Category: Quality Improvement

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Clinical General Healthcare Costs Healthcare Disparities Law Public Health Quality Improvement

On Public Charge

A step forward or a step back from self-sufficiency?

By: Souma Kundu

At the start of 2020, I remember the Trump administration celebrating what it saw as a victory for “self-sufficiency,” and “protecting law-abiding legal citizens from undue tax burdens”. Following a battle in the lower court, in a much-anticipated Supreme Court ruling, the court sided 5-4 with the administration, allowing enforcement of the 2019 expansion of the Public Charge rules.

This court ruling on Public Charge marks only the latest iteration of a policy dating back to the 1882 Immigration Act. While the definition and enforcement has varied over time, the essence of the law remains true to its origins: immigrants who are deemed unable to take care of themselves without becoming dependent on public assistance are unsuitable for American citizenship and therefore denied entry. Historically, public charge was determined by a holistic review of an applicant’s circumstances including age, health, financial status, education and skills. The use of public benefits for cash assistance and long-term institutionalization could be considered in this review, but other programs such as nutritional/housing assistance or public insurance were not included. In 2019, the United States Citizenship and Immigration Services (USCIS) expanded on the existing criteria to consider public benefits such as supplemental nutrition assistance, Medicaid or public housing. Additionally, it stipulated that the use of any of these public benefits for more than twelve months within any 36 month period may classify an applicant as a “public charge” effectively making them ineligible for permanent residency.

At the heart of this policy’s long-standing history is a deep-rooted belief that self-reliance is inextricably linked to the worth of an individual. It also posits that requiring public assistance is not only a burden to society, but one that is unlikely to be paid off or utilized for eventual gain.

But is this policy, and its predecessors really helping us increase self-sufficiency? Or is it robbing the US of its vast current and future population of contributing citizens? Even more pressing in 2020, is the impact of enforcing public charge during a pandemic leading to an underutilization of health care and resources only to increase morbidity and mortality across the nation?

From the lens of a healthcare worker, the general concern that efforts to rehabilitate lead to dependence baffles me. In medicine, from a sprained ankle to a surgery, achieving ultimate goals of “returning maximum function” all depend on how we can aid the healing process along the way. Generally, the use of a brace to offload the weight of a broken foot is not contested. Neither is the need for physical therapy to retrain our muscles after injury. But when it comes to rehabilitation of a person, our nation is much more skeptical of the process.

The abundance of research in the US and other countries on long-term effects of various welfare programs such as cash assistance, nutrition, and housing, point to the overwhelming benefits to the health of the recipients. Interestingly, benefits can also be seen towards community, by way of increased rates of labor participation, education attainment, employment status and productivity (Banerjee, Blattman, et. al). In a 2019 study on long-term economic impacts of childhood Medicaid, researchers found Medicaid-eligible children had higher wages starting in their twenties with wages increasing as they age. By the time these children reach age 28, their expected annual tax on earnings will return 58 cents for each Medicaid dollar spent to the government (Brown 2020). Providing basic human needs can be life changing – and it seems not just an ethical imperative, but a sound investment.

As many physicians, policy makers, immigration lawyers and researchers have feared, the changes to public charge determination is adding fear and confusion, resulting in underutilization of services available to immigrant families. Even programs such as the Children’s Health Insurance Program (CHIP), which is exempt from public charge review, have experienced a decrease in utilization.  An early impact study of public charge since enforcement began in February 2020, showed a 1% increase in the US’ noncitizen population that was associated with a 0.1% drop in child Medicaid use, estimated as a decline in coverage of 260,000 children. Researchers attribute this drop in enrollment to the fear and misinformation spreading amongst immigrants around public charge (Barofsky 2020).

As a medical student in San Diego where roughly two-thirds of our county’s population is Spanish-speaking, the impact of fear-mongering could not be more clear. Since the start of the pandemic, our once overflowing children’s hospital emergency department has been eerily quiet. Parents are worried for the safety of their families at the cost of health consequences from delays in care. At a time when access to medical care is imperative, our patients without documentation fear being turned away, or worse, turned in.

