Way back in the eighties when I was Human Services Commissioner in New Jersey, I established something called the Garden State Health Plan (GSHP).  It was the first — and I think the only — federally qualified state-run HMO for Medicaid beneficiaries.  One goal of the GSHP was to reallocate the Medicaid dollar, giving more to primary care physicians who at the time were paid $9 for a general office visit, and a little less for ER visits and specialty care.  At this it worked pretty well, about tripling reimbursements for primary care.  The other goal was to manage care and produce better health outcomes and real savings to the Medicaid program.  At this the plan failed.  For the most part there were no mechanisms in place to actually manage care, and too many of the provider groups who showed up to accept the now increased payments were Medicaid mills that did not fit anyone’s description of ideal primary care case managers.

The GSHP was one of many attempts in the early days of Medicaid managed care to do primary care case management, all with slightly different structural and financial arrangements.  Just before going to state government, I had helped establish some of the earliest models of Medicaid managed care through the Program for Prepaid Managed Health Care at the Robert Wood Johnson Foundation, which funded and evaluated 16 demonstration sites across the country and was cosponsored by the Health Care Financing Administration (HCFA) — now the Centers for Medicare and Medicaid Services(CMS) — and the National Governors Association.  Medicaid managed care arrangements of the day varied widely; some involved for-profit providers, some major teaching centers, some (my favorites) knitted together community clinics in a variety of capitated and non-capitated arrangements.  These efforts had some success in linking individuals to a usual source of care, but challenges in coordinating care and assuring quality of care remained.

Over time, Medicaid managed care continued to evolve as states expanded the role of managed care in their Medicaid programs.  Today, a majority of families on Medicaid receive their health coverage through private managed care organizations.  Through managed care and primary care case management arrangements, states have tried to secure better access to primary care and restrain costs, and many states are using managed care and pay-for-performance programs as vehicles for improving the quality of care.

Cut to present day.  Just recently, our Medicaid Commission released a policy brief on Community Care of North Carolina (CCNC), an “enhanced medical home model” for Medicaid beneficiaries in North Carolina.  As a veteran of Medicaid managed care efforts in an earlier era, it is tempting to see all this as just a new label for the same old thing.  But it isn’t.  The program in North Carolina is fundamentally different from the first generation Medicaid managed care programs in several key respects.  Most importantly, CCNC has the capacity to actually manage care across both health and social service providers, and it focuses on the highest cost, highest need patients who account for a substantial share of spending.  It relies on a community team approach to care that is structured around local networks of physicians and hospitals, as well as social service agencies and local health departments.  Each patient has a primary physician who is responsible for coordinating his or her care and is on call 24/7.  The program provides case managers — often a social worker or nurse — to manage and monitor care and comprehensive disease management programs for beneficiaries with chronic conditions such as asthma, diabetes, or congestive heart disease.  Case managers and physicians utilize the latest best-practice guidelines, provide patient education, and coordinate services across providers.  And, a broad range of data are collected through chart reviews and the analysis of claims data and fed back to health professionals to help assess performance and guide continuing program improvements.  In short, the ability to actually manage care and do it for those who need it most is a jump to light speed beyond the earliest Medicaid managed care models.

Findings available to date suggest that these efforts have paid off in North Carolina.  An evaluation of CCNC found that the state achieved savings relative to its prior arrangements estimated at $150 to $170 million for 2006, and a second evaluation documented savings for asthma and diabetes patients through reduced hospitalizations and ER visits.  How well other states could replicate North Carolina’s efforts and whether they would achieve the same successes is not known, although some 31 states currently are trying out similar models in one form or other.

There are a few big messages to take away from this experience.  One is the evidence that basic delivery changes have the potential to make a difference and produce savings.  This is not cutting edge or controversial comparative effectiveness research or complex payment reform; it’s basic, sensible care management with the delivery system and data system changes necessary to make it happen.  I suspect a number of variations on this approach could be effective depending on local circumstances.  The key is providing a usual source of care and truly managing care for those who need it most, whether that is called “primary care case management” as it was 25 years ago, or an ”enhanced medical home” as it is in North Carolina.  A second message is that Medicaid, often characterized in public debate like other public programs as lagging behind the private sector in its ability to innovate, can be a leader in demonstrating how to improve care and lower costs through delivery system changes.  A third message is about the importance of focusing efforts on the sickest, highest cost patients, because they have the greatest health care needs and account for such a substantial share of health care spending.  A small percentage of the U.S. population (5%) accounts for nearly half of health care spending.  If we want to get a handle on increases in spending in Medicare and Medicaid, we will need to do more to reach out to and more effectively manage care for these high cost groups.

The North Carolina experience and the growing interest in similar initiatives in other states suggests that much more can be done both to improve the care of the sickest, highest cost patients and potentially drive down health care spending in public programs and for the nation overall.  In a world where success stories in controlling health care costs (without sacrificing coverage or access) have been hard to find, this is important news.

