Author: Ann Marie Marciarille

Kansas City is being wired for high speed internet, in a big way.  Indeed, my neighborhood is fast approaching its installation dates.

Lots of people have been wondering if high speed internet connectivity might improve access to health care in Kansas City, particularly for seniors and the homebound. Kansas City, you see, is a city with limited public transportation and a city with considerable sprawl. 

Now, low income seniors are often concentrated in older residential neighborhoods that can be quite some distance from health services that target them. In addition to beefed up senior transit, I have been wondering if health education and self-care counseling might be transformed by the arrival of the fiberhood.

In Kansas City, Kansas at KU's Alzheimer's Disease Center,  a pilot project is underway to use the fast streaming characteristics of the hood to help people living with dementia and their family caregivers by offering  review and consultation on real-time as well as recorded video of behavioral challenges in need of immediate discussion.

I am all for anything that helps the hidden among us who live with dementia and the, also curiously hidden, who are family caregivers for those who live with dementia.  There is shame there. If I learned only one thing in my time on the State of California's Alzheimer's and Dementia State Plan Task Force Advisory Group,it is that family caregivers are deeply ashamed to admit that they may be having trouble caring for a loved one with dementia — as if it were a failure of love or effort rather than a brain disorder. People living with dementia can be challenging as can family members. Aging into dependence on an adult child (often a senior themselves) is complicated enough a life transition without cognitive impairment added to the mix.

If we are to face the "silver tsunami" of aging Americans with equanimity, we need to be thinking hard about anything we can do to bolster family caregivers in their darkest hours.

 

CNN's Money Blog has an interesting map outlining who loses out under Obamacare.  You can look at it here: http://politicalticker.blogs.cnn.com/2013/07/25/who-loses-out-under-obamacare/.

When you look at it you will see Missouri squarely within the non-expansion states, a decision estimated to affect 4.9 million uninsured Americans nationwide.  But there's more to the story than that, of course, and you may drill down into the demographic characteristics of those who make up the majority of uninsured individuals at less than the 138% federal poverty level of ACA Medicaid expansion, to see who really loses out on the decision not to expand Medicaid.

You can see these numbers presented graphically at the website of the Kaiser Commission on Medicaid and the Uninsured: http://kff.org/disparities-policy/issue-brief/the-impact-of-current-state-medicaid-expansion-decisions-on-coverage-by-race-and-ethnicity/.

What do we learn? Nearly six in ten uninsured Blacks at less that 138% FPL reside in states not moving forward with Medicaid expansion at this time. This compares with four in ten uninsured Hispanics and four in ten uninsured Whites and just about one quarter of uninsured Asians in these low income groups. This is another way of illustrating that the decisions of Texas, Florida, and Georgia not to expand Medicaid under the ACA will disproportionately harm African Americans. So much press coverage focuses on the state by state head count, when it might more usefully focus on the total population head count.

Maybe a glance at the first map already told you this, if you know anything about the demographics of non-expansion states. But maybe seeing the differential skewed not just by income but by race helps to clarify just who wins and loses here. For that matter, a population-oriented analysis shows who really benefits here as well.

 

 

Missouri Governor Nixon has signed into law a Missouri bill requiring that ACA Navigators be licensed by the Missouri Division of Insurance.  I am still wondering: "Licensed as what?" since the infrastructure to license these top level federally funded guides to Missouri's federally operated exchange is not in place.

In politics — as in the rest of life –  timing is everything.  If no Missouri  state health insurance Navigator licensing infrastructure is in place as of the  date of signing, will emergency state insurance regulations be necessary in order for Navigators to be in place when ACA enrollment opens on October 1st?  If not, who will perform the Navigator function in Missouri? Might we find volunteers in the already licensed but explicitly precluded from the Navigator role by federal law group known as for-profit commercial health insurance brokers?

This could get interesting. I think of these last attempts to derail an ACA insurance counseling system designed to promote direct purchase of health insurance as the revenge of the disintermediated.