Meanwhile, disenrollment affects more than just immigrant families foregoing public assistance. Safety-net hospitals which rely heavily on Medicaid and CHIP payment are estimated to be at risk for a loss of $68 billion in health care services for Medicaid and CHIP enrollees (Raphael 2020). A drop in Medicaid enrollees will lead to increases in uncompensated care, lower Medicaid and CHIP revenue, alongside the cost of complications and emergencies secondary to foregoing early/preventive care. The fear and reluctance that public charge has created is not a simple reduction in federal spending, but rather a shifting of the burden with downstream financial havoc.

With the ample evidence that negates the assertion that the use of public assistance dooms one to a lifetime of dependency, and evidence to the contrary, that foregoing use has downstream effects on society, I urge us to rethink the dominant narrative around welfare and its implications for our nation. If we reject the belief that we must limit the use of public resources in favor of nurturing our communities most in need, we are much more likely to manifest our nation’s values of self-sufficiency and unlocking its potential. I’m not asking you to give up on self-reliance, I’m asking you to invest in it.

References:

  1. Blattman C, Jamison J, Green E, Annan J. The returns to cash and microenterprise support among the ultra-poor: a field experiment. SSRN Journal. Published online 2014.
  2.  Banerjee AV, Hanna R, Kreindler G, Olken BA. Debunking the stereotype of the lazy welfare recipient: evidence from cash transfer programs worldwide. SSRN Journal. Published online 2015.
  3. Brown DW, Kowalski AE, Lurie IZ. Long-term impacts of childhood medicaid expansions on outcomes in adulthood. Review of Economic Studies. 2020;87(2):792-821.
  4. Barofsky J, Vargas A, Rodriguez D, Barrows A. Spreading fear: the announcement of the public charge rule reduced enrollment in child safety-net programs: study examines whether the announced change to the federal public charge rule affected the share of children enrolled in medicaid, snap, and wic. Health Affairs. 2020;39(10):1752-1761.
  5. Raphael JL, Beers LS, Perrin JM, Garg A. Public charge: an expanding challenge to child health care policy. Academic Pediatrics. 2020;20(1):6-8.
Categories
Clinical General Healthcare Costs Innovation Quality Improvement Technology

Let Me Be Brief: Principles of Value-Based Health Care

A series of briefs by Texas Medical Students

By: Sanjana Reddy, Tsola Efejuku, and Courtney Holbrook

In the seminal 2006 text, Redefining Health Care, Harvard Business School professors Michael Porter and Elizabeth Teisberg describe a healthcare market with a “positive sum” game; a market where all professional and economic incentives are aligned towards the maximization of “value,” defined as the “the quality of patient outcomes relative to the dollars expended.”1 Value in health care is the measured improvement in a patient’s health outcomes for the cost of achieving that improvement.1 Value-based care transformation is often conflated with cost reduction methods, quality improvement, or even evidence-based care guidelines. Rather, the goal of value-based care is to enable healthcare systems to improve health outcomes for patients over the full cycle of care. Tiesberg further elucidates three key dimensions (the Triple C’s) for measuring patient outcomes: capability (the ability for patients to do what is important to them), comfort (relief from emotional and physical suffering), and calm (reducing the chaos of navigating the healthcare ecosystem).2

In the U.S., improving patient-centered outcomes has become a highly discussed topic with ABIM’s Choosing Wisely program3, American College of Physicians’ High Value Care initiative4, and even major publications like the American Journal of Medicine’s recurring column on high-value care practice.5 In response to escalating healthcare costs, the Centers for Medicare & Medicaid Services (CMS) and other payers have shifted from traditional fee-for-service payments to value-based reimbursements such as the CMS Merit-Based Incentive Payment System (MIPS).6 Value-based health care empowers the clinician-patient relationship, places care delivery decisions at the expertise of a coordinated clinical team, and focuses on outcomes that matter most to patients.

The leadership of professional organizations, such as the Texas Medical Association (TMA), is invaluable to the process of defining and upholding the principles of value-based health care for systems and individual practitioners. Current TMA policy recognizes the need to advocate for high-value care principles in undergraduate and graduate medical education (Res. 201-A-18)7 and the adoption of the Choosing Wisely campaign (265.023).8 Although the evidence-based model (265.018.)9 previously adopted by the TMA does not encompass the full principles of the value-based decision making model, TMA resolutions on Cost Effectiveness (110.002)10 and Cost Containment (110.007)11 reinforce the need for cost-effective utilization of care.

