The Book Stops Here
By RICHARD A. FRIEDMAN, M.D.
There won’t be many book parties when the latest version of the American Psychiatric Association’s official manual of mental disorders, known as the D.S.M.-5, rolls off the presses this week. Instead, the long-awaited guide has touched off a heated debate among psychiatrists about its scientific value and clinical usefulness.
In an interview with The New York Times, for example, Dr. Thomas R. Insel, director of the National Institutes of Mental Health, harshly criticized the new manual for defining mental disorders based on symptoms rather than underlying biological causes; in response, Dr. David Kupfer, the chairman of the task force that revised the D.S.M. and a professor of psychiatry at the University of Pittsburgh, said the new manual did the best it could with the scientific evidence available and added that any shortage of such evidence was “a failure of our neuroscience and biology.”
What are the public and those who work in medicine to make of this high-level kerfuffle?
Well, Dr. Insel’s call for understanding the neurobiology of psychiatric disorders is laudable but curiously lacking in historical perspective. Scientists have been searching for decades for the neural basis of mental disorders — the holy grail of psychiatry — but the goal has proved frustratingly elusive.
Indeed, the official “Decade of the Brain,” so designated by Congress and the first President Bush, ended 13 years ago. And while that decade (and the decade after that) did yield important findings in basic neuroscience, I am hard pressed to think of a single truly novel and effective biological therapy for any psychiatric disorder that has come of it.
Even with molecular biology and the most sophisticated brain imaging, such knowledge is probably years away. Effective new therapeutics based on that knowledge may take still more years to develop. And even a definitive understanding of neurobiology would not necessarily shed light on the interactions between genetics and environment that lead to many mental disorders. In the meantime, the millions of Americans with mental illness need treatment now. They and their psychiatrists don’t have the luxury of waiting for definitive scientific knowledge.
New Efforts to Undercut Health Reforms
By THE EDITORIAL BOARD
Congressional Republicans are trying to exploit two controversies bedeviling the Obama administration to undermine the health care reform law. They are using an uproar over misguided tactics by Internal Revenue Service employees to target conservative political groups seeking tax-exempt status as an excuse to prohibit the agency from playing a pivotal role in carrying out the Affordable Care Act. And they want to use a controversy over efforts by the secretary of health and human services, Kathleen Sebelius, to encourage private donations to help enroll people in new health care exchanges as a cudgel to disrupt such efforts.
Under the health reform law, the I.R.S. is required to examine tax returns to determine who is eligible for a tax-credit subsidy to buy health insurance and who must pay a fine for failing to buy insurance. A Republican bill in the Senate would prohibit the I.R.S. from enforcing the reform law (a related Republican bill in the House would do the same unless there are certifications made that the I.R.S. will not target groups or individuals for political reasons).
An investigation by the Treasury Department’s inspector general blamed midlevel workers, confusing rules and ineffective management, but it found no evidence that the staff had been under political pressure to focus on conservative groups. Still, Republicans have scheduled hearings to try to link the scandal to health care reform. Putting any limits on the I.R.S. role in determining health subsidies for uninsured Americans would be disastrous.
The controversy surrounding Ms. Sebelius involves her efforts to persuade nonprofit groups and business executives to donate money to or otherwise assist Enroll America, a nonprofit group that aims to help people enroll in new health care exchanges, pick suitable policies and apply for tax credits. She was driven to solicit help because Republicans have repeatedly and shamefully denied requests for money needed for this purpose.
A spokesman for the department said Ms. Sebelius has made only two fund-raising calls. She called the Robert Wood Johnson Foundation and H&R Block, neither of which is regulated by her department. She had engaged in “a dialogue” with a wide range of business and nonprofit groups, he said, on how they might help the uninsured.
The problem is that Enroll America is led by former members of the Obama White House, and Mr. Obama’s presidential campaigns and some of the people solicited by current or former administration officials felt as though they were being pressured into giving. An investigation by the Government Accountability Office into this matter, as Congressional Republicans are seeking, could shed light on who said what to whom. Whatever the outcome of an inquiry, there are many patient groups working to help the uninsured, and donors should not be deterred from supporting those groups.
Of course, many Republicans are not interested in making sure that millions get help. In fact, as Jeremy Peters reported in The Times last week, the House has voted 37 times to repeal the Affordable Care Act or deprive it of funds since January 2011. That is about 15 percent of the time spent on House floor votes.
Maine Senate backs bill to expand Medicaid, pay hospital debt
The bill, fiercely opposed by Republicans, is designed to combine one of the Democrats' leading policy initiatives with Gov. LePage's payback plan.
By Steve Mistler smistler@pressherald.com
Staff Writer
Staff Writer
AUGUSTA — Following a national push by Democrats to bolster a linchpin of the federal health care law, the state Senate gave preliminary approval Monday to a bill that would expand Medicaid in Maine.
