Friday, November 30, 2012

Health Care Reform Articles - November 30, 2012

November 28, 2012

Health Care Entitlements

Congressional Republicans are insisting that big cuts to Medicare and Medicaid be on the table in the negotiations over the so-called fiscal cliff and deficit reduction. That stance is largely a political move against two programs, which have been critical to the public welfare for the past half-century.
Postelection polls show that large majorities of voters for both President Obama and Mitt Romney opposed making large Medicare cuts as a way to reduce the budget deficit. And, the fact is, the Obama administration has already pledged to extract more than $1 trillion in savings over the next decade from these programs. There is not much more that can be cut without hurting the most vulnerable Americans.
The Affordable Care Act contains provisions that will reduce projected Medicare spending by $716 billion over 10 years, primarily by reducing the annual increases in Medicare reimbursements for hospitals, nursing homes and other health care providers and by reducing unjustified subsidies paid to private Medicare Advantage plans. During the campaign, the Romney-Ryan ticket criticized the president for making such a big cut and even fatuously promised to restore all of it.
On top of those savings, President Obama, in his budget for fiscal year 2013, proposed cutting another $340 billion from Medicare spending over 10 years through tactics like requiring drugmakers to pay rebates to Medicare in some circumstances; reducing payments to some health care providers for treating patients just released from the hospital; reducing coverage of bad debts that hospitals and skilled nursing homes have failed to collect from patients; and charging higher premiums to high-income beneficiaries.
Those cuts seem acceptable as part of a larger budget deal to avert the fiscal cliff. There may be room to squeeze additional savings from health care providers as long as their fiscal health is not jeopardized. But, beyond that, there are very limited options for further reducing Medicare or Medicaid spending.
Upper-income beneficiaries already pay higher Medicare premiums, and there may be some room to charge them more. But middle-income beneficiaries need to be protected from higher costs. And the half of all Medicare beneficiaries who have incomes below $20,000 already pay sizable portions of their income for health care and certainly cannot afford to pay more.
Some ideas should be off the table entirely. The election made it clear that there is strong opposition to turning Medicare into a voucher system. And, as for raising the Medicare eligibility age, respected analysts have concluded that this change would actually increase total health care costs and shift the burden to employers and individuals, without saving the government much money.
Finally, it’s important to keep in mind that short-term cuts in Medicare are not urgently needed. Medicare spending per enrollee is projected to increase more slowly than per capita gross domestic product or private insurance spending per enrollee over the next decade, and it is only in the following years that strong cost controls may have to come into play as the population ages and medical costs continue to rise.
Maine’s health reform law back to the drawing board 
BY GINA HAMILTON, Times Record, Brunswick, Maine   November 28, 2012
When Public Law 2011 Chapter 90 was being debated last year in the Legislature, supporters insisted the reason Maine’s health care costs are among the nation’s highest was that the market was over-regulated.
End some of the red tape, they argued, and the free market will provide competition and bring down costs. Supporters went so far as to say that all uninsured people in Maine would be able to afford coverage.
Although much of the plan remains to be implemented, four of its provisions have already gone into effect, and have already caused higher net premiums for most policyholders.
The law permits insurance companies to increase the difference between what they charge older or rural customers and what they charge younger or urban customers in the individual and small group markets. As a result, Maine’s largest insurance provider — Anthem Blue Cross — raised premiums for the majority of its individual policyholders, especially older ones. Small-business premium rates increased, especially in northern and eastern Maine — rate increases of 70 percent, in some cases.
Relatively few policyholders saw a decrease in premiums, averaging 7 percent to 8 percent.
The law permits an insurance company to “close” its individual or small-group book of business at will and issue new plans. Because the plans are “new,” they do not qualify for regulatory protection. Anthem again led the way: It closed its existing programs and offered a new plan called HealthChoice Plus that drastically reduced benefits, cut maternity coverage altogether, increased deductibles and increased cost-sharing compared to the older, defunct plans.
The law imposes a new tax that requires every privately insured person to pay up to $6 per month to establish coverage for high-risk people by a new private, nonprofit corporation whose meetings — where they decide how public tax money will be spent — will not be open to the public. Maine policyholders together will pay a tax of $22 million — and possibly up to $33.5 million — for this high-risk pool, without knowing what or whom constitutes “high risk.”

