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Improving Medicare and Medicaid – An Imperative. Group 2 Sara, Dave, Paul, William. Agenda. Background Quality Issues Cost Issues Access Issues Conclusion. An Introduction. National Health Care Spending In 2005, US health care expenditures: Reached $2 trillion

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Presentation Transcript
  • Background
  • Quality Issues
  • Cost Issues
  • Access Issues
  • Conclusion
an introduction

An Introduction

National Health Care Spending

In 2005, US health care expenditures:

Reached $2 trillion

Projected to reach $4 trillion by 2015.

4.3 x the amount spent on national defense.

Gross domestic product (GDP) in 2005:

16% of GDP in the United States

10.9% of GDP in Switzerland

10.7% in Germany

9.7% in Canada

9.5% in France

Nearly 47 million Americans are uninsured.

the impact of rising health care costs on access to health care
The Impact of Rising Health Care Costs on Access to Health Care
  • Primary reason people are uninsured is the high cost of health insurance coverage.
    • 60% - get health care through their employer.
    • 27% - covered by government sponsored health care.
    • 13% - self employed or working for companies which do not provide health insurance benefits - purchase coverage directly through private health insurance companies.
  • Any high risk factors, health insurance companies may be unwilling to insure him at any price.
the impact of rising health care costs on access to health care1
The Impact of Rising Health Care Costs on Access to Health Care
  • Currently 34 states offer some form of risk pool, covering about 183,000 people.
  • That leaves a large chunk of the population without any sort of health care coverage whatsoever.
  • 48% of insured working-age adults whose insurance does not include prescription drug coverage reported medical bill or debt, compared to 33% with prescription drug coverage.
  • 65% of working-age adults who reached the limit of what their insurance plan would pay for a specific treatment or illness experienced medical bill problems, medical debt, or both.
medicare medicaid quality problems
Medicare Medicaid: Quality Problems
  • System centered, not patient centered
  • Fragmented and uncoordinated care
  • Safety - Medicaid alleged to be less safe
  • Lack of effectiveness measurements
  • Inefficient, long waits for service, waste
  • Not equitable, inconsistent from state to state
medicare medicaid quality solutions
Medicare Medicaid: Quality Solutions
  • Patient as “source of control”
    • System adaptable to patients desires,
    • New forms of communication and care availability.
    • Transparency for informed decisions
  • Improve collaboration and communication among clinicians and institutions
  • Monitor threats to patient safety
    • Structural issues
medicare medicaid quality solutions1
Medicare Medicaid: Quality Solutions
  • Introduce Evidenced-based practice
    • Compare care against other benchmarks and organizations
  • Nurture continuing care relationships
    • Eliminate duplication or lack of service
  • Ensure that all mandatory services are obtainable
    • (e.g. dental coverage)
  • Leverage Electronic Medical Record and Informatics systems
medicare medicaid cost problem
Medicare / Medicaid: Cost Problem
  • Medicaid Funding Structure
    • Sources / Growth
  • Medicare Funding Structure
    • Sources / Growth
  • Fundamental Problems
    • Aging population
    • Cost of service increases (2019 solvency)
    • Fraud
improving cost medicaid
Improving Cost: Medicaid
  • Medicaid Maximization
    • Ensure all eligible state programs are reimbursed
  • Cost Sharing
    • Private Insurers, Estate, Employers
  • Reconfigure Long Term Care Services
    • Emphasize home / community care
  • Selective Contracting
improving cost medicare
Improving Cost: Medicare
  • Mimic successful private payer initiatives
    • Pay for Performance
    • Managed Care
  • Clinical Care Teams
  • Prescription Drug Management
    • Formulary
    • Eliminate Drug Negotiation Barrier
m m access problems
M/M: Access Problems

