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Upcoming Event
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Web Briefing: The Future of Delivery System Reform in Medicare
Policymakers and others continue to debate how
best to introduce payment and delivery system reforms to tackle rising health
care costs, quality of care, and inefficient spending. Medicare has taken a
lead in testing a variety of new models, including Accountable Care
Organizations (ACOs), medical homes, and bundled payments, that include
financial incentives for providers to work together to lower spending and
improve care for patients in traditional Medicare. Many of the new models are
managed through the Center for Medicare and Medicaid Innovation (CMMI), which
was established by the Affordable Care Act and is part of the Centers for
Medicare & Medicaid Services (CMS).
On November
28, 2017 at 12:30 p.m. ET, the
Kaiser Family Foundation will hold a web briefing on payment and delivery system reforms in Medicare. We will
explore the latest evidence on savings and quality among various payments
models (including ACO, medical home, and bundled payment models), and discuss
future directions that CMS may consider to lower costs and improve care in
the coming years. The briefing will include time for audience Q&A.
Panelists include:
In addition, KFF recently launched the Evidence Link, an interactive online tool to provide current information on Medicare payment and delivery system reform models, answers to frequently asked questions (FAQs), maps, timelines, and the latest data on how these models are performing in terms of savings and quality. Filling the need for trusted information on national health issues, the Kaiser Family Foundation is a nonprofit organization based in Menlo Park, California. |
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Tuesday, November 21, 2017
Web Briefing: The Future of Delivery System Reform in Medicare
September 2017 monthly report on state Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment data
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Today the Centers for
Medicare & Medicaid Services (CMS) released the September 2017 monthly
report on state Medicaid and Children's Health Insurance Program (CHIP)
eligibility and enrollment data. The full report is available on Medicaid.gov at https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html |
Providers call on CMS for more flexible alternative payment models
By Maria
Castellucci | November 20, 2017
Provider
groups called on the CMS to create more opportunities for physicians to
participate in existing and new alternative payment models in order to advance
the Innovation Center's mission of moving healthcare delivery from volume to
value.
In letters to the CMS, several healthcare organizations asked the agency to create advanced alternative payment models that are more flexible and include specialty physicians to encourage more participation.
The comments were in response to the agency's request for information in September after CMS Administrator Seema Verma argued that the Innovation Center's old policies burdened providers and led to consolidation.
The deadline for comments is Monday night.
A few provider groups took the opportunity to encourage the CMS to reconsider statutes that could impede providers from participating under advanced APMs.
The Association of American Medical Colleges, which represents nearly 400 major teaching hospitals, urged the CMS to consider lowering the threshold of Medicare payments required to be considered an advanced APM under MACRA. Under current statute, clinicians must have at least 75% of their Medicare revenue come from an APM by 2023 in order to be eligible for a bonus.
"The future threshold of 75% will be very challenging and few eligible clinicians may be able to meet it," the AAMC said.
America's Essential Hospitals, which represents 325 safety-net hospitals, also wrote that the CMS should take a "flexible approach when setting nominal risk thresholds for new models, to allow for greater participation by essential hospitals in advanced APMs."
Provider organizations also encouraged the CMS to streamline models and make them less burdensome on providers.
The process for stakeholders to develop physician-focused payment models is "lengthy," according to the AAMC. The association suggested the CMS establish a "fast track" approval process to prevent physician participation from becoming "merely theoretical, undermining the intent of the statutory provision."
Hospital organizations including the Federation of American Hospitals supportedthe CMS' decision to make alternative payment models voluntary and scale back or cancel bundled payment models.
But there should be even more voluntary payment models, according to commenters. The American College of Cardiology "strongly" requested the CMS create models for physician specialties. These doctors currently lack opportunities to join advanced APMs under MACRA.
The organization said advanced APMs for specialties should focus on an episode of care like a procedure or a clearly defined acute event. They added that the CMS should work with specialty societies to develop the models.
And in its letter, the Medicare Payment Advisory Commission suggested the Innovation Center design a new accountable care organization to create more opportunities for providers to participate in an APM. The ACO would be judged based on total Medicare Part A and Part B spending.
In letters to the CMS, several healthcare organizations asked the agency to create advanced alternative payment models that are more flexible and include specialty physicians to encourage more participation.
The comments were in response to the agency's request for information in September after CMS Administrator Seema Verma argued that the Innovation Center's old policies burdened providers and led to consolidation.
The deadline for comments is Monday night.
A few provider groups took the opportunity to encourage the CMS to reconsider statutes that could impede providers from participating under advanced APMs.
The Association of American Medical Colleges, which represents nearly 400 major teaching hospitals, urged the CMS to consider lowering the threshold of Medicare payments required to be considered an advanced APM under MACRA. Under current statute, clinicians must have at least 75% of their Medicare revenue come from an APM by 2023 in order to be eligible for a bonus.
"The future threshold of 75% will be very challenging and few eligible clinicians may be able to meet it," the AAMC said.
America's Essential Hospitals, which represents 325 safety-net hospitals, also wrote that the CMS should take a "flexible approach when setting nominal risk thresholds for new models, to allow for greater participation by essential hospitals in advanced APMs."
Provider organizations also encouraged the CMS to streamline models and make them less burdensome on providers.
The process for stakeholders to develop physician-focused payment models is "lengthy," according to the AAMC. The association suggested the CMS establish a "fast track" approval process to prevent physician participation from becoming "merely theoretical, undermining the intent of the statutory provision."
Hospital organizations including the Federation of American Hospitals supportedthe CMS' decision to make alternative payment models voluntary and scale back or cancel bundled payment models.
But there should be even more voluntary payment models, according to commenters. The American College of Cardiology "strongly" requested the CMS create models for physician specialties. These doctors currently lack opportunities to join advanced APMs under MACRA.
The organization said advanced APMs for specialties should focus on an episode of care like a procedure or a clearly defined acute event. They added that the CMS should work with specialty societies to develop the models.
And in its letter, the Medicare Payment Advisory Commission suggested the Innovation Center design a new accountable care organization to create more opportunities for providers to participate in an APM. The ACO would be judged based on total Medicare Part A and Part B spending.
Maria Castellucci is a general assignment
reporter covering spot news for Modern Healthcare’s website and print edition.
She writes about finances, acquisitions and other healthcare topics in markets
across the country. Castellucci is a graduate of Columbia College Chicago and
started working at Modern Healthcare in September 2015.
What do nurses want?
By Jay Greene | November
20, 2017
Michigan has had more
than its share of labor disputes between hospitals and nurses.
A high-profile walkout among nurses in Marquette, a public dispute at Huron Valley-Sinai Hospital in Commerce Township, and the formation of unions at two hospitals in 18 months are just part of the story.
The conflicts have several causes, and are critical in an industry that's being graded on dollars and cents but also on quality — and one where lives are at stake.
Higher pay isn't at the top of the list of what nurses want, although that wish is in their top five. What they most ask hospitals for is a safer workplace, for themselves and their patients, where nursing shifts are limited to 12 hours or less, patients can count on sufficient numbers of nurses per shift and hospitals don't regularly rely on nurses to perform housekeeping or patient transportation duties in addition to patient care.
Crain's interviewed nurses at seven hospitals, most of whom are in unions and involved in contract negotiations. Three hospital nursing executives also were interviewed.
Scott Balko, an operating room nurse at UP Health System-Marquette, said the No. 1 issue for nurses at the 300-bed hospital is mandatory overtime driven by poor working conditions because of understaffing that he said discourages nurses from applying for jobs and causes unnecessary turnover.
"We don't have the number of nurses to do the job. They are working longer shifts and putting patients in unsafe conditions," Balko said. "There are no regulations on hours for nurses like there are for truck drivers."
Stephanie DePetro, an emergency room nurse also at UP Health, the former Marquette General Hospital, said nurses want specific nurse-patient ratios for each department. "There are work standards for many professions, but there is no law for how many patients we are asked to care for," she said.
Last month, 400 nurses went on a two-day strike in Marquette to protest working conditions and lack of solutions from management over a union contract under negotiation for five months. UP Health is a for-profit hospital purchased in 2012 by Nashville-based Duke LifePoint.
