Obamacare Is Making Insurance Companies More Efficient

Obamacare may already be making private health insurers more efficient, according to a year-over-year comparison of data related to the biggest consumer protection in the law.

Last year, insurers had to rebate $1.1 billion to consumers because they failed to meet the minimum payout percentage required by the law.  That was the first year the payout provision, or mandatory minimum loss ratio, was in effect.

This year, the federal government has announced that the rebate will be just half that – slightly more than $504 million.

And the number of consumers who receive a rebate will also be smaller.  Last year, 12.7 million customers received rebates.  This year, the number receiving rebates has dropped by one-third, to 8.5 million.

Why are fewer and smaller rebates a good thing?

According to the Department of Health and Human Services, this is evidence that insurers are “spending more of their premium dollars directly toward patient care and quality, not red tape and bonuses.”

The loss ratio provision is sometimes described as the 80/20 rule.  It states that, for every health insurance plan it offers, a private insurer must pay out at least 80 cents of every premium dollar on patient benefits, reserving only 20 cents for administrative costs and profits.  (For some plans, the requirement is 85 cents.)  Whenever it does not, it has to rebate its customers the difference.

The provision does not affect Medicare, because Medicare has significantly lower administrative costs than private insurers, and regularly pays out around 95 cents in care for every dollar it takes in.

Those who receive rebates may be happy, but it is better not to receive one.  A rebate is a sign that your insurance company has not paid out enough in benefits to the people as a whole who are covered by your plan.  This can happen to any insurer – especially when its customers have a healthier year than expected.  But if you have received rebates for two years in a row, you might want to ask why, and consider whether another plan would be better for you.

HHS breaks the data down by state and by three categories.  This year there were six states in which every plan met the standard in the individual insurance category, fifteen states in which every plan met the standard in the small group category, and ten states in which every plan met the standard in the large group category.

In no state did every insurer meet the standard in all three categories, but there were six states in which insurers met the standard in at least two categories.  

In Vermont and Alabama, every small group and large group market insurer met the standard.  In South Dakota, Rhode Island, Maine, and Hawaii, every individual and small group market insurer met the standard.  Rhode Island probably edges out the other states as best overall – in the one category its insurers will pay some rebates, the average will be only $43 per policyholder.

For this year, every Connecticut insurer met the standard in the large group market, after at least some fell short in all three areas last year.  And there was a big drop in the average rebate in the individual market, from $124 to $64.  The small group market, though, saw an increase, from $162 to $357.

And even Floridians, with a weak state insurance regulator, have something to celebrate.  The size of the average rebates went down in all three categories, from $240 to $164 in the individual market, from $190 to $94 in the small group market, and from $94 to $51 in the large group market.

In general, the results for this year appear clearly more attributable to the work of the federal government than to the states. 

In fact, last year, there were 37 total times across all fifty states when all the insurers in a given category met the standard.  This year, that number went down to 31.

But the bottom line is unmistakable.  On the whole, insurers are paying attention to this consumer protection, and working to meet this new standard.  And this is something that would not be happening if it were not for Obamacare.

As HHS headlined in its release, consumers have saved a total of $3.4 billion upfront in their insurance premiums this year as a result of Obamacare, in addition to the $500 million in rebates.  This may not be all we wanted.  But it is a start.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

States Expanding Medicaid Face Challenges of Their Own

Last week, I wrote about the states that have decided not to expand Medicaid this year.  The decision will cost them in money and lives. 

But the 24 (and counting) states that have chosen to expand Medicaid will face challenges of their own.  As a new article in Health Affairs Blog reveals, expanding states will have plenty to do to assure that the benefits of expansion reach those most in need.

The article, entitled Lessons of Early Medicaid Expansions Under the Affordable Care Act, reviews the experiences of five states and the District of Columbia in expanding Medicaid benefits to additional populations using authority granted to them under Obamacare.  The five states were Connecticut, California, Minnesota, New Jersey, and Washington.

All of the states were able to capture federal dollars to support state or local low-income insurance programs.  But, according to the authors, there were seven lessons these states learned that could be warning signs to other states banking on the savings.

One lesson was that they could not predict the size of their eligible populations as well as they thought they could.

For example, when Connecticut’s expansion was approved in 2010, it was estimated that 45,000 people would be affected.  By May of 2013, over 90,000 had been enrolled.  So while Connecticut may have saved $50 million on the first 45,000; it may have spent all of that on the second.