On the federal level, exceptions to key legislation have been enforced recently to further advocate for value-based healthcare options. In November 2020, the CMS and Department of Health and Human Services Office of the Inspector General (OIG) released new exceptions to the Anti-Kickback Statute and the Stark law, effective January 19, 2021. These exceptions now allow more providers to participate in coordinated and value-based care arrangements that can improve quality and outcomes, lower costs, and increase health system efficiency, without the fear of severe criminal or civil legal backlash.12

The practice of value-based health care, although strong in theory, is not without flaws. The primary weakness of this system is that physicians are often responsible for things out of their control, such as referred providers’ costs and pre-existing conditions.13 This system requires widespread buy-in from all providers in order to collectively reduce costs and increase quality of care—effectively changing the culture of health care. Notably, this system inherently disincentivizes caring for patients of low socioeconomic status, particularly minorities, who inevitably generate higher costs due to health disparities.14 Weinick et al. emphasize adding a metric to the value-based healthcare system that addresses equity in health care. Their guide illustrates how to utilize value-based health care to reduce racial disparities, primarily by appending equity in pay-for-performance models.15

Goals of the Medical Student Section include staying informed about current policies regarding value-based health care since these policies are constantly changing and significantly affect reimbursement rates. Medical students are afforded the opportunity to learn about the principles of value-based health care from the very beginning of their training. Knowing the alphabet soup of value-based care (MIPS, APM, MACRA, etc.) will benefit patients and providers alike by improving outcomes, reducing costs, and maximizing reimbursements. In an effort to emphasize value-based health care early in the practice of medicine, the American Board of Internal Medicine sanctioned the Dell Medical School Value Institute for Health & Care’s STARS (Students and Trainees Advocating for Resource Stewardship) program. Over the past few years, student representatives across the country have met to learn about the principles of high-value care, review the Choosing Wisely campaign, and start their own initiatives at their respective medical schools. In Texas, students at UTHSC San Antonio’s Long School of Medicine created an ongoing Value-Based Health Care elective and degree distinction pathway. Dell Medical School offers online instructional modules and is a leader in patient-centered outcomes research. Medical students have a tremendous opportunity to impact high-value care through education, research, and student-led initiatives.

References:

  1. Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006. Boston, MA: Harvard Business School Press.
  2. Liu TC, Bozic KJ, Teisberg EO. “Value-based healthcare: person-centered measurement: focusing on the three C’s.” Clin Orthop Relat Res. 2017;475:315–317.
  3. https://www.choosingwisely.org/
  4. https://www.acponline.org/clinical-information/high-value-care
  5. https://amjmed.org/advancing-high-value-health-care-a-new-ajm-column-dedicated-to-cost-conscious-care-quality-improvement/
  6. https://www.cms.gov/newsroom/fact-sheets/quality-payment-program
  7. Texas Medical Association. Policy Compendium. Evidence-Based Medicine 265.018.
  8. Ibid. High-Value Care in Undergraduate and Graduate Medical Education 200.054.
  9. Ibid. Choosing Wisely Campaign 265.023.
  10. Ibid. Cost Effectiveness 110.002.
  11. Ibid. Cost Containment 110.007. 
  12. Modernizing and Clarifying the Physician Self-Referral Regulations Final Rule (CMS-1720-F). CMS. Accessed May 27, 2021. https://www.cms.gov/newsroom/fact-sheets/modernizing-and-clarifying-physician-self-referral-regulations-final-rule-cms-1720-f.
  13. Burns, J. “What’s the downside to value-based purchasing and pay for performance?” Association of Health Care Journalists. September 6, 2014. https://healthjournalism.org/blog/2014/09/whats-the-downside-to-value-based-purchasing-and-pay-for-performance/.
  14. “Value-Based Health Care Must Value Black Lives,” Health Affairs Blog, September 3, 2020. DOI: 10.1377/hblog20200831.419320
  15. Weinick, Robin & Rafton, Sarah & Msw, & Walton, Jim & Do, & Hasnain-Wynia, Moderator & Flaherty, Katherine & Scd,. (2021). Creating Equity Reports: A Guide for Hospitals.
Categories
Clinical General Healthcare Cost Healthcare Costs Healthcare Disparities Innovation Patient-Centered Care Primary Care Quality Improvement

