Is Managed Care the Answer for Dual Eligibles?

Is managed care the answer for dual eligibles?

More and more persons with disabilities are among the growing number of dual eligibles, i.e. people eligible for both Medicare and Medicaid coverage.  Persons with disabilities are eligible for Medicare either because of age or their disability and are eligible for Medicaid because of the poverty that has been forced upon them. 

There are good arguments both for and against managed care for this population, as can be seen from this article in the LA Times:  http://www.latimes.com/news/local/la-me-healthcare-duals-20111114,0,3197520.story.

Whatever we do to make healthcare better for this population now, we need to be realistic about how this problem came about and decide how to prevent this in the future.  What we do now is focus on one aspect of policy at a time and try to put a bandaid on it.  What we end up with is an unwieldy and unworkable system. 

A disability policy that is based on current reality, that does not force persons with disabilities to live in poverty in order to obtain critical services is needed soon.  Current policy is so expensive the system is about to implode.  It is possible to have a policy that saves government many dollars and still improve the lives of persons with disabilities. 

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

Why Disability Policy Needs to Change

We talk about the need for disability policy to change, and people wonder how big the problem is.  Consider this scenario.  It is only one person, but it is a realistic reflection of how disability policy works now.

A woman with a disability makes the decision that working is better than not working, even though she is not able to get health insurance because of her disability.  Of course, since she has no insurance, she never really gets ahead.  However, she considers work to be therapeutic and continues. 

As time goes on, the aging process catches up with her and she is diagnosed with a chronic disease on top of her original disability.  Now there is a significant cost added and she just plain cannot keep up.  Since she is working, she is not eligible for any assistance.  Over time, she loses all that she owns and even becomes homeless.  Ahh!  Now she is eligible for assistance.  She gets disability benefits (since she cannot work during this process), medical assistance (what she most needs) and subsidized housing.  Now she can begin putting her life back together and get back to work.  Right?

Of course, there is the need to continually report and qualify for her benefits.  Every program requires its own reporting, even though they all use the same information.  Some programs even require reports two or three times a year.  This really does nothing to motivate or improve self-esteem.  It is a real downer.  It also forces her to keep her income to a level that does not put her over limits required for receiving assistance.  No way to get ahead.

But, she manages this and is at least grateful that her medical expenses are covered.  She gets the adaptive equipment she needs and takes care of herself medically.  Then it happens.  She turns 65 and it all changes.  Her $700 a month in Social Security benefits gets cut by $115 to pay for Medicare.  Then she finds that her medications are not longer completely covered.   With the extra help available, her plan D provides for a lower copay.  She needs only to pay $1.10 for generic medications and $3.30 for name brand medications, for covered drugs.  And that’s the catch.  “Covered drugs” does not cover all her medications.  Other medical supplies are also cut, mostly in half.  Medicare only covers adaptive equipment that allows her to function in her home.  What is needed to go outside and have any kind of life is not covered.  Added up, her medical expenses again eat up most of her income.  The prospect of again becoming homeless looms.  There is really no way out.

At what point does any of this make sense? 

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

Primary Care and Healthcare Access

Another healthcare issue for persons with disabilities is physical access. 

Physical access goes beyond ramps and elevators.  It includes restrooms, exam rooms and any other room or space that is ordinarily accessed by patients.

There are standards for all accessible bathrooms put out by the Federal Access Board.

More recently, this same Federal Access Board has published guidelines for accessible healthcare facilities.  These guidelines include adequate space between and in exam rooms, accessible exam tables, lifts, scales and other equipment.  Almost no healthcare facilities meet these guidelines.

Primary care providers are the ones who see persons with disabilities the most, since they are in charge of coordinating all the other care.  Yet, these very same providers are paid the least and so are least able to afford the equipment needed by persons with disabilities.  This puts all of us who need this type of equipment at a disadvantage.