Connecticut will still benefit in the long run – the original expansion took place under the old federal reimbursement rate.  Higher reimbursement begins in 2014.

But I spoke recently with one former state official, who echoed the concerns of others.  He said that taking into consideration all of the state’s financial difficulties in recent years, perhaps the state should have waited to expand.

Another lesson was that it was not as easy to enroll newly eligible people as the states thought it would be.

On the surface, enrollment seemed straightforward enough.  If a person’s income was below a certain cut-off – 138 percent of poverty – he or she was eligible under the expansion and could enroll.

But this presumes that people are following the news as closely as our public officials do.  And it also presumes that they can easily calculate how much income 138 percent of poverty means for them, taking into account their own family situation.  Finally, it presumes that they can get to the right place to file an application and verify their income, their address, and other information.

Beyond that, once they were enrolled, they often moved or had other changes in their status.  And that meant making certain that the state found them at their new address and captured up-to-date information.

The federal government anticipated these challenges when it provided for more navigators to assist with enrollment.  But not every state is on board with the widespread use of navigators. Even though Florida chose not to expand Medicaid, it still passed a law this year placing some unnecessary and onerous registration requirements on the new navigators.  States following Florida’s lead may discourage both Medicaid and private insurance enrollment in general.

The authors also found that expanding states were covering more people with mental illnesses than they anticipated.

To anyone following the implementation of Obamacare closely, this is no surprise.  The mental health coverage required by both Obamacare and the soon-to-be-implemented Mental Health Parity Act is far more generous – and fairer – than it has ever been.

The authors think that the jury is out on whether every expanding state will experience this.  The early expanders typically focused on very poor people, and there may be more people with mental illness in this group than in the poor and near-poor populations most affected by Medicaid expansion.  We will find out soon enough whether this is so.

Finally, the authors also noted that the political context for expansion is important. 

At bottom, states that want to provide coverage to more people will find a way to do it.  Those that do not, will not.

But in every state, the political drumbeat for better coverage is going to get louder over the next year or two.  

And, according to the authors, the drumbeat may be loudest among the safety net providers.  Hospitals and community health centers have the most to gain by expansion, and the most to lose in states where the numbers of uninsured remain the highest.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Grim Numbers Result from Failure to Expand Medicaid

In the aftermath of the decisions by state governors and legislators not to expand Medicaid, the grim numbers are beginning to roll in.  Failure to expand Medicaid will cost states more than 19,000 lives and over a billion dollars per year.

And that, sadly, is only the beginning.

Source: RAND Analysis, Health Affairs, June 2013

I wrote about this prospect earlier this year, when I concluded that as many as 36,000 lives could hang in the balance of the Medicaid expansion debate.

Now we have some new numbers from a RAND Corporation analysis, published this month by Health Affairs, which quantified the impact of failing to expand Medicaid in fourteen states (as of April 2013) where governors opposed the expansion.  The fourteen states were Alabama, Georgia, Idaho, Iowa, Louisiana, Maine, Mississippi, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Texas, and Wisconsin.

It found that in 2016 there would be 3.6 million fewer insured people in these states.  Collectively, the states would lose $8.4 billion annually in federal reimbursement.  And they would also need to spend an additional $1 billion annually on uncompensated care as a result of their short-sighted decision.

In addition – and most chillingly – there would be 19,000 additional deaths in those states each year.  This is two and a half times the number of total combined combat deaths by coalition troops since the beginning of the wars in Iraq and Afghanistan, and more than the total number of homicide deaths in the nation each year.

But these numbers are already out of date, overshadowed by legislative decisions of the last month.

After the analysis was completed, several more states have moved to reject expansion.  Florida adjourned its legislative session in early May without agreeing to the expansion.  Nebraska’s expansion bill died in mid-May.  As recently as two weeks ago, Michigan’s Republican governor was calling for federal help to try to convince legislators in that state to put Medicaid expansion back into the budget.  And both the Ohioand New Hampshire Senates rejected Medicaid expansion just last week.

These decisions will cost hundreds of millions more dollars, while adding millions to the number of uninsured.  Florida’s rejection alone will account for one million more uninsured people and cost state taxpayers at least $430 million.

Failure to expand Medicaid in these states and others will also add thousands more deaths to the tally.

The irony is that all of these states have strong pro-life constituencies.  But the moral imperative of protecting lives doesn’t always extend to those who are already among the living – especially when it is the Affordable Care Act that offers the protection.