Tom Casperson, R-Escanaba, said he believes nurses when they tell him how they are often left no choice but to work overtime when hospitals fail to properly staff shifts. He said hospitals tell him the nursing shortage prevents them from hiring more nurses, a contention nurses dispute.
The U.S. Bureau of Labor Statistics reports more than 100,000 registered nurse jobs will be available annually until 2022.
A high-profile walkout among nurses in Marquette, a public dispute at Huron Valley-Sinai Hospital in Commerce Township, and the formation of unions at two hospitals in 18 months are just part of the story.
The conflicts have several causes, and are critical in an industry that's being graded on dollars and cents but also on quality — and one where lives are at stake.
Higher pay isn't at the top of the list of what nurses want, although that wish is in their top five. What they most ask hospitals for is a safer workplace, for themselves and their patients, where nursing shifts are limited to 12 hours or less, patients can count on sufficient numbers of nurses per shift and hospitals don't regularly rely on nurses to perform housekeeping or patient transportation duties in addition to patient care.
Crain's interviewed nurses at seven hospitals, most of whom are in unions and involved in contract negotiations. Three hospital nursing executives also were interviewed.
Scott Balko, an operating room nurse at UP Health System-Marquette, said the No. 1 issue for nurses at the 300-bed hospital is mandatory overtime driven by poor working conditions because of understaffing that he said discourages nurses from applying for jobs and causes unnecessary turnover.
"We don't have the number of nurses to do the job. They are working longer shifts and putting patients in unsafe conditions," Balko said. "There are no regulations on hours for nurses like there are for truck drivers."
Stephanie DePetro, an emergency room nurse also at UP Health, the former Marquette General Hospital, said nurses want specific nurse-patient ratios for each department. "There are work standards for many professions, but there is no law for how many patients we are asked to care for," she said.
Last month, 400 nurses went on a two-day strike in Marquette to protest working conditions and lack of solutions from management over a union contract under negotiation for five months. UP Health is a for-profit hospital purchased in 2012 by Nashville-based Duke LifePoint.
Tom Casperson, R-Escanaba, said he believes nurses when they tell him how they are often left no choice but to work overtime when hospitals fail to properly staff shifts. He said hospitals tell him the nursing shortage prevents them from hiring more nurses, a contention nurses dispute.
The U.S. Bureau of Labor Statistics reports more than 100,000 registered nurse jobs will be available annually until 2022.
But nurses such as Judy
Moore, an intensive-care and step-down unit nurse also at DMC Huron
Valley-Sinai Hospital in Commerce Charter Township, question whether nurse
staffing problems are caused by a nursing shortage or simply because nurses
don't want to work at hospitals when they have few rights. A growing number of
nurses have retired, changed occupations or become administrators in recent
years, experts say.
"(Hospitals) tell us they can't hire more staff because of a nursing shortage," Moore said. "There is not a nursing shortage. There are plenty going into colleges now. (Hospitals) are just not hiring."
In March 2016, Huron Valley Sinai nurses voted in a union that is affiliated with the Michigan Nurses Association. But after 16 months of negotiations, the nurses are still without a contract.
Earlier this month, the Huron Valley nurses union released a scathing 38-page report that documented 240 incidents of poor patient care they say were directly related to insufficient numbers of nurses per unit. They asked for an investigation by the state Department of Licensing and Regulatory Affairs. They also filed a lawsuit in Oakland County Circuit Court over alleged public health code violations.
Moore said DMC has frozen nurse hiring, which has resulted in fewer floor nurses because turnover continues at high rates.
Shawn Levitt, DMC's chief nursing officer, declined to address difficult contract issues. "We don't negotiate contracts in the media," she said. Lori Stallings, Huron Valley chief nursing officer, said hospital management is making good progress in the talks, but wasn't sure when a contract might be signed.
Casperson, who joined to support hundreds of nurses from all over Michigan in Marquette for the strike, is one of six legislators who are co-sponsoring the Safe Patient Care Act that is part of a three-bill, bi-partisan package.
"I am supporting the nurses because when nurses work to exhaustion, it is a patient safety issue," Casperson said.
Nurse strikes rare in Michigan
A nursing strike is an extreme event that doesn't happen often in Michigan. But nurses say it illustrates the growing rift between nurses and management over key issues that involve patient and nurse safety, staffing, pay and respect.
Two top hospital executives told Crain's they believed staffing and patient care issues are exaggerated by nurses and what they really want is higher pay. But nurses pushed back and said that may have been true in the past, but now the primary issue is too few nurses per shift and mandatory overtime that pushes many nurses to work 16-hour days.
Crain's research has found six strikes since 1979 at hospitals in Michigan, a 1994 strike at Marquette General, the one this year and two at the University of Michigan Hospital in the 1980s.
The longest strike and dispute went on for nearly three years starting in November 2002 at the former Northern Michigan Hospital in Petoskey, now McLaren Northern Michigan.
In 1979, nurses at St. Francis Hospital in Escanaba struck for 120 days before it was settled with help from a federal mediator. Nurses nearly struck four times since 2000 at Genesys Regional Medical Center in Grand Blanc Township before settling on contracts.
In the past 18 months, nurses have formed unions at Huron Valley-Sinai and Munson Medical Center in Traverse City.
Share same goal
Nurses interviewed by Crain's said they believe more hospitals in Michigan are voting for unions or considering ones to help argue their case for better patient care to management. Nursing councils or committees are not strong enough voices, they say.
Hospitals have waged intense bidding wars to fill nursing vacancies. They have offered nurses huge signing bonuses and even sport-utility vehicles and vacations to the Bahamas. However, those efforts often only served to exacerbate turnover, spurring nurses to remain in jobs just long enough to claim the prizes before moving to other hospitals with better incentives, several nurses told Crain's.
At the same time, hospitals also have engaged in various methods to hold down nursing salaries. In settlements from 2009 to 2015, eight health systems in metro Detroit paid about $90 million to settle a class action lawsuit over nurse wages that spanned 2002 to 2006 and involved more than 20,000 nurses, Crain's reported in a story in September 2015.
Some systems that settled included Detroit Medical Center, Beaumont Health, Henry Ford Health System, Trinity Health and St. John Providence Health System.
On the flip side, many hospitals have taken steps to improve relations with nurses. Some have been certified as "magnet" hospitals from the American Nurses Association and the Institute of Healthcare Improvement.
So far, more than 300 hospitals nationwide, including Beaumont Health, the University of Michigan and 12 other hospitals in Michigan, have been credentialed as magnet hospitals.
A 2013 study by the University of Pennsylvania found that magnet hospitals have 14% lower mortality risk and 12% lower failure to rescue rates. Magnet hospitals are more likely to offer more flexible hours, lower caseloads and pay for advanced training and give nurses more authority.
Nurses tell Crain's they want to be fairly paid, but they really want better working conditions that would allow them to offer better patient care, said John Armelagos, president of the MNA and nurse for 30 years at the University of Michigan Hospitals.
Armelagos said nurses are at the front lines in patient care and act as advocates for patients and their families.
"We need to ensure there are enough nurses to take care of patients on every unit and every shift so we can respond and monitor our patients," said Armelagos, who works in inpatient psychiatric adult and adolescent units. "When there are not enough nurses to take care of patients, peer review research shows that patients suffer, outcomes are more negative and mortality increases per patient."
In the 1980s, Armelagos said UM nurses twice struck for safer staffing and higher wages. Since then, nurses and management have worked much more closely together to resolve differences, he said.
Marge Calarco, chief nursing officer at the University of Michigan, said UM and its nurses agree that safe staffing enables nurses to care for patients in a cost-effective way that produces the best outcomes. But she said nurses also want to be treated with respect by management and valued for the service they provide to society.
"Gallup (polls have shown consistently that) nursing is the most trusted by the population," said Calarco, who has been a nurse more than 30 years, the last 15 years as UM's chief nurse. "Every year except for 9-11 when firefighters were recognized, we are the most trusted profession. We are closest to families and patients, 24 hours, seven days per week. We provide exquisite care and are the heart of health care in many ways."
