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The human angle

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Illinois

* It’s easy to just say “Cut people off All Kids coverage if they make too much money.” But, as always, there is a very strong human dimension to any budget cut. WBEZ has an article about one of the 4,000 children who will lose All Kids coverage on July 1st, because her family makes more than $60,000 a year…

The Wright household is wrapping up dinner this weekday night. Vinita Wright cooked fried rice and husband Jim rinses bowls as he loads the dishwasher.

The couple has guardianship over Sara Opsenica, the daughter of a family friend. Sara’s a high school freshman diagnosed with cancer, specifically, non-Hodgkin’s lymphoma. Vinita shows me a bag of liquid Sara gets hooked up to overnight.

VINITA WRIGHT: This is nutrition. We call it TPN. I don’t know what that means. But it’s basically nutrition. There are lipids in it, that’s why it’s white. it’s a fatty substance.

Sara’s prescriptions, hospital visits, chemotherapy have all been paid for underAll Kids. Sara was diagnosed last fall but had been on All Kids for several years. Sara’s father had been unemployed but he’s now a shuttle bus airport driver, and his health insurance coverage is haphazard; he’ll be off it a while, then he’ll have coverage, only to be off again. The family says All Kids has been a relief.

SARA OPSENICA: My dad doesn’t make a lot of money. We just have Social Security because my mom passed away. The All Kids have paid for everything. I don’t think - we have a small co-pay of my prescriptions but I don’t think my dad has gotten any hospital bills. […]

Back in Chicago’s West Chesterfield neighborhood, Vinita Wright is considering what will happen to Sara Opsenica, the girl in her care. Vinita says Sara’s chemo treatment should last another 16 months, but All Kids runs out in less than three.

VINITA WRIGHT: There’s so much stress connected to this cancer business…to not have to deal with a whole other several layers of stress having to do with which bill do we attempt to pay first.

Cutting Medicaid will be without a doubt the toughest vote some legislators will ever take in their careers.

* Meanwhile, the Tribune recently looked at the Medicaid numbers…

• Stop services for people who simply don’t qualify. Some recipients don’t even live in the state. Some make too much money to get health care designated for the poor. An estimated 100,000 to 300,000 people can be removed, saving $100 million to $700 million a year. Julie Hamos, director of the Department of Healthcare and Family Services, is moving to scrub the rolls.

• Speed the switch to managed care to save money and improve quality of care. Managed care generally means patients are assigned a “medical home” — a doctor (it could be an HMO-style clinic) who oversees their care. Doctor and hospital fees are geared to delivering better health care, not just more of it. So far, only a fraction of those patients have been switched to managed care. The state now says it can dramatically pick up the pace, moving some 85 percent of Medicaid recipients into managed care by the end of fiscal 2013.. Savings: $200 million to $500 million a year. We’ve heard these promises before, though. Time to deliver. […]

Prescription drug coverage costs Medicaid $814 million a year. Eliminating that wouldn’t be wise because many drugs help control chronic conditions and prevent expensive hospital stays. But drug coverage can be prudently trimmed. If Medicaid recipients were limited to five prescriptions a month (there are virtually no limits now), the program would save a whopping $136 million. Several states have done this. The hope is that a limit would force doctors to better coordinate recipients’ prescription drug care. Possibly on the block: Illinois Cares Rx, a supplemental drug program for seniors that doesn’t draw federal reimbursement. It costs $72 million a year.

There’s lots more on the table, such as hospice care (about $89 million); adult dental care ($51 million); durable medical services and supplies such as wheelchairs and ventilators ($150 million); adult speech, hearing and language therapy ($411,000); podiatric services ($5.8 million); bariatric surgery ($8.4 million); group psychotherapy for nursing home residents ($14 million); even therapy for refugees who were torture victims in their native countries ($133,000).

All of that still doesn’t come close to $2.7 billion. That’s why there’s a 6 percent cut for hospitals and nursing homes in play. Savings: $550 million. Hospitals argue that the state should exhaust other options before trimming providers, who are already reimbursed at low rates. But providers likely will feel some pain. “Everybody,” the governor says, “will take a haircut.”

* And Alex Brill of the American Enterprise Institute has a couple of smallish proposals…

Recent research suggests that instead of arbitrarily reducing access to prescriptions, policies focused on improving adherence — that is, ensuring that patients take their prescriptions as prescribed without missing doses — hold more promise for cost savings. A study conducted by economist William Encinosa and colleagues has demonstrated how increasing adherence among diabetes patients can reduce hospitalization rates and save on health-care costs. Another study, by Dr. Michael Sokol and colleagues, examined adherence among high cholesterol and hypertension patients, in addition to those with diabetes and found similar results. New techniques and technologies have been shown to effectively improve prescription drug adherence. Private insurers have particularly strong incentives to coordinate care in this way, as is the case for Medicaid managed care organizations that include pharmacy services.