The people who will die prematurely as a result of decisions not to expand Medicaid include children with special health care needs – think of children who await organ transplants as examples – and adults with chronic diseases.  These people survive under the most challenging of physical and mental conditions, and have done nothing to incur the wrath of political leaders. 

And yet there is an undercurrent of anger toward those who are acting to save these lives that is, frankly, chilling.

Here is what the Republican Party of Benton County, Arkansas, published in its April 2013 newsletter directed at Republican legislators who supported the Medicaid expansion in that state:

“The 2^nd Amendment means nothing unless those in power believe you would have no problem simply walking up and shooting them if they got too far out of line and stopped responding as representatives.  It seems that we are unable to muster that belief in any of our representatives on a state or federal level.

“But we have to have something, something costly, something that they will fear and that we will use if they step out of line.  If we can’t shoot them, we have to at least be firm in our threat to take immediate action against them politically, socially, or civically if they screw up on something this big.  Personally, I think a gun is quicker and more merciful, but hey, we can’t.”

So we should think about shooting Republicans who vote for Medicaid expansion? 

Could the opposition to Medicaid expansion be more absurd and less grounded in reality? 

I suppose it could, if it involves giving up billions in federal dollars, costing state taxpayers billions more, throwing millions onto hospitals’ charity care rolls, and costing thousands their lives.

Come hear Paul Gionfriddo speak about what comes next for the health and mental health of South Floridians now that the legislature failed to expand Medicaid.  Sponsored by the Mental Health Association of Palm Beach County, and open to the public.  On Thursday, June 20, at noon at 909 Fern Street, West Palm Beach.  To Register: http://www.mhapbc.org/index.cfm?fuseaction=events.details&content_id=132

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The Medicare Myth, Or Why We Can't Trust Anything Our Politicians Tell Us about Health Care Financing

The 2013 Medicare Trustees report is out, and it proves once again that the so-called Medicare funding crisis is a myth that has been manufactured by political leaders more interested in cutting the size of government than in assuring access to health care for all.

Those may seem like strong words, but we have been waiting for a long time for government leaders to tell us the truth about Medicare.  That it hasn’t contributed to our budget deficit.  That its trust fund is solvent. 

And, most important, that it would take only the tiniest of tax increases to preserve Medicare as we know it for everyone who is alive today.

The 2013 report was released last week.  Nearly one in every six (or 50.7 million) Americans is covered by Medicare.  42 million of them are age 65 and over, but 8.5 million are younger and living with serious disabilities.

The combined Medicare expenditures – for parts A, B, and D – were $574 billion in 2012.  Taxes, co-pays, and other income produced $537 billion in revenue.  The remaining $37 billion came from trust funds – not as some politicians want us to believe from general governmental spending.

Furthermore, there were two trust funds to help cover that shortfall.  The one we always hear about – the so-called “HI fund” that supports Medicare Part A expenditures – had $244 billion in it at the start of 2012. 

Was that enough?  The trustees advise that there should be at least one year of reserves in that fund at any time.  At the start of the year, it had 92 percent of that – almost exactly the recommended amount. 

As a result, when its share of the 2012 shortfall came to $24 billion – less than anticipated a year earlier – it extended the life of the fund to at least 2026.  That was the headline in many of the news reports.

But there is more.  Based on current projections, the trustees now expect that there will be surpluses added to the fund between 2015 and 2020 – partially because of the Affordable Care Act and partially because of the lower health care inflation of the last few years.

Only the Heritage Foundation could refer to this as a “bleak future.”

Dire warnings aside, we still should not sit on our hands doing nothing over the next thirteen years, nor refuse to consider containing Medicare costs in the future.

Based on current projections, Medicare spending, which consumes 3.6 percent of GDP today, will grow to 6.5 percent of GDP over the next 75 years. 

Some may call this unsustainable growth.  But another way to look at it is to consider that energy costs alone consumed 8.3 percent of GDP in 2010, and helped lead to the investments and innovations that could lead to American energy independence within the next ten to fifteen years. We can always use that kind of investment and innovation in health services.

And this is the biggest exploding myth of all – how much would it actually take to finance a Medicare program that consumed 6.5 percent of our GDP?

According to the trustees, it would take a tax increase of – are you ready for this? - .55 percent to employees and .55 percent for employers.  This isn’t a typo.  We’re not talking 55 percent or even 5.5 percent - we’re talking about five-tenths of 1 percent to preserve Medicare as we know it for everyone alive today.