Calarco said more than 15 years of research shows that hospitals that have adequate nurse staffing have lower mortality and morbidity. UM works closely with its nursing union to ensure each department has sufficient number of nurses for each shift, she said.
"Nurses want to practice in an environment where they are required to take care of sicker and sicker populations," Calarco said. "Populations in hospitals today, 30 years ago would not have survived. Acuity is growing, and expertise is critical. If you don't have safe staffing, you can't do it."
But Calarco said she is not a proponent of mandated nurse-patient ratios because they don't allow hospitals sufficient flexibility to take into account patient acuity levels that vary from day to day.
"We at UM take staffing very seriously and do it very well," said Calarco, adding that "there are many places in Michigan and across the county that do not to have the resources for safe staffing."
Calarco acknowledged that some hospitals look first to reduce costs by cutting nursing staff, which is the largest workforce at hospitals. She said she understands these hospitals set the stage for nurse unions to form and for calls for mandated nurse-patient ratios.
"Some hospitals, faced with economic challenges, cut nurse staffing," Calarco said. "We know, the data is clear, that once nurse staffing is cut to unsafe levels, you see decreases in patient outcomes and increases in mortality. I have always seen it is shortsighted, and I have advocated for strong staffing here."
Echoing what floor nurses tell Crain's, Calarco said hospitals actually lower costs when they have safe staffing. "Hospitals don't always understand that. (When hospitals have fewer nurses) they have more overtime, need more premium labor, more agency nurses, just to get the work done," she said, adding that quality also diminishes when regular nurses aren't available. "It is a short-term fix that isn't good for the long run."
Nurses' main issues
Cindy Rydahl, a surgical services nurse at Munson Medical Center in Traverse City, said nurses need a larger voice in decisions hospitals make on staffing and patient care.
"We want safe staffing because the acuity of our patients is sicker than they used to be," Rydahl said. "Our nurse patient ratios need to be improved. We are seeing more emergency patients and they need more care. Acuity is the biggest problem."
In August, Munson nurses approved a union for its 1,200 nurses through the Michigan Nurses Association. Negotiations are expected to start soon on a contract.
"We want a voice. We want to be listened to and heard," said Rydahl, who has been a nurse for 33 years. "We are at the bedside and know what patients need because we care for them and listen to the families."
She said the hospital and nurses have a shared governance committee, but nurses decided to form a union because the committee has been ineffective in resolving issues.
Loraine Frank-Lightfoot, Munson's vice president of patient care services and chief nursing officer, said Munson has been taking steps the past 16 months since she has been at the hospital to address staffing ratios in various departments.
"I agree that the old shared governance structure was not as effective as could have been. When I went to meetings, there were not a lot of front-line nurses there," said Frank-Lightfoot, who has been a nurse for 32 years. "I am very participatory, and we now have 150 front-line staff involved with committees."
Frank-Lightfoot said she understands how difficult it is for nurses to work with insufficient staffing. She said many nurses have been hired in the past year and the vacancy rate has been cut to 3.3%, far below than the national average of 8.8%, she said.
"There have been key areas that have been harder for us to recruit — OR, ER and critical care," she said. "We lost a lot of (nurses who worked) in the OR, and it is a steep learning curve" for new nurses.
But Frank-Lightfoot said she believes the major issue at Munson for the nurses is pay.
"Mandatory overtime and safe staffing are not the real issues," she said. "I believe the issues are around compensation. That is the key."
Frank-Lightfoot acknowledged that Munson fell behind market wages for nurses in the past. "We have put $18 million in staff wages, and we are catching up," she said.
Nurses speak out
Kathy Lehman, an emergency nurse at DMC Huron Valley-Sinai, said a reduction in nurses and support staff has been plaguing the for-profit hospital and many others across Michigan.
"We have seen a reduction in staff in ancillary care, patient care technicians, sitters, environmental services and patient transporters," said Lehman, a nurse for 17 years, the last 11 at Huron Valley.
Moore said hospital consolidation and for-profit ownership has led to bigger lobbies but fewer caregivers at the bedside. A nonprofit hospital until 2011, Huron Valley-Sinai is part of DMC, which is owned by for-profit Tenet Healthcare Corp. of Dallas.
Levitt said Huron Valley staffs nurses and others based on daily patient counts and industry standards. Stallings cited "A" grades since 2012 that Huron Valley has received from the Leapfrog Group for patient safety.
Moore said Huron Valley nurses "have lost our voice at the hospital, as far as what we feel is best for the patient."
But Levitt said Huron Valley is also a magnet hospital certified by the American Nurses Association that has a shared governance model where nursing practice issues are brought forward and worked out.
Lehman confirmed that Huron Valley has a professional nurse council, but suggestions have been put on hold. "We are a magnet hospital and should be sitting in on decision-making, but it isn't happening," she said.
Moore said nurses have committees for pharmacy, finances and quality. "But they have taken nurses' voices away from hospitals and are making decisions based on profit," she said, adding: "Patients were never at risk when we were nonprofit. Decisions aren't local anymore. They are always made at the corporate level."
On the other hand, nurses like Moore and others interviewed by Crain's insisted they would do their job and go beyond normal staffing to take care of patients.
"I am here at Huron Valley because I love taking care of the community. No matter what is going on, the nurses work really hard so patients are not compromised," Moore said.
Tom Hall, a multi-department float nurse at McLaren Lapeer Hospital, said the MNA-sponsored union has been negotiating a new contract with the hospital since May. The Lapeer nurses signed their first union contract in the mid-1990s and have a range of issues to iron out with the McLaren hospital, including sufficient number of employed nurses.
Hall said Lapeer nurses want lower staffing ratios, which have been increasing the past five years as the Affordable Care Act has cut Medicare reimbursement rates.
"How would you feel to be the sixth, seventh or eighth patient for a nurse working 16 hours?" said Hall.
Sheila Kahn-Monroe, vice president of labor relations with McLaren, said the 12-hospital system allows local hospitals to set nurse staffing policies, although corporate policy is focused on ensuring safe staffing and that the nursing workforce has the right skill mix.
Kahn-Monroe said the McLaren Lapeer contract talks are fairly typical and she expects a signed deal by the end of the year. "We are using a collaborative, interest-based approach and working through discussions," she said. "Nurses want lower nurse-staff ratios."
Kahn-Monroe said 10 of McLaren's 12 hospitals have nursing unions. Three are engaged in contract talks, including Lapeer, Bay and Macomb hospitals, she said.
"Each facility looks at census and whether they need to move resources" into clinical departments based on volume and acuity changes, Kahn-Monroe said. When volume or acuity levels rise, hospitals bring in additional nurses to maintain good patient care, she said.
However, Kahn-Monroe said hospitals review patient activity every four hours and if volume dips, nurses could be sent home. "We balance that to make sure they get the hours they need," she said.
Obamacare impact?
One of the biggest problems nurses some hospitals have faced under Obamacare is how executives react when their hospital Medicare quality scores dip and they don't qualify for higher federal reimbursements under value-based payment formulas.
"If the hospital doesn't get all 9s or 10s, we don't qualify for reimbursement, and the nurses are belittled and given more work to get the scores up," Hall said. "It sometimes adds two to three hours of different work every day just to get the reimbursement. We don't get extra help."
Hall said one bad patient experience can lower Medicare patient satisfaction scores. "If they provided enough nurses to do the extra work, we could more easily get the scores," he said. "If you are that eighth patient you will write the bad score. If we had enough nurses where you are the fourth patient, we have more time to do a good point."
Kahn-Monroe said she does not believe that McLaren Lapeer blamed nurses for lower than expected patient satisfaction scores.
"Lapeer does need some work, but it isn't just nurses. I take exception that nurses are being singled out," said Kahn-Monroe, adding that when patient satisfaction scores dip the entire patient care team is asked to improve. "We go back to staff and ask how we can improve," she said.
Rydahl said Munson nurses often agree to overtime because paperwork requires an extra 30 minutes to an hour to complete after a 12-hour shift. "We have too many patients who needed nursing care," she said. "I would be abandoning my patients if I left. It is a scheduling problem as well as higher acuity."