In addition to saving money by reducing hospitalizations, another option the state could consider is ensuring that Medicaid patients receive the lowest-cost version of a given prescription drug. Research I have conducted on wasteful spending in the Medicaid drug program found that all too often states reimburse for a version of a drug that is more costly than another product with the exact same active ingredient, dose, form and bottle size. I estimate that the Medicaid drug program wasted $329 million nationwide in 2009. In Illinois, taxpayers could have saved about $11 million if the cheapest version of a given pharmaceutical had been consistently dispensed.

posted by Rich Miller
Thursday, Apr 12, 12 @ 11:49 am

Comments

on the last point, I wonder if the writer considered the amount of brand rebates when suggesting that the state should go all generic. The rebate is a significant factor in the state’s decision to allow brand drugs to be dispensed. Jim Parker and his team at HFS actually do a great job controlling the drug spend and managing the program. This is an area where Illinois is actually among the best in the nation.

Comment by anon Thursday, Apr 12, 12 @ 12:25 pm
There are no good choices but, as was pointed out, someone should try to think things through in terms of total cost before making changes. Otherwise there will be a higher cost later …

Borrowing to pay off the backlog of bills should be back on the table; it won’t solve the budget problem but it could ease it a bit. And it would have a serious economic benefit for the providers who are owed; might even turn out to be a one time mini-stimulus to the Illinois economy.

Comment by Retired Non-Union Guy Thursday, Apr 12, 12 @ 12:27 pm
If one adds all the Tribbie #s they don’t get close to the total needed to balance the books.
Surprise!
That just proves how diificult the task at hand is
And it suggest how something must be done to control health care costs for all

Comment by CircularFiringSquad Thursday, Apr 12, 12 @ 12:30 pm
Care should be taken in making a broad based move regarding the cheapest form of a drug. My spouse is a Pharmacy Tech and there are certain generics that even though they are supposedly the exact formula as the brand name, are not. Some patients have had severe reactions or have seen their symptoms return when taken off a brand name and put on a generic. Pharmacists will tell you that all generics are not equal. Some there is no difference in patient reactions others there are drastic differences.
This is why public policy researchers are not licensed to dispense medications.

Comment by Irish Thursday, Apr 12, 12 @ 12:49 pm
It’s bad news when politicians make program promises to people that they cannot ultimately deliver on.

Taking things away is much tougher than never giving them out in the first place.

Illinois politicians granted too many services that they could not pay for and now the time has come to rectify that problem. It’s a shame.

Comment by Old Milwaukee Thursday, Apr 12, 12 @ 1:02 pm
I think the $2.7 is not going to happen, it’s just too difficult to do in one year. They need to look at getting to about half of this and cutting other areas and increasing revenues. It’s time for the Governor to agree to the gaming legislation to help the budget.

We did not start over-spending on Medicaid over night, we got here over a serious of years and it will take several years to fix it. We can get there by half this year if we just meet half way on some Medicaid spending and use a one year 6% cut to hospitals and nursing homes. To cusion I think the $2.7 will be too difficult to do in one year. They need to look at getting to about half of this and cutting other areas and increasing revenues. It’s time for the Governor to agree to the gaming legislation to help the budget. We did not start over-spending on Medicaid over night, we got here over a serious of years and it will take several years to fix it. We can get there by half this year if we just meet half way on some Medicaid spending and use a one year 6% cut to hospitals and nursing homes. To cushion the blow, the GA should pass a debt restructuring bill to get their bills caught up; this will give most organizations the cash flow to handle the 6% cut.

Stop services to those who do not qualify - $400 million
Managed Care - $350 million
Prescription drugs savings- $136 million
6% cut to hospitals and nursing homes - $550

Total savings - $1.436 billion

Comment by Ahoy Thursday, Apr 12, 12 @ 1:34 pm
We agree that Medicaid reform is essential to reduce state spending. Community-based services for Illinois seniors have effectively reduced the growth of state Medicaid spending for long term care. Between 1980 and 2008, the number of persons 75+ increased 54%; Illinois Department on Aging Community Care Program (CCP)participants increased by over 66,000, while nursing home residency declined by 8%. For 2008, CCP services saved the State $260 million in senior-related health care costs. Monthly state spending for nursing home care for a Medicaid-eligible older adult currently averages $3,000, compared to $800/month for homecare, and $30/month for home delivered meals.

