Wednesday, July 31, 2013

Health Care Reform Articles - July 31, 2013

Shumlin administration gears up for the nitty-gritty of single payer

By Andrew Stein, July 29, 2013
Gov. Peter Shumlin put Vermont on a path to creating the nation’s first single payer health care system when he signed Act 48 in 2011. But since then, his administration has made little progress up that mountain, drawing questions and accusations from the far political left and right about the governor’s sincerity.
Now, Shumlin and his team are beginning to shift gears, planning the implementation of a publicly funded, universal health care system. In the past two months, the administration has moved two of its policy heavyweights to the fifth floor Office of Health Care Reform — right around the corner from where the governor sits.
Michael Costa, former policy director at the Tax Department, took the elevator up to his new office at the beginning of June. He is charged with figuring out how to finance a single payer system with tax dollars.
David Reynolds, a co-architect of the Affordable Care Act and a former health policy adviser to Sen. Bernie Sanders, joined the team in July. He is tasked with bringing the moving parts of a single payer system together.
Costa and Reynolds join Robin Lunge, director of Health Care Reform, who helped craft the single payer legislation and has overseen the administration’s health care policy initiatives since July 2011.
“This shows that we’re serious,” said Secretary of Administration Jeb Spaulding. “But that’s not why we’re doing this. We’re doing this because we are serious.”
Shumlin doesn’t flinch when questioned about the proposal’s vulnerable points, like shifting more than a billion dollars in health insurance dollars to the tax sector.
“I am bound and determined to pass the first sensible single payer health care system in the country, and that’s going to be the most ambitious policy lift in Vermont history,” Shumlin said on Monday. “So, obviously, we’re going to gear up our staff and engage Vermonters from all walks of life.”

Maine exchange insurance rates due, but with snag

1:00 AM 

The coverage plans for individuals are so different from existing ones in Maine that comparing the costs of new and old may be impossible.

By Joe Lawlor
Staff Writer
Let the spinning begin.
Maine residents intending to buy insurance on the new health insurance exchange will find out Wednesday what rates they will pay.
In other states, including California and New York, release of the rates led to furious numbers wars. Liberal and conservative commentators – using the same data sets – simultaneously declared that individual insurance rates would be declining dramatically or spiking upward.
The self-employed or people who otherwise don't have health benefits through an employer will be buying subsidized insurance on the exchange or paying a penalty. Less than 10 percent of people in the entire health insurance market will be buying insurance on the exchange, according to the Maine Bureau of Insurance.
Starting Oct. 1, individuals and small groups can buy health insurance on the exchange for coverage to begin in 2014, a key provision under the Affordable Care Act.
But while partisan battles between Republican Gov. Paul LePage and Democrats in the Legislature were waged over the Affordable Care Act, including an unsuccessful attempt to expand Medicaid, the rates may not create as much of a stir.
That's because in Maine, a health care expert said, it will be nearly impossible to compare the new rates with current rates that people pay on the individual market.

An Obamacare scorecard Part 1: What's gone, what's on hold, and what's still in place
By Trudy Lieberman
For all the controversy about the Affordable Care Act, confusion and lack of knowledge among the public is still widespread. Meanwhile, it keeps changing, as portions are altered, fixed, or dropped. After all those changes, what is Obamacare, exactly? What is out, what is on hold, and what is still standing in this large and controversial law? What are Obamacare's plusses and minuses so far? Part 1 of a two-part scorecard.
For all that has been written, spoken, screamed, and whispered about the Affordable Care Act, there is still a lot of confusion and lack of knowledge among the public. No wonder, I suppose. Republicans continue to attack it as if it were a scourge from hell. Democrats are desperate to tout it. Meanwhile, it keeps changing, as portions are altered, fixed, or dropped. Maybe it's a good moment to take stock. For starters, after all those changes, what is Obamacare, exactly? What is out, what is on hold, and what is still standing in this large and controversial law? And what have been Obamacare's plusses and minuses so far? Here's the first of a two-part scorecard.

The individual mandate. 
This is the heart of the law--the requirement that everyone carry insurance or face penalties, and it is still scheduled to take effect January 1, with enrollment in the state health exchanges beginning October 1. Most Americans--about 160 million of them--are insured through their workplace, but some 50 million have no insurance at all. Many of those who have no coverage now will be able to shop in the state exchanges set up by the ACA and, depending on their income, receive a subsidy to help pay the premiums. Those with incomes up to 150 percent of the poverty level ($17,235 for individuals and $35,325 for a family of four) will get further help by having their out-of-pocket costs cut by as much as two-thirds. And if people have pre-existing conditions, they won't be turned down for coverage.
An important wrinkle : Workers with employer coverage who pay more than 9.5 percent of their income for that insurance can shop in the exchange and receive subsidies for themselves or their families. But because of the way the Treasury Department has interpreted this provision, if the worker's contribution to an individual policy is less than 9.5 percent of income but the contribution to a family policy is more than that, family members are out of luck when it comes to getting subsidies.
Medicaid expansion. 
One of the pillars of reform, Medicaid expansion, is sort of in and sort of out, thanks to the Supreme Court and several reluctant GOP-led states. Obamacare was supposed to bring coverage to some 15 million people through the expansion by raising the eligibility limit to 138 percent of the federal poverty level--or to about $32,500 for a family of four and $15,000 for a single person. The Supreme Court ruled that states had the option of dropping out of his expansion, however. By early July 19 states said they would not expand their Medicaid programs, 23 plus the District of Columbia said yes they would, while five were undecided and three were considering another kind of expansion. As a result, people with incomes below the poverty line --the poorest of the poor--are stuck if they live in states that have chosen not to expand. These people have almost no coverage options. They have little money to buy insurance on their own, and because of the way the law was written, they are barred from shopping in the exchanges and receiving subsidies.
Hospital penalties and bonuses. 
These carrots and sticks aimed at encouraging better care remain in effect--despite grumbles and complaints from hospital officials. Medicare now penalizes hospitals for readmitting too many patients, though there have been fits and starts implementing the program. Medicare made some mistakes in calculating penalties and had to reduce them a bit, but so far has penalized about 2,200 hospitals. Hospitals also get bonuses or penalties if they meet or don't meet certain targets that measure quality of care. One example of good care: giving beta blockers to patients who've had heart surgery. Hospitals scoring the highest were not necessarily the ones with brand name reputations.
The CLASS Act 
Short for the Community Living Assistance Services and Support Act, the CLASS Act was supposed to be a down payment on a national program to pay for long-term care, a big shortcoming in the US health system. It was a voluntary effort in which people could join a government plan and pre-fund their long-term care needs. When they needed care, they would get a daily cash benefit to pay for services. The program was none too popular with many politicians. In the end the government found it unsustainable. Because it was voluntary (meaning there was no mandate to buy here), lots of people had to sign up to make it viable. If they didn't, premiums would rise, and very few people could afford them. There was no way, the government decided, to make the program actuarially sound over 75 years.
Co-op insurance companies. 
These are gone, too. About $6 billion in federal start-up money for co-ops was supposed to spur their development as a lower-priced alternative to big insurance carriers; it was sort of a sop to the public option advocates. Twenty-four co-ops were funded even though the government had begun to reduce funding. Then came the New Year's surprise. In final negotiations over the fiscal cliff deal, Congress killed the remaining funding for 40 more co-ops whose applications were in the pipeline. Insurers, it seems, were not keen on the new competition.