This is less than the two-thirds of 1 percent it was projected to cost last year, and much less than the 1.9 percent it was projected to cost just five years ago, before Obamacare.  So even the trend line looks good.

None of this, of course, fits into the “Medicare in Crisis” political narrative of our times, and it is why this report will probably get even less attention than last year’s report.

Because this is the truth.  While our Congress still has some work to do on Medicare – most notably reforming the reimbursement formula that has led to the need for an annual “doc fix” that could still add another 3 percent to Medicare’s draw from GDP – the program is mostly on the right track.

There is no reason to scare Americans into believing that Medicare is in crisis, and even less of a reason to argue that the government can’t be trusted to provide efficiently and effectively for the health care needs of its most vulnerable citizens.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

New Programs Show Value of Health and Behavioral Health Integration

A Kaiser Health News sampling of the latest headlines about Obamacare reflects our continuing anxiety over the law just months before it is fully implemented.

The most interesting to me was this one.  According to a new CNN poll, only 43 percent of the public favors Obamacare.  But of those who oppose it, only 35 percent do so because it is too liberal.  Sixteen percent say that it is not liberal enough!

No matter how you feel about Obamacare, one of the most significant changes it facilitates will be the integration of health and behavioral health care – meaning that care for both physical and mental illnesses will soon be delivered together.

This only makes sense.  People with cancer, for example, often develop depression or anxiety that complicates their care.  And people with mental illness often develop physical conditions – sometimes as a side effect from the medications they take – that can cut twenty-five years from their lives.

Integrating health and behavioral health care has not been the norm over the past century. 

In a nutshell, this is because regular health care evolved from an acute care model – the idea that we could cure disease with aggressive, short-term interventions.  Mental health care evolved from a chronic care model – that mental illnesses could be managed, but not prevented or cured.

What we have learned in the last 20 to 30 years shows that both models can be useful in treating all diseases.

So we began to manage some diseases that we could not cure using a newer chronic disease model.  HIV/AIDS treatment is an example, but so are today’s treatments for many chronic conditions, including cancers, heart diseases, diabetes, and hypertension.  And we began to use an acute care model to treat mental illness, offering short-term stabilization in addition to longer-term therapies.

With diseases co-occurring and treatments often intersecting, care integration was the logical next step.

In its 2010 document, Evolving Models of Behavioral Health Integration in Primary Care, the Milbank Memorial Fund offered numerous examples of the care integration approaches that have evolved over the past twenty years. 

And while care integration has been slow to gain traction, that is about to change as a result of the Affordable Care Act.

Access to insurance despite pre-existing conditions, prohibitions on rescinding coverage after a person gets a chronic disease, and greater parity in health and behavioral health benefits are three reasons why, from a consumer perspective. 

More billing options and better reimbursement rates for primary care providers offering behavioral health screening and support services are two reasons why, from a provider perspective.

And the call for early intervention to prevent future tragedies is one big reason why, from a purely political perspective.

This week and next, I have the good fortune of being witness to two cutting-edge integration initiatives that reflect our changing environment. 

I serve on the Board of Directors of the Jerome Golden Center for Behavioral Health, and this week attended the grand opening of its new primary care clinic.

For the first time in its forty year existence, this safety net community mental health center will offer formal primary care services in the same location in which it offers behavioral health services.  Patients will benefit from one-stop shopping, and receive monitoring and treatment for health conditions as they are treated for behavioral illnesses. 

Integrating health services into behavioral health services in this way is a far less common approach to integration than doing it the other way around.  HRSA, for example, notes that 70 percent of community health centers offer at least some mental health services.  But some people – especially those with serious mental illnesses – often access only behavioral health providers, because they are reluctant or unable to seek out care in multiple locations.

And in the coming week, I’ll be at the annual meeting of Mental Health America for a presentation by the Mental Health Association of Palm Beach County about its Be Merge initiative.  Through Be Merge and related initiatives, MHAPBC is training primary care and mental health providers to work together in any model to integrate health and behavioral health services.

The initiative has won Mental Health America’s 2013 Innovation in Programming Award, and is clearly ready for prime time.  MHAPBC has made the training and toolkit available online through the University of South Florida, for use by agencies and providers throughout the nation.

As these two initiatives show, integration has finally arrived.  Better late than never.

Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Veterans and Mental Illness: A 2013 Update

Fifty-four percent of Iraq and Afghanistan war veterans who have sought treatment in the VA system since 2001 have been treated for mental disorders.