Munson often schedules too few nurses in hospital departments, said Rydahl, and that often requires nurses to do many non-nursing duties. They include patient transportation, housekeeping and patient sitting, she said.
Moore said DMC Huron Valley-Sinai also has cut staff in patient transportation, environmental services and housekeeping.
"We are leaving the floor to transport patients, to take out the garbage and sweep the floors," Moore said. "Patients are asking where the help is. We want to care for patients, and we are not getting support."
Armelagos said UM nurses addressed the issue on non-nursing duties years ago in their contracts. "Hospitals are foolish when they have nurses doing non-nursing tasks," he said. "The work is comprehensive enough not doing the work as a clerk. But when something needs to be done in the hospital and there is nobody else do it, nurses do it. Hospitals know this and cut support staff on purpose."
Lehman said nurses have several complaints about how Huron Valley-Sinai schedules nurses. When patient volume drops during the day, the hospital sends nurses home. "It is called 'K' time. You go home without pay or you can use vacation hours," said Lehman, adding that except for the operating room and cardiac catheter laboratory there is no on-call schedule.
"We work three 12-hour days, and sometimes much longer," Lehman said. "What every nurse wants is some kind of a floor. We want to know how many nurses are on call during a day and keep to a safe staff ratio. You have to take into consideration emergencies because we need to be able to see patients safely."
For example, Lehman said often in the emergency department nurses face short-staffing when trauma cases mount up, increasing typical 4-1 patient to nurse ratio up to 7-1 or more.
While Hall said mandatory overtime is limited in the Lapeer nurses' current contract, the hospital does not always abide by staffing guidelines for every department.
"We do have some nurses who will stay voluntarily. It is not considered mandated hours because a nurse has volunteered," Hall said. "If no one will stay, that is when they go to mandatory."
The last two years, however, McLaren Lapeer has been unable to hire enough nurses, Hall said.
"They like to say it is because of the nursing shortage. But we have several schools that produce 40 to 60 nurses per semester," said Hall, noting that there are three hospitals in Flint that also hire nurses. "We deal with issues of competitive pay. If you pay lower wages than other hospitals, you won't get as many nurses."
Hall said he knows several nurses at Lapeer who have graduated from nursing school and decided to go into home health or health insurance because of pay and working conditions at hospitals.
Kahn-Monroe said McLaren Lapeer recently hired a number of nurses to fill vacancies. "We had some turnover there, but we were able to hire people in," she said.
Calarco said nursing shortages are cyclical and often based on geography, with rural hospitals sometimes having more trouble attracting nurses than suburban hospitals because of pay and other factors.
But Calarco said hospital vacancies are sometimes created when there is low nursing staff and nurses become overworked and dissatisfied. She said there is no shortage of nurses in Ann Arbor, partially because nurses want to work at UM.
"You have a downward spiral when you create more vacancies to fill," she said. "Nurse recruiting and retention is impacted by practice environment of hospitals."
"What do nurses want?" originally appeared in Crain's Detroit Business.
"(Hospitals) tell us they can't hire more staff because of a nursing shortage," Moore said. "There is not a nursing shortage. There are plenty going into colleges now. (Hospitals) are just not hiring."
In March 2016, Huron Valley Sinai nurses voted in a union that is affiliated with the Michigan Nurses Association. But after 16 months of negotiations, the nurses are still without a contract.
Earlier this month, the Huron Valley nurses union released a scathing 38-page report that documented 240 incidents of poor patient care they say were directly related to insufficient numbers of nurses per unit. They asked for an investigation by the state Department of Licensing and Regulatory Affairs. They also filed a lawsuit in Oakland County Circuit Court over alleged public health code violations.
Moore said DMC has frozen nurse hiring, which has resulted in fewer floor nurses because turnover continues at high rates.
Shawn Levitt, DMC's chief nursing officer, declined to address difficult contract issues. "We don't negotiate contracts in the media," she said. Lori Stallings, Huron Valley chief nursing officer, said hospital management is making good progress in the talks, but wasn't sure when a contract might be signed.
Casperson, who joined to support hundreds of nurses from all over Michigan in Marquette for the strike, is one of six legislators who are co-sponsoring the Safe Patient Care Act that is part of a three-bill, bi-partisan package.
"I am supporting the nurses because when nurses work to exhaustion, it is a patient safety issue," Casperson said.
Nurse strikes rare in Michigan
A nursing strike is an extreme event that doesn't happen often in Michigan. But nurses say it illustrates the growing rift between nurses and management over key issues that involve patient and nurse safety, staffing, pay and respect.
Two top hospital executives told Crain's they believed staffing and patient care issues are exaggerated by nurses and what they really want is higher pay. But nurses pushed back and said that may have been true in the past, but now the primary issue is too few nurses per shift and mandatory overtime that pushes many nurses to work 16-hour days.
Crain's research has found six strikes since 1979 at hospitals in Michigan, a 1994 strike at Marquette General, the one this year and two at the University of Michigan Hospital in the 1980s.
The longest strike and dispute went on for nearly three years starting in November 2002 at the former Northern Michigan Hospital in Petoskey, now McLaren Northern Michigan.
In 1979, nurses at St. Francis Hospital in Escanaba struck for 120 days before it was settled with help from a federal mediator. Nurses nearly struck four times since 2000 at Genesys Regional Medical Center in Grand Blanc Township before settling on contracts.
In the past 18 months, nurses have formed unions at Huron Valley-Sinai and Munson Medical Center in Traverse City.
Share same goal
Nurses interviewed by Crain's said they believe more hospitals in Michigan are voting for unions or considering ones to help argue their case for better patient care to management. Nursing councils or committees are not strong enough voices, they say.
Hospitals have waged intense bidding wars to fill nursing vacancies. They have offered nurses huge signing bonuses and even sport-utility vehicles and vacations to the Bahamas. However, those efforts often only served to exacerbate turnover, spurring nurses to remain in jobs just long enough to claim the prizes before moving to other hospitals with better incentives, several nurses told Crain's.
At the same time, hospitals also have engaged in various methods to hold down nursing salaries. In settlements from 2009 to 2015, eight health systems in metro Detroit paid about $90 million to settle a class action lawsuit over nurse wages that spanned 2002 to 2006 and involved more than 20,000 nurses, Crain's reported in a story in September 2015.
Some systems that settled included Detroit Medical Center, Beaumont Health, Henry Ford Health System, Trinity Health and St. John Providence Health System.
On the flip side, many hospitals have taken steps to improve relations with nurses. Some have been certified as "magnet" hospitals from the American Nurses Association and the Institute of Healthcare Improvement.
So far, more than 300 hospitals nationwide, including Beaumont Health, the University of Michigan and 12 other hospitals in Michigan, have been credentialed as magnet hospitals.
A 2013 study by the University of Pennsylvania found that magnet hospitals have 14% lower mortality risk and 12% lower failure to rescue rates. Magnet hospitals are more likely to offer more flexible hours, lower caseloads and pay for advanced training and give nurses more authority.
Nurses tell Crain's they want to be fairly paid, but they really want better working conditions that would allow them to offer better patient care, said John Armelagos, president of the MNA and nurse for 30 years at the University of Michigan Hospitals.
Armelagos said nurses are at the front lines in patient care and act as advocates for patients and their families.
"We need to ensure there are enough nurses to take care of patients on every unit and every shift so we can respond and monitor our patients," said Armelagos, who works in inpatient psychiatric adult and adolescent units. "When there are not enough nurses to take care of patients, peer review research shows that patients suffer, outcomes are more negative and mortality increases per patient."
In the 1980s, Armelagos said UM nurses twice struck for safer staffing and higher wages. Since then, nurses and management have worked much more closely together to resolve differences, he said.
Marge Calarco, chief nursing officer at the University of Michigan, said UM and its nurses agree that safe staffing enables nurses to care for patients in a cost-effective way that produces the best outcomes. But she said nurses also want to be treated with respect by management and valued for the service they provide to society.