State budget problems worsen; Republican leaders call for quick solutions

Posted Nov. 29, 2012, at 8:02 p.m.
AUGUSTA, Maine — For the second straight day, news of a growing state budget shortfall has left leaders scrambling to solve the problem, raising the possibility of seating an Appropriations Committee before the January opening of the legislative session.
On Thursday, Gov. Paul LePage’s administration said it now anticipates a shortfall of more than $100 million in the state’s Medicaid budget for this fiscal year.
News of the Medicaid shortfall came a day after the state’s revenue forecasting committee reduced tax collection estimates by $37 million for the fiscal year that ends June 30, 2013.
The worsening financial outlook spurred two Republican legislators who will assume leadership roles in the next Legislature to now say they would support allowing LePage to curtail state spending as soon as the law allows him to do so.
“I support the governor’s temporary curtailment proposal as a means to deal with the immediate revenue shortfall,” Rep. Kenneth Fredette, R-Newport, the incoming House minority leader, said Thursday in a statement. “Quite frankly, state government cannot spend money that it doesn’t have, and we are mandated by the state constitution to have a balanced budget.”
In the same release, Sen. Roger Katz, R-Augusta, joined Fredette in advocating for immediate spending cuts to address a $37 million reduction in projected state tax collections for this fiscal year.
“Although in a perfect world, these curtailments should be made following legislative discussion, the time crunch here warrants the governor’s approach,” Katz said.
After the state’s revenue forecasting committee announced downward projections Wednesday, Fredette and Katz said they favored addressing them as part of a supplemental budget proposal rather than through curtailment, a temporary measure that would allow government agencies to start trimming immediately.
However, after hearing more information Thursday about what appeared to be downward trends in state tax collections — and the growing Medicaid problem — that could stretch into the next two-year budget cycle, Fredette called for curtailments to minimize the size of a supplemental budget he anticipates will go before the new Legislature.
Fredette and Katz both served on the 125th Legislature’s Appropriations Committee.
“I expect a fairly sizable supplemental budget [to balance the state’s books for the fiscal year that ends June 30, 2013],” Fredette said. “The idea of curtailment, of reducing expenses quickly under executive order, makes sense now in terms of the budget for the rest of this fiscal year.”
Fredette urged LePage to provide legislators with information about the current fiscal year’s structural gap as quickly as possible so they can begin work on a supplemental budget. He also called for putting the next Legislature’s Appropriations Committee to work on a supplemental budget as soon as possible, perhaps even before the traditional January opening of the new legislative session.

Here is a column I wrote in January, 2012  the last time saving money by cutting Medicaid in Maine was being debated.

Do we need to gut MaineCare?

Posted Jan. 19, 2012, at 1:30 p.m.
For more than a month, the Legislature has been focused on the governor’s proposal to cut $221 million from the Department of Health and Human Services budget by revoking Medicaid eligibility for about 65,000 low-income and disabled Mainers. His proposal has generated controversy, including marathon hearings, state house rallies, articles in many of Maine’s papers as well as a petition that garnered more than 8,000 signatures in less than two weeks, all opposing the cuts.
I hope our legislators are enjoying this exercise in democracy because, even if they are able to satisfactorily resolve the immediate crisis, they can look forward to a repeat performance in a year or two unless they have the courage, wisdom and bipartisanship to attack the fundamental flaws in the ways we finance and deliver health care services. Maine’s very real problems with MaineCare are only symptoms of defects in our overall health care system. The most visible signs are out-of-control costs and diminishing access to quality health care.
For the past few decades, insurance companies have been systematically pushing the least healthy off their rolls. As a result, many people have been forced to turn to public programs such as Medicaid, swelling its roles, or to their own inadequate resources. Predictably, the amount of uncompensated care facing hospitals and other providers is growing. The Maine Hospital Association recently sounded the alarm, warning that layoffs and further reductions in service would result from the proposed MaineCare cutbacks.
Attempts in the past to slow this trend by tinkering with the existing employment-based system have not succeeded. Our health care system does not need a tune-up. It needs an overhaul. And it must begin with the way we finance health care.
As the MaineCare hearings are demonstrating, our current fragmented system of financing health care breeds conflict. We have separate financing systems for different groups. Each constituency is focused on protecting its own program, often without regard to the effect on others. Each may believe they are being asked unfairly to shoulder somebody else’s burden. The result is stalemate.
That is one reason to move from our fragmented financing system to a single publicly managed pool in which everyone would participate. All would play by the same rules and eligibility issues would be moot. Questions of fairness among groups of people would largely disappear and our health care version of class warfare would be eliminated. Such a program’s universal base of beneficiaries would protect the plan’s popularity, funding and political viability. Care that exceeds the program’s benefits could be purchased privately.
In addition to simplifying administrative costs, this program could ratchet down out-of-control prices and windfall incomes and profits by individuals and corporations. Centralizing health care data would make it much easier to detect fraud, waste and abuse.
More than enough money to cover everybody would be freed up. It is credibly estimated that such a program could result in saving the people of Maine more than $1 billion dollars in the first year alone, and all but eliminate the pain and suffering created by fighting arbitrary insurance company denials. These changes would accelerate reforms in the way we pay purveyors of medical goods and services. That would permanently reduce the rate of future inflation of health care costs.