Introduction

Financing a sufficient and sustained response to the HIV/AIDS epidemic in low- and middle- income countries has emerged as one of the world’s greatest health and development challenges, and one that will be with us for the foreseeable future. International assistance from donor governments, through bilateral aid and contributions to the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund) and other financing channels such as UNITAID, the international drug purchase facility, is a critical part of this response. Other sources of funding include multilateral institutions, the private sector, and domestic spending by many affected-country governments and the households and individuals within them. Although funding from all these sources has risen significantly over the past decade, the difference between the UNAIDS estimate of resources needed compared to resources available in 2008 was approximately $6.5 billion. The current global economic crisis has raised concerns about the ability to fill this gap, most of which will need to be filled by the international community. Tracking funding by the international community, therefore, is critical.

Each year, UNAIDS and the Kaiser Family Foundation collect and analyze data to document international assistance for AIDS in low- and middle- income countries. This latest report provides data from 2008, the most recent year available. As such, it represents funding levels reflecting budgets largely set in place before the acceleration of the current global economic crisis. The analysis is based on data provided by governments — including the Group of Eight (G8), Australia, Ireland, The Netherlands, Norway, Sweden, and other donor government members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC) — as well as from the European Commission (EC). It includes bilateral assistance, contributions to the Global Fund and, for the first time, contributions made to UNITAID, the international drug purchase facility, an innovative financing mechanism used to purchase drugs to fight HIV/AIDS, TB, and malaria. Data were collected and analyzed as part of a collaborative effort between UNAIDS and the Kaiser Family Foundation, with research assistance provided by the Stimson Center.

Key Highlights

In 2008, international AIDS assistance from the G8, EC, and other donor governments reached its highest level to date:

• Identified new commitments totalled US$8.7 billion, of which US$6.7 billion was through bilateral channels (including earmarked multilateral commitments) (see Chart 4). Funding for the Global Fund totalled US$2.8 billion, of which US$1.7 billion represents an adjusted “AIDS share” (see Chart 7). Funding for UNITAID, the international drug purchase facility, totalled $349 million, of which $265 million represents an adjusted “AIDS share.”
• Disbursements, which reflect actual resources made available in a given year and therefore provide a better measure of resource availability, totalled US$7.7 billion in 2008 (see Chart 4).
• Disbursements have risen significantly over the past several years: Between 2002 and 2008, disbursements increased by more than six-fold, including a 56 percent increase in the last period (see Chart 4).

Increases in international AIDS assistance from donor governments have been driven by a subset of G8 Members and, notably, a few non-G8 Members:

• In 2008, the United States was the largest donor in the world, accounting for more than half (51.3%) of disbursements by governments. The United Kingdom accounted for the second largest share (12.6%), followed by the Netherlands (6.5%), France (6.4%) and Germany (6.2%). Norway and Sweden followed, at 2.0% respectively, each accounting for more than some G8 Members (see Chart 5).
• Most international assistance identified for purposes of this analysis is channelled bilaterally (or is earmarked through multilateral instruments, such as UNAIDS, and is therefore considered bilateral), accounting for 74% of disbursements in 2008; the remainder is provided through the Global Fund and UNITAID. Funding channel patterns vary significantly by donor (see Chart 8).

Other international financing sources — not documented in this report — include multilateral institutions such as U.N. agencies, multilateral development banks such as the World Bank, and the private sector.

UNAIDS estimates that US$22.1 billion was needed to address the epidemic in low- and middle- income countries in 2008:

• Of this, an estimated US$15.6 billion was available from all sources (public and private), with bilateral international assistance accounting for 37% (US$5.7 billion in disbursements).
• The U.S., U.K., and the Netherlands accounted for the largest shares of such assistance funding.
• Still, there was a gap of US$6.5 billion between resources available from all sources and resources needed in 2008, as estimated by UNAIDS (see Chart 9).

Assessing “fair share” in the context of international assistance is a challenging task and there is no single, agreed upon methodology for doing so. Two different methodologies used in this analysis indicate that, in 2008:

• The U.S. provided 22% of the funding available for AIDS from all sources (donor governments, multilaterals, the private sector, and domestic sources), the largest share of any donor and just below its share of the world’s economy as measured by gross domestic product or GDP (24% in 2008). The U.K., the Netherlands, and Ireland each provided greater shares of total AIDS resources than their shares of GDP (see Chart 10).
• When standardized by GDP per US$1 million, to account for differences in the sizes of government economies, the Netherlands provided the highest amount of resources for AIDS in 2008, followed by the United Kingdom, Ireland, and the U.S., ranking fourth (see Chart 11).

This report by the Kaiser Family Foundation and the American Cancer Society profiles six cancer patients and survivors and the challenges they face to help gauge how the recession and rising unemployment is affecting workers who are most in need of ongoing medical care.

The report, “Patients Under Pressure: Profiles of How Families Affected by Cancer are Faring in the Recession,” illustrates the kinds of problems such patients face in a recession, including obstacles to continuing coverage through COBRA; difficulty in finding an insurer who will sell them non-group coverage; the limited availability of public coverage; and the medical debt that patients can incur and the delays in care they often suffer if they become uninsured even for short periods of time.

