Medicaid plans as shifting as the sands, states weighing options

State Medicaid programs continue to change in response to various factors, from Florida changing its hepatitis C treatment policy to favor patients, to non-expansion states considering the financial impact of potential options. Louisiana just began enrolling the newly eligible this week, and the state projects that many more will seek coverage. South Dakota’s governor is employing some creative techniques to argue that expansion will not cost the state additional funds, and North Carolina is trying to shift plan oversight to outside organizations.

Florida and Hepatitis C

Florida is now providing vital medications to Medicaid patients with hepatitis C at an earlier stage of the disease. In the past, patients have only been offered the drug when they were at fibrosis level three or four, which indicates a high level of scar tissue in the liver and is sometimes the point where patients are in need of a transplant. These drugs are expensive to the program, costing as much as $31,000 each month. Florida amended its program criteria on June 1, 2016, removing the fibrosis level from the criteria.

Louisiana, welcome to Medicaid expansion

Louisiana opened its enrollment process to those newly eligible under the program’s expansion on June 1. The Department of Health and Hospitals (DHH) projects that about 375,000 individuals will eventually receive coverage under the expansion, although the department has been communicating with about 175,000 people about qualification. It is uncertain what effect this will have on other Louisiana health issues, such as doctor training programs. Budgetary problems, including proposed cuts to hospitals, is causing residents to go out of state for training- where they are likely to stay. Safety net hospitals, which treat many poor and uninsured patients, are particularly concerned about the reduction in funding as the state legislature attempts to resolve a budget shortfall.

Utah’s expansion comes with much less fanfare

After Utah’s legislature decided to pass a very reduced expansion plan, one that Democrats bemoaned as a “cruel trick” and “fiscal insanity,” little has been said about the matter–an extreme contrast to years of fighting over the plan of action. The plan will provide coverage to somewhere around 10,000 citizens, a reduced estimate from the original 16,000 tally. Officials expect that the money to be invested in the expansion will not stretch far to cover very many residents due to the high health costs associated with those who have gone without care. Although there has been an opportunity for hearings and public comment, the state has received little input. Some blame the timing of hearings, which would require those interested to come in during a workday, while others believe that the public feels that the legislature is uninterested in their opinions.

North Carolina seeks waiver

North Carolina is requesting that CMS allow it to transfer Medicaid oversight to three managed care organizations and provider-led entities. Although a representative felt that the state provider community has embraced the plan, the state legislature is less than united. The state Senate recently unanimously rejected House changes to its reform bill, which would require the state agency to provide progress reports and disclose a work plan for changes to be made to state health care programs.

South Dakota wants to expand Medicaid without spending more money

South Dakota Governor Dennis Daugaard (R) believes that he can figure out how to expand the state’s Medicaid program to cover about 50,000 more citizens without increasing state spending. Although he believes the math can work if the federal government shoulders more Medicaid costs for Native Americans in the state, the governor is concerned about pushback from the legislature.

Highlight on Utah: New tool cuts costs, improves outcomes

In a study published by the Journal of Hospital Medicine,  investigators from the University of Utah Medical Center (UUMC)  found that a Value Driven Outcomes (VDO) tool reduced the number of unnecessary laboratory tests performed on hospitalized patients and cut costs. Investigators Peter Yarbrough, M.D., Kensaku Kawamoto, M.D., Ph.D.,  and three physician colleagues from UUMC estimated that their multifaceted intervention saved the hospital more than $250,000 the first year. Although patients often need daily laboratory work, Yarbrough said, “it can create a culture where you’re ordering tests without thinking about what you’re going to do with the results.” The goal of the study was to try to create a thoughtful process for deciding what laboratory tests to order for hospitalized patients.

Study design

The study compared the changes in laboratory costs between the hospitalists and other physician providers at UUMC.  The hospitalist services were performed by four teams of Internal Medicine residents and medical students. The control group comprised physicians from the surgical, cardiology, pulmonary, hematology, and oncology departments. Patients admitted to the psychiatric, rehabilitation, or obstetrics units were excluded from the study.  Their use of laboratory tests was measured during a seven-month baseline period, after which the intervention was introduced. The study period continued for 15 months. the design controlled for differences in age and took into account the level of comorbidity.