The employer mandate .
This is in the big one in this bucket. In early July the Obama administration announced a one-year postponement until 2015 of the employer mandate, the requirement that businesses with more than 50 full-time employees had to provide health insurance or pay a penalty. The idea was to prod employers that did not provide coverage to do so. Again business complained about the record keeping and reporting requirements.
The law said they had to provide coverage to full-time employees working 30 hours a week. That was tough for firms whose workers' hours fluctuated. Who was a full-time worker? Who was part-time? Many firms were threatening to cut worker hours to avoid the requirements. The delay means that workers in firms that don't provide coverage might be offered so-called "skinny plans." Such plans might cover some drugs and preventive services, but not hospital care or surgeries, for example. There's little protection for catastrophic illness, but the premiums are cheap for employers and workers. The employee's share may be as little as $40 or $50 a month.

SHOP exchanges.
These marketplaces for small businesses to buy insurance for employees, will offer only one plan in 2014 instead of an array of choices the law envisioned. The administration said there were "operational challenges," and the choice option would be available in 2015. Most small businesses offer only one choice now, so the exchange won't be of much value unless more carriers can sell their products.
Rules requiring smokers to pay more for their coverage. During debate there was little doubt that insurers would be able to charge smokers more money, because they present greater health risks and more potential costs for insurance companies. But now smoking penalties applied to policies sold through the exchanges are delayed a year because of what the administration described as a "system limitation." The law says insurers cannot charge older people more than three times it charges a younger person, and it allows carriers to charge smokers 50 percent more. The problem, discovered a few months ago: the system cannot process a premium for a 65-year-old smoker that is more than three times the premium for a 21-year old smoker.
Scaling back verification requirements for insurance exchanges. Because about 60 percent of people buying in the exchange probably will be eligible for subsidies, exchange officials needed a way to verify if they were indeed eligible; that is their income was low enough and they had no other insurance coverage. But the administration says that they have now encountered "legislative and operational barriers." The upshot: the government will rely on the honor system to make sure applicants for insurance are telling the truth about their income and insurance status. The government will do a check when people file their income tax returns in 2015. If income and insurance status change during the year, a family could end up with a tax liability or a tax refund, depending on the subsidy they got and whether their incomes went up or down during the year.

The Independent Payment Advisory Board. 
The law called for this 15-member board appointed by the president to advise Congress on actions Medicare could take to reduce the growth of healthcare spending. Congress could take an up or down vote on the recommended measures. The board, however, cannot recommend changes in premiums, benefits, eligibility, or taxes, or other changes that would result in "rationing" of care to Medicare beneficiaries. Nevertheless, it has become something of a political football, with Republicans charging that the board could lead to death panels and rationing, because seniors wouldn't be able to get treatments, especially the costly ones.
The board is in virtually inactive right now. Members have not been appointed, but more relevant is that Medicare's costs have slowed somewhat, and in April Medicare's chief actuary declared that that medical cost inflation would not be high enough to trigger the work of the IPAB. It may not see action for a few years, and then what it does will depend on the political winds and the pace of medical inflation.
The National Health Care Workforce Commission. 
The Affordable Care Act set up this 15-member body to prepare for the increased demand in primary care needed by all the newly insured people buying in the shopping exchanges. It's no secret that the US has a shortage of primary care doctors. The commission was to examine such issues as the right mix of primary care docs and specialists, and whether pharmacists could help coordinate care. The administration requested $3 million for the commission to begin its work, but Congress has not appropriated the money. Federal officials have told commission members they cannot even meet to discuss its work. The stalemate is not about money; $3 million dollars is a droplet in the federal budget. The commission is tied up in the Beltway's larger political struggle.
Next: Obamacare Scorecard Part 2--The hits and misses and mixed reviews of the Affordable Care Act.

