as well, as it describes such cuts resulting in slashes to the hot meal program for a large portion of the clients at Athens Community Council on Aging in Athens, Georgia, and threatened heart and stroke research projects funded by the National Institutes of Medicine at the Virginia Commonwealth University. In addition to the termination of programs, the CHF also focuses on the impacts these cuts have on health employment, as “budget cuts have forced the layoffs of more than 50,000 public health professionals who monitor and respond to virus outbreaks, immunize children and the elderly, inspect restaurants, and care for the indigent.”

“Just a tiny fraction of the federal budget goes toward supporting all of our nation’s public health needs—everything from preventing disease to keeping our food and drugs safe, to ensuring that Americans have access to primary care doctors,” the president of the CHF, Emily Holubowich, stated as she explained the current funding situation, “That small pot of money has faced huge cuts in recent years, many triggered simply because Congress couldn’t find a permanent solution to sequestration.” Advocates associated with the CHF were reported to have recently visited the Capital to brief congressional staff members on the effects of the cuts outlined in the report and to ask Congress to reverse this trend. The CHF represents over 90 public health advocacy organizations and works to “preserve and strengthen public health investment in the best interest of all Americans.”

Cutting Costs: Medical Homes, Urgent Care Centers, or Both?

The New York Times recently published adjacent stories about two very different ways to cut health care spending. On one hand, health insurers and other payers are increasingly moving toward accountable care organizations (ACOs) and patient-centered medical homes (PCMH) to replace the former fee-for-service method of payment. Medicare and some Medicaid agencies are making similar choices. What these arrangements have in common is care coordination—capitated payments to the physician, practice, or organization, additional compensation for coordinating the care of patients with complex or chronic medical conditions, and incentive payments based upon cost savings and health outcomes.

Medical Homes and Value-Based Purchasing

The Blue Cross Blue Shield Association (BCBSA)  announced on July 9, 2014 that its member organizations participated in 350 locally-developed programs in 49 states, involving ACOs, PCMHs, value-based purchasing, and pay-for-performance arrangements. BCBSA reported that these programs saved it $500 million in 2012, while the member associations reported reductions in emergency room visits, especially “primary care-sensitive” visits, hospital admissions, and use of radiological imaging. At the same time, management of patients’ diabetes improved, and the use of preventive services, such as breast cancer screenings and pneumonia vaccinations, increased.

The story also profiled a physician who used the incentive payments he received for care coordination to provide preventive services. He even used them to offer Weight Watchers meetings at his office at a reduced cost.

Urgent Care Centers

In the same issue, the Times reported that investors are increasingly attracted to urgent care centers.  These facilities are walk-in clinics that cater to people with medical problems that are relatively simple and can be addressed quickly. They may offer evening and weekend hours.  People often use them instead of the emergency room to get treatment for minor injuries. Both the wait and the cost are significantly lower than a visit to the emergency room. Other patients may be attracted to UCCs because they can see a doctor when they want to rather than within typical business hours.

Urgent care centers (UCCs) may meet the needs of patients for whom an emergency department is not an appropriate care setting.

So can overworked, underfunded emergency departments refer their Medicaid patients with nonemergency conditions to UCCs? Not necessarily.

Unlike hospitals with emergency departments, UCCs  have no obligations under the Emergency Medical Treatment and Active Labor Act (EMTALA). They may refuse service to Medicaid beneficiaries, the uninsured, or anyone else who cannot pay the entire bill before they receive treatment.

Apparently, private equity firms see high profit potential from clinics that serve a high volume of patients with simple problem. The ability to cherry-pick patients gives these businesses an edge over the competition. Venture capital firms have invested $2.3 billion in UCCs since 2008.  Insurance companies and health systems also are investing in UCCs.

UCCs are inexpensive and convenient, but they’re not for everyone. According to the American Academy of Urgent Care Medicine (AAUCM), the UCC is not meant to replace the office of a primary care physician. They’re not looking to build long-term relationships with patients.The AAUCM encourages patients to use their members’ facilities when their primary physician is not available, and it emphasizes the UCC’s commitment to send records on to the primary care physician when the urgent problem has been addressed.