This is one more reason that this country needs to address the issues related to primary care.  No healthcare system, managed care, fee-for-service, or any other configuration, will work until we can provide stable, quality, accessible primary care.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

High Cost of Low Pay for Primary Care

Something for insurers to consider when setting reimbursement rates is that the shortage of primary care physicians plays a role in raising the cost of healthcare.

When there is no primary care physician available, people tend to go to the more expensive provider – emergency rooms.  While walk-in centers fill the gap for some, many walk-in centers do not take Medicaid, so persons with disabilities usually have to opt for the most expensive service available, simply because it is available.  This should be a real cause for concern since it means that people who use healthcare services the most are using the most expensive services.

This problem is not resolved by health centers and health systems if they have do not retain the same primary care providers.  This is because coverage and continuity of care are not interchangeable.  Coverage may be provided by new primary care physicians, but the time needed to develop the relationship that assures continuity of care is not there.  So, even with new good primary care physicians, the default option for some people will still be the emergency room.

Consider this – a person with a disability feels ill.  This person has not yet really connected with a  new primary care physician after his or her previous one has left a practice.  This person then faces the choice of calling a stranger (new but not yet established primary care doctor), and wait for a call back, with no certainty of whether or when that stranger will be available, or going to an emergency room where he or she will certainly be seen, even by a stranger.  For some disabilities, a minor problem can escalate to a major one quickly so the certainty of care will be the choice in almost every case.  This problem does not get resolved by the instant transfer of medical records either, since that transfer does not establish the relationship that is necessary for true continuity of care.

So, if paying primary care physicians less causes poorer healthcare delivery at a higher price it seems logical that Medicare, Medicaid and all other insurers should re-evaluate the reimbursement structure, looking at the bigger picture.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

Shortage of Primary Care Doctors

The United States Department of Health and Human Services Health Resources and Services Administration has designated more than half the states in the U.S. as Primary Care Health Professional Shortage Areas.  Does this scare you?

While the reasons for this shortage are many and complex, one reason for this shortage is that health care providers in this group are paid significantly less than specialists.  The low pay leads to fewer physicians going into primary and the need for some primary care providers to move to other practices more frequently in order to earn more money.

This is a problem for all healthcare consumers, but it puts persons with disabilities in a particularly difficult position. 

Optimal healthcare is usually achieved through a partnership between the patient and healthcare provider.  This partnership takes time to establish.  This partnership then directs the tone and direction of other services.  Then, of course, it is left up to the primary care provider to write referrals and prescriptions and letters of necessity for these other services.  When a person cannot connect with a primary care physician or when primary care physicians come and go, this relationship is disrupted, sometimes for several years at a time, leaving a significant gap in needed continuity of care. 

Persons with disabilities often have to manage several some complex healthcare needs.  With a primary healthcare provider that has become a trusted partner in this management, it’s possible to stay ahead of these needs to set up contingency plans for dealing with them before they get out of hand.  Losing a trusted partner in this management can lead to problems that would be otherwise preventable.  This gets even more complicated when a person with a disability needs a referral to a specialist in order to satisfy some insurance requirement and getting a referral from a stranger who has not had the chance to understand the need is delayed. 

This shortage then sets up a bad relationship since the person with a disability needs to push to get needs met before problems get worse.  Nobody wins.

I will comment on the cost implications of this shortage in another post.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

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The problems with disability policy based on medical model

When disability policy was developed, disability was viewed in the medical model.  The understanding was that the person had a medical problem that was in need of fixing and that, until that medical problem could be fixed, that person was unable to work.  If the medical problem could not be fixed, the person would be considered totally and permanently disabled. 

We put physicians and other medical providers in charge of whether or not a person could work, whether or not a person receives various disability benefits and what services and accommodations a person with a disability needs. 

While we are inundating medical providers with paperwork to attest to these things, no one seems to take into consideration that they are not the ones with all the answers. 