Revealing a Health Care Secret: The Price

The Surgery Center of Oklahoma is an ambulatory surgical center in Oklahoma City owned by its roughly 40 surgeons and anesthesiologists. What makes it different from every other such facility in America is this: If you need an anterior cruciate ligament reconstruction, you will know beforehand — because it’s on their Web site — that it costs $6,990 if you self-pay in advance. If you need a tonsillectomy, that’s $3,600. Repair of a simple closed nasal fracture: $1,900. These prices are all-inclusive.
Keith Smith, the co-founder of the center, said that it had been posting prices for the last 4 of its 16 years. He knew something was happening, he said, when people started coming from Canada. “They could pay $3,740 for arthroscopic surgery of the knee and not have to wait for three years,” he said. Then he began getting patients from elsewhere in the United States and began to find out — “I get 8 or 10 e-mails a week” — that he was having an effect on prices far away. “Patients are holding plane tickets to Oklahoma City and printing out our prices, and leveraging better deals in their local markets.”
The Oklahoma City TV station KFOR, which ran a story on the Surgery Center on July 8, said that several other medical facilities in Oklahoma are now posting their prices as well.
KFOR’s story has been picked up by news outlets around the United States. Clearly what the Surgery Center has done is resonating.
On, which compares prices offered by different facilities in the same city, Smith’s prices are consistently the cheapest or near it in Oklahoma City. Several hospitals charge $17,200 for laparoscopic hernia repair — for which Smith charges $3,975. A gallbladder removal is $24,000 at some hospitals in the city; it’s $3,200 at the Surgery Center. His prices are better in part because ambulatory surgical centers are cheaper than hospitals (for many reasons), but also there’s a virtuous circle here. He can post his prices because they are good ones. And they are good because he’s chosen to compete on price.
What’s remarkable is that this is remarkable. Why should a business become the subject of news stories simply because it tells people the cost of its services?

Medicare has proved itself after 48 years

By Rob Stone, M.D.
The Herald-Times (Bloomington, Ind.), July 30, 2013
Who is the most popular health insurer in America? Not Anthem Blue Cross. It’s Medicare. And what insurer is the most efficient? Medicare again, operating at only 1.4 percent overhead, while the private insurers strain to meet the Affordable Care Act maximum overhead of 20 percent.
While the Affordable Care Act struggles to be born, it’s worth looking again at how well Medicare works. Last year the respected journal Health Affairs published a study showing how Medicare performs better than private health insurance plans.
According to the report, “Medicare beneficiaries are less likely to have cost-related access problems, high premium and out-of-pocket health care expenses as a share of income, and financial problems because of medical bills. And compared to non-elderly adults with employer-based coverage, Medicare beneficiaries are more likely to have access to a medical home – a primary care provider who knows their medical history well, is accessible, and helps coordinate their care,” and are “far more likely to report excellent quality of care.”
Medicare is not perfect and needs improvement, but it performs far better than the best of the private plans – the employer-sponsored health plans. Individual and small group plans have even worse performance. The Health Affairs article concluded, “Medicare is doing a better job than employer-sponsored plans at fulfilling the two main purposes of health insurance: ensuring access to care and providing financial protection.”
In my work as a physician I see it every day – patients under the Medicare eligibility age of 65 struggling to find affordable insurance, or fighting with their insurance company when they try to make a claim, or driven to bankruptcy by impossibly high deductible payments. But if they can hang on until they reach Medicare age, then they can finally get the care they need, without the hassles. “Pre-existing conditions” are not an issue. You can pick the hospital and doctor of your choice.
We need to celebrate and protect Medicare, a uniquely American approach to health care. Somehow Congress in their infinite wisdom decided 48 years ago that we should have a universal health care system for everyone over 65, but that the rest of us were on our own.

Treat health care as a social need, not a commodity

By Elizabeth R. Rosenthal, M.D.
The Journal News (Westchester, N.Y.), July 25, 2013
The 48th birthday of Medicare on Tuesday reminds us that the birth of the Affordable Care Act has not and will not fix our broken health-care system.
Health care is simply unaffordable for too many of us. In October, the last phase of the reform act known as “Obamacare” will begin with the opening of the health-care exchanges (now known as “the marketplace”). Here many more people will be able to buy more affordable health insurance.
However, by continuing to rely on our for-profit, market-based system, we are wasting billions of dollars on inflated administrative costs. These dollars should instead be going to pay for actual health care.
We need to follow Medicare’s lead — with greatly reduced administrative costs — and treat health care as a social need instead of as a commodity, as an opportunity for profit-making.
Original Medicare, born July 30, 1965, brought affordable health care to the elderly, lifting most of them out of poverty. It has been working well for 48 years and is one of the most popular government programs. In recent years, efforts have been made to privatize it: The Part D drug program and the Medicare Advantage plans are both private. This has led to higher costs.
Although original Medicare’s costs are rising, they are rising more slowly than overall health-care costs. Lowering the costs to government by shifting more of the costs onto patients (e.g., through higher deductibles) does nothing to lower the total health-care expenditure. Even with the arrival of the Affordable Care Act’s insurance exchange, 2,000 New Yorkers will die each year for lack of health care.
We can do better. New York can adopt a publicly funded, privately delivered single-payer plan for all New Yorkers. We can pass the New York Health Bill (A5389/S2078) that provides such a plan. This will save New York billions of dollars and lift the burden from municipalities and companies of providing health care for their workers.
New York could show the nation that access to health care should not depend on one’s ability to pay. By doing so, we would also boost support for national legislation, the Expanded and Improved Medicare for All Act, H.R. 676, which would assure that every resident of the United States has access to high-quality care.
It is immoral to leave so many to suffer and die due to lack of health care. We can, with an improved and expanded Medicare for all, bring health justice to all.

Tom Coburn seeks answers on Hill staff health coverage
By: Jennifer Haberkorn
July 31, 2013 02:59 PM EDT
Sen. Tom Coburn has placed a hold on the nominee to lead the Office of Personnel Management because of the agency’s silence over an Obamacare provision that essentially requires Hill staffers and members of Congress get their health coverage in the new exchanges in 2014.
Coburn told POLITICO he wants to know how the agency will rule on the provision because he wants time to possibly pursue a legislative fix, if necessary, to ensure the federal government would still be able to pay for a portion of Hill staffers’ health insurance premiums. The provision was drafted in a way that moves most of them into the exchanges without the employer contribution that other federal workers will still receive.
“I don’t care what the answer is — give us an answer so that if we want to do a legislative fix to take care of the people who actually work for us,” the Oklahoma Republican told POLITICO. “I mean, they’re going to be the only set of federal employees that actually get paid by the federal government that have to go in the exchange.”