Now it is official that, after only one year, nine Medicare Pioneer accountable care organizations — among those who did not produce savings in their first year in the program — will leave the Pioneer ACO program for the Medicare Shared Savings Progam ACO model. Modern Healthcare reported it, CMS put its own spin on it, and the blogosphere has lit up with speculation.

What can we conclude after one year? 

Very very little about health care finance that we did not already know — health care provider compensation in the United States is premised  on some very entrenched principles, not the least provider insulation from cost and price among them.  Turns out, these entrenched principles are difficult to change. But even some of the departing Pioneer ACOs slowed health care cost growth somewhat. Slowing it enough to generate savings and enough savings to incite provider appetite for assuming both upside and down-side risk is another, longer term, project.

We might also tentatively conclude that it is easier to change provider behavior on quality than it is on cost.  A number of the departing Pioneer ACOs had significant — albeit short term– success in meeting quality benchmarks such as lowering risk-adjusted hospital readmission rates and improving  diabetes care. This is also not unexpected. Health care is likely to grow more expensive before it gets cheaper under the ACA.

Why the rush to try and draw conclusions after one year of Pioneer ACO experience?

We are an impatient people.  This is our virture and our vice. Whitman was correct. We are a resistless restless people.

Let's try not to draw too many firm conclusions too soon from a program just born.

Here's the ICMTR's charge:

http://www.senate.mo.gov/MedicaidTransformation/simr-charge.htm

It is interesting to see the reduction of fraud and abuse first and foremost in the ICMTR's charge.  There is much that can be done on this.

Missouri, for instance, does not allow whistleblowers to file qui tam (private attorney general proceedings) proceedings under the state false claims act — robbing the state statute of the strongest potential enforcement mechanism it might have in lean prosecutorial budgetary times. The statute's hostility to qui tam standing also renders  Missouri ineligible for important cooperative cases and recoupment with the federal government, because the state statute does not meet the stringency standards for such bonuses.

This one has been kicking around for some time. Missouri attempted to enact a buttressed  false claims act in 2011.  H.B. 374 included a qui tam provision and an anti-retaliation provision, and mirrored the language of the FCA.The bill did not pass before the legislature adjourned that session.

I wonder if fiscal watchdogs will line up to support another attempt at Missouri false claims act reform.

David Rivkin and Elizabeth Foley have a vivid Op-Ed in the June 19, 2013 Wall Street Journal. Titled: "An ObamaCare Board Answerable to No One" the piece begins by singling out the Independent Payment Advisory Board (IPAB) as the ACA's "new beast, with god-like powers."  They then offer "a vivid illustration of the extent to which life-and-death medical decisons have already been usurped by governmennt bureaucrats" — the Sarah Murnaghan transplant case.

But, IPAB hasn't been formed yet. IPAB, even once formed, will have no individual utilization review decision power — the ACA leaves this power where it has vested for some time now, in the hands of commercial insurance company utilization review schemes. No such review exists for government funded insurance. What, then, could Rivkin and Foley be talking about when discussing Secretary Sebelius's decision to maintain two separate lung-transplant lists: one for children and one for adults? Will IPAB be in charge of the difficult decisions that must be made about organ transplant availability?

Organ transplant availability is a sorry mess in the United States, a morass of  easily-gamed conflicting lists, rules, and programs. You can learn more about the gaming of an overwhelmingly de-centralized system here: http://www.npr.org/blogs/money/2012/05/29/153914790/who-decides-whether-this-26-year-old-woman-gets-a-lung-transplant  Interestingly, it is not the government that has made it so chaotic.

Now, maybe you didn't know these things.  And maybe some of the readers of the Wall Street Journal didn't know these things.  But I am going to guess that David Rivkin and Elizabeth Foley could have found these things out with some research.  Maybe the Wall Street Journal's fact checkers could have helped them out.

But then the Op-Ed would have to have taken on IPAB's defects on its own terms.