Let Me Be Brief: Medicaid Expansion

A series of briefs by the Texas Medical Students

By: Ammie Rupani and Alwyn Mathew

In 2019, 18% of Texans had no form of health insurance.1 650,000 Texans have lost their health insurance due to unemployment during the pandemic. The rate of uninsured Texans is staggering and has only been worsened by the pandemic. During this critical time, we must talk about Medicaid Expansion and the potential solutions for millions of people with no health insurance. As a medical student, I have seen patients defer life-saving medications such as insulin in order to afford rent or groceries. Consequently, these choices have brought such people to the Emergency Room in diabetic ketoacidosis, which could have been easily avoided with regular insulin treatments. Stories like this are far too common in Texas, and it is important to recognize such outcomes are easily preventable with improved access to health insurance coverage. How can we as students learn to treat people, when the system we are bound to  practice in is perpetuating their very diseases?

Retrieved from Texas Comptroller

Medicaid is a health insurance program managed through the Federal Centers for Medicare and Medicaid Services (CMS). Medicaid is currently jointly funded by the Federal and State governments with the Federal government matching each dollar the State spends. Texas Medicaid is primarily a fee-for-service model that has poor reimbursement rates and high administrative burden that discourages physicians from accepting Medicaid in their practice. Currently, Texas Medicaid coverage is only offered to children, pregnant women, seniors, and people with severe disabilities, who also fall below a certain income threshold. For example, a single mother making minimum wage at her  full-time job is not eligible for Medicaid because she earns too much. However, she does not qualify for Federal subsidies covering some of the insurance cost because she does not earn enough. The Patient Protection and Affordable Care Act of 2010 would help address this woman’s dilemma since Medicaid Expansion would cover all individuals with incomes up to 138 percent of the Federal Poverty Level, amounting to $16,643 for individuals and $33,948 for a family of four. Medicaid Expansion would provide a health insurance option to an estimated 2.2 million uninsured low-wage Texas adults.2

Although the original arguments against Medicaid Expansion in Texas focused on States’ rights and limiting Federal dependence on funding, the primary opposition to this program was the Federal mandate. In 2012, the US Supreme Court ruled that the Federal government could not mandate the Expansion of Medicaid in any State, leading to Texas and several States opting out of the program. Realizing the benefits and improvement in health outcomes, several States have since adopted the Expansion program offered through CMS, including Arkansas (2014) and Louisiana (2016). Currently, Texas spends nearly $40 billion (State and Federal funds) for the Medicaid program, with a 60-40% distribution between the Federal and State Government respectively.3 Expansion would be fiscally sound for Texas as it will reduce the strain on our State budget and draw in more Federal resources. Looking past the dollar amount, it is crucial that medical students and other healthcare professionals recognize the benefits of improved access and early medical intervention that can be achieved through Medicaid Expansion.3

TMA’s Legislative Recommendations4
  • Develop a meaningful, statewide health care coverage initiative using federal dollars to:
    • Extend meaningful coverage to low-income uninsured working-age adults, and
    • Establish a state-administered reinsurance program to reduce premiums for people enrolled in marketplace
  • Provide 12-months’ comprehensive coverage for women who lose Medicaid 60 days
  • Establish 12-months’ continuous coverage for children enrolled in Medicaid, the same benefit given to children enrolled in the Children’s Health Insurance Program.
  1. Accounts TCof P. Uninsured Texans. Retrieved from- https://comptroller.texas.gov/economy/fiscal-notes/2020/oct/uninsured.php
  2. How Many Uninsured Adults Could Be Reached If All States Expanded Medicaid? – Tables. KFF. https://kff.org/report-section/how-many-uninsured-adults-could-be-reached-if-all-states-expanded-medic aid-tables/. Published June 25, 2020.
  3. Federal and State share of Medicaid Spending, 2019, Kaiser Family Foundation- retrieved from – https://kff.org/medicaid/state-indicator/federalstate-share-of-spending/?dataView=1&currentTimeframe=0 &sortModel=%7B%22colId%22:%22State%22,%22sort%22:%22desc%22%7D
  4. Provide Meaningful Health Care Coverage for Uninsured Texans. Texmed. https://texmed.org/Template.aspx?id=55300.
  5. Status of state medicaid expansion decisions: Interactive Map, 2021. Retrieved from- https://kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/
Categories
Clinical General Opinion Patient-Centered Care Quality Improvement

Notes from a waiting room: What are doctors doing while I’m waiting?