Tuesday, July 30, 2013

Health Care Reform Articles - July 30, 2013

Definition of Cancer Should Be Tightened, Scientists Say

A group of experts advising the nation’s premier cancer research institution has recommended sweeping changes in the approach to cancer detection and treatment, including changes in the very definition of cancer and eliminating the word entirely from some common diagnoses.
The recommendations, from a working group of the National Cancer Institute, were published on Monday in the Journal of the American Medical Association. They say, for instance, that some premalignant conditions, like one that affects the breast called ductal carcinoma in situ, which many doctors agree is not cancer, should be renamed to exclude the word carcinoma so that patients are less frightened and less likely to seek what may be unneeded and potentially harmful treatments that can include the surgical removal of the breast.
The group, which includes some of the top scientists in cancer research, also suggested that many lesions detected during breast, prostate, thyroid, lung and other cancer screenings should not be called cancer at all but should instead be reclassified as IDLE conditions, which stands for “indolent lesions of epithelial origin.”
While it is clear that some or all of the changes may not happen for years, if it all, and that some cancer experts will profoundly disagree with the group’s views, the report from such a prominent group of scientists who have the clear backing of the National Cancer Institute brings the discussion to a much higher level and will most likely change the national conversation about cancer, its definition, its treatment and future research.
“We need a 21st-century definition of cancer instead of a 19th-century definition of cancer, which is what we’ve been using,” said Dr. Otis W. Brawley, the chief medical officer for the American Cancer Society, who was not directly involved in the report.
The impetus behind the call for change is a growing concern among doctors, scientists and patient advocates that hundreds of thousands of men and women are undergoing needless and sometimes disfiguring and harmful treatments for premalignant and cancerous lesions that are so slow growing they are unlikely to ever cause harm.

Tracing Germs Through the Aisles

Twice a month for a year, Lance Price, a microbiologist at George Washington University, sent his researchers out to buy every brand of chicken, turkey and pork on sale in each of the major grocery stores in Flagstaff, Ariz. As scientists pushed carts heaped with meat through the aisles, curious shoppers sometimes asked if they were on the Atkins diet.
In fact, Professor Price and his team are trying to answer worrisome questions about the spread of antibiotic-resistant germs to people from animals raised on industrial farms. Specifically, they are trying to figure out how many people in one American city are getting urinary infections from meat from the grocery store.
Professor Price describes himself as something of a hoarder. His own freezer is packed with a hodgepodge of samples swabbed from people’s sinuses and inner ears, and even water from a hookah pipe. But the thousands of containers of broth from the meat collected in Flagstaff, where his nonprofit research institute is based, are all neatly packed into freezers there, marked with bar codes to identify them.
He is now using the power of genetic sequencing in an ambitious attempt to precisely match germs in the meat with those in women with urinary infections. One recent day, he was down on his hands and knees in his university office in Washington, studying a family tree of germs from some of the meat samples, a printout of more than 25 pages that unfurled like a roll of paper towels. Its lines and numbers offered early clues to Professor Price’s central question: How many women in Flagstaff get urinary infections from grocery store meat? He expects preliminary answers this fall.
Researchers have been warning for years that antibiotics — miracle drugs that changed the course of human health in the 20th century — are losing their power. Some warn that if the trend isn’t halted, there could be a return to the time before antibiotics when people died from ordinary infections and children did not survive strep throat. Currently, drug resistant bacteria cause about 100,000 deaths a year, but mostly among patients with weakened immune systems, children and the elderly.
There is broad consensus that overuse of antibiotics has caused growing resistance to the medicines. Many scientists say evidence is mounting that heavy use of antibiotics to promote faster growth in farm animals is a major culprit, creating a reservoir of drug resistant bugs that are finding their way into communities. More than 70 percent of all the antibiotics used in the United States are given to animals.

Montana's State-Run Free Clinic Sees Early Success

A year ago, Montana opened the nation's first clinic for free primary healthcare services to its state government employees. The Helena, Mont., clinic was pitched as a way to improve overall employee health, but the idea has faced its fair share of political opposition.
A year later, the state says the clinic is already saving money.
Pamela Weitz, a 61-year-old state library technician, was skeptical about the place at first.
"I thought it was just the goofiest idea, but you know, it's really good," she says. In the last year, she's been there for checkups, blood tests and flu shots. She doesn't have to go; she still has her normal health insurance provided by the state. But at the clinic, she has no co-pays, no deductibles. It's free.
That's the case for the Helena area's 11,000 state workers and their dependents. With an appointment, patients wait just a couple minutes to see a doctor. Visitation is more than 75 percent higher than initial estimates.
"For goodness sakes, of course the employees and the retirees like it, it's free," says Republican State Sen. Dave Lewis.
He wonders what that free price tag is actually costing the state government as well as the wider Helena community.
"If they're taking money out of the hospital's pocket, the hospital's raising the price on other things to offset that," Lewis says.
He and others faulted then-Gov. Brian Schweitzer for moving ahead with the clinic last year without approval of the state legislature, although it was not needed.
Now, Lewis is a retired state employee himself. He says, personally, he does like going there, too.
"They're wonderful people, they do a great job, but as a legislator, I wonder how in the heck we can pay for it very long," Lewis says.
Lower Costs For Employees And Montana
The state contracts with a private company to run the facility and pays for everything — wages of the staff, total costs of all the visits. Those are all new expenses, and they all come from the budget for state employee healthcare.
Even so, division manager Russ Hill says it's actually costing the state $1,500,000 less for healthcare than before the clinic opened.