Comment by SeniorAdvocate Thursday, Apr 12, 12 @ 1:52 pm
I listened to that NPR story this morning. While I generally like their programming, I thought this piece was the worst kind of journalism– all horror show with no informative value. Sure, kids having cancer is terrible– nobody is going to argue otherwise. But without contextualizing the tremendous rising cost and huge current deficit it’s a meaningless story. If you assume that money is no object you might as well offer All Kids to *every* family regardless of income. Heck, make it “All Humans” and cover everybody– don’t stop at the IL border. Why not just “All” and cover animals too? The point is not that some kids will be adversely affected, it is that resources are limited (or even non-existant when you consider the deficit on top of current spend) so spending must be prioritized. Income levels are a rational way to do that, and one of the most equitable as well. Unless NPR is volunteering to put up the difference with its donors, reporting like this story is doing a disservice to its listeners, encouraging a fantasy land with infinite money to allocate.

Comment by Anonymous Thursday, Apr 12, 12 @ 2:29 pm
The family featured in the WBEZ piece, as well as others who will be affected by the AllKids eligibility rollback, should be advised to look into other state programs, such as the Comprehensive Health Insurance Plan or the Illinois Pre-Existing Condition Insurance Plan, as an alternative. Those program have monthly premiums that are considerably higher than AllKids, but for children with serious pre-existing conditions, I would imagine that a higher cost program is far better than going uninsured.

Comment by cover Thursday, Apr 12, 12 @ 3:02 pm
I forgot to mention, it’s nice to see an outside entity such as the American Enterprise Insitute make a common-sense budget recommendation, with a realistic savings estimate. Outsiders who bring pie-in-the-sky ideas to the table often crowd out reality. (Illinois Policy Institute, you’re one of the most guilty of this bad habit.)

Comment by cover Thursday, Apr 12, 12 @ 3:05 pm
Cutting hospice care is absolutely the wrong thing to do. Hospice care is so much less expensive than hospital care; if you cut hospice, then people who are dying and who need pain medication and other basic care (nutrition, basic nursing) will have to be admitted to the hospital, which is much, much more costly. This is absolutely the wrong way to go.

Comment by soccermom Thursday, Apr 12, 12 @ 3:08 pm
Health care costs are going to be the never-ending headache of our times. So much care, for so much longer, for so much more money. And everybody wants it.

Comment by wordslinger Thursday, Apr 12, 12 @ 3:36 pm
Anonymous@2:29:

So what you are saying is, yeah, the kid has cancer but too bad because we can’t afford it. That’s a wonderful attitude to have.

Comment by Demoralized Thursday, Apr 12, 12 @ 3:36 pm
Demoralized,
I think ANON 2:29 is trying to get people to get their head out of the sand and understand that we have an infinite amount of need and a finite amount of resources. And if they keep providing an infinite amount of services, then nobody is going to have anything, because the whole program will collapse.

Reality bites.

Comment by Old Milwaukee Thursday, Apr 12, 12 @ 3:57 pm
So what you are saying is, yeah, the kid has cancer but too bad because we can’t afford it. That’s a wonderful attitude to have.

Yes– a wonderfully realistic one to have. How are you at basic math skills? How do you propose to pay for it?

Comment by Anonymous Thursday, Apr 12, 12 @ 4:01 pm
And if they keep providing an infinite amount of services, then nobody is going to have anything, because the whole program will collapse.

Bingo.

Comment by Anonymous Thursday, Apr 12, 12 @ 4:02 pm
On Medicaid and need a doc? Good luck. Need a dentist? Good luck finding one. ER will provide the bare minimum needed. So cut the rates an additional 6%. It will make it much easier to find a provider looking to expand their Medicaid services. Looks like a problem that will cure itself because people will simply be unable to afford the care and will not go. What provider is going to be big enough to provide services below their actual cost and stay in business? Net result: fewer dollars spent.

Comment by zatoichi Thursday, Apr 12, 12 @ 4:03 pm
“Cutting Medicaid will be without a doubt the toughest vote some legislators will ever take in their careers. ”

Tougher than raising taxes? If so, they should just raise taxes.

Comment by Ratman Thursday, Apr 12, 12 @ 4:19 pm
If the State decides to eliminate funding for dental, speech/language therapy and durable medical equipment; in addition to cutting 6% to nursing homes then they need to change the rules they expect nursing homes to follow. There are many unfunded mandates related to the annual checkups (dental, medical, vision, etc.), quality of the resident’s wheelchair, etc. that are difficult to meet. If the State eliminates funding for those services along with cutting nursing homes the quality in the homes the State is demanding cannot happen.

Comment by Anna Thursday, Apr 12, 12 @ 5:24 pm
Call me a pessimist, but my best guess is the major savings suggested (managed care, ridding roles of ineligibles) won’t save anywhere near the amounts “predicted”. Many ineligibles aren’t users, and unless there is a lot of fat hidden in the current fee for service costs (which I don’t believe) managed care savings will be far less than anticipated, though at least we are not talking the billions of savings that were talked about just a few years ago. And remember, what ever we save, 50% of it is lost federal reimbursement.