Hello Clinical Laboratory, my old friend,

I’ve come to take my blood test with you again. Because my specialist wants the latest update, so I visit you every 3 months. My appointment was 48 minutes ago, and there are 16 people who arrived earlier than me, still waiting. As the clock ticks, I can hear everything but the sound of silence. Of course you are not alone, Clinical Lab; my other doctors made me wait for them as well. On average, Americans wait 19 minutes and 16 seconds to see a physician, according to Vitals’ Wait Time Report [1]. But the report forgot to add the wait time for check-in at registration and in the examination room. The funny thing about waiting in a clinical laboratory is that a majority of the patients have been fasting before a blood test. So now your patients are not just becoming impatient, but also hungry (or as young people like to call it, “hangry”) as we enter lunchtime.

You offered some reading material to help us pass the time. Many clinics present entertainments like magazines and television to improve the waiting experience [2]. I once visited a fancy clinic that provided an espresso machine for parents and a touchscreen-wall video game for their children. But I have to tell you: I have watched this Judge Judy episode four times in other clinics’ waiting rooms, and I have no desire to touch this well-thumbed Cosmopolitan magazine. Thank you, but, no thanks.

You might wonder why I care about waiting so much. Let me be honest with you: like most of your patients, I compare the waiting time with the time actually spent with the doctor [3]. As patients, if we spend 45 minutes waiting but only get 5 minutes of the doctor’s time, we won’t feel all that waiting was worth it. Certainly, I understand that a vast amount of effort was made behind the scenes. Like the story of Picasso and the bold woman, most people don’t understand that a seemingly effortless one-stroke drawing actually took a lifetime of practice to achieve [4]. I imagine that Dan Ariely and Jeff Kreisler would happily back me up in their book Dollars and Sense: “Assessing the level of effort that went into anything is a common shortcut we use to assess the fairness of the price we’re asked to pay” (in our case, we pay with time).  To solve the problem of customers being reluctant to pay for “invisible effort,” Dan offered the solution of providing transparency [5]. For example, shipping tracking shows all the transactions in each location, and an open-kitchen restaurant shows its staff busy fulfilling food orders. Needless to say, due to medical confidentiality, you can’t have an “open clinic” that shows the staff taking blood pressures or running tests to everyone in the waiting room. But perhaps you could still give us some indication of the “behind the scenes work.” Tell me that you were reading my medical history, that you were double-checking my results, or that you were researching the latest cure. It would make me feel much better to know that you were doing all the “ground work” while I was waiting for you. And I will pretend that I didn’t see you eating bonbons and doing crossword puzzles as I walked past the doctors’ lounge.

And now, I would like to end this letter with a quote from Oscar Wilde’s “The Importance of Being Earnest”:

If you are not too long, I will wait here for you all my life.

Yours truly,

Yi-Lin

 

References:

  1. Vitals wait time report. (2018). Retrieved from https://www.vitals.com/about/wait-time
  2. Ahmad, B., Khairatul, K., & Farnaza, A. (2017). An assessment of patient waiting and consultation time in a primary healthcare clinic. Malaysian Family Physician : The Official Journal of the Academy of Family Physicians of Malaysia, 12(1), 14–21.
  3. Huang, X. (1994). Patient attitude towards waiting in an outpatient clinic and it’s applications. Health service management research. Retrieved from http://journals.sagepub.com/doi/pdf/10.1177/095148489400700101
  4. Airey, D. (2017, September 25). Picasso and pricing your design work. Retrieved from https://www.davidairey.com/picasso-and-pricing-your-work/
  5. Ariely, D., & Kreisler, J. (2017). Dollars And Sense: How We Misthink Money And How To Spend Smarter. Harper

———

Author: Yi-Lin Cheng (website)

Editor: Mary Abramczuk

Image credit: Abraham Solomon, “Waiting for the Verdict” (England. 1859), The J. Paul Getty Museum, via Getty.edu