Medi-Cal Blamed for Poor Care in Lawsuit

Several sources are reporting a lawsuit filed in California alleging poor care in the state’s Medicaid program, Medi-Cal (1). The suit alleges that Medi-Cal failed to pay doctors enough to provide proper care. The suit was filed by five Latino residents on behalf of California’s 13 million lower-income residents, more than half of them Latinos. The suit alleges that "…California has created a separate and unequal system of health care, one for the insurance program with the largest proportion of Latinos (Medi-Cal), and one for the other principal insurance plans, whose recipients are disproportionately white.”

The state budget includes $107 billion in state and federal funding for Medi-Cal this year, but the spending is not enough to restore reimbursement cuts made during the Great Recession of 2008. A proposal in the U.S. Senate to repeal the Affordable Health Care law (ACA, Obamacare) could drastically reduce funding for Medicare and the individuals who can access it.

Thomas Saenz, an attorney with the Mexican American Legal Defense and Educational Fund who filed the lawsuit, said he believes it is the first time the civil rights approach has been tried in California. According to Saenz this legal approach is possible because California is one of the few states to specifically prohibit discriminatory effects in state programs.

Other states in the Southwest also have disproportionately large Hispanic populations in their Medicaid programs (Table 1).

Table 1. Percent Caucasian and Hispanic total population/Medicare population by State (2,3).

Reimbursement does appear disproportionately low in California which ranked 48th in the nation in 2015 in how much it paid hospitals, doctors and other healthcare providers for treating Medi-Cal patients, according to the Kaiser Family Foundation (4). In the Southwest the state with the highest reimbursement was Nevada (5-10). California reimbursement averaged only 47% of Nevada reimbursement for the procedures listed (Table 2).

Table 2. Medicare reimbursement for common procedures by state (4-9).

The reason for the wide differences in reimbursement rates is unclear but is likely historical dating back to cost containment programs from the 1980’s and 90’s (11). The differences do not appear to be explained by differing costs of living. None of the procedure reimbursements correlated with the cost of living in the largest city in each state (Phoenix, Los Angeles, Denver, Albuquerque, Honolulu, and Las Vegas, p>0.1, all comparisons).

The chances of the lawsuit’s success are unclear since there is no precedent. However, it seems likely that if the suit is successful, more suits will be filed since California Medi-Cal’s situation of disproportionately providing care to minorities is not unique.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Thompson D. Latino plaintiffs sue California alleging poor health care. Associated Press. July 12, 2017. Available at: http://abcnews.go.com/Health/wireStory/latino-plaintiffs-sue-california-alleging-poor-health-care-48592841 (accessed 7/13/17).
2. Kaiser Family Foundation. Population distribution by race/ethnicity. 2015. Available at: http://www.kff.org/other/state-indicator/distribution-by-raceethnicity/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 7/13/17).
3. Kaiser Family Foundation. Distribution of the nonelderly with Medicaid by race/ethnicity. 2015. Available at: http://www.kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D (accessed 7/13/17).
4. Dickson V. Low Medi-Cal payments could weaken expanded coverage for undocumented children. Modern Healthcare. June 17, 2015. Available at: http://www.modernhealthcare.com/article/20150617/NEWS/150619908 (accessed 7/13/17).
5. California Department of Health Care Services Medi-Cal. Medi-Cal Rates. June 15, 2017. Available at: https://files.medi-cal.ca.gov/pubsdoco/rates/rateshome.asp (accessed 7/13/17).
6. Arizona Health Cost Containment System. Physician fee schedules. 2017. Available at: https://www.azahcccs.gov/PlansProviders/RatesAndBilling/FFS/Physicianrates/ (accessed 7/13/17).
7. Colorado Department of Health Care Policy and Financing. Provider rates & fee schedule. June 2017. Available at: https://www.colorado.gov/pacific/hcpf/provider-rates-fee-schedule (accessed 7/13/17).
8. Quest Hawai’i. Medicaid fee schedule. 2013. Available at: http://www.med-quest.us/ (accessed 7/13/17).
9. Nevada Division of Health Care Financing and Policy. Fee schedules. Available at: http://dhcfp.nv.gov/Resources/Rates/FeeSchedules/ (accessed 7/13/17).
10. New Mexico Human Services Department. New Mexico Medicaid fee for service CPT code fee schedule. 2017. Available at: http://www.hsd.state.nm.us/uploads/FileLinks/e7cfb008157f422597cccdc11d2034f0/7.17_CPT_Codes__2_.pdf (accessed 7/13/17).
11. Tatar M, Paradise J, Grafield R. Medi-Cal managed care: an overview and key issues. Kaiser Family Foundation. Mar 02, 2016. Available at: http://www.kff.org/report-section/medi-cal-managed-care-an-overview-and-key-issues-issue-brief/ (accessed 7/13/17).