If a primary care physician’s office is a medical home,  perhaps the UCC could be considered the medical motel.



States Should Expand Medicaid: The Consequences of Ignoring Federal Dollars

Twenty-four states have not yet expanded their Medicaid services, potentially depriving themselves of billions of federal dollars and leaving 5.7 million people without health care coverage in 2016, according to research by the Urban Institute, a nonprofit social and economic policy research organization. The Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) allows the opportunity for substantial economic boosts to states that expand their Medicaid eligibility to nonelderly members of families that earn less than 133 percent of the federal poverty level, so why haven’t these states taken advantage of this opportunity?

The Study’s Evidence

The Council of Economic Advisors (CEA) released a report along with the Urban Institute that gathered data and formed analyses on past Medicaid policy decisions’ effects on states as well as on economic and health policy literature. The analysis pointed to several benefits of expanding Medicaid eligibility including improved health care access, better preventative care, financial security, improved mental health, and healthy state economies.

Some of these benefits result in:

  • 1.4 million additional people having a usual source of clinic care;
  • 651,000 additional people receiving “all needed care” over a full year;
  • 829,000 people getting preventative cholesterol-level screenings and 214,000 middle-aged women receiving mammograms;
  • 255,000 fewer people handling devastating medical costs each year;
  • 810,000 fewer people having trouble paying other medical-related bills; and
  • 458,000 fewer people with depression.

As if all this weren’t enough, the federal government will pay 100 percent of health coverage costs for newly eligible individuals through 2016 and 90 percent through 2020 and subsequent years. In 2014, the government paid only 50 to 70 percent of health care costs for eligible low-income persons. The Urban Institute said that if all states would increase Medicaid eligibility, states would see a reduction in uncompensated care, offsetting additional Medicaid costs and producing $10 billion in savings over 10 years.

The CEA further outlines direct consequences of expanding Medicaid in states, including its effects on health insurance coverage, using the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM) that gives a state-by-state analysis on how the decision to expand (or not) Medicaid affects health insurance coverage in each state. The model shows that if all states increased the eligibility, there would be 10 million insured people by 2016. Finally, the study showed states with expanded Medicaid report that 575,000 have excellent overall health, which allow them to be gainfully employed and contribute to their communities—a lesson for the 24 states refusing to expand the program.

Autism Support Costs Millions in a Lifetime, Yet Experience-Based Improvements Are Lacking

Over the span of a lifetime, the cost of supporting a person with autism spectrum disorder (ASD) in the United States is estimated to be between $1.4 million and $2.4 million, according to a study published in the Journal of the American Medical Association (JAMA) Pediatrics, with the total varying depending on whether the individual has an intellectual disability. The totals included both direct costs, such as medical bills, and indirect costs, such as loss of productivity.

“A defining feature of the lives of many people on the autism spectrum,” wrote the researchers in an editorial, “is a lifetime of engagement with service systems providing health and therapeutic interventions, education and training, and other societal supports. Therefore, getting an autism spectrum disorder diagnosis is not just a medical experience or a service encounter. For the person with autism, diagnosis is a doorway into a social role as a potential lifelong service user.”

According to the study, the largest costs for children with ASD were special education services, as well as productivity lost by the children’s parents in having to provide extra care for the child. In adulthood, the researchers found that residential care and supportive living accommodation, as well as the individual’s own loss of productivity, were the largest costs. Medical expenses were higher for adults with ASD than for children.

Despite the high costs of supporting children with autism (with $11 billion spent each year on special education for school-age children)—and despite the Individuals with Disabilities Education Act Part B Indicators initiative, which mandates states’ measuring and reporting of the provision of such services—the researchers found that outcomes are not tracked and reported in ways that provide a useful picture of who gets the services, the cost of services, and what benefits arise. The researchers wrote, “There is not so much a lack of effort as there is a lack of learning from effort already expended.”

The study concluded that because of the substantial direct and indirect economic impact of ASD, there is a need to improve the search for effective interventions in a landscape of scarce societal resources. According to the researchers, “We need a revolution in measuring access, quality, investments, and outcomes at community and population levels.”