Thursday, November 29, 2012

Health Care Reform Articles - November 29, 2012

Obama faces huge challenge in setting up health insurance exchanges

By Elise Viebeck 11/25/12 02:45 PM ET
The Obama administration faces major logistical and financial challenges in creating health insurance exchanges for states that have declined to set up their own systems.
The exchanges were designed as the centerpiece of President Obama’s signature law, and are intended to make buying health insurance comparable to booking a flight or finding a compatible partner on

Sixteen states — most of them governed by Republicans — have said they will not set up their own systems, forcing the federal government to come up with one instead.
Another five states said they want a federal-state partnership, while four others are considering partnerships.
It's a situation no one anticipated when the Affordable Care Act was written. The law assumed states would create and operate their own exchanges, and set aside billions in grants for that purpose.

State posts a job, sparks a mystery

Yesterday at 11:49 PM 

It's to coordinate a health insurance exchange, which Gov. LePage has previously sworn not to implement.

A job posting on Maine's state government website is mystifying some officials who are concerned about the planned expansion of health insurance under the federal Affordable Care Act.
Two weeks after Gov. Paul LePage announced that he wouldn't implement an online exchange to help eligible Mainers find federally subsidized insurance plans, the state's human resources website has a posting for a management position to create and oversee such an exchange.
The posting for a "health exchange coordinator" confused several state officials who have long expected that Mainers would have to use the federal exchange, known as the Health Plan Finder, which is scheduled to go online before Oct. 1, 2013.
"I thought (the job posting) was a joke when I first saw it," said state Rep. Sharon Treat, D-Hallowell, ranking minority member of the Legislature's Insurance and Financial Services Committee.

Group ranks Maine among best states in hospital safety

Posted Nov. 28, 2012, at 7:01 p.m.
Maine hospitals scored second-highest in the nation for patient safety in a new report card from a nationally recognized nonprofit organization.
Eighty percent of hospitals in the state earned an “A” in the Hospital Safety Score ratings released Wednesday by the Leapfrog Group, a national patient safety group. Only Massachusetts, where 83 percent of hospitals earned an “A,” scored higher.
The letter grades reflect the risk that a patient could be harmed by a preventable medical error while hospitalized. At least 180,000 patients are killed every year from errors, accidents, injuries and infections in American hospitals, according to Leapfrog.
The grades are based on 26 measures of patient safety. Leapfrog assesses public data on measures including falls, bed sores and how consistently hospitals follow recommended treatment protocols, such as administering antibiotics to patients within an hour before surgery.
Leapfrog’s scores are part of a growing effort nationally to help consumers become better informed health care shoppers. The federal government also is looking more closely at patient safety data, making a push through Medicare and Medicaid to pay health care providers based on the quality of care they offer.
“Maine hospitals have worked hard to improve hospital safety for a number of years and their high ranking shows the results of their work,” Elizabeth Mitchell, CEO of the Maine Health Management Coalition, an employer-led group that includes hospitals and insurers, said in a press release.
In Maine, 16 hospitals won an “A” grade, including both Bangor hospitals and rural hospitals such as Cary Medical Center in Caribou and Miles Memorial Hospital in Damariscotta.
Three hospitals — Maine Medical Center in Portland, Franklin Memorial in Farmington and the Augusta campus of MaineGeneral — earned a “B.” The Waterville campus of MaineGeneral scored an “A.”
York Hospital earned the lowest grade, a “C” rating. A spokeswoman for the hospital said it since has confirmed with Leapfrog that it has a “B” grade, which Leapfrog disputed.