Comment by steve schnorf Thursday, Apr 12, 12 @ 5:39 pm
To paraphrase the audience at the September Republican debate on CNN, “Let her die.”

Comment by Chevy owner/Ford County Thursday, Apr 12, 12 @ 5:53 pm
Unfortunately, most of the folks here offering up solutions (like our lawmakers) are not the ones depending on the program. I have a disabled child and we rely on these programs to keep him alive! IDK where they get that the prescription drug coverages is so lenient because we are ALWAYS having to jump through hoops for things as mundane as phenobarbital for seizures! That is one of the oldest drugs around. I know it is a controlled substance yes, but seizure meds for a kid with seizure disorder isn’t rocket science.

A group of parents whose children participate in ONE program the state is targeting have offered up over $27 million in suggested cuts/changes to the program Thwt would allow the services to continue. So far crickets from the state.

If these cuts are made, many children with disabilities will be forced to become hospitalized permently, taking up precious ICU beds AND after thirty days the total cost of care would fall to the State at up to six times more than it costs to keep the program and the kids at home. What sense does this make?

Educate yourselves on the facts. Www.saveMFTDWaiver.com

Comment by Stephilou273 Thursday, Apr 12, 12 @ 7:24 pm
Haven’t heard anyone suggest buy-in to Medicaid, rather than cutting people off altogether. Enable higher income families to pay a high(er) premium to continue coverage. Families who are currently eligible should be “grandfathered”, as provided when the income threshold was capped at 300% of FDL. Major managed care savings are “illusory”, as demonstrated by other states, especially at the outset — unless, of course, the managed care contractors use cutthroat, client hassling tactics that deny medically necessary care.

Comment by Anonymous Thursday, Apr 12, 12 @ 7:33 pm
It’s easy to put a number out there - $2.7 billion for example. It’s a lot harder to say to real people “sorry, but you get no medicine or hospital care”.

I agree with Schnorf that the savings just aren’t there. The Tribune numbers don’t add up to anything near $2.7 billion.

This will end in a debacle in May. The GA and Gov will push payments back and cut some rates but they won’t have the numbers they say they need to have. It will be a clustermuster.

Comment by DuPage Dave Thursday, Apr 12, 12 @ 7:34 pm
=== Enable higher income families to pay a high(er) premium to continue coverage.===

That was the theory behind the AllKids expansion.

Comment by Rich Miller Thursday, Apr 12, 12 @ 9:37 pm
Why didn’t the state stop services to those who do not qualify many years ago? If they had, then the deficits and debt would be smaller today.

Comment by Anon Thursday, Apr 12, 12 @ 11:36 pm
Since a relatively small percentage of Medicaid recipients consume the lion’s share of the budget it is time to begin to address the voluntary lifestyle choices these people make that adversely impact their health. Smoking, the lack of exercise and attendant obesity, drinking, illegal drugs and other voluntary actions that combine to make a person a high cost medical risk must be factored into the level of healthcare the state should be willing to provide. I just don’t understand why the state should pony up hundreds of thousands of dollars of taxpayer money for someone whose chronic respiratory problems are directly related to their decision to smoke. Yes, it is social Darwinism. A free country has a right to demand responsibility from its citizens if it is going to provide the level of expensive health care that people have come to expect.

Comment by wishbone Friday, Apr 13, 12 @ 12:14 am
wishbone, government health insurance death panels were recently publicly debated in this country and pretty soundly rejected by the population.

Comment by Rich Miller Friday, Apr 13, 12 @ 7:24 am
–Since a relatively small percentage of Medicaid recipients consume the lion’s share of the budget it is time to begin to address the voluntary lifestyle choices these people make that adversely impact their health. Smoking, the lack of exercise and attendant obesity, drinking, illegal drugs and other voluntary actions that combine to make a person a high cost medical risk must be factored into the level of healthcare the state should be willing to provide. ==

You can back that up anytime, please.

–Yes, it is social Darwinism. A free country has a right to demand responsibility from its citizens if it is going to provide the level of expensive health care that people have come to expect.–

Social Darwinism has been practiced in other societies, but I wouldn’t call them free.

Before you go down that road, Wishbone, better make sure you’re on the right side of the Social Darwinists who will be making those life-and-death decisions on rationing health care.

Comment by wordslinger Friday, Apr 13, 12 @ 7:37 am
wordslinger asked:”You can back that up anytime, please.”

Sure, here is an official government statement on the issue: “Half of the population spends little or nothing on health care, while 5 percent of the population spends almost half of the total amount.”

Link here: http://www.ahrq.gov/research/ria19/expendria.htm

Raising the specter of death panels does nothing to address the issue of voluntary personal actions contributing to the bankrupting of our social safety net. I don’t give a damn if people smoke or use drugs, but the general public should not have to bear the costs of those personal decisions.

Comment by wishbone Friday, Apr 13, 12 @ 11:01 am