This is the second most-frequent diagnosis among these veterans.  It is an indicator of the profound effect recent war service is having on the mental health and well-being of our veterans.

The data come from a March, 2013, report entitled Analysis of VA Healthcare Utilization Among Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) Veterans.  

Here are some numbers that reflect how extensive the use of VA services has been during the last decade.

As of the end of 2012, 2.5 million troops had served since the beginning of the Iraq and Afghanistan wars.  Just over 1.6 million had become eligible for VA healthcare.  Of that group, almost 900,000 had used VA healthcare services by the end of 2012.

These 900,000 veterans most often sought treatment in VA centers in the south or in the west.  More than 85,000 sought treatment in the VA South Central Healthcare Network, while more than 80,000 sought treatment in the VA Desert Pacific Healthcare Network.  By contrast, less than 39,000 sought treatment in the VA New England Healthcare System.

Of those seeking treatment, 88 percent were male, and 12 percent were female.  93 percent had been seen on an outpatient basis only, while 7 percent had been hospitalized in a VA hospital on at least one occasion. 

Almost half were under the age of 30.

And the 550,000 who accessed care during 2012 alone represented 9 percent of the total number of veterans receiving VA care during the 2012 fiscal year.

And while – as might be expected – musculoskeletal system conditions were the most frequent diagnosis (58 percent) over the entire decade, nearly as many veterans (54 percent, or over 486,000) were diagnosed with mental disorders.

Many had two or more disorders.

Post-traumatic Stress Disorder, or PTSD, was the most frequent mental disorder treated in VA settings.  Over a quarter million OEF/OIF/OND veterans were treated for PTSD by the end of 2012.  But depressive disorders were nearly as prevalent, with more than 200,000 veterans being diagnosed with those.  Also, nearly 200,000 veterans were treated for neurotic disorders.

Together, these numbers provide strong statistical evidence that repeated exposure to environmental risk factors, including violence, are factors in multiple mental health conditions.

On the other hand, only 59,000 were diagnosed with alcohol dependence and only 32,000 with drug dependence.  These numbers suggest just as strongly that the mental disorders among returning veterans were not caused by risk factors within the control of the veterans themselves.

On Memorial Day, all of these data should give us pause to think about the inadequate federal and services and systems to which our OEF/OIF/OND veterans are returning. 

While the VA has taken steps in recent years to extend additional services to returning veterans, including allowing veterans to enroll in VA health services for up to five years after service and waiving co-pays for health problems related to military service, a significant number of veterans have not yet entered – or will never enter – the VA system.  

In addition, as a number of news outlets, including the Daily Beast, reported in March 2013, 245,000 veterans had been waiting for more than a year for disability benefits as of December 2012.  The average wait time for Iraq and Afghanistan veterans was between 316 and 327 days.

The federal government could be doing more for these men and women, but so could our states.

Funding for mental health services were cut by $4.6 billion by states between 2009 and 2012, and the unwillingness of many states to expand Medicaid benefits this year is certain to take a toll on many of our returning veterans and their families.   

We all know that this is no way to treat our returning veterans.

So as we raise our flags on another Memorial Day, we should never forget that our responsibility to those who serve our country extends over 365 days. 

Now is the time to pay back those for the sacrifices they have made.  Or are we so cold as to expect these mostly young veterans to have made this sacrifice – along with the toll it took on their health and mental health – all by themselves?   

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The Stories Behind the Headlines: Is This the Best We Can Do?

Health policy has often been in the news headlines this month.  

To cite three examples, CDC released a new report about causes of death.  CMS published data showing wide variations in hospital charges for common procedures.  And, in the context of a newly-reported Oregon Medicaid expansion study, states have been making decisions about Medicaid expansion.

Let's look at the mental health policy stories behind the headlines.

Suicide on the Rise

The CDC reported this month that as of 2009, there were more deaths from suicide in the United States than there were from motor vehicle accidents.

Suicide rates increased by over 28 percent among men and women aged 35-64 from 1999 to 2010.  While men were three times more likely to commit suicide, the rate increased more for women (32 percent) than for men (27 percent).

Suicide rates are highest in the west, but they are increasing in 39 states.

Men are most likely to commit suicide with firearms, women with poison.  The most rapidly growing cause is suffocation.

During the same period, results were down slightly among elders, and up slightly among youth.  CDC speculated that the bad economy could be affecting rates.  It also noted that baby boomers have had elevated suicide rates throughout their lives.

So what are we doing about this?  The recent Medicaid and Medicare debates suggest a whole lot less than we should be.