Maine DHHS facing $100 million shortfall

Lawmakers expected a $10 million-plus shortfall, but the number given by DHHS commissioner Mary Mayhew sent shock waves through the capitol.

AUGUSTA – As lawmakers brace for a potential order from Gov. Paul LePage to cut millions in state spending, the Department of Health and Human Services delivered more bad news Thursday. 
On Thursday, DHHS Commissioner Mary Mayhew, seen last year with Gov. LePage, announced that her department is facing a $100 million shortfall.
2011 Staff File Photo

Related headlines

DHHS Commissioner Mary Mayhew told the Legislature's budget-writing committee that her department is facing a $100 million shortfall in the budget year ending June 30, 2013. Nearly all of the spending overage stems from MaineCare, the state version of the Medicaidprogram providing health care for low-income residents.
The incoming Legislature will likely confront the DHHS budget gap with a supplemental budget when the session begins sometime in January. 
The shortfall was a shock to lawmakers, who are already bracing for an order from LePage to address a $35.5 million revenue gap. That problem could be dealt with a curtailment that makes equitable across-the-board cuts to state spending.
The MaineCare shortfall is more difficult, in part because it will be lawmakers who will have to make tough decisions.

Blue Hill hospital to discuss concerns with Stonington branch at community meeting

Posted Nov. 29, 2012, at 3:25 p.m.
STONINGTON, Maine — Island residents will hear what Blue Hill Memorial Hospital has to say about local concerns with its Stonington branch at a community meeting scheduled for Dec. 5.
The hospital held a series of “focus groups” in May to listen to what Deer Isle and Stonington residents had to say about Island Family Medicine, the hospital’s primary care clinic in Stonington, according to hospital spokeswoman Kelley Columber.
At 6:30 p.m. Wednesday, Dec. 5, the hospital will hold a meeting to review the results of the focus groups and give an outline of how the hospital plans to address patient concerns. The meeting will be held at the Reach Performing Arts Center at Deer Isle-Stonington High School.
Blue Hill Memorial Hospital leases the space for the clinic from Island Medical Center. Columber said the focus groups were the hospital’s response to complaints heard by directors on the Island Medical Center board.
“The board [members] had come to [the hospital] and expressed that they were hearing concerns from the community about access,” Columber said.
Columber declined to discuss details about residents’ concerns, or about how the hospital will address them, before the meeting.
One Deer Isle resident who participated in the focus groups said he was surprised when his wife was turned away from Island Family Medicine when she needed stitches. He said it’s part of a general criticism that Island Family Medicine is inflexible with scheduling.
“They’re not structured to accept appointments ahead of time,” the man said. He asked not to be named for fear of alienating acquaintances at IFM. “You have to call the morning you want something. People complained they had to have the clinic on speed dial to get an appointment.”
Blue Hill Memorial Hospital has been engaging in a series of goodwill events with the community, including a public meeting in September to quell the furor from some in Blue Hill upset by the hospital’s recent purchase of nearby residential properties.
At that meeting, Chief Medical Officer Cathy Ober acknowledged that the hospital has only a 50 percent market share on the Blue Hill Peninsula, meaning about half of peninsula residents choose other medical facilities.