"Gallup (polls have shown consistently that) nursing is the most trusted by the population," said Calarco, who has been a nurse more than 30 years, the last 15 years as UM's chief nurse. "Every year except for 9-11 when firefighters were recognized, we are the most trusted profession. We are closest to families and patients, 24 hours, seven days per week. We provide exquisite care and are the heart of health care in many ways."
Calarco said more than 15 years of research shows that hospitals that have adequate nurse staffing have lower mortality and morbidity. UM works closely with its nursing union to ensure each department has sufficient number of nurses for each shift, she said.
"Nurses want to practice in an environment where they are required to take care of sicker and sicker populations," Calarco said. "Populations in hospitals today, 30 years ago would not have survived. Acuity is growing, and expertise is critical. If you don't have safe staffing, you can't do it."
But Calarco said she is not a proponent of mandated nurse-patient ratios because they don't allow hospitals sufficient flexibility to take into account patient acuity levels that vary from day to day.
"We at UM take staffing very seriously and do it very well," said Calarco, adding that "there are many places in Michigan and across the county that do not to have the resources for safe staffing."
Calarco acknowledged that some hospitals look first to reduce costs by cutting nursing staff, which is the largest workforce at hospitals. She said she understands these hospitals set the stage for nurse unions to form and for calls for mandated nurse-patient ratios.
"Some hospitals, faced with economic challenges, cut nurse staffing," Calarco said. "We know, the data is clear, that once nurse staffing is cut to unsafe levels, you see decreases in patient outcomes and increases in mortality. I have always seen it is shortsighted, and I have advocated for strong staffing here."
Echoing what floor nurses tell Crain's, Calarco said hospitals actually lower costs when they have safe staffing. "Hospitals don't always understand that. (When hospitals have fewer nurses) they have more overtime, need more premium labor, more agency nurses, just to get the work done," she said, adding that quality also diminishes when regular nurses aren't available. "It is a short-term fix that isn't good for the long run."
Nurses' main issues
Cindy Rydahl, a surgical services nurse at Munson Medical Center in Traverse City, said nurses need a larger voice in decisions hospitals make on staffing and patient care.
"We want safe staffing because the acuity of our patients is sicker than they used to be," Rydahl said. "Our nurse patient ratios need to be improved. We are seeing more emergency patients and they need more care. Acuity is the biggest problem."
In August, Munson nurses approved a union for its 1,200 nurses through the Michigan Nurses Association. Negotiations are expected to start soon on a contract.
"We want a voice. We want to be listened to and heard," said Rydahl, who has been a nurse for 33 years. "We are at the bedside and know what patients need because we care for them and listen to the families."
She said the hospital and nurses have a shared governance committee, but nurses decided to form a union because the committee has been ineffective in resolving issues.
Loraine Frank-Lightfoot, Munson's vice president of patient care services and chief nursing officer, said Munson has been taking steps the past 16 months since she has been at the hospital to address staffing ratios in various departments.
"I agree that the old shared governance structure was not as effective as could have been. When I went to meetings, there were not a lot of front-line nurses there," said Frank-Lightfoot, who has been a nurse for 32 years. "I am very participatory, and we now have 150 front-line staff involved with committees."
Frank-Lightfoot said she understands how difficult it is for nurses to work with insufficient staffing. She said many nurses have been hired in the past year and the vacancy rate has been cut to 3.3%, far below than the national average of 8.8%, she said.
"There have been key areas that have been harder for us to recruit — OR, ER and critical care," she said. "We lost a lot of (nurses who worked) in the OR, and it is a steep learning curve" for new nurses.
But Frank-Lightfoot said she believes the major issue at Munson for the nurses is pay.
"Mandatory overtime and safe staffing are not the real issues," she said. "I believe the issues are around compensation. That is the key."
Frank-Lightfoot acknowledged that Munson fell behind market wages for nurses in the past. "We have put $18 million in staff wages, and we are catching up," she said.
Nurses speak out
Kathy Lehman, an emergency nurse at DMC Huron Valley-Sinai, said a reduction in nurses and support staff has been plaguing the for-profit hospital and many others across Michigan.
"We have seen a reduction in staff in ancillary care, patient care technicians, sitters, environmental services and patient transporters," said Lehman, a nurse for 17 years, the last 11 at Huron Valley.
Moore said hospital consolidation and for-profit ownership has led to bigger lobbies but fewer caregivers at the bedside. A nonprofit hospital until 2011, Huron Valley-Sinai is part of DMC, which is owned by for-profit Tenet Healthcare Corp. of Dallas.
Levitt said Huron Valley staffs nurses and others based on daily patient counts and industry standards. Stallings cited "A" grades since 2012 that Huron Valley has received from the Leapfrog Group for patient safety.
Moore said Huron Valley nurses "have lost our voice at the hospital, as far as what we feel is best for the patient."
But Levitt said Huron Valley is also a magnet hospital certified by the American Nurses Association that has a shared governance model where nursing practice issues are brought forward and worked out.
Lehman confirmed that Huron Valley has a professional nurse council, but suggestions have been put on hold. "We are a magnet hospital and should be sitting in on decision-making, but it isn't happening," she said.
Moore said nurses have committees for pharmacy, finances and quality. "But they have taken nurses' voices away from hospitals and are making decisions based on profit," she said, adding: "Patients were never at risk when we were nonprofit. Decisions aren't local anymore. They are always made at the corporate level."
On the other hand, nurses like Moore and others interviewed by Crain's insisted they would do their job and go beyond normal staffing to take care of patients.
"I am here at Huron Valley because I love taking care of the community. No matter what is going on, the nurses work really hard so patients are not compromised," Moore said.
Tom Hall, a multi-department float nurse at McLaren Lapeer Hospital, said the MNA-sponsored union has been negotiating a new contract with the hospital since May. The Lapeer nurses signed their first union contract in the mid-1990s and have a range of issues to iron out with the McLaren hospital, including sufficient number of employed nurses.
Hall said Lapeer nurses want lower staffing ratios, which have been increasing the past five years as the Affordable Care Act has cut Medicare reimbursement rates.
"How would you feel to be the sixth, seventh or eighth patient for a nurse working 16 hours?" said Hall.
Sheila Kahn-Monroe, vice president of labor relations with McLaren, said the 12-hospital system allows local hospitals to set nurse staffing policies, although corporate policy is focused on ensuring safe staffing and that the nursing workforce has the right skill mix.
Kahn-Monroe said the McLaren Lapeer contract talks are fairly typical and she expects a signed deal by the end of the year. "We are using a collaborative, interest-based approach and working through discussions," she said. "Nurses want lower nurse-staff ratios."
Kahn-Monroe said 10 of McLaren's 12 hospitals have nursing unions. Three are engaged in contract talks, including Lapeer, Bay and Macomb hospitals, she said.
"Each facility looks at census and whether they need to move resources" into clinical departments based on volume and acuity changes, Kahn-Monroe said. When volume or acuity levels rise, hospitals bring in additional nurses to maintain good patient care, she said.
However, Kahn-Monroe said hospitals review patient activity every four hours and if volume dips, nurses could be sent home. "We balance that to make sure they get the hours they need," she said.
Obamacare impact?
One of the biggest problems nurses some hospitals have faced under Obamacare is how executives react when their hospital Medicare quality scores dip and they don't qualify for higher federal reimbursements under value-based payment formulas.
"If the hospital doesn't get all 9s or 10s, we don't qualify for reimbursement, and the nurses are belittled and given more work to get the scores up," Hall said. "It sometimes adds two to three hours of different work every day just to get the reimbursement. We don't get extra help."
Hall said one bad patient experience can lower Medicare patient satisfaction scores. "If they provided enough nurses to do the extra work, we could more easily get the scores," he said. "If you are that eighth patient you will write the bad score. If we had enough nurses where you are the fourth patient, we have more time to do a good point."
Kahn-Monroe said she does not believe that McLaren Lapeer blamed nurses for lower than expected patient satisfaction scores.
"Lapeer does need some work, but it isn't just nurses. I take exception that nurses are being singled out," said Kahn-Monroe, adding that when patient satisfaction scores dip the entire patient care team is asked to improve. "We go back to staff and ask how we can improve," she said.