Oregon Study Links Medicaid Expansion to Reductions in Mental Illness

By now, everyone knows that the Florida legislature decided not to expand Medicaid to over 1 million residents.

Florida isn’t alone – it looks like elected officials in approximately half the states will turn down Medicaid expansion for at least this year, and forfeit billions of dollars that could be used for patient care.

Many expansion opponents latched onto a study published this month in the New England Journal of Medicine to support the case against expansion.  The study analyzed the results of an Oregon Medicaid expansion program over a two-year period.  It concluded that the Oregon expansion had no effect “on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions.”

Expansion proponents looked for a silver lining, arguing that the study also showed that Oregon’s expansion improved access to care and increased the use of preventive services.

But both seemed to overlook the study’s most definitive conclusion – diagnoses of depression went down by 30 percent among those covered by the Medicaid expansion. 

Mental Health America notes that depression has been estimated to cost $77 billion annually.  So how many billions could we save by cutting depression rates by 30 percent?

And why isn’t this garnering all the headlines?

New CMS Data Show Wide Variations in Payments for Psychosis Care

This past week, the Centers for Medicare and Medicaid Services (CMS) released data on charges for hospitals throughout the country.  The release attracted plenty of attention, because there were wide variations in what different hospitals charged for the “same level of care.”

CMS wants high-charging hospitals to lower their charges.

Those charges, however, may not be the most important numbers in the data.  The real headline is in what Medicare actually pays for the “same level care” throughout the country.

If you suffer from psychosis, you’re better off being hospitalized in Maryland – where Medicare pays an average of $11,277 per discharge, twice as much as it does in a half dozen other states – than in any other place in the country.

The variation in payments in states – even within geographic regions – was astonishing.   I put a table with the numbers for all the states on my State Rankingspage, but here are just a few examples.    Alabama hospitals were paid only $5,256 per discharge, while those in Florida were paid $7,006 and those in Georgia $6,605.  Connecticut hospitals were paid $8,239 (note: the overall number of discharges was very small for Connecticut), while those in Massachusetts were paid $7,494.  North Carolina hospitals were paid $6,188; those in Virginia were paid $5,851 and those in the District of Columbia were paid $9,444.  California and Oregon hospitals were paid $8,916 and $8,816, respectively, but Washington hospitals were paid only $6,504.

You can see information for all the states here.

When we look at the three reports together, they certainly beg at least this question.  Is this really the best we can do?

Paul Gionfriddo will be speaking at the breakfast meeting of the Middlesex (CT) County Coalition on Housing and Homelessness on Friday, May 17, at 8 a.m.  It is open to the public; RSVP to ann@anendinten.org. 

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

The People on the Plaza

On a recent bright and sunny Monday afternoon, I took the sixteen-minute BART ride from Oakland – where I was doing some work – into downtown San Francisco.  I went to several places where people who are homeless tend to congregate. 

What I saw made me wonder.  Do we realize that if we do nothing, up to half of the people who are chronically homeless are likely to die in the next ten years?

I exited the BART train at the Civic Center/UN Plaza station.  When I arrived above ground, I saw more than a hundred homeless people in the vicinity of the station.  They were sitting or resting on the plaza, pretty much keeping to themselves.

Scores of tourists, business people, and shoppers hurried about their business.  There was no interaction between the two groups.  It reminded me of the way old-time cartoons had the action layered on top of a static backdrop – a crowd bustling with activity set against the backdrop of stationary homeless people.

I witnessed something similar in at least three other settings that afternoon.

I walked into Buena Vista Park, a beautiful, wooded park on a hill along Haight Street with awesome, expansive views of San Francisco.  As I climbed its paths, I passed by several people out walking their dogs.  They barely noticed the homeless people sleeping or sitting on the grassy lawn nearby. 

In the nearby panhandle of Golden Gate Park, a few joggers and sunbathers also ignored the small groups of homeless people sitting together under the trees.

And at the Powell Street station later on that afternoon, hundreds of shoppers passed by scores of homeless people without paying them the least bit of attention.

At first, I didn’t see what was wrong with this picture.  I was impressed with the live-and-let-live spirit of the community, where no one hassled anyone else. 

But then I looked more closely.  The people passing through the plaza were so accustomed to the homeless people on the plaza that they were not moved – either to anger or to sympathy – by seeing them.

San Francisco has an estimated 24,000 people who are homeless.  Its governmental agencies and nonprofit community do far more for them than most. 