Cite as: Robbins RA. Medi-Cal blamed for poor care in lawsuit. Southwest J Pulm Crit Care. 2017;15(1):42-4. doi: https://doi.org/10.13175/swjpcc091-17 PDF 

Rating the VA Hospitals

USA Today is listing the star rating system for the Department of Veterans Affairs medical centers based on the quality of care. The website has a link that allows searches for individual medical centers. The ratings have been done for years but the VA has refused to release the ratings saying they are meant for internal use only.

The top-rated hospitals received a 5 and the lowest a 1. According to the star ratings the best hospitals are in the Northeast and upper Midwest.  In the Southwest the ratings are not so good with the top-rated hospital Palo Alto and the lowest a tie between Phoenix and Albuquerque (Table 1).

Table 1. Southwest VA medical center star compare VA hospitals ratings.

Quality can be difficult to measure and it is not clear what metrics were used in the VA ratings. For this reason, the VA star ratings were compared to another hospital rating service Compare VA Hospitals (2). This scale uses a 1-100 scale with 100 being the best. In this scale the Palo Alto turned out to be the best in the country with Phoenix and the VA being more in the middle of the pack. There was no correlation between the ratings (r=0.2386, p>0.05). This is consistent with a previous publication in the SWJPCC which showed no or little correlation between the various hospital ratings.

The lack of correlation between rankings and not knowing the metrics which determine the rankings suggest that the VA is right, the rankings should remain for an internal use rather than adding to the confusion already generated by the various hospital rankings.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Slack D. Exclusive: Internal documents detail secret VA quality ratings. USA Today. December 7, 2016. Available at: http://www.usatoday.com/story/news/politics/2016/12/07/internal-report-details-secret-quality-ratings-veterans/94811922/ (accessed 12/14/16).
2. Health Grove by Graphiq. Compare VA hospitals. Available at: http://va-hospitals.healthgrove.com/ (accessed 12/14/16).
3. Robbins RA, Gerkin RD. A comparison between hospital rankings and outcomes data. Southwest J Pulm Crit Care. 2013;7(3):196-203. [CrossRef]

Cite as: Robbins RA. Rating the VA hospitals. Southwest J Pulm Crit Care. 2016;13(6):309-10. doi: https://doi.org/10.13175/swjpcc138-16 PDF 

Substitution of Assistants for Nurses Increases Mortality, Decreases Quality

Substituting nursing assistants for professional nurses is associated with poorer quality of care and increased mortality according to a study published in BMJ Quality & Safety (1). Linda H. Aiken PhD and colleagues analyzed the effect of increasing the proportion of less extensively trained nurses at 243 acute care hospitals in Belgium, England, Finland, Ireland, Spain, and Switzerland. They surveyed 13,077 nurses and 18,828 patients who had been in 182 hospitals between 2009 and 2010. They also consulted mortality records for 275,519 patients who had had surgery in 188 of the hospitals between 2007 and 2009.

Overall, 47% of the professional nurses in the study had bachelor's degrees, although they were unevenly distributed, with some hospitals having none. In a hospital that has average nurse staffing levels and skill mix, the researchers estimated that replacing one professional nurse with a lower-skilled worker increased the odds of a patient dying by 21%. Conversely, each 10% increase in the proportion of nurses with high-level skills was associated with an 11% decrease in the odds of a patient dying postoperatively and a 10% decrease in the odds of a patient giving the hospital a low rating.

Overall, the findings paralleled those from the United States and are consistent with the concept that a higher level of education leads to improved care. "We find a nursing skill mix in hospitals with a higher proportion of professional nurses is associated with significantly lower mortality, higher patient ratings of their care and fewer adverse care outcomes," the researchers write. They conclude "that caution should be taken in implementing policies to reduce hospital nursing skill mix because the consequences can be life-threatening for patients."

Richard A. Robbins, MD

Editor, SWJPCC

Reference

1. Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf. 2016. Published on-line 11/15/16. [CrossRef] 

Cite as: Robbins RA. Substitution of assistants for nurses increases mortality, decreases quality. Southwest J Pulm Crit Care. 2016;13(5):252. doi: https://doi.org/10.13175/swjpcc121-16 PDF

Hospital Employment of Physicians Does Not Improve Quality

The Annals of Internal Medicine posted a manuscript on-line today reporting that the growing trend of physician employment by hospitals does not improve quality (1). In 2003, approximately 29% of hospitals employed members of their physician workforce, a number that rose to 42% by 2012. The authors conducted a retrospective cohort study of U.S. acute care hospitals between 2003 and 2012 and examined mortality rates, 30-day readmission rates, length of stay, and patient satisfaction scores for common medical conditions for 803 hospitals that switched to the employment model compared with 2085 control hospitals that did not switch. Switching hospitals were more likely to be large (11.6% vs. 7.1%) or major teaching hospitals (7.5% vs. 4.5%) and less likely to be for-profit institutions (8.8% vs. 19.9%) (all p values <0.001).