Rydahl said Munson nurses often agree to overtime because paperwork requires an extra 30 minutes to an hour to complete after a 12-hour shift. "We have too many patients who needed nursing care," she said. "I would be abandoning my patients if I left. It is a scheduling problem as well as higher acuity."
Munson often schedules too few nurses in hospital departments, said Rydahl, and that often requires nurses to do many non-nursing duties. They include patient transportation, housekeeping and patient sitting, she said.
Moore said DMC Huron Valley-Sinai also has cut staff in patient transportation, environmental services and housekeeping.
"We are leaving the floor to transport patients, to take out the garbage and sweep the floors," Moore said. "Patients are asking where the help is. We want to care for patients, and we are not getting support."
Armelagos said UM nurses addressed the issue on non-nursing duties years ago in their contracts. "Hospitals are foolish when they have nurses doing non-nursing tasks," he said. "The work is comprehensive enough not doing the work as a clerk. But when something needs to be done in the hospital and there is nobody else do it, nurses do it. Hospitals know this and cut support staff on purpose."
Lehman said nurses have several complaints about how Huron Valley-Sinai schedules nurses. When patient volume drops during the day, the hospital sends nurses home. "It is called 'K' time. You go home without pay or you can use vacation hours," said Lehman, adding that except for the operating room and cardiac catheter laboratory there is no on-call schedule.
"We work three 12-hour days, and sometimes much longer," Lehman said. "What every nurse wants is some kind of a floor. We want to know how many nurses are on call during a day and keep to a safe staff ratio. You have to take into consideration emergencies because we need to be able to see patients safely."
For example, Lehman said often in the emergency department nurses face short-staffing when trauma cases mount up, increasing typical 4-1 patient to nurse ratio up to 7-1 or more.
While Hall said mandatory overtime is limited in the Lapeer nurses' current contract, the hospital does not always abide by staffing guidelines for every department.
"We do have some nurses who will stay voluntarily. It is not considered mandated hours because a nurse has volunteered," Hall said. "If no one will stay, that is when they go to mandatory."
The last two years, however, McLaren Lapeer has been unable to hire enough nurses, Hall said.
"They like to say it is because of the nursing shortage. But we have several schools that produce 40 to 60 nurses per semester," said Hall, noting that there are three hospitals in Flint that also hire nurses. "We deal with issues of competitive pay. If you pay lower wages than other hospitals, you won't get as many nurses."
Hall said he knows several nurses at Lapeer who have graduated from nursing school and decided to go into home health or health insurance because of pay and working conditions at hospitals.
Kahn-Monroe said McLaren Lapeer recently hired a number of nurses to fill vacancies. "We had some turnover there, but we were able to hire people in," she said.
Calarco said nursing shortages are cyclical and often based on geography, with rural hospitals sometimes having more trouble attracting nurses than suburban hospitals because of pay and other factors.
But Calarco said hospital vacancies are sometimes created when there is low nursing staff and nurses become overworked and dissatisfied. She said there is no shortage of nurses in Ann Arbor, partially because nurses want to work at UM.
"You have a downward spiral when you create more vacancies to fill," she said. "Nurse recruiting and retention is impacted by practice environment of hospitals."
"What do nurses want?" originally appeared in Crain's Detroit Business.
Uninsured rates lower in states that run their own ACA exchanges
By Shelby
Livingston | November 20, 2017
The average uninsured rate in states that use the federal
HealthCare.gov exchange is nearly double that of states that set up their own
public health insurance exchanges, data released by the CDC shows.
In the first six months of 2017, HealthCare.gov states had an average uninsured rate of 16.1%, while states with their own exchanges—like California and Colorado—had an average uninsured rate of 8.3%.
The disparity in coverage in states that use HealthCare.gov and those with state-based exchanges can be explained, at least in part, by Medicaid expansion.
"States that went all in on implementing the ACA set up their own exchanges, but crucially also expanded Medicaid," said Larry Levitt, senior vice president at the Kaiser Family Foundation. He added that many states with their own exchanges have been more aggressive in outreach, which may have also helped lower the uninsured rate in the state.
Nearly all of the 12 states that run their own exchanges have expanded Medicaid under the Affordable Care Act, so people with incomes up to 138% of the federal poverty level have access to Medicaid coverage.
Meanwhile, 17 states that use HealthCare.gov or partner with the federal exchange for some functions opted not to expand Medicaid. A growing body of evidence has shown that states that expanded Medicaid in general have lower uninsured rates and healthier individual marketplaces.
According to the CDC data, the uninsured rate among adults ages 18 to 64 residing in Medicaid expansion states was 8.8% in the first six months of 2017, down from 18.4% in 2013. But in states that didn't expand Medicaid, the uninsured rate is 19% in the first half of 2017, down from 22.7% in 2013.
The CDC also found that the percentage of people enrolled in a private health insurance plan with a high deductible climbed to 42.9% in the first half of 2017 from 39.4% in 2016. The percentage has increased every year since 2010, when 25.3% of privately-insured individuals were enrolled in high-deductible plans. High-deductible health plans have a deductible of at least $1,300 for self-only coverage and $2,600 for family coverage.
In total, 28.8 million people of all ages, or 9% of Americans, were uninsured in the first half of 2017, about the same amount as in 2016. Among adults ages 18 to 64, the uninsured rate was 12.5%.
About 176.8 million people, or 65.4%, under age 65 were covered by private health insurance plans in the first half of this year, including 10.1 million, or 3.7%, covered by the ACA exchanges.
In the first six months of 2017, HealthCare.gov states had an average uninsured rate of 16.1%, while states with their own exchanges—like California and Colorado—had an average uninsured rate of 8.3%.
The disparity in coverage in states that use HealthCare.gov and those with state-based exchanges can be explained, at least in part, by Medicaid expansion.
"States that went all in on implementing the ACA set up their own exchanges, but crucially also expanded Medicaid," said Larry Levitt, senior vice president at the Kaiser Family Foundation. He added that many states with their own exchanges have been more aggressive in outreach, which may have also helped lower the uninsured rate in the state.
Nearly all of the 12 states that run their own exchanges have expanded Medicaid under the Affordable Care Act, so people with incomes up to 138% of the federal poverty level have access to Medicaid coverage.
Meanwhile, 17 states that use HealthCare.gov or partner with the federal exchange for some functions opted not to expand Medicaid. A growing body of evidence has shown that states that expanded Medicaid in general have lower uninsured rates and healthier individual marketplaces.
According to the CDC data, the uninsured rate among adults ages 18 to 64 residing in Medicaid expansion states was 8.8% in the first six months of 2017, down from 18.4% in 2013. But in states that didn't expand Medicaid, the uninsured rate is 19% in the first half of 2017, down from 22.7% in 2013.
The CDC also found that the percentage of people enrolled in a private health insurance plan with a high deductible climbed to 42.9% in the first half of 2017 from 39.4% in 2016. The percentage has increased every year since 2010, when 25.3% of privately-insured individuals were enrolled in high-deductible plans. High-deductible health plans have a deductible of at least $1,300 for self-only coverage and $2,600 for family coverage.
In total, 28.8 million people of all ages, or 9% of Americans, were uninsured in the first half of 2017, about the same amount as in 2016. Among adults ages 18 to 64, the uninsured rate was 12.5%.
About 176.8 million people, or 65.4%, under age 65 were covered by private health insurance plans in the first half of this year, including 10.1 million, or 3.7%, covered by the ACA exchanges.
Shelby Livingston is an insurance reporter.
Before joining Modern Healthcare in 2016, she covered employee benefits at
Business Insurance magazine. She has a master’s degree in journalism from
Northwestern University’s Medill School of Journalism and a bachelor’s in
English from Clemson University.
THE HIDDEN COST OF INADEQUATE HEALTH COVERAGE
The fuss over
ObamaCare produces confusion and obscures some important realities that deserve
our attention. Much of the political debate creates a polarizing force
like a centrifuge, splitting the pros and the cons into opposing camps that
line up behind positional opinions about whether healthcare is a right or not.