According to a recent article in the San Francisco Chronicle, the city has moved 8,000 people off the streets since 2004, and has 1,155 emergency shelter beds.  A new homeless health care clinic will open this summer with the capacity to accommodate 50,000 visits per year.  And because the homeless population is aging, 77 new apartments are opening for homeless seniors.

But that doesn’t mean that chronic homelessness isn’t a problem anymore.

The National Alliance to End Homelessness released a new report last month that documented some improvements in the prevalence rates of both overall homelessness and chronic homelessness in the United States over the past ten years. 

But the same report shows that the numbers of homeless people have remained steady during the last four years, in spite of an improving economy.  (Perhaps cutbacks in mental health funding are a reason.) One person in every five hundred is homeless. And out of every ten thousand veterans, 29 are homeless.

Here's something to think about.

The Chronicle article also noted that the mean age of the homeless population increased from 34 to 53 between 1990 and 2010, and that the life expectancy of a person on the streets is 64.  It is possible that chronic homelessness is decreasing because of better services.  But it is also possible that it is decreasing because chronically homeless people are dying off.  In the next ten years, half could be dead.

The NAEH report makes it clear that the problem of homelessness is not limited to warm weather and service-rich communities like San Francisco. 

In fact, Colorado, Oregon, Washington, Wyoming, and Alaska are among the eleven states with the highest rates of homelessness in the country. 

There is a clear connection between behavioral illnesses and chronic homelessness.  I plan to talk about this in a presentation I will be making at a breakfast open to the public sponsored by the Middlesex County Coalition on Housing and Homelessness in Haddam, Connecticut on Friday, May 17.

My goal in that talk will be simple – to remind people that no matter where you fall on the philosophical spectrum, doing nothing about homelessness is not an option. 

You may be able to walk right by the people on the plaza without them saying a word, but this doesn’t mean that they shouldn’t command your attention.

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Is Medicare Clearing Better Pathways to Wellness for Men With Depression?

You would expect Medicare to spend about the same for a man with heart, lung, or kidney disease as it does for a woman.  And if you looked at the actual numbers, you would not be surprised.  On average, it does. 

So why does Medicare spend so much more on men when you couple these disease with depression? That is a question that deserves an answer.

The startling numbers, which show just how wide the disparity is, are in the chart accompanying this column.  They are very similar to some others that I shared in my column last week.

They all come from the 2010 CMS Medicare public use data files, the most recent ones available.  The CMS file includes information on all 48 million Medicare recipients. 

Last week, I wrote that men with depression in the 65-69 year old age group enjoyed an 11% Medicare spending advantage over women in the same age group.  (The men were those on Medicare only, not both Medicare and Medicaid.)  I also wrote that the disparity persisted both as they aged and when they were diagnosed as having both depression and dementia.

That column raised at least one troubling question – why are women with depression being undertreated relative to men, when they are two to three times more likely to be diagnosed with it?

I received a number of possible answers to that question, but the most common one was that perhaps men’s needs are more intensive.  Because they are diagnosed less frequently, they may simply be sicker by the time they are, and therefore need more treatment.

The Medicare data do not include a severity measure, so there is no way to tell for sure.  But there is at least some indirect empirical evidence for this. The Medicare spending gap in favor of men is wider for hospital care (Part A) than it is for outpatient treatment of drugs (Parts B/D).

If there were an intensity advantage, however, it should disappear as people get sicker.

But it doesn’t. If anything, it may get a little wider. 

This week, I looked at some groups with greater health needs – Medicare recipients in the 65-69 year old age group who were dually diagnosed with depression plus heart disease, depression plus lung disease, depression plus kidney disease, or depression plus cancer.  In every case, being sicker (i.e., having a second diagnosis of depression on top of the other chronic disease) led to a wider gap in spending.

Three of the examples are captured in the chart.  As expected, there’s very little gender bias in Medicare spending on heart disease (2% more on men), lung disease (1% more on men), or kidney disease (4% more on men).  There is a gender bias in spending on cancer, but it favors women (Medicare pays 26% less on men with cancer).

When you add depression to these conditions, the spending tilts in favor of men again.  

• The 2 percent difference in spending favoring men with heart disease grew to 9 percent when the men and the women had both heart disease and depression. 
• The 1 percent difference in spending on lung disease expanded to 13 percent when both lung disease and depression were present. 
• And the 4 percent difference in spending favoring men with kidney disease ballooned to 30 percent when both kidney disease and depression were present.