Monday, November 26, 2012

Health Care Reform Articles - November 26, 2012

Medicare payment changes draw fire

Neurologists rip lower test fees

Sunday, November 25, 2012

Health Care Reform Articles - November 25, 2012

Dealing With Doctors Who Take Only Cash

A FEW weeks ago, my wife and I were at our wits’ end: our 4-month-old daughter wouldn’t sleep for more than an hour at a time at night. We had consulted books and seen our pediatrician, but nothing was working. So my wife called a pediatrician who specializes in babies who struggle with sleep problems.
The next day, he drove an hour from Brooklyn to our house. He then spent an hour and a half talking to us and examining our daughter in her nursery. He prescribed some medicine for her and suggested some changes to my wife’s diet. Within two days, our baby was sleeping through the night and we were all feeling better.
The only catch was this pediatrician did not accept insurance. He had taken our credit card information before his visit and given us a form to submit to our insurance company as he left, saying insurance usually paid a portion of his fee, which was $650.
A couple of weeks later, our insurance company said it wouldn’t pay anything. Here’s how the company figured it: First, it said a fair price for our doctor’s fee was $285, about 60 percent less, because that was the going rate for our town. Then, it said the lower fee was not enough to meet our out-of-network deductible.
While we were none too happy with the insurance company, we remained impressed by the doctor: he had made our baby better and was compensated for it, all the while avoiding the hassle of dealing with insurance.
Last year, I wrote about doctors who catered only to the richest of the rich and charged accordingly. But after my experience, I became interested in doctors for the average person who take only cash. What pushes a doctor to go this route, often called concierge medicine? And how hard is it to make a living?
As to why doctors decide to switch to a concierge practice, the answer is almost always frustration.
“About four years ago, one insurance company was driving me crazy saying I had to fax documents to show I had done a visit,” said Stanford Owen, an internal medical doctor in Gulfport, Miss. “At 2 a.m., I woke up and said, ‘This is it.’ ”
Dr. Owen stopped accepting all insurance and now charges his 1,000 patients $38 a month.

Can Maine Democrats, Republicans come together on insurance overhaul?

Posted Nov. 23, 2012, at 5:45 p.m.
AUGUSTA, Maine — They branded it the “rate hike law” on the campaign trail this fall. And now that Democrats have taken back control of both chambers of the Maine Legislature, one of their first targets is the health insurance overhaul package passed by House and Senate Republicans last year and signed into law by Gov. Paul LePage.
Rep. Sharon Treat, D-Hallowell, submitted legislation before this month’s elections to repeal or substantially alter one of the Republicans’ signature legislative achievements from the past two years. Now she’s working out the specifics.
“I’m not interested in just sort of rolling back the clock to the day before the Republicans took over two years ago,” Treat said. “I want to take a thoughtful approach to it.”
Ultimately, though, Treat and her Democratic colleagues could face a significant obstacle to making major changes to the law: LePage supports it and could veto any attempts to alter it. “The governor has no interest in repealing this health insurance reform,” spokeswoman Adrienne Bennett said.
The insurance overhaul bill — called Public Law, or PL, 90 — was an attempt to spur more competition in Maine’s health insurance market by making it easier for insurers to offer new plans for small groups and individuals and by allowing small businesses to band together and negotiate more favorable rates.
The bill also created a high-risk pool — or reinsurance program — to protect insurance companies from the high costs of covering patients who require the most medical care. The law funds the program in part through a $4 assessment on the monthly premium of anyone with private insurance.
In addition, the law allows insurers to charge different rates based on patients’ age, geography and health status. Proponents say that part of the bill is an attempt to woo more young, healthy patients into the marketplace by allowing insurers to charge them less.
Eventually, the law will allow insurers to market plans certified in other states to Maine consumers.
“It gives people choices of different products and creates competition among more than three insurance companies,” said Sen. Rodney Whittemore, R-Skowhegan, who chaired the Legislature’s Insurance and Financial Services Committee and co-sponsored the insurance reform bill. “If you had 12 companies all competing for that market, that’s definitely going to drive that cost down.”
But Treat said the law does away with important consumer protections and has disproportionately caused premium increases among small businesses in rural areas.
“We heard loud and clear during this election that this law was not working for people and small businesses,” she said.