For those opposed to the taxpayer shouldering the financial burden of
providing healthcare to those without insurance coverage, the less the
taxpayers must fork out to subsidize the uninsured the better. All the
while, there is an implied assumption on the part of the entitlement crowd that
just providing insurance coverage for the uninsured is the end game. In
my opinion, we are all laboring under serious misunderstandings of the reality
of the healthcare system and the way the costs are absorbed by society.
I was looking for some
solid research about the cost of the uninsured, and I came across a powerful
and highly useful study from way back in 2003 when the early debate about
universal coverage was just beginning. The approach they took to
analyzing the problem still has significant value today, and what it says helps
shed light on the misunderstandings referenced above. In a preface to the
third chapter of the book Hidden Cost, Value Lost*, there is this
revealing assertion from their research:
The health care
services received by uninsured individuals that they do not pay for themselves
are picked up or “absorbed” by a number of parties, including:
- practitioners and institutions,
both public and private, that serve the uninsured at no charge or reduced
charges;
- the federal government,
localities, and states that support the operation of hospitals and
clinics, both through direct appropriations and implicit subsidies like
the Medicare and Medicaid disproportionate share hospital payments; and
- philanthropic donations.
While uninsured
individuals examined in this research consumed less than half the amount of
healthcare compared to those with full insurance coverage, they did not simply
stop receiving healthcare services altogether. Instead, when their health
conditions worsened to a point where they ultimately sought care, they showed
up at emergency rooms, urgent care centers, and community clinics to be
treated. As everyone knows, ERs are extremely expensive places to receive
care. Further, due to worsened health status because they were not
treated earlier, these individuals ended up with a higher rate of
hospitalization with conditions that were otherwise avoidable had they been
treated in a physician's office before things advanced.
Since these uninsured
people had lower incomes than those with insurance coverage, the out-of-pocket
costs for healthcare represented much higher levels of their total incomes.
Thus, much of the cost of healthcare was non-collectable, and the
unpaid fees were passed on to healthcare providers, local governments, and
charities. In the end, specific to hospitals and community clinics, the
federal government ended up paying subsidies in various different forms (e.g.,
disproportionate share payments, continuing medical education payments, etc.).
Either directly through federal, state, and local governments, or
indirectly through charitable donations, these costs factored their ways into
the tax-payer's wallets. There is "no free lunch" when low-income
individuals go without health insurance.
The next part of the
study goes on to reveal the additional costs that are hidden by the economy.
When people get sick, people miss work until they can get back on their
feet again. That is one of the primary reasons larger employers provide
health insurance: "presenteeism." Absence from work reduces
productivity, and insurance coverage helps minimize the amount of missed time
from the job by ensuring that workers can get treatment quickly and return to
productive work as soon as possible. Therefore, there is a drag on the
U.S. economy when workers are unable to seek healthcare services in a timely
manner, to recover, and to return to productive work.
The authors of this
book came to the following startling conclusion in Chapter 4: Other Costs
Associated with Uninsurance
The Committee’s best
estimate of the aggregate, annualized economic cost of the diminished health
and shorter life spans of Americans who lack health insurance is between
$65 and $130 billion for each year of health insurance forgone. These are
the benefits that could be realized if extension of coverage reduced the
morbidity and mortality of uninsured Americans to the levels for
individuals who are comparable on measured characteristics and who
have private health insurance. These estimated benefits could be
either greater or smaller if unmeasured personal characteristics were responsible for
part of the measured difference in morbidity and mortality between those
with and those without coverage. This estimate does not include spillover
losses to society as a whole of the poorer health of the uninsured
population. It accounts for the value only to those experiencing poorer
health and subsumes the losses to productivity that accrue to uninsured
individuals themselves.
We could pile on to
this limited quantification, as it mentions regarding the "spillover
losses to society as a whole of the poorer health of the uninsured population.”
But letting this limited estimate suffice for the sake of this argument,
the $65 to $130 billion annual cost in 2003, rescaled for inflation and the
lower number of uninsured due to ObamaCare today, still represents an enormous
cost for us to ponder.
The punchline to this
line of thought should be obvious at this point: can we afford to NOT
provide health coverage for these uninsured citizens? Between
the uncompensated care costs we now absorb anyway plus the economic costs
involved with lost productivity, we must reckon with the alternative in a new
light. Regardless of whether you believe that healthcare is a right or a
privilege, we need to look beyond that polarizing division to the true costs
involved and the implications of our decision: to cover or not to
cover? If you think that Healthcare Savings Accounts (HSAs) are
the magic answer, you need to understand that the low-income individuals we are
talking about do not have enough income to set aside anything in a tax-free
account that would be big enough to pay for their healthcare services in the
first place. What is required is decent health insurance that removes the
financial barriers to access healthcare when it can do the most good, which is
early on and easily accessible. Only then can we put people back to work
quickly and productively. Once we do that, they can be fully functioning
and contributing members of the American society.
*Hidden Cost, Value
Lost, Institute of Medicine. 2003. Hidden Costs, Value Lost:
Uninsurance in America. Washington, DC: The National Academies Press. https://doi.org/10.17226/10719;
The fifth of a series of six books on the consequences of uninsurance in the
United States, illustrates some of the economic and social losses to the
country of maintaining so many people without health insurance. The book
explores the potential economic and societal benefits that could be realized if
everyone had health insurance on a continuous basis, as people over age 65
currently do with Medicare.
https://risehealth.org/the-hidden-cost-of-inadequate-health-coverage
White House: True Cost Of Opioid Epidemic Tops $500B
Associated Press
November 20, 2017
WASHINGTON (AP) — The White House
says the true cost of the opioid drug epidemic in 2015 was $504 billion, or
roughly half a trillion dollars.
In an analysis to be released Monday,
the Council of Economic Advisers says the figure is more than six times larger
than the most recent estimate. The council said a 2016 private study estimated
that prescription opioid overdoes, abuse and dependence in the U.S. in 2013
cost $78.5 billion. Most of that was attributed to health care and criminal
justice spending, along with lost productivity.
The council said its estimate is
significantly larger because the epidemic has worsened, with overdose deaths
doubling in the past decade, and that some previous studies didn't reflect the
number of fatalities blamed on opioids, a powerful but addictive category of
painkillers.
The council also said previous
studies focused exclusively on prescription opioids, while its study also
factors in illicit opioids, including heroin.
"Previous estimates of the
economic cost of the opioid crisis greatly underestimate it by undervaluing the
most important component of the loss — fatalities resulting from
overdoses," said the report, which the White House released Sunday night.
Last month at the White House,
President Donald Trump declared opioid abuse a national public health
emergency. Trump announced an advertising campaign to combat what he said is
the worst drug crisis in the nation's history, but he did not direct any new
federal funding toward the effort.
Trump's declaration stopped short of
the emergency declaration that had been sought by a federal commission the
president created to study the problem. An interim report by the commission
argued for an emergency declaration, saying it would free additional money and
resources.
But in its final report earlier this
month, the panel called only for more drug courts, more training for doctors
and penalties for insurers that dodge covering addiction treatment. It did not
call for new money to address the epidemic.
More than 64,000 Americans died from
drug overdoses last year, most involving a prescription painkiller or an
illicit opioid like heroin.
Follow Darlene Superville on Twitter: http://www.twitter.com/dsupervilleap
https://insurancenewsnet.com/oarticle/white-house-true-cost-opioid-epidemic-tops-500b#.WhQ1GFVuKJA
Here’s What Americans Really Want In Health Insurance
The Herald-Mail
(Hagerstown, MD)
11/21/2017
Americans would rather have lower
insurance deductibles than more health care providers. They'd rather have
health insurance for everyone than the right to opt out of coverage. And
regardless of their political leanings, they're not enthused about what Republicans
in Congress have been trying to give them.
These are among the findings of the
American Family Survey released Thursday by the Deseret News and the Center for
the Study of Elections and Democracy at Brigham Young University.
As Senate Republicans seek to
eliminate the Obamacare individual mandate as part of a proposed tax reform
bill, the survey finds Americans deeply divided on priorities for health care
policy.