After an informal review of patient charts, an examination of the physicians’ work flow, and a review of the literature, Yarbrough, Kawamoto, and their coauthors noted that interns ordered the most tests and were responsible for the greatest variation in utilization of laboratory services. They noted that unnecessary testing  poses several risks to patients. False positives results lead to additional unnecessary testing. Over long hospital stays, frequent blood draws increase the risk of anemia. One cardiology study found that cardiac patients lost an average of 454 ml of blood per stay, nearly half a liter. Being awakened early in the morning for daily blood draws can deprive patients of needed rest, negatively affecting their hospitalization experience, as well.

The interventions

The first component of the UUMC intervention was education of the physicians involved on the cost of overuse of laboratory services, the results of previous interventions, and the current intervention and its goals. The residents were issued pocket cards with the most common laboratory tests and the amount charged for each. The rounding process was standardized, incorporating a checklist that required review of previous lab results, pain, telemetry, lines and tubes, nursing presence, and follow-up needed for each patient. All plans for lab testing were to be discussed during rounds. A third year medical student was tasked with making sure that the entire checklist was addressed for every patient.

Each month, the hospitalists reviewed laboratory costs using their VDO tool. The data were presented as a monthly average, though individuals could compare their performance to that of other providers in the group.  There was a financial incentive for the Department of Internal Medicine as a whole, in that 50 percent of the savings would be shared with the department to use for future quality improvement projects, but there was no financial incentive for individual physicians. The results were measured every two weeks.

Results

The number of basic metabolic panels, complete metabolic panels, and complete blood counts dropped significantly. The average daily cost of laboratory services per patient fell from $138 to $123. The laboratory cost per visit dropped by $128.  Length of stay was not significantly affected, but remained constant in both the control group and the intervention group. Readmissions within 30 days fell from 14 percent to 11 percent in the intervention group.

The multifaceted nature of the intervention makes it difficult to tease out the relative effects of the various components. The hospitalists involved, however, believed that the use of the VDO checklist and the feedback at monthly meetings were the most important factors affecting the changes in their behavior.

West Virginia Joins States’ Trend of Requiring Autism Coverage, Amends Legislation

West Virginia passed legislation in 2011 that will require insurers, both private and public, to cover applied behavioral analysis which is a treatment for many autism spectrum disorders. However, many flaws have been discovered in the language regarding coverage limits, including age and spending limits, which make execution of the law difficult. Additionally, language had been included in the final draft of the law that was supposed to be removed prior to its passage. The state’s legislation announced on January 23, 2012 that it had initiated a course of action to address the mistakes.

Approximately one in 110 American children is diagnosed with autism, a developmental disorder that prevents a child’s brain from developing normally in areas affecting communication and social skills. While a cure has not been discovered, early intervention treatments have proven to manage the disorder’s symptoms. Many parents contend that the therapeutic needs of their children are not sufficiently met in the public school system, so they are forced to seek treatments outside of school. Such treatments, including applied behavioral analysis, can be expensive, costing some families upwards of $50,000 annually.

The recent trend, adopted by 26 states, including West Virginia, mandate insurers to cover autism treatment. Some other states have passed legislation requiring more restricted coverage of the disorder under mental health parity laws. The only states remaining that have not addressed the issue in some fashion are Oklahoma, Utah and Wyoming. Ron Ashworth, the Board Chair for Sisters of Mercy Health Systems, is an advocate of autism coverage for both social and economic reasons. He states, “…without early treatment, the cost to society is immense–over $100,000 per individual. The cost of insuring for autism is much less than not insuring.” Advocates maintain that coverage will not greatly inflate the cost of insurance premiums, if at all, while it reduces the chance that autistic children will grow to be non-productive adults who are a greater financial burden on taxpayers.

Some disagree, including the Council for Affordable Health Insurance, which estimates that insurance premiums may go up one to three percent by mandating insurers to cover autism spectrum disorder-related treatments. Challengers of the mandate argue that parents of children affected by autism and even their school districts need to assume responsibility for autism treatment and that mandating coverage interferes with the free market. Others contend that many treatments for autism are investigational and experimental, making it inappropriate to require coverage.

While its passage may be controversial, West Virginia Acting Governor, Earl Ray Tomblin, takes pride in the passage of the state’s mandate and recognizes the difficult five year-long lobbying process by parents of autistic children and other advocates. Tomblin stated, “I feel these families’ pain and am happy to be a part of improving their lives…It is my hope that this legislation will bring opportunities for a better life to our children with autism and their families…”