Autism, Autistic-Like, and Health Insurance Reform

Filed in Children's Issues, State Initiatives by on October 13, 2009 2 Comments

Kate Greenwood_high res 2011 compIn his post Implementing Reform: Children with Special Health Care Needs, Professor John Jacobi notes that providing “health insurance” to children with special health care needs (“CSHCN”) does not ensure that their needs will be met.  Many private health insurance plans do not cover services such as occupational, physical, or speech therapy for CSHCN.  Private plans frequently limit coverage for such therapies to otherwise healthy children who need therapy to facilitate their recovery from an illness or injury.

Through their power to regulate insurance, states can require private plans to extend coverage for needed therapies to CSHCN.  For example, in legislation passed earlier this year, New Jersey became one of an estimated 15 states to specifically require insurers to provide treatment for individuals with autism.  Children with autism have benefited from a wave of recent legislation — 8 states enacted laws related to autism and insurance coverage in 2009 alone.  Children with other special needs have been largely left behind.  Many go without services; others may be shoehorned into an inappropriate autism diagnosis.  A recent documentary, Autistic-Like, tells the story of parents pressured to accept an autism diagnosis in order to access state-funded services for their son.  While New Jersey’s autism mandate is admirably broad, requiring private insurers to cover occupational, physical, and speech therapy for individuals with “autism or another developmental disability,” other states’ mandates are strictly limited to children on the autism spectrum.

Insurance mandates are attractive to legislators because they are off budget.  They are not, however, without cost.  The Council for Affordable Health Insurance, an insurance industry association, estimates that “an autism mandate increases the cost of health insurance by about 1 percent.”  Mandates like New Jersey’s, which extends beyond autism, could lead to even greater cost increases.  Piecemeal reform that privileges some special needs over others has costs of its own, however, not the least of which are borne by children living with labels that do not fit.

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  1. Auriandra says:

    Mayo Clinic attacked for Pro-Reform Stance (daily kos)
    Wed Oct 14, 2009 at 08:22:03 PM CST

    In an article yesterday in the Washington Post, Mayo Clinic was attacked for cutting off access to Medicaid and Medicare patients. In fact, these cutbacks were extremely limited. The story is the second in the Post by Alec MacGillis that reflects the position of an organization known as the AAMC. Mayo’s response:

    Mayo Clinic feels that this story is a distraction from the true issue at hand—that of getting Congress to pay for value. As we have stated on this blog numerous times before, the only way to raise the bar for care while at the same time bending the cost curve, is to reward the best outcomes—Pay for Value, not volume.

    Mayo continues to see Medicare patients from its region (MN, IL, WI, IA, SD and ND or 99% of Mayo’s Medicare patients). The change affected only a small number of patients coming from Montana and Nebraska. The change in Arizona involved a single primary care clinic, at which Mayo continues to see Medicare patients for specialty services. This has been conflated in the conservative blogosphere into the meme that ‘Mayo is no longer accepting any Medicare or Medicaid patients.’ This is an outrage.

    Like an earlier article in the Washington Post by the same reporter, Alec MacGillis, titled “Is the Mayo Clinic a Model Or a Mirage? Jury Is Still Out”, it is an unabashed attempt to discredit Mayo as an appropriate ideal for reforming US health care. Behind the stories appears to be the AAMC, the Association of Academic Medical Centers, which represents the country’s teaching hospitals and lobbies for the continuation of special extra payments to these hospitals. The official of the AAMC quoted in the article is in fact “AAMC’s ‘voice’ on advocacy issues,” Dr. Atul Grover. The AAMC is best known in the industry as lobbying for the continuation special extra payments to these hospitals.

    The gist of the attacks has been to question Mayo’s quality, its low costs, how sick its patients are, and whether its practice is “transferrable.” I hope to settle these questions by providing the facts as they have been well established and that are surely well known by the AAMC and other organizations.

    The data in the tables below shows that the attacks on Mayo’s patient mix, quality, costs and outcomes are unsubstantiated. For this data, I accessed the publicly available American Hospital Directory (ahd.com) which compiles data from HHS’s Center for Medicare and Medicaid Services, the Agency for Healthcare Quality and Research, and other public sources.

    oThe Dartmouth Atlas (showing regional differences in surgery and costs
    o The Commonwealth Fund State Scorecard (new)
    o The Kaiser Family Foundation StateHealthFacts (newly updated)

    Mayo’s Credentials as High Quality, Low Cost Provider

    For the analysis below, there are two sets of medical centers provided for comparison. The first is the complete list of hospitals in the Top Ten of the annual US News and World Report rankings (in which Mayo has scored second place every year just after Johns Hopkins since the ranking was introduced in the early 1990s. All data is for Medicare.