Care at the End of Life

Three years ago, at the height of the debate over health care reform, there was an uproar over a voluntary provision that encouraged doctors to discuss with Medicare patients the kinds of treatments they would want as they neared the end of life. That thoughtful provision was left out of the final bill after right-wing commentators and Republican politicians denounced it falsely as a step toward euthanasia and “death panels.”
Fortunately, advance planning for end-of-life decisions has been going on for years and is continuing to spread despite the demagogy on the issue in 2009. There is good evidence that, done properly, it can greatly increase the likelihood that patients will get the care they really want. And, as a secondary benefit, their choices may help reduce the cost of health care as well.
Many people sign living wills that specify the care they want as death nears and powers of attorney that authorize relatives or trusted surrogates to make decisions if they become incapacitated. Those standard devices have been greatly improved in recent years by adding medical orders signed by a doctor — known as Physician Orders for Life Sustaining Treatment, or POLST — to ensure that a patient’s wishes are followed, and not misplaced or too vague for family members to be sure what a comatose patient would want.
Fifteen states, including New York, have already enacted laws or regulations to authorize use of these forms. Similar efforts are under development in another 28 states. The laws generally allow medical institutions to decide whether to offer the forms and always allow patients and families to decide voluntarily whether to use them.
With these physician orders, the doctor, or in some states a nurse practitioner or physician assistant, leads conversations with patients, family members and surrogates to determine whether a patient with advanced illness wants aggressive life-sustaining treatment, a limited intervention or simply palliative or hospice care.

As drug industry’s influence over research grows, so does the potential for bias

By Published: November 24

For drugmaker GlaxoSmithKline, the 17-page article in the New England Journal of Medicine represented a coup.
The 2006 report described a trial that compared three diabetes drugs and concluded that Avandia, the company’s new drug, performed best.
“We now have clear evidence from a large international study that the initial use of [Avandia] is more effective than standard therapies,” a senior vice president of GlaxoSmithKline, Lawson Macartney, said in a news release.
What only careful readers of the article would have gleaned is the extent of the financial connections between the drugmaker and the research. The trial had been funded by GlaxoSmithKline, and each of the 11 authors had received money from the company. Four were employees and held company stock. The other seven were academic experts who had received grants or consultant fees from the firm.
Whether these ties altered the report on Avandia may be impossible for readers to know. But while sorting through the data from more than 4,000 patients, the investigators missed hints of a danger that, when fully realized four years later, would lead to Avandia’s virtual disappearance from the United States:
The drug raised the risk of heart attacks.
“If you looked closely at the data that was out there, you could see warning signs,” said Steven E. Nissen, a Cleveland Clinic cardiologist who issued one of the earliest warnings about the drug. “But they were overlooked.”
A Food and Drug Administration scientist later estimated that the drug had been associated with 83,000 heart attacks and deaths.

Many younger vets among the ranks of uninsured

By Chris Adams — McClatchy Newspapers
Belleville (Ill.) News Democrat - McClatchy, Nov. 19, 2012
WASHINGTON — More than quarter of all veterans who served in Iraq and Afghanistan don’t have health insurance and aren’t part of the Department of Veterans Affairs health system, according to an analysis of VA data.
The uninsured rate among these recent veterans is higher than for other war periods and for veterans as a whole, raising concerns that veterans recently back from the wars might not be taking advantage of care to which they are entitled.
Veterans advocates and some lawmakers have pushed to automatically enroll veterans in the VA health care system, which could fill in the gap for some of the veterans not now covered by the VA or the private market.
“It is critically important that we continue to reach out and inform veterans of the health care and benefits they have earned through their service to country,” said VA spokesman Josh Taylor. “We have made progress, but there is more work to do.”
The numbers are from the 2010 National Survey of Veterans, conducted by the VA periodically to determine the state of America’s veteran population.
Veterans who have left combat operations from the recent wars are eligible for VA health care for five years and after that must qualify based on the disability- or income-based standards. While some veterans can use the VA health system for life, most don’t; of 22 million veterans, 8.6 million are part of the VA’s system, 2011 numbers show.
That’s a surprise to many people, who assume all veterans qualify for the VA’s network of hospitals and clinics, said Steffie Woolhandler, a researcher who has tracked veteran health insurance status.
“I’m quite sure that most doctors believe that vets have health insurance, because they generally express surprise when I present my work on vets at meetings and in medical journals,” said Woolhandler, a professor of public health at City University of New York and a visiting professor at Harvard Medical School. “I’m pretty sure most of the lay public thinks so, too.”