Yesterday, a number of legislators queried officials of the Gov. Bobby
Jindal Administration about large reductions, nearly a quarter of the
budget for the state’s charity hospital system, run by the Louisiana State
University System, due to an unexpected
clawback of the federal government of excess monies being sent the state’s
way for Medicaid. The enabling legislation not yet a month old, they seemed
unaware that Rome was not built in a day and pressed for details on specific
cuts. Absent that, some lapsed into encounter group mode and testified about
their feelings on this matter.
These, for the most part, revolved around a scenario of people
clamoring for care that would be unable to access it at the facilities of the
country’s only state-run hospital system for the care of the indigent, leading
both to swamping non-state facilities or abandoning their quests to have
medical attention for their hangnails or whatever else might ail them.
Naturally, this dystopian view has next to no relation to reality.
First, it is a myth
that the uninsured loosen a barrage onto hospital emergency rooms. In fact,
it is not the uninsured who over-utilize hospitals as primary care vehicles –
they are only slightly more likely to use them as privately-insured folk – but Medicaid
patients. And in a state whose policy until recently was to encourage Medicaid
clients to visit its own hospitals, this would exaggerate even more this
inefficient tendency. But with the advent of the Bayou Health program that
steers deliberately about three-quarters of all Medicaid clients to non-state
primary care givers outside of hospitals of any ownership, this should decrease
demand on hospitals. Which is all well and good because hospitals aren’t there
to provide primary care, only the far fewer cases where more intense medicine
needs to be practiced.
Second, worries about cuts taking services offline leading to a supply
shortage are unfounded. Relatively speaking, Louisiana
is one of the most over-bedded states in the nation regarding hospitals,
with only eight states smaller in population and the District of Columbia
having more per capita. Utilization
is even more exaggerated, where the state
ranks in the top five in hospital admissions, ranks
fourth for admissions by state-owned facilities, yet only 15th
in outpatient visits (which still is significantly above every other state
in the south and west). All of this adds up to a portrait of one of two things:
either Louisiana’s population is significantly less healthy than those of states
around it, or cultural norms encourage over-utilization of health services and
disproportionately in the direction of the most expensive, least efficient
delivery.
The latter seems much more likely, and signals that a cultural shift
beginning with Bayou Health will make provision more efficient with a move away
from using government facilities. Therefore, cuts can be made to complement
incentives that take away overcapacity that tempts inefficient overutilization,
all without any real decline in access or quality.
Still, and third, legislators might argue specific geographical areas
might be impacted adversely. But most of the state’s charity hospitals are in
urban areas with plenty of alternatives for care beyond primary. In fact, with
the exception of the greater New Orleans area still suffering the ravages of
the hurricane disasters of 2005, all of these areas have number of beds per capita well above the national
average (2.9 per 1,000 in 2010). Any plan that LSU comes up with can strategically
pare back beds, a little less so with emergency room services perhaps, and
shunt primary care away from state hospitals, without significant reduction in
care available. As long as the money-follows-the-person model is used and
propagated, care will be available.
Of course, the optimal strategy would be to get the state out of the
direct provision of care all together, which means keeping only the (coming
soon) New Orleans and Shreveport facilities (and maybe one of the facilities
such as in Bogalusa that instructs in rural health care) devoted to teaching. Then
markets could produce much better the actual supply needed. This would mean
selling off at least a half a dozen facilities – but which would require
legislative approval. And it’s here we come to understand the actual concerns
on legislators.
With there being no real crisis with the ratcheting back of state
supply of services, their real brooding comes because of the impact the cuts
could have on their political careers, specifically regarding two
constituencies. The more numerous but, interestingly, least likely to respond
to political cues are the clients of state hospitals, mostly the uninsured or
on Medicaid. While their demographic profiles suggest they are the least likely
to participate in politics, they are many and some will.
The other constituency is much smaller in number but more intensely participates
in politics, those who work in these facilities. Populism is fading in
Louisiana but still has potency, and thus the idea that the state needs to be
in the business of direct jobs provision dies hard, in health care, prisons,
and other areas. Those therefore directly affected by cutbacks or closures/privatization
often resist vigorously change good for the state as a whole and particularly
taxpayers, but which would bring turmoil to their lives.
1 comment:
I'm not sure how you can conclude that Louisiana is "overbedded" when you only consider the supply of beds per capita and not the demand for beds as evidence in favor of that conclusion. In fact, in the very next sentence, you say that Louisiana is in the top five in admissions, and 15th in outpatient visits. Yet instead of concluding that there is more demand than average in Louisiana, you make a comparison to only southern states, which makes no sense given that the averages are national averages.
Post a Comment