In a party-line vote after nearly four hours of passionate debate, the Senate voted 20-15 to advance L.D. 1546, a bill that ties Medicaid expansion with Gov. Paul LePage's plan to pay off the state's estimated $186 million share of debt to Maine's 39 hospitals.
Sen. Richard Woodbury, an independent from Yarmouth, voted with the Democratic majority.
The bill, fiercely opposed by Republicans, is designed to combine one of the Democrats' leading policy initiatives with a hospital payback that LePage has pushed since he campaigned for governor in 2010.
The hospital payback distinguishes Maine from other states where Democratic lawmakers have made Medicaid expansion a key front in the battle over the Affordable Care Act.
While some Republican governors have agreed to participate in Medicaid expansion, their colleagues in other states are resisting expanding the public insurance program for the poor, which now covers 17 percent of the 260 million Americans with health insurance.
With high deductible health plans, it pays to shop around for care
Posted May 20, 2013, at 9:22 a.m.
When Maria and Vadim Brodsky’s then 7-year-old daughter needed an MRI two years ago to examine a tumor in her head, they took her to a hospital in their health plan’s network and were dismayed to receive a $4,500 bill.
The couple had a $6,000 deductible on their family plan. And even though the bill was reduced to $3,000 — the price the provider and insurer had agreed to by contract — the Brodskys had to cover all of it.
The following year when their daughter needed another MRI, the Huntingdon Valley, Pa., couple took her to a standalone facility and put the procedure on a credit card. The total bill: $600.
Welcome to the new world of health insurance where high deductible plans are growing more popular and the consumers in those plans often have an incentive to haggle with providers.
Although many plans still protect people from high out-of-pocket costs for care, these days an increasing number of consumers have cheaper, high deductible plans where they must cover the first $1,000, $5,000 or even $10,000 of care before insurance kicks in.
For this group, it pays to shop around, say experts.
“It’s definitely worth it to look at different hospitals or outpatient services, because prices can vary dramatically,” says Carrie McLean, senior manager of customer care at eHealthInsurance.com, an online vendor.
Five years ago, 12 percent of workers faced a deductible of at least $1,000 for single coverage. Today more than a third do, according to the Kaiser Family Foundation’s 2012 survey of employer-sponsored plans. Increasingly, a high-deductible plan, often linked to a tax-advantaged health savings account, is the only insurance offered on the job, even at big companies that have long offered generous coverage.
Proponents of high-deductible plans say consumers will make more cost-conscious health care choices if they have to spend more of their own money. According to an analysis by the Robert Wood Johnson Foundation, consumers in such plans cut their medical spending by between 5 and 14 percent. But results were mixed on whether they cut back only on unnecessary care or on treatment that was needed.
As patients increasingly owe a bigger share of the bill, “providers and patients have gotten creative about paying out-of-pocket costs,” says Mark Rukavina, a principal at Community Health Advisors in Boston who consults for nonprofit hospitals. “The price that appears on an invoice may be fluid.”
Insurers in recent years have helped ease some of the burden by only billing consumers for the companies’ lower contracted rates. And the Affordable Care Act takes some pressure off by requiring many health plans to cover preventive services without applying those charges to the deductible. Still, high bills are a fact of life.
One effective way patients can cut costs is by agreeing to pay cash at the time a service is provided. Many doctors and hospitals offer such “prompt pay discounts.”
“If they’re willing to pay in cash and I don’t have to wait six weeks for reimbursement [from the insurer], I’ll reduce the bill by 10 to 25 percent,” says Dr. Joseph Mambu, a family physician in Lower Gwynedd, Pa.
Patients who pay hospitals within 30 to 60 days of billing — the time frames vary — can often get up to a 30 percent discount, adds Rukavina.
It’s also worth asking a hospital about their financial assistance policies, says Rukavina. They’re not necessarily only for uninsured patients. “Many have policies for the uninsured as well as underinsurance and might provide relief for the amounts due after insurance has paid,” he says.
Paying directly, however, can have downsides because it bypasses the insurance claims process, advocates warn. For one thing, those immediate payments won’t be applied to the deductible, so if the patient has more medical expenses later in the year, he or she won’t get “credit” for the amount spent. And, if there’s an error in the bill, you may not find out about it.
If more people are on Medicaid, why are Maine hospitals giving away more care for free?
Posted May 17, 2013, at 2:18 p.m.
The financial health of Maine’s hospitals has landed at the center of State House debate this spring as lawmakers tussle over whether Maine should expand its Medicaid program under the federal health care reform law.