Wrinkle in Health Law Vexes Lawmakers’ Aides

WASHINGTON — As President Obama barnstorms the country promoting his health care law, one audience very close to home is growing increasingly anxious about the financial implications of the new coverage: members of Congress and their personal staffs.
Under a wrinkle that dates back to enactment of the law, members of Congress and thousands of their aides are required to get their coverage through new state-based markets known as insurance exchanges.
But the law does not provide any obvious way for the federal government to continue paying its share of the premiums for the comprehensive coverage.
If the government cannot do so, it could mean an additional expense of $5,000 a year for individuals and $11,000 for families under some of the most popular plans.
Not surprisingly, that idea is unpopular on Capitol Hill.
“It’s a very serious concern,” said Representative Billy Long, a Missouri Republican who said staff members were “freaked out” at the prospect of paying the full cost of insurance out of their own pockets.
“They’re thinking about leaving government service,” said Mr. Long, noting that some staff members already lived in group houses and cramped apartments to make ends meet on Capitol Hill salaries. “They’re thinking about taking jobs other places. We have tried, and tried, and tried to get the answer on what they’re going to be paying. The Office of Personnel Management cannot tell us.”
The personnel office arranges health insurance benefits for federal employees.
The nonpartisan Congressional Research Service pinpointed the problem 10 days after President Obama signed the health care law in March 2010. Since then neither Congress nor the administration has addressed it.
With the exchanges scheduled to open in just nine weeks, the Obama administration is struggling to come up with a creative interpretation of the health care law that would allow the federal government to kick in for insurance as private employers do, but so far an answer has proved elusive.
The issue is politically charged because the White House and Congress are highly sensitive to any suggestion that lawmakers or their aides are getting special treatment under the health law. The administration is already under fire from Republicans for delaying a requirement that larger businesses offer insurance to their full-time employees.

Don’t Give Up on Health Care Cost Control

S.G.R. More than 99 percent of Americans have no idea what these three letters stand for. And yet they are extremely valuable: worth about $140 billion. This week, a House committee will finally take up the issue.
The S.G.R., or the Sustainable Growth Rate formula, was enacted as part of the Balanced Budget Act of 1997 to restrain the inevitable increase in Medicare’s annual spending on physician services. It set a reasonable target for each year’s increase, and Medicare was supposed to spend less than that amount. If it failed, then the per-service payments to physicians in the following year would be reduced to hit the target.
Nice idea in theory. Never worked out in practice.
Since 2002, the cost for physician services has consistently exceeded the S.G.R. target. Doctors have been delivering more services, and the services have become ever more complex and, therefore, expensive. But instead of enforcing the mandated cuts, every year Congress has passed a “doc fix,” coming up with billions to keep paying physicians the same amount and avert any reductions.
Strangely, despite never complying with the law, Congress has never seen fit to change the formula for calculating the target. Consequently, S.G.R. cuts have accumulated since 2002, to the extent that today the law ostensibly requires that physician payments be cut by 24.4 percent.

Everyone — Democrats and Republicans — agrees that the law is seriously flawed. Since the target level applies to total nationwide physician costs, there is no incentive for individual doctors to be more efficient. And the cuts are indiscriminate: they would hit high-quality, cost-effective doctors just as hard as inefficient free spenders, and underpaid primary-care doctors as much as overpaid specialists.
Physicians desperately want the S.G.R. repealed and replaced so they can charge what they want without the potential of massive cuts hanging over them each year. But according to the Congressional Budget Office, getting rid of it and simply letting payments increase would cost just under a projected $140 billion over 10 years. If Congress were to adhere to its “pay-as-you-go” principle of accounting for every new expenditure, it would have to find that money in either tax hikes or cuts in other programs — both nearly impossible in the current climate.
Enter the House Energy and Commerce Committee. This week, the committee is expected to begin marking up a bill that its subcommittee on healthapproved last Tuesday. The bill would repeal the S.G.R. formula and replace it with a stable annual 0.5 percent payment increase until 2018. Beginning in 2019, the bill would then link Medicare payments to the quality of care each physician provides, as measured by an enhanced quality reporting system.

Heart surgery in India for $1,583 costs $106,385 in US

Posted July 29, 2013, at 2:30 p.m.
MUMBAI, India — Devi Shetty is obsessed with making heart surgery affordable for millions of Indians. On his office desk are photographs of two of his heroes: Mother Teresa and Mahatma Gandhi.
Shetty is not a public health official motivated by charity. He’s a heart surgeon turned businessman who has started a chain of 21 medical centers around India. By trimming costs with such measures as buying cheaper scrubs and spurning air-conditioning, he has cut the price of artery-clearing coronary bypass surgery to 95,000 rupees ($1,583), half of what it was 20 years ago, and wants to get the price down to $800 within a decade. The same procedure costs $106,385 at Ohio’s Cleveland Clinic, according to data from the U.S. Centers for Medicare & Medicaid Services.
“It shows that costs can be substantially contained,” said Srinath Reddy, president of the Geneva-based World Heart Federation, of Shetty’s approach. “It’s possible to deliver very high-quality cardiac care at a relatively low cost.”
Medical experts like Reddy are watching closely, eager to see if Shetty’s driven cost-cutting can point the way for hospitals to boost revenue on a wider scale by making life- saving heart operations more accessible to potentially millions of people in India and other developing countries.
“The current price of everything that you see in health care is predominantly opportunistic pricing and the outcome of inefficiency,” Shetty, 60, said in an interview in his office in Bangalore.

