Changing Health Care Systems and Rheumatic Disease (1996) / Chapter Skim
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7: Changing Health Care Systems and Access to Care for the Chronically ill
7: Changing Health Care Systems and Access to Care for the Chronically ill
Pages 115-146
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7 Changing Health Care Systems and Access to Care for the Chronically Ill ~5
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From page 117... ...
Thus, having skilled practitioners for the care of SLE or RA patients is not a priority of managed care plans because they might attract patients. It is widely believed budging by the New York Times and other newspaper 117
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From page 118... ...
At present, we are seeing a definite limit on referrals in some managed care plans. Although we do not have adequate data, it is the perception of most physicians and of most patients that physicians having the most experience with a specific disease provide the best care, which leads to the best outcome for the patient.
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From page 119... ...
Although an era of managed care and more integrated systems in theory offers much promise for those with long-tenn or complex illness, the chronically ill are likely to face new barriers to access to appropriate care, given current market dynamics and insurance trends. The risks are especially high for the 40 million people without insurance coverage and the 29 million with inadequate or unstable coverage.90 This workshop offers a timely opportunity to discuss access barriers intrinsic to current market dynamics and changing systems as well as ongoing and new challenges to serving vulnerable populations well.
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From page 120... ...
THE CHRONICALLY ILL: PROMISES AND RISKS IN AN ERA OF MANAGED CARE AND COMPETITIVE MARKETS Chronic Illness Chronic illness poses particular challenges for medical and health care systems. As noted in a recent paper by Stan Jones, chronically ill patients typically require specialized as well as primary care with a varied team of providers, and needs persist and fluctuate over timed Care and treatment of chronic illness tend to focus on preventing or slowing the progression of illness rather than curing disease and require that patients work in partnership with physicians in following often complex care regimes.
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From page 121... ...
For children, for example, recent estimates indicate that the 70 percent of children who are relatively healthy account for only 10 percent of total expenses, whereas the 20 percent of children with minor chronic problems and the 10 percent with serious illness or severe chronic disease account for 90 percent of expenses.92 As a result, children win chronic illness are two to five times more expensive than "average." Costs are similarly and dramatically skewed at the other end of the age spectrum (See Figure 7-19. SICKEST 10% AVERAGE HEALTHIEST 90% HEALTHIEST 10% so $s,ooo $10,000 $15,000 $20,000 $25,000 FIGURE 7-1 Average per capita costs for subgroups of Medicare beneficiaries, 1993 (authors' calculations are based on Health Care Financing Review, Statistical Supplement, 1995~.
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From page 122... ...
In practice, current market dynamics are more likely to reward those plans that succeed in avoiding risk and penalize those that gain a reputation for outstanding care for the seriously or chronically ill. With most public and private purchasers paying plans on th basis of average costs, with only minor adjustment for risk (usually age, sex, and disability status)
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From page 123... ...
Unless purchasers structure payments to adjust for higher expected costs based on health status, plans that seek to compete on the high end of quality and to promote reputations for caring for the chronically ill are likely to be at a competitive disadvantage Reports from recent efforts of a California purchasing alliance to adjust for risk indicate that a disproportionate share of patients with chronic illness can result in significant pricing disadvantage, outweighing the potential gain from managing care more effectively. The plan with the highest concentration of those with chronic disease or serious illness required a 20 percent adjustment in its premium based on the underlying health status of its membership.97 94For examples from the Federal Employees Heath Benefits Plan and state employee plan experiences, see Schoen, C, and L Zacharias (1994)
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From page 124... ...
Capitation for primary care services alone, however, leaves in place primary care and specialist incentives to "do more." FFS payment without risk sharing remains the norm for PPOs. Although managed care plans typically require varying mixes of withholds or bonuses to give physicians financial incentives to stay within budget targets, to date, payment incentives at the provider level in IPA or network model HMOs and PPOs continue to reward physicians who see sicker and more complex patients.98 The next few years will offer an opportunity to monitor what happens as plans seek to move risk downward in more mature, managed care markets.
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From page 125... ...
Patient reports on care from those with chronic illness in different managed care plans, as well as comparisons with broad-access FFS coverage are needed to evaluate variations. A recent Commonwealth Fund study of experiences in three cities, for 99Shaughnessy, PW, RE Schlenker, DF Hittle (1994)
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From page 126... ...
is the major organization setting standards for managed care plans. It accredits HMOs and promulgates managed care plan quality indicators known as HEDIS (Health Plan Employer Data and Information Set)
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In communities with a high penetration of managed care plans, market forces are cutting deeply into resources for uncompensated care. As these pressures drain resources and the ability to cross-subsidize with revenues Tom insured patients, we are likely to see significantly greater access barriers, with traditional entry points to flee care closing their doors.