And the cancer spending gap dropped from 26 percent down to just 15 percent.

The difference is clearly the depression.

Medicare simply spends less on women with depression, even when they have other serious chronic conditions.  You can decide for yourself about the reason.  Are men underdiagnosed? Are women overdiagnosed?  Are men overtreated? Are women undertreated?

The CMS data set does not answer those questions.

But it does tell us this – Medicare-eligible men and women with depression, at least in this age group, are clearly being treated differently.  For whatever reason, the men are getting more, and the women are getting less.

Today is the start of Mental Health Month.  This year’s theme is “Pathways to Wellness.”  So here’s my question, similar to last week’s.   Is Medicare clearing better pathways to wellness for men with depression than it is for women?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/ 

Women and Depression - Stoicism or Neglect?

Are women with depression more stoic than men, or are men just getting preferential treatment?

According to the National Institute on Mental Health, women are 70 percent more likely than men to experience depression during their lifetime.  Depression hits women harder than men in nearly every age group.

But if some fascinating data from the Centers for Medicare and Medicaid Services are any indication, we also spend a lot less on treating them than we do men.   

Are women more stoic, or are we just neglecting their mental health needs?

The data that shed some disturbing light on this subject come from the CMS Chronic Conditions Public Use Files.  These files include data for every 2010 Medicare beneficiary – approximately 48 million people.

In 2010, according to the CMS data, 9296 men between the ages of 65 and 69 who were newly-enrolled in Medicare Part B had depression and no other chronic condition.  And so did many more newly-enrolled women in the same age group - 23953 to be exact.

Medicare spent an average of $4650 (Part A, Part B, and Part D combined) on newly-eligible and enrolled 65-69 year old men with depression.  But it spent an average of only $4010 on women with depression in the same age group. 

In other words, Medicare spent 16 percent more on the men than it did on the women.

It is possible that those first-year data were an anomaly.  After all, they represented an average of just seven months of coverage.  It is possible that the men just got earlier, more aggressive treatment for depression when they first enrolled in Medicare, and that the women caught up later on in the year.

But this wasn’t the case.  When I looked at men and women in the same age group who had a full year of Medicare coverage in 2010, the disparity persisted. 

The numbers were just bigger.  There were around 35,000 men and over 85,000 women enrolled in both Parts A and B, and around half those numbers in Part D.  And we did spend more on women with depression - $5761 on average.  But we spent $6386 – or 11 percent more than that – on men.

The difference could be explained in part because men got more hospital-based care.  Medicare spent almost 50 percent more on Part A services, on average, for men.  But it still spent more on their Part B (physician/community) and Part D (prescription drug) care, too.

And here’s the interesting thing – the disparity seemed to persist as men and women aged.

I looked fifteen years down the road, at the 80-84 year old population.  Because women live longer, there were around three times as many women with depression in this age group as there were men.  But we were still spending more on the men.

Among 80-84 year olds with depression and no other chronic condition, Medicare spent 14 percent more overall on men than it did on women – an average of $7141 versus $6247.

And the disparity in spending also persisted when men and women had depression plus certain other chronic conditions – Alzheimer’s Disease and related disorders, and diabetes.

For example, Medicare paid out 23 percent more in first-year care for a 65-69 year old male with depression plus Alzheimer’s Disease or other dementia than it did for a 65-69 year old woman with the same two diseases.  And the difference over a full year was still 10 percent.

And Medicare paid out 34 percent more in the first-year care for a 65-69 year old male with depression plus diabetes than it did for a 65-69 year old woman with same two diseases.  And while that vast difference narrowed over a full year, it was still 7 percent.

These differences also persisted as people aged.  In the 80-84 age group, Medicare paid 22 percent more for men with depression plus diabetes than it did for women, and 7 percent more for depression plus dementia than it did for women.

This disparity cannot be explained away by suggesting that the men might also have other chronic conditions complicating their cases.  These are equivalent groups – neither the men nor the women had any other diagnoses at the time.

So as we enter another Mental Health Month and strive to strip away the stigma and misconceptions related to mental illnesses, perhaps one question we should be asking ourselves is this. 

Is stoicism or stigma the reason we spend less on mental health care for women with depression?

To reach Paul Gionfriddo via email: gionfriddopaul@gmail.com.  Twitter: @pgionfriddo.  Facebook: www.facebook.com/paul.gionfriddo.  LinkedIn:  www.linkedin.com/in/paulgionfriddo/