Monday, July 29, 2013

Health Care Reform Articles - July 29, 2013

Status and Stress

Although professionals may bemoan their long work hours and high-pressure careers, really, there’s stress, and then there’s Stress with a capital “S.” The former can be considered a manageable if unpleasant part of life; in the right amount, it may even strengthen one’s mettle. The latter kills.
What’s the difference? Scientists have settled on an oddly subjective explanation: the more helpless one feels when facing a given stressor, they argue, the more toxic that stressor’s effects.
That sense of control tends to decline as one descends the socioeconomic ladder, with potentially grave consequences. Those on the bottom are more than three times as likely to die prematurely as those at the top. They’re also more likely to suffer from depression, heart disease and diabetes. Perhaps most devastating, the stress of poverty early in life can have consequences that last into adulthood.
Even those who later ascend economically may show persistent effects of early-life hardship. Scientists find them more prone to illness than those who were never poor. Becoming more affluent may lower the risk of disease by lessening the sense of helplessness and allowing greater access to healthful resources like exercise, more nutritious foods and greater social support; people are not absolutely condemned by their upbringing. But the effects of early-life stress also seem to linger, unfavorably molding our nervous systems and possibly even accelerating the rate at which we age.
The British epidemiologist Michael Marmot calls the phenomenon “status syndrome.” He’s studied British civil servants who work in a rigid hierarchy for decades, and found that accounting for the usual suspects — smoking, diet and access to health care — won’t completely abolish the effect. There’s a direct relationship among health, well-being and one’s place in the greater scheme. “The higher you are in the social hierarchy,” he says, “the better your health.”
Dr. Marmot blames a particular type of stress. It’s not necessarily the strain of a chief executive facing a lengthy to-do list, or a well-to-do parent’s agonizing over a child’s prospects of acceptance to an elite school. Unlike those of lower rank, both the C.E.O. and the anxious parent have resources with which to address the problem. By definition, the poor have far fewer.
So the stress that kills, Dr. Marmot and others argue, is characterized by a lack of a sense of control over one’s fate. Psychologists who study animals call one result of this type of strain “learned helplessness.”

Medical Procedures May Be Useless, or Worse

We usually assume that new medical procedures and drugs are adopted because they are better. But a new analysis has found that many new techniques and medicines are either no more effective than the old ones, or worse. Moreover, many doctors persist in using practices that have been shown to be useless or harmful.
Scientists reviewed each issue of The New England Journal of Medicine from 2001 through 2010 and found 363 studies examining an established clinical practice. In 146 of them, the currently used drug or procedure was found to be either no better, or even worse, than the one previously used. The reportappears in the August issue of Mayo Clinic Proceedings.
More than 40 percent of established practices studied were found to be ineffective or harmful, 38 percent beneficial, and the remaining 22 percent unknown. Among the practices found to be ineffective or harmful were the routine use of hormone therapy in postmenopausal women; high-dose chemotherapy and stem cell transplant, a complex and expensive treatment for breast cancer that was found to be no better than conventional chemotherapy; and intensive glucose lowering in Type 2 diabetes patients in intensive care, which not only failed to reduce cardiovascular events but actually increased mortality.
In some instances, doctors routinely refused to give beneficial therapies despite a lack of evidence that they were harmful. Vaccines were unnecessarily withheld from multiple sclerosis patients in the belief that they increased flare-ups; women with lupus were denied oral contraceptives for fear they increased the severity of the disease; and epidural anesthesia was delayed during childbirth on the theory it increased the rate of Caesarean sections. Yet good studies showed that none of these fears was justified..
“Contradicted practices don’t disappear immediately,” said the lead author, Dr. Vinay Prasad. “There’s an inertia, a 10-year period of time when the contradicted procedure continues to be practiced.”
Dr. William E. Boden, chief of medicine at the Stratton VA Medical Center in Albany, who was not involved in the work, found the study useful and provocative. “It’s challenging us to look at things we’ve done and attempt to find whether there’s evidence to support their use,” he said. “There’s going to be increasing pressure to come forward with making sure that the health care dollars we’re allocating are being well utilized.”