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From page 128... ...
RAND surveys in 1993 found that nearly half of private sector insured employees had only one plan offered by their employer, and only 18 percent had a choice of three or more plans.~03 A Commonwealth Fund study found that nearly one-third of those enrolled in managed care plans in three cities did not have a choice of an alternative plan.~04 Today even larger employers are seeking to narrow the range of choices in order to minimize administrative complexity, avoid adverse risk issues, and improve control. Employers have not yet moved into larger purchaser alliances capable of offering a broader range of plans meeting group standards.
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Data from the Commonwealth Fund Managed Care Survey, 1994.
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From page 130... ...
As a result, moving on and off Medicaid, even into a private job with insurance, is likely to mean a change in care networks. More typically, moving off Medicaid means becoming uninsured: nearly two-thirds of low income women leaving Medicaid over a two-year period lost their insurance.'07 Recent Commonwealth Fund surveys indicate that Dequent, usually involuntary changes in plans today are the norm rather than the exception.
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From page 131... ...
An early RAND study and, more recently, the Commonwealth Fund three-city survey found evidence that low-income enrollees fared less well than others enrolled in similar managed care organizations.' The transition to managed care is likely to require time, education, and outreach efforts to ensure that new enrollees understand plan guidelines and link up with new care systems. Case studies of managed care plans with a long history of caring for lower-income and minority Medicaid populations have found that the adjustment process is a two-way street managed care Commonweal Fund (1996)
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From page 132... ...
Minorities are also more likely to report discrimination or feeling "unwelcome" by virtue of race or ethnicity. In a recent Commonwealth Fund survey of minority health, 15 percent of minority adults believed they would have received better care if they were of a different race or ethnic group.ll4 Only two-thirds of minority adults felt "very" welcome at their doctors' offices.
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From page 133... ...
new methods of paying for care in managed care plans that give plans an incentive or at least neutralize disincentives to provide access and care for the chronically ill; and 3. Standards, data reporting, and monitoring to hold plans accountable for quality care for sicker, more vulnerable populations.
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From page 135... ...
The care and treatment of chronic illness require that patients work in partnership with physicians in following often complex care regimens. That is the area I want to focus on the complexity of this system and how it affects this issue of care versus cure, the patient's role, and the nature of the services that the patient is being asked to handle.
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These associations of lower socioeconomic status and poor health status outcomes have been noted in many different countries with varying health care systems. Individuals with lower socioeconomic status are those individuals who are vulnerable and at risk.
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ky I would like to combine my two interests (a very amateur ethicist but a professional nephrologist) and say a word about some of the ethical issues I perceive in managed care, and then share with you certain analogies that I think are not too far-fetched between another chronic illness-namely, end stage renal disease and some of the issues you were discussing with regard to rheumatic diseases.
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As I mentioned, we have had an experiment in managed care in end stage renal disease for the last 23 years. In 1973, the federal government undertook to care for virtually all Americans with end stage renal disease.
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From page 139... ...
ACCESS TO CARE FOR THE CHRONICALLY ILL 139 mean to 30 percent more than the mean among different units" a 60 percent swing in mortality from the best to the worst. Similarly, the cost of a single dialysis treatment varies from $35 less than the federal payment to $35 more than the federal payment among different units.
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From page 141... ...
This can lead to the assumption that because these are the sickest patients, they must have chronic disease. I wonder if a lot of those patients are not acutely ill-whether a lot of that utilization is not by chronically ill elderly people but by people who were previously well and had a heart attack or emergency major surgery or something similar.
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From page 142... ...
However, in following the New York Times coverage of this issue, certainly you get a sense that many HIV patients are not faring very well in managed care plans because they can't get to their infectious disease specialists or their physicians haven't had enough experience with HIV patients and aren't up on the latest techniques. WILLIAM HAZZARD: The exponential rise in cost per capita in the sickest resembles the exponential rise in cost per capita in the final illness.
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From page 143... ...
I think it is beginning to move us in the right direction. Basically we need accreditation, quality measures, reporting of those quality measures, right of patients to appeal, a grievance process, some right to care in an emergency situation without waiting to have it approved by a plan, right of physicians to act in their patients' best interests, and appropriate payment methods for managed care plans-methods that eliminate financial disincentives or penalties for caring for the chronically ill.
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From page 144... ...
THEODORE FIELDS: Dr. Davis, you mentioned that it is probably not in the interests of managed care companies to advertise that they have services for the chronically ill, particularly if an expensive service is involved.
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From page 145... ...
ACCESS TO CARE FOR THE CHRONICALLY ILL 145 guidelines to immunize clinicians against inevitable, but unpredictable, adverse effects and their legal consequence. KAREN DAVIS: Let me add one thing to that last point.
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