3 Key Measures

  • Providers accepting new M/M patients
    • Declined to 71%; varies by specialty
  • Patients delayed or did not receive care
    • For Seniors, this increased to 11% in 2001
  • Lack of timely appointments
    • Check-up delay > 3 weeks – 37%
    • Illness appointment wait > 1 week – 40%
medicaid access crises
Medicaid Access Crises
  • Homeless
    • 2 Million homeless any night
    • Only 30% qualify for Medicaid
    • Dropped due to address issues
  • Gaps
    • Leaving prison or mental health facility
    • Immigrants with <5 years in US
  • Undocumented
    • New rule – must prove citizenship
    • Original or certified documents required
    • Florida, Iowa, Kansas, Louisiana, New Mexico & Ohio attributed declines to the rule
improving access increasing supply
Improving Access: Increasing Supply
  • Improve the availability of timely, coordinated services for M/M patients
    • Pilot opening M/M clinics
      • Staffed by physicians, nurses, therapists, PAs & NPs
        • w/o the burden of practice start-up costs
      • Salaried positions – not based on reimbursement
      • Loan forgiveness program (% of loan by year)
        • 20% of total amount for Year 1, increasing by year
      • Scholarships in exchange for commitment
    • Clinics target areas & specialties with worst access stats.
improving access outreach
Improving Access: Outreach
  • Increase the promotion of healthy behaviors, preventative care, and M/M clinics
    • Leverage technology – easy website
      • Provide tailored information
      • Ask questions
      • Find a M/M clinic
      • Find a community screening activity
    • Leverage existing groups to promote
      • Meals on Wheels
      • Senior Centers, Community Centers
      • State & local Departments of Health
improving access removing barriers
Improving Access: Removing Barriers
  • Streamline documentation
    • Accept affidavits
  • Involve States
    • Wash state sued on behalf of immigrant children
  • Coordinate transitions
    • From jails
    • From mental health facilities


Why is the number of uninsured people increasing?

1/3 of firms in the U.S. did not offer coverage in 2005.

38% of workers are employed in smaller businesses,

Rapidly rising premiums cited for not offering coverage.

The employees can't always afford their portion of the premium

Coverage is unstable during life's transitions

Losing a job or quitting can mean losing affordable health coverage

Employer-sponsored coverage cut by a change from FT to PT work, or self-employment, retirement or divorce.

COBRA continuation out of reach


How does being uninsured harm individuals and families?

  • Less preventive care
  • Diagnosed at more advanced disease stages,
  • Once diagnosed
    • Receive less therapeutic care
    • Higher mortality rates than insured individuals.
  • Nearly 50% of uninsured children did not receive a checkup in 2003, almost twice the rate (26%) for insured children.


For about 20% of the uninsured (vs. 3% of those with coverage) - usual source of care is the emergency room.

Nearly $100 billion per year is spent to provide uninsured residents with health services - Hospitals provide about $34 billion worth of uncompensated care a year.

Preventable deaths among uninsured adults age 25-64 is in the range of 18,000 a year.

Uninsured are 30 to 50% more likely to be hospitalized for an avoidable condition.

Over 1/3 of the uninsured have problems paying medical bills.

call to action

Call to Action

Getting Everyone Covered through Medicare and Medicaid will Save Lives and Money

The impacts of going uninsured are clear and severe.

Many uninsured individuals postpone needed medical care:

Resulting in increased mortality

Resulting in billions of dollars lost in productivity

Resulting in increased expenses to the health care system.

We are all vulnerable to the potential loss of health insurance.

Every American should have health care coverage, participation should be mandatory, and everyone should have basic benefits.

improving medicare and medicaid conclusion
Improving Medicare and Medicaid - Conclusion
  • Improving cost of care, access to care and quality of care to beneficiaries of Medicaid and Medicaid becomes not just important, but imperative.
  • Contact your legislators; grill the presidential candidates; be the change you want to see.
  • Physician Shortage Areas: Medicare Incentive Payments not an Effective Approach to Improve Access, United States General Accounting Office
  • “Date raise concerns about Medicaid access”,, Volum 18, number 4
  • “Lacking Papers, Citizens are Cut from Medicaid”, New York Times, March 12, 2007
  • “Poverty in the United States: A Snapshot: One out of Eight people in the USA are living in poverty”,
  • “Washington state sues over Medicaid access for immigrant children”, the Jurist Legal News and Research, March 6, 2007
  • “Low pay hurts Medicaid access to specialists”, Joel Finkelstein, AMNews, July 26, 2004
  • "Insurance Coverage and Care of Patients with Non-ST Segment Elevation Acute Coronary Syndrome," James E. Calvin, Matthew T. Roe, Anita Y. Chen, et al, Annals of Internal Medicine, (Nov. 21, 2006) 145 (10): 739-748
  • "Study Says Uninsured Lack Follow-Up Care," Lindsey Tanner, Associated Press, September 13, 2005
  • “The Business Case For Quality: Case Studies And An Analysis”, Sheila Leatherman, Donald Berwick, Debra Iles, Lawrence S. Lewin, Frank Davidoff, Thomas Nolan and Maureen Bisognano, Health Affairs, 22, no. 2 (2003): 17-30
  • “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care”, Elliott S. Fisher, MD, MPH; David E. Wennberg, MD, MPH; Thérèse A. Stukel, PhD; Daniel J. Gottlieb, MS; F. L. Lucas, PhD; and É toile L. Pinder, MS