While most disabilities have a physiological beginning, that doesn’t necessarily mean they need or will respond to medical interventions.  For example, if a person is in an accident and incurs a brain injury, the disability can be permanent.  However, the time for effective medical therapy is only for a short period after the injury.  If the person still has the disability after 20 years, what do we expect a physician to do? 

Some disabilities are the result of medical conditions that need ongoing treatment, but many do not need medical intervention.  Yet, we put them all in the same category and require that there be medical documentation of all kinds of things related to disability. 

In the meantime, since most medical providers have the same view of disability as the average population, they are responding with the viewpoint that they are supposed to be able to decide major life issues for these people.  Should the person work?  What are the person’s transportation needs?  Does a person need a roll-in shower?  What about a parking pass?  Should the person be in a nursing home?  If so, can we keep the person out with appropriate services?  What services?  (Read the last three again to note the irony.)

Removing disability issues from the medical establishment could benefit persons with disabilities, ease the burden on medical providers and reduce costs for society.  Since the medical model is now recognized as not appropriate for determining disability, let’s next consider what the basis for disability needs to be.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

New Mobility Shows Healthcare Access Problems

You would think that healthcare facilities would be the most accessible for persons with disabilities.  You would be wrong.  New Mobility magazine highlights some of the problems locating accessing healthcare at http://www.newmobility.com/articleViewIE.cfm?id=11897.  

One problem is that healthcare providers think in terms of “helping” and not accommodating.  In the case of the woman looking for a mammogram, helping was no help at all.  Other times, “helping”, especially when it takes the form of lifting, can be dangerous, both for the patient and the staff.  If a patient that is being lifted has a full-body spasm, he or she can take out three people!  The result could be a workers’ compensation suit, and ADA suit and a malpractice suit.  I guarantee that would cost a lot more than an accessible table and proper lifting equipment.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

Surgeon Misses the Point in this Lesson

A story about how a surgeon learned about communicating directly with his patient http://www.kevinmd.com/blog/2011/06/surgeon-point-communicate-patient.html has lessons that were missed.

The surgeon who referred to the patient as “mentally retarded” is from South Africa, where that language may or may not still be acceptable.  In the US it is not. 

However, the bigger lesson is that he really did the right thing, even though he was never convinced of that.  He brushed aside the information being offered by the father when he first met them, making it clear that he preferred to speak with the patient directly.  The surgeon then felt he had painted himself into the corner when he realized the young man had an intellectual disability.  He continually referred to the patient’s limitations and, frankly, seemed to have a very low expectation of that patient.

What the surgeon never realized, even after the father thanked him for respecting his son, was that persons with disabilities often have far more capability than we credit them with and this was an example of that.  The most important thing for healthcare providers to recognize is that they should always communicate directly with their patients.  Patients will understand at their own levels.  Only if decisions are to be made and the patient has not been able to communicate understanding at his or her level should others be brought into the conversation.  Unfortunately, this doctor was focused on his own relief that he was not chastised for brushing off the father. 

He accidentally did the right thing.  Now, if we could only get him to realize that.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude

AHA Takes on Racial Disparities in Care, Leadership

http://www.healthleadersmedia.com/print/LED-268710/AHA-Takes-On-Racial-Disparities-in-Care-Leadership 

This article shows that the AHA is still unaware of a serious gap – persons with disabilities.  While it is important to address racial and ethnic disparities, this group needs to be reminded that persons with disabilities are the third largest market segment in the United States.  At this time, physical access to healthcare is seriously lacking and attitudes toward persons with disabilities range from dismissive to overly solicitous, skipping respect and accommodations.  Medical schools and nursing schools routinely discriminate against applicants with physical disabilities, making it even more difficult to recognize the importance of this demographic. 

One possible solution would be for the healthcare industry to stop looking at disability in the medical model and start looking at this population as a market segment.  For purposes of patient care, employee safety and equal respect and opportunities for all, this needs to be addressed sooner rather than later.

Annette Bourbonniere

www.accessing-ability.com

401-846-1960

Fax:  401-846-1944

Twitter:  @AccessInclude