    # US News Top 11 Sev CMI adj Cost COL Adjusted
    1 Johns Hopkins 1.82 $12,484 0.96 $11,985
    2 Mayo/Saint Marys 1.97 $8,926 1.00 $8,926
    3 Reagan UCLA 2.16 $11,625 1.03 $11,974
    4 Cleveland Clinic 2.33 $6,987 0.97 $6,777
    5 Mass General 1.85 $9,774 1.25 $12,218
    6 Columbia Presb 1.89 $10,525 1.24 $13,051
    7 UCSF 2.07 $14,803 1.13 $16,727
    8 U Penn 2.27 $9,032 0.97 $8,761
    9 Barnes-Jewish 1.86 $7,800 0.93 $7,254
    10 Brigham & Women’s 2.02 $9,937 1.25 $12,421
    10 Duke 2.00 $7,920 1.02 $8,078
    US AVERAGE 0.89 ahd.com CNNMoney

    The second list includes nearby health systems or similarly organized practices (in addition to Cleveland Clinic in the first list these include Intermountain Health and Geisinger Clinic). Gunderson/Lutheran is a somewhat smaller integrated group practice. HealthPartners (Regions Hospital) is a successful co-op.

    Other Major Centers Sev CMI adj Cost COL Adjusted
    Geisinger 1.87 $7,157 0.84 $6,012
    Gunderson-Lutheran 1.70 $7,941 0.95 $7,544
    Intermountain 2.03 $8,287 0.95 $7,873
    Mayo/Saint Marys 1.97 $8,926 1.00 $8,926
    Olmsted Medical Group 1.23 $8,620 1.00 $8,620
    Regions Mpls/StP 1.63 $8,128 1.00 $8,128
    U of Minnesota 1.85 $11,432 1.00 $11,432
    U Wisconsin Madison 0.98 $10,529 0.93 $10,968
    US AVERAGE ahd.com CNNMoney

    In brief, Mayo sees a mix (severity) of patients commensurate with that of its peer hospitals. It does this while achieving lower costs and high quality (see ahd.com).
    The Commonwealth data [pdf]shows that Minnesota in which the Mayo system is the primary provider has low instances of unnecessary deaths; Mayo’s region is typical of Minnesota as a whole (Dartmouth).

    The Dartmouth studies have shown that in addition, Mayo does very well in terms of avoiding unnecessary procedures, manages end-of-life care well, and saves money as well. A specific study of patients with chronic conditions by the Dartmouth Institute for Health Policy and Clinical Practice and the Robert Wood Johnson Foundation, which accompanied its 2008 Atlas, reported:

    Consider this comparison between the Mayo Clinic’s flagship St. Mary’s Hospital and
    UCLA Medical Center.
    • Spending: UCLA spent more than $93,000 per patient over the last two years of
    life. The Mayo Clinic, by contrast, spent $53,432—a little more than half the
    amount of UCLA on similar patients over the same period of time.
    • Utilization: Chronically ill patients in their last six months of life had more than
    twice as many physician visits at UCLA compared with Mayo, and they spent
    almost 50 percent more days in the hospital.
    • Resource Use: Compared to the Mayo Clinic, UCLA uses one-and-a-half times
    the number of beds, almost twice as many physician FTEs in managing similar
    patients.

    This study concludes “If the U.S. health care system mirrored the practice patterns of gold-standard health care systems such as the Mayo Clinic in Minnesota, Medicare could save tens of billions of dollars annually. Those savings would come just when Medicare needs that money most, as baby boomers prepare to retire in droves, putting unprecedented pressure on the health-care system.”

    IN THESE STATISTICS it should be noted that in addition to Mayo, the other centers which also achieve these goals are also centers which practice in the tradition of the “integrated group practice.” These include the Cleveland Clinic (which is the most similar to Mayo but sees a high percentage of Medicaid patients), Geisinger Clinic (Pennsylvania), and Intermountain Health (Utah).

    This analysis should settle the question as to whether Mayo provides excellent care to a challenging set of patients, does this at lower cost, and achieves excellent results in terms of measures of quality and patient satisfaction, avoiding both unnecessary surgeries and unnecessary deaths, by well established criteria.

    If others have data that contradicts this, it would be better for us all if they would produce it rather than mislead the country at this critical time.

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