For example, nine out of 10 Hillary
Clinton voters say they would prefer making insurance accessible to all over
giving people more flexibility to opt out. Just four out of 10 Donald Trump
voters agree.
And three-quarters of Clinton voters
want to guarantee coverage for pre-existing conditions even if it means higher
monthly costs, while fewer than half of Trump voters say the same.
The one thing most Americans agree on
- regardless of who they voted for - is that they would trade a wider network
of doctors for lower deductibles. But overall, Trump voters champion lower
costs, lower taxes and freedom of choice, while Clinton voters want universal
access, guaranteed coverage and help for the poor, the report said.
The third annual American Family
Survey questioned 3,000 adults on a variety of political and social issues that
affect families, such as health insurance, addiction and social media use. This
year's findings are especially relevant as Congress wrangles over what to do
with the beleaguered Affordable Care Act even as Americans are enrolling in
insurance plans for next year.
And they help to explain why Congress
has been unable to enact changes to the health care law despite two attempts
this year by Republicans, who campaigned on repealing on replacing Obamacare.
Conducted in July, the American
Family Survey reveals that more than half of Americans have an immediate family
member with a chronic or serious health condition, and that personal experience
with illness impacts what people want from the nation's health care policy.
Illness in America
With an $1,800 monthly premium for
health insurance that will go up another $400 in January, the Cashin family,
who live in Portola Valley, California, illustrates why the cost of health
care, not the options available, matter so much to Americans.
Kimberley Cashin, a stay-at-home
mother of two boys, 6 and 7, has a chronic genetic disease called Ehlers Danlos
Syndrome, which made it difficult for her to find insurance before the
Affordable Care Act took effect.
Now, under the current health care law,
insurance companies can't discriminate against people like Cashin who have
pre-existing conditions.
But as premiums and deductibles have
gone up, and some insurers have pulled out of the federal marketplace because
their losses were higher than they expected, the family's premiums have become
"excruciating,"
Cashin said. She hasn't yet told her husband that
they're climbing again in a few months because she doesn't want him to be
stressed.
One striking finding of the American
Family Survey is how many families, like the Cashins, are struggling with serious
health issues.
"One of the things we asked was
whether you or your spouse or your children are dealing with a serious medical
condition. Almost 6 in 10 respondents said they are dealing with something
serious that requires regular medicine or regular trips to the doctor. That's a
big number. So, I think understanding a little more about how that affects
people is key," said Christopher F. Karpowitz, co-director of the Center
for the Study of Elections and Democracy at BYU, and a co-author of the report.
Forty-four percent of respondents say
they themselves require ongoing treatment or medicine, while 43 percent said a
spouse does and 24 percent said a child.
Their responses on other questions
suggest that personal experience with chronic or serious health conditions can
inform decisions more than partisanship when people consider what they want
from a national health care bill.
"For example, people who've had
a serious medical condition in the family are just a lot more likely, whether
they're Trump voters or Clinton voters, to believe that pre-existing conditions
should be covered, or that we should help people who can't afford insurance to
have insurance," Karpowitz said.
Interestingly, a chronic illness does
not seem to determine how much a family spends on health care. The type of
insurance they have does.
People on Medicaid report paying the
least to have coverage, while people who buy policies on their own, like the
Cashins, pay the most.
Before subsidies for Obamacare
policies became available in 2013, the percentage of uninsured Americans
younger than 65 hit 18.2 percent, according to 2010 data from the Centers for
Disease Control and Prevention.
The American Family Survey found that just 8
percent of respondents report they have no health coverage this year.
Of those with insurance, 44 percent
have policies provided by their employer, 24 percent have Medicare, 18 percent
have Medicaid and 12 percent had purchased a policy themselves.
As for out-of-pocket costs, whether
they have employer-provided insurance or buy their own, people pay about the
same amount whether they are healthy or sick. Out-of-pocket costs rise for
people on Medicare and are the highest for people with no insurance.
Having a chronically ill family
member also impacts Americans' opinions on helping the poor get health
insurance. The number of Trump and Clinton voters who prioritize helping the
poor rises by 10 percentage points when they have illness in their immediate
families.
The majority of Trump voters would
still prefer lower taxes over helping the poor, but "results nonetheless
still provide some evidence for the notion that experiencing an ongoing medical
difficulty that requires medical care boosts concern for the plight of the poor
in obtaining health insurance," the report says.
What Americans really want
So far, Congress has failed to act on
two replacements for the Affordable Care Act that have been proposed, and the
American Family Survey reveals why: Americans generally don't like what the
Republicans have proposed, even if they are Republicans themselves.
"Consistent with other surveys,
many elements of the Republican plan proved highly unpopular, regardless of
income or family medical challenges," the report summary said.
The American Family Survey asked
people to assess four components of the Republican plans: eliminating the
mandate that people have insurance or face penalties; giving states control
over insurance rules; cutting federal funding for Medicaid; and making
available a greater variety of plans. Of these, only offering a greater variety
of plans had the approval of respondents across the political spectrum.
Ninety percent of Trump voters, 63
percent of Clinton voters and 72 percent of all respondents approved of this
component.
The only other overwhelmingly
positive response in this category was among Trump voters on the question of
removing the insurance mandate: Nearly three-quarters said they want the
mandate gone. Just 18 percent of Clinton voters do.
As for the other Republican proposals
- cutting Medicaid and giving states more control of what insurance companies
cover and charge - fewer than half of respondents expressed support, regardless
of their political party, family income, and health status.
"The only exception to this
unpopular slate of reforms is allowing for a greater variety of plans,"
the authors of the summary report wrote.
Matthew Fiedler, a fellow with the
Center for Health Policy in Brookings' Economic Studies Program, said that
finding is consistent with other research he has seen, and reflects what he
sees as an inconsistency between what some Republicans say they want to do and
their beliefs about the role of government in health care.
"When Republicans have talked
about their proposal and what they're trying to achieve, they say they want to
keep people covered and they want that coverage to be affordable and they want
people with pre-existing conditions to be protected," he said.
"But the problem is, the set of
policies that they're committed to really won't do that."
Where we go from here
Cashin, who leads an online community
of mothers dealing with chronic illness, said that although she and her husband
initially supported the Affordable Care Act, and they voted for Barack Obama twice,
they're hoping a replacement passes that will relieve the staggering premiums
that she and others in her Facebook group are having to pay. One woman Cashin
knows will be paying $2,700 a month for health insurance for a family of four
come January, she said.
But until America finds a way to
lower the cost of health care, not just the cost of health insurance, either
premiums or deductibles will remain high, Fiedler said.
"A lot of the debate we've been
having is about how we finance care, how many people have coverage, who pays
for that coverage and what does that coverage cost," he said.
"But there's an underlying
question, which is, 'What the underlying cost of health care?'"
The proposals put forth so far, he
said, are largely a Hobson's choice for consumers: pay more for premiums and
less for health care, or pay less for premiums and more for health care.
Debate over health insurance tends to
be partisan and ideological, but when the conversation turns to how to reduce
the cost of care, there's room for more bipartisan discussion and work, he
said, adding, "This could potentially be a productive place of where the
debate could go."
"The only way we're going to be
able to reduce deductibles for everyone system-wide over the long run is if we
find ways to reduce that underlying cost of care."
For the Cashin family, which leans
Democratic (although both spouses voted for President George W. Bush), the
issue now goes beyond politics.
"I do think a new bill is
necessary. I'm just hoping that the millions of people that are currently
covered can maintain their coverage," Cashin said.
"There's this dichotomy: We have
all these people who were essentially uninsurable, and now we're insured, but
at the same time, families are getting hit with these premiums," she said.
"It's not a balanced system.
Somehow, some way, we need to fix that,
without affecting those who are not insured."
Lois Collins contributed to this
article.
Jennifer Graham, Deseret News
HiveEMAIL: jgraham@deseretnews.comTWITTER: @grahamtoday
https://insurancenewsnet.com/oarticle/heres-americans-really-want-health-insurance#.WhQzG1VuKJA
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