It is a follow up to “Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System,” a joint report released by the Foundation and the American Cancer Society in February.

Report (.pdf)

This report provides the first comprehensive inventory of how HIV prevention is delivered across the country, based on a survey of the 65 health departments receiving direct federal HIV prevention funding, including every state and territory, plus six cities.

The report was authored by researchers at the Kaiser Family Foundation and the National Alliance of State and Territorial AIDS Directors.

Report (.pdf)

This document contains the key findings from the July Health Tracking Poll. The survey was designed and analyzed by public opinion researchers at the Kaiser Family Foundation and was conducted July 7 through July 14, 2009, among a nationally representative random sample of 1,205 adults ages 18 and older. Telephone interviews conducted by landline (800) and cell phone (405, including 126 who had no landline telephone) were carried out in English and Spanish. The margin of sampling error for the total sample is plus or minus 3 percentage points. For results based on subgroups, the margin of sampling error is higher.

Key Findings (.pdf)

This document contains the toplines from the July Health Tracking Poll. The survey was designed and analyzed by public opinion researchers at the Kaiser Family Foundation and was conducted July 7 through July 14, 2009, among a nationally representative random sample of 1,205 adults ages 18 and older. Telephone interviews conducted by landline (800) and cell phone (405, including 126 who had no landline telephone) were carried out in English and Spanish. The margin of sampling error for the total sample is plus or minus 3 percentage points. For results based on subgroups, the margin of sampling error is higher.

Toplines (.pdf)

The July Kaiser Health Tracking Poll finds a majority of the public remains supportive of taking action on health reform now, though there is some softening of support as criticisms and doubts seem to be registering.

As has been the case over the past ten months, a majority of the American people continue to believe that health reform is more important than ever despite the country’s economic problems, and the public believes by a two to one margin that the country will be better rather than worse off if Congress and the president enact health reform.

But with health reform moving from the abstract to concrete legislative proposals, criticisms made during the policy debate appear to be having an impact on the public and several indicators have softened somewhat from earlier this year. A larger share of the public is worried that Congress and the president will pass a bill that’s bad for their family than are worried that health care reform will not happen this year. While a majority of the public favors health care reform now, the share that is supportive is down five percentage points since June.

The July Kaiser Health Tracking Poll, the fourth in a series designed and analyzed by the Foundation’s public opinion survey research team, examines voters’ specific health care issue interests and experiences and perceptions about health care reform.

Key Findings

Chartpack

Toplines

Most Medicare beneficiaries have at least 40 Medicare Advantage (MA) plan options to choose from this year. While some favor a robust marketplace, others argue that fewer plan offerings, or more transparent differences across plans designs, would help beneficiaries choose plans most likely to meet their individual needs. While consumers generally show interest in choice and economists see it as enhancing value, research shows that individuals faced with a large number of alternatives often avoid making a decision or choose options that may not be the best for them economically.

This report prepared for the Kaiser Family Foundation presents new data on Medicare Advantage plans, and uses these data to examine a range of policy options that would simplify choices for Medicare beneficiaries, including changes recently proposed by the Obama Administration. This paper assesses the implications for beneficiaries and the potential change in the number of plan offerings as a result of each option. It was authored by Marsha Gold of Mathematica Policy Research.

Report (.pdf)

This analysis paper examines the availability, affordability and stability of the health insurance coverage of the American middle class, defined as those with incomes of $44,000 to $88,000 for a family of four. It also addresses the growing burden of health care costs for the middle class, the adequacy of today’s health insurance plans to protect them from large medical bills, and the difference both make as individuals and families make health care decisions for themselves.

Key findings include:- Nearly a quarter of the nation’s 45 million non-elderly uninsured are middle class;- Most middle class Americans with insurance get it through their employers, a source of coverage that has been put in jeopardy by the economic recession;- Health insurance and medical care have become less affordable for the middle class as the growth in insurance premiums and medical costs has far outpaced that of wages.

Report (.pdf)

The Kaiser Family Foundation and the Pew Research Center’s Project for Excellence in Journalism conducted this study of how the U.S. news media covered health issues over a six-month period from January 2009 through June 2009. It is an update of a study measuring news media coverage of health issues from January 2007 to June 2008. The study finds that news about health and health care made up roughly five percent of all news content from the first half of 2009.

Health policy and the state of the U.S. health care system was the most covered health-related topic—forty percent of all the health news coverage in the first half of the year. But the bulk of that coverage did not come until June, when health legislation started making its way through Congress. After health policy/the health care system (40%), public health (36%) was the second most covered topic, dominated by news of the swine flu outbreak. About a quarter (24%) of all health news focused on specific diseases or conditions. This reflects a substantial shift in the nature of health coverage from the previous study, when news concerning specific diseases dominated coverage of health with roughly 42 percent, followed by public health at 31 percent and finally health policy and the U.S. health care system at 27 percent.

Study (.pdf)