The Charitable-Industrial Complex

I HAD spent much of my life writing music for commercials, film and television and knew little about the world of philanthropy as practiced by the very wealthy until what I call the big bang happened in 2006. That year, my father, Warren Buffett, made good on his commitment to give nearly all of his accumulated wealth back to society. In addition to making several large donations, he added generously to the three foundations that my parents had created years earlier, one for each of their children to run.
Early on in our philanthropic journey, my wife and I became aware of something I started to call Philanthropic Colonialism. I noticed that a donor had the urge to “save the day” in some fashion. People (including me) who had very little knowledge of a particular place would think that they could solve a local problem. Whether it involved farming methods, education practices, job training or business development, over and over I would hear people discuss transplanting what worked in one setting directly into another with little regard for culture, geography or societal norms.
Often the results of our decisions had unintended consequences; distributing condoms to stop the spread of AIDS in a brothel area ended up creating a higher price for unprotected sex.
But now I think something even more damaging is going on.
Because of who my father is, I’ve been able to occupy some seats I never expected to sit in. Inside any important philanthropy meeting, you witness heads of state meeting with investment managers and corporate leaders. All are searching for answers with their right hand to problems that others in the room have created with their left. There are plenty of statistics that tell us that inequality is continually rising. At the same time, according to the Urban Institute, the nonprofit sector has been steadily growing. Between 2001 and 2011, the number of nonprofits increased 25 percent. Their growth rate now exceeds that of both the business and government sectors. It’s a massive business, with approximately $316 billion given away in 2012 in the United States alone and more than 9.4 million employed.
Philanthropy has become the “it” vehicle to level the playing field and has generated a growing number of gatherings, workshops and affinity groups.
As more lives and communities are destroyed by the system that creates vast amounts of wealth for the few, the more heroic it sounds to “give back.” It’s what I would call “conscience laundering” — feeling better about accumulating more than any one person could possibly need to live on by sprinkling a little around as an act of charity.
Posted July 25, 2013, at 11:08 a.m.
A new approach to health care under the federal health reform law that rewards hospitals financially for keeping patients healthy at less cost is beginning to yield results in Maine.
Under the model, outlined in the Affordable Care Act, health systems throughout the U.S. are forming alliances of doctors and hospitals called “accountable care organizations.” ACOs are a cornerstone of the federal law that many hope will slow the ever-rising health care costs eating up more and more of Americans’ paychecks.
The experimental approach rewards health providers with financial incentives for keeping patients healthy and happy rather than steering them toward more visits and procedures. If providers reduce costs while providing high-quality care for a certain population of patients, they can share in the savings with the health insurer. Likewise, if they fail to cut costs or miss certain quality targets, hospitals may get pinched financially.
Several health organizations in Maine are experimenting with the new model, and two shared early results this week.
Eastern Maine Healthcare Systems of Brewer partnered with Medicare for its ACO. The health system, parent to Bangor’s Eastern Maine Medical Center, was one of 32 organizations nationally chosen by Medicare, the government health insurance program for seniors, to pioneer the new model.
On Wednesday, EMHS released early data on its “Pioneer ACO” effort.
To be eligible for the incentive payments, ACOs must demonstrate their progress by tracking the health of participating patients through quality measures, such as the number of avoidable hospital admissions and how well providers monitor patients with high cholesterol.
During 2012, EMHS improved its readmission rate — which reflects how many patients wind up back in the hospital a month after being discharged — by 13.2 percent. Its readmission rate — 14.97 percent — was lower than the average rate of 15.42 among all the other Pioneer ACOs throughout the country, according to EMHS.
EMHS also touted another measure that tracks whether nurses follow up with patients to ensure they’re taking the right medications after being discharged from the hospital. That follow-up occurred 91 percent of the time among Medicare patients participating in the ACO, according to EMHS. The average among the other ACOs was much lower, about 72 percent.
As for savings, the EMHS ACO reduced the cost of caring for Medicare patients by 4.9 percent, placing it among the top five of the Pioneer ACOs, according to the health system. EMHS declined to release the dollar amount saved.
The ACO included 9,200 Medicare patients in its first year, and since has expanded to about 14,000 patients.

Maryland Regulators Slash Rates For Obamacare Insurance Policies - Kaiser Health News

Citing what they called flawed data and unreasonable assumptions, Maryland insurance regulators on Fridaysharply reduced prices for health plans that will be sold to individuals and families through the state's insurance marketplace starting Oct. 1.
In some cases, the final premiums were cut by a third for the Maryland Health Connection exchange, pleasing advocates of affordable coverage but prompting others to question whether such low prices can be sustained.
Regulators reduced prices for all nine carriers filing to sell policies in the marketplace.
"People are going to have access to plans at reasonable prices," said Maryland Health & Mental Hygiene Secretary Joshua Sharfstein, whose department is not involved in insurance regulations. "Plus people are going to have access to tax credits on top of that. So we think that's good news."
While Oregon, Rhode Island and other states have also lowered insurers' proposed prices for new insurance policies, Maryland's move is one of the most aggressive, analysts said.

IOM Finds Differences In Regional Health Spending Are Linked To Post-Hospital Care And Provider Prices

Big health spending variations throughout the country are largely driven by differences in the use of post-acute services such as skilled nursing homes and home health care by Medicare beneficiaries, and by higher prices that some hospitals and doctors charge commercial insurers, according to an Institute of Medicine report released Wednesday.

The report recommended that Medicare push ahead with using its financial might to make hospitals, doctors and other providers work more closely and reap rewards or lose money based on how well and efficiently they care for their patients. The IOM panel – which telegraphed this in an interim report, rejected an idea that has been promoted by some members of Congress to pay more to medical providers in areas of the country where Medicare spending is lower, such as Rochester, N.Y., and less in places where it is high, such as Fort Lauderdale, Fla.
The 178-page document represents the government's most thorough effort to dig into one of the great questions in health research: Why does it cost more to treat patients in some areas of the country than in others? The topic has led to feuds among researchers amid a decades-long disagreement about whether overly aggressive or greedy doctors and facilities are to blame, or whether the true culprits are patients in places that have excessive obesity or other widespread health problems or patients who demand more medical services.

The Hype Over Hospital Rankings

LAST week U.S. News and World Report released its annual list of “Best Hospitals.” Web sites are being updated to celebrate victories. (Johns Hopkins ranks No. 1!) Magazines will be plump with advertising. (NewYork-Presbyterian is first in New York and tied for seventh nationally!) And, because I am a reporter covering health care, my in-box is accumulating e-mails from the “Honor Roll” of the Top 18 hospitals.
But what does this annual exercise mean for patients? And what does it say about American health care?
After all, Harvard and Princeton, which tied for No. 1 in the magazine’s 2013 Top 10 national universities list, didn’t take out ads to proclaim their triumph; they will fill their classrooms no matter. And as in the college ratings, there are no big surprises in the top hospital group: they are the big academic medical centers — the Mayo Clinic, Massachusetts General Hospital, the Cleveland Clinic. More to the point, even though you might well fly across the country for four years of schooling, you are far more likely to stay near your home for medical care.  No one’s flying to Mayo in Minnesota to get inhalers for asthma, even though it ranks No. 1 for pulmonary medicine.
But American hospitals are a bit like restaurants, competing for your business (and donations). As such they go all out to promote their brand, even though hospitals and doctors are not permitted to advertise in many other countries.
For American hospitals large and small, it clearly pays to advertise, particularly in these tough economic times and with the Affordable Care Act poised to throw tens of millions of newly insured patients into the market. But for patients the rankings and, especially, the subsequent promotions generally have limited benefit, experts say.
“Nearly every hospital has a banner out front saying they’re a ‘top hospital’ for something in some rating system,” said Dr. Nicholas Osborne, a Robert Wood Johnson Clinical Scholar at the University of Michigan. “Those ratings have become more important for hospital marketing than for actually helping patients find the best care.”