The issue came to a fore this past week as debate erupted over a Democratic plan to tie Medicaid expansion to the repayment of Maine’s $484 million hospital debt, which accrued as the state fell behind on reimbursing hospitals for services they provided to patients covered by Medicaid.
Democratic supporters of Medicaid expansion say growing the public, low-income health insurance program can address a key financial concern for hospitals: growth in the amount of care they must provide for free to uninsured people with no ability to pay.
Meanwhile, Gov. Paul LePage’s administration and Republicans have argued that Maine should learn from past moves extending Medicaid coverage to new categories of low-income residents. Since those previous expansions took effect, they say, the amount of free care provided by Maine hospitals has continued to grow.
The amount of free care, or charity care, provided by Maine’s hospitals has grown quickly in recent years. The trend has been driven by a slow economy in which employees have lost jobs and thus their health insurance; changes in the private insurance market that have made high-deductible plans more common; and decisions by many of Maine’s hospitals over the past decade to provide free care to higher-income patients.
More care for free
In 2011, the state’s 39 hospitals provided free care that amounted to $196 million. That’s about 4 1/2 times the amount of free care that was on the hospitals’ books in 2000, according to the Maine Hospital Association.
On average, the amount of free care provided by Maine hospitals grew 15.7 percent a year between 2001 and 2009, compared with 7.3 percent average annual growth in total health care spending in Maine. Free care accounted for most of the growth in hospitals’ uncompensated care, a category that combines free care and bad debts that hospitals have billed but have been unable to collect.
Free care also has grown as a percentage of hospital revenues. It amounted to 1.5 percent of gross patient service revenues at Maine’s 39 hospitals in 2005, according to an analysis of figures collected by the Maine Health Data Organization. In 2011, free care was worth nearly 2.6 percent of gross revenues.
Under Maine law, hospitals must provide care for free to anyone who needs treatment, earns up to 150 percent of the federal poverty level ( $23,265 for a two-person household), and has no way to pay the bill.
Hospitals commonly provide free care to those with no health insurance, but the uninsured don’t account for all free care Maine hospitals provide, said Derrick Hollings, chief financial officer of Eastern Maine Healthcare Systems, the parent organization for seven hospitals including Bangor’s Eastern Maine Medical Center.
Even some low-income Maine residents with health insurance qualify for free care when they meet the income guidelines and their insurer requires they pay a large portion of the bill out of pocket.
“If they are willing to pay for part of their care — they’re working, they don’t want a free ride, they’d like to pay for as much of the care as they possibly can — we would accept that partial payment,” Hollings said. “The other part of that, the cost of it, would be recorded as free care.”
The figure that hospitals list as free care is the “sticker price” that hospitals bill but few consumers actually pay because private insurers, Medicare and Medicaid all reimburse hospitals at lower rates.
GOP: Flaw in Obamacare language should delay decision on expanding Medicaid
Posted May 14, 2013, at 11:34 a.m.
AUGUSTA, Maine — Republicans and Gov. Paul LePage have drawn attention to a drafting error in the federal Affordable Care Act in recent days as they resist attempts by Democratic legislative leaders to tie an expansion of Maine’s Medicaid program to one of LePage ’s top priorities: repayment of the state’s $484 million debt to its hospitals.
The information has Maine’s House Republican leader, Rep. Kenneth Fredette of Newport, suggesting that a specially formed study group should spend the summer and fall examining the state’s options for expanding Medicaid. The extra time would take pressure off the Legislature to reach an accord on the contentious issue in the final weeks of its session, he said.
Democratic House Speaker Mark Eves, however, says the suggestion is the latest tactic by Republicans to hold up an expansion of Medicaid coverage for low-income people under the federal Affordable Care Act, which would take effect Jan. 1, 2014.
At issue is an error in the text of the Affordable Care Act that would qualify about 48,000 low-income parents and adults without children for federal help to purchase private health insurance if Maine opts not to expand Medicaid. Those 48,000 residents would otherwise be eligible for Medicaid if the state expands its low-income health insurance program.
If not for the drafting error, those 48,000 residents would be eligible only for Medicaid.
If Maine opts against the expansion, however, neither the federal subsidy help nor Medicaid coverage would be available to about 28,000 adults without children who earn less than 100 percent of the federal poverty level — less than $11,490 for a one-person household.
“There may be legitimate arguments in there for maybe having that portion be covered by Medicaid expansion and the other population be covered by insurance subsidies,” said Fredette. “It shows the complexities of the issue, why it needs to be done over the long term so we get it right and so that we don’t expose Maine taxpayers to these ongoing [Medicaid funding] crises that we have.”
The Affordable Care Act was designed to extend health insurance coverage to nearly all Americans through a major expansion of Medicaid and through federal subsidies designed to help others purchase private insurance through insurance exchanges.