The authors used Medicare Provider Analysis and Review File (MedPAR) from 2002 to 2013 to calculate hospital-level risk-adjusted performance on mortality, readmissions, and length of stay for acute myocardial infarction, congestive heart failure, and pneumonia. Hospital Compare data from 2007 to 2013 was used to assess overall patient satisfaction. After conversion to a physician employed model, no difference was found in any of 4 primary composite quality metrics with the single exception of readmission rates for pneumonia. That decline was modest (19.3% vs. 19.1% readmissions) and judged not likely to be clinically significant by the authors.

Recently, Baker and colleagues found that hospital employment of  physicians is associated with higher spending and prices (2). This data combined with the data from the present study suggest that the trend is for higher healthcare costs without an improvement in quality. Commenting in Medscape Richard Gunderman, a well-known healthcare delivery researcher from the University of Indiana, said that those who think quality comes from increasingly larger organizations with more advanced information technology and greater standardization across the system will see these results as surprising and disappointing (3). Pointing to high levels of burnout and widespread complaints of lack of time with patients, Gunderman said less physician control over individual patient care has taken a toll. "There's no doubt that a demoralized workforce will tend to drive quality down," he said. "Many hospitals and health systems around the country are grappling with poor and, in some cases, dismal engagement scores. I think that's an indication that a lot of physicians feel that the changes taking place across healthcare are problematic."

Funding for the study was provided by the Agency for Healthcare Research and Quality. Limitations of the study was that the patients were primarily Medicare beneficiaries aged 65 years and older. Therefore, the applicability of the findings to a younger population is unknown, however, the authors doubted that after switching to an employment model, hospitals would improve care for one group and not another.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Scott KW, Orav EJ, Cutler KM, Jha AK. Changes in hospital–physician affiliations in U.S. hospitals and their effect on quality of care. Ann Intern Med. 2016. Available at: http://annals.org/article.aspx?articleid=2552987 (accessed 9/20/16). [CrossRef]
2. Baker LC, Bundorf MK, Kessler DP. Vertical integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff (Millwood). 2014 May;33(5):756-63. [CrossRef] [PubMed]
3. Frellick M. Physician employment by hospitals does not improve quality Medscape. September 19, 2016. Available at: http://www.medscape.com/viewarticle/868978?nlid=109338_2863&src=wnl_dne_160920_mscpedit&uac=9273DT&impID=1200121&faf=1#vp_2 (accessed 9/20/16). 

Cite as: Robbins RA. Hospital employment of physicians does not improve quality. Southwest J Pulm Crit Care. 2016;13(3):133-4. doi: http://dx.doi.org/10.13175/swjpcc099-16 PDF

Hospital Executive Compensation Act Dropped from Ballot

The Hospital Executive Compensation Act did not qualify for the November 8, 2016 ballot in Arizona as a state statute (1). The Service Employees International Union (SEIU) dropped the initiative just before arguments were to begin in a lawsuit that challenged the legality of signature gatherers who failed to register with the state. The measure would have limited total pay for executives, administrators and managers of healthcare facilities and entities to the annual salary of the President of the United States. A similar measure in California was also dropped by the SEIU in 2014.

Supporters of the proposal said it would decrease escalating healthcare costs. Opponents of the measure, including the Arizona Chamber of Commerce who filed the suit challenging the proposition, alleged that it would lead to poorer healthcare. However, a survey conducted by the Southwest Journal of Pulmonary and Critical Care showed that most supported the measure and felt that it would not lead to poorer healthcare (2).

References

1. Ballotpedia. Arizona hospital executive compensation act (2016). Available at: https://ballotpedia.org/Arizona_Hospital_Executive_Compensation_Act_(2016) (accessed 8/22/16).
2. Robbins RA. Survey shows support for the hospital executive compensation act. Southwest J Pulm Crit Care. 2016;13:90. [CrossRef] 

Cite as: Robbins RA. Hospital executive compensation act dropped from ballot. Southwest J Pulm Crit Care. 2016;13:91. doi: http://dx.doi.org/10.13175/swjpcc081-16 PDF