The law was designed to make Medicaid available to those earning up to 133 percent of the poverty level — $15,282 for a one-person household — and federal tax subsidies available to those earning between 133 percent and 400 percent of the poverty level.
The drafting error, however, makes the subsidies available to those earning between 100 percent of the poverty level and 400 percent, rather than starting at 133 percent. About 6 million people nationwide fall in that overlap category — between 100 percent and 133 percent of the poverty level. The health care law’s drafters are considering the drafting error a “happy coincidence” because it could make insurance coverage available to more people even if about half the states opt out of the Medicaid expansion, according to a February article in Governing Magazine.
The Story Behind the Biggest Mistake in Obamacare
The main purpose of the Affordable Care Act (ACA) was to provide health insurance for most of the tens of millions of Americans who don't currently have any coverage. But after an impossible-to-predict move from the Supreme Court seemed to gut the law's ability to do that, millions of people will instead get coverage through a drafting error that was never supposed to become law.
Here's the mistake: Under the ACA, Americans with an income below 138 percent of the federal poverty level qualify for Medicaid, the public low-income insurance program, starting in 2014. But at the same time, Americans with an income of 100 percent of the federal poverty level and above (up to 400 percent) qualify for federal tax subsidies to purchase private insurance on the health insurance marketplaces created by the law, which also open in 2014. Those are the two main ways that uninsured people are supposed to get health coverage under the law.
The ACA stipulates that an individual can't qualify for both Medicaidand a tax subsidy (as people between 100 and 138 percent of the federal poverty level technically would). To address that gap, the ACA said that anyone who qualifies for both would just automatically be enrolled in Medicaid. So why don't the thresholds simply meet at 138 percent? Well, they were supposed to, but because of an oversight while the bill was being amended in the Senate, they don't.
But it didn't matter as long as the Medicaid expansion was mandatory, which it was always supposed to be. But then the Supreme Court ruled last June that the expansion wasn't required -- states could choose whether or not to expand Medicaid eligibility to 138 percent of the poverty line. That's an outcome no one saw coming, not even the people who wrote the law.
Maine Doctors: Accepting Federal Health Care Dollars is the Right Prescription for Maine
March 20, 2013
AUGUSTA -- Health care providers serving in the Legislature and from the Maine Medical Association strongly endorsed a bill that would allow Maine to accept federal health care dollars to cover more Maine people.
The measure, LD 1066, An Act To Increase Access to Health Coverage and Qualify Maine for Federal Funding, would increase access to health care for up to 69,500 Maine people under the Affordable Care Act.
“Accepting these federal dollars to get health care to more Maine people is the right prescription for Maine,” Rep. Linda Sanborn, the sponsor of the bill, and a retired family physician from Gorham, said at a press conference Wednesday. “Maine has an opportunity to cover more people and save millions of dollars currently spent to treat uninsured people in emergency rooms.”
Maine is projected to save $690 million in the next 10 years if it accepts the federal dollars, according to the nonpartisan Kaiser Foundation and the conservative Heritage Foundation.
Sen. Geoff Gratwick, a co-sponsor of the bill and a rheumatologist and arthritis specialist from Bangor, said the bill would also boost Maine’s economy.
“Building a strong economy and a strong middle class means making sure people have the health care they need, when they need it, at an affordable cost,” Gratwick said. “Accepting federal funds to increase health coverage will strengthen Maine’s economy and provide health coverage to thousands of hard-working Mainers.”
The measure would infuse $250 million of additional federal funding into Maine’s economy and create more than 3,100 jobs in Maine. Close to 1,700 of those jobs will be created directly by health care businesses.
Maine Medical Association President Dr. Dieter Kreckel said his organization of 3,800 doctors also endorsed the measure because it would lead to a healthier population.
“We know that individuals with health insurance are more likely to have a regular doctor and be healthier,” said Kreckel. “As health care costs continue to rise for everyone, we need to ensure that people have access to primary care and preventive services before their health care needs become high-cost emergencies or more difficult to treat.”
Gov. Paul LePage, who had publicly shunned the Affordable Care Act, has recently expressed interest in accepting the federal dollars. Governors across the country, including high-profile Republicans, have accepted the federal health care funds.
Sanborn noted the bill currently has Republican co-sponsors in both the Senate and House.
Bill sponsors also include Rep. Jane Pringle, a retired primary care doctor and medical clinic director from Windham, Rep. Anne Graham, a pediatric nurse practitioner from Yarmouth, and Rep. Ann Dorney, a family doctor from Norridgewock.
Pringle spoke at the press conference about her personal experience treating patients without insurance. Graham and Dorney demonstrated their support at the event, as did medical professionals including an osteopath and a physician assistant.
The bill will have a public hearing before the Health and Human Services Committee in the coming weeks.
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