Obama Intends to Let Health Care Law Prove Critics Wrong by Succeeding

GALESBURG, Ill. — President Obama waved aside persistent Republican criticism of his signature health care law last week, saying in a New York Times interview that the overhaul would become vastly more popular once “all the nightmare scenarios” from his adversaries proved wrong.
The president accused Republicans of “all kinds of distortions” about the legislation. He said bluntly that his administration had a simple plan to build support for the law, which continues to be viewed with suspicion by large numbers of Americans. “We’re going to implement it,” he said.
Mr. Obama said he decided to delay a requirement that businesses provide insurance to their employees because of concerns expressed by executives about its administrative burdens. Some companies that already provide insurance had balked at provisions requiring them to show proof. The president said delaying that part of the law for a year would give the Treasury Department and other agencies a chance to make it “a little bit simpler” for companies to comply.
But he rejected criticism that by delaying the provision he had exceeded his constitutional authority.
“This is the kind of routine modifications or tweaks to a large program that’s starting off that in normal times in a normal political atmosphere would draw a yawn from everybody,” Mr. Obama said. “The fact that something like this generates a frenzy on Republicans is consistent with the fact that they’ve voted to repeal this thing 38 times without offering an alternative that is plausible.”
Mr. Obama said members of Congress who questioned his power to delay the provision should “make that case.” But he pointedly suggested that the criticism had less to do with the substance of the issue and more to do with political efforts to undermine his presidency.

'Critically Ill' author Frederick Southwick on what ails our healthcare system

By Judy Mandell
3:35 PM PDT, July 26, 2013
Mary Southwick was 34 when she developed pain on the bottom of one foot. After seeing a neurologist who said she had a nerve injury caused by dancing, she developed thrombophlebitis and was admitted to the hospital. An intern underdosed her heparin (blood thinner), and she suffered a large blood clot in a lung. This was soon followed by a heart attack, then respiratory failure, renal failure and shock.
Her physician husband interceded and transferred her care to a trusted cardiologist. Because her lungs filled with fluid, she had to be intubated and placed on a respirator. She also suffered kidney failure. While a tube was being placed to filter her blood to remove fluid, Southwick had two cardiac arrests. Remarkably, she made a full recovery.
Frederick Southwick, chief of infectious diseases at the University of Florida in Gainesville, says his wife's trauma motivated him to write the book "Critically Ill: A 5-Point Plan to Cure Healthcare Delivery." Here he offers some guidance to negotiate the healthcare system.

Boothbay region 'full of fear' as hospital closing looms

Updated: 7:36 AM

MaineHealth officials call it the best path forward, but a community with many older residents worries about having no ER nearby.

By Colin Woodard
Staff Writer
BOOTHBAY HARBOR - They come to Jane Good's beauty shop in Southport nearly every day to have their hair done and share their fears that the pending closure of the St. Andrews Hospital emergency room could mean their death.
They are Good's longtime customers, many of whom have been coming to her for decades, now in their 70s and 80s. They come from across the Boothbay region, a 14-mile peninsula, and sit in Good's salon, attached to her house with a doorway view of her kitchen, and ask how this could be happening.
"They just want to be able to be taken to St. Andrews in five minutes if something goes wrong," says Good, one of the leaders in the fight to stop the closure. "This whole community is so full of fear, fear that somebody they know is going to die because they can't get to the hospital in time."
But on Oct. 1, St. Andrews, located five minutes up the road and over the swing bridge in Boothbay Harbor, will cease to be a hospital. Its emergency department will close and 25 hospital beds will disappear. A 10-hour-a-day urgent care center will take its place, but ambulances and emergency cases will be directed another half-hour north to Miles Memorial Hospital in Damariscotta, which is itself being downsized from 38 beds to 25.

Proposal Challenges TIAA-CREF on For-Profit Health Insurance 
    by Robert Kropp
Advocacy groups urge the pension fund to divest its holdings in private health insurance companies, arguing that the industry has a well-documented history of unethical behavior and abuses. -- Should sustainable institutional investors hold the stocks of private health insurance companies in their portfolios?

It's a question that advocates for a single-payer healthcare system is asking theTeachers Insurance and Annuity Association - College Retirement Equities Fund (TIAA-CREF), the financial services organization and one of the nation's largest pension funds. A signatory to the United Nations' Principles for Responsible Investment (PRI), TIAA-CREF states in its investment philosophy that it seeks "to invest in areas that affect social change and environmental stewardship while also producing competitive financial returns."

There's no doubt that private health insurance companies such as CIGNA, Humana, Aetna, Coventry, and WellPoint help TIAA-CREF's portfolio produce competitive financial returns. According to Healthcare-NOW!, an organization advocating for the passage of single-payer healthcare legislation, average profits for the five companies increased by almost 50% during the fiscal year that ended in July, 2011. Meanwhile, 3,700 families file for bankruptcy every day in the US, and cite illness and medical bills as the primary causes. Sixty percent of those filing for bankruptcy had private insurance.

A 2012 study by physicians associated with Physicians for a National Health Program (PNHP) found that Medicare had overpaid private insurance companies in the amount of $282.6 billion since 1985, most of which occurred in the last eight years.

In 2011, Healthcare-NOW! and PHNP launched the Divestment Campaign for Health Care, which in 2012 informed TIAA-CREF of its intention to file a shareowner resolution calling for divestment from private health insurance companies. The Campaign withdrew the proposal for one year after TIAA-CREF and MSCI, its vendor for environmental, social, and corporate governance (ESG) ratings, agreed to dialogue. 

Detroit Looks to Health Law to Ease Costs

As Detroit enters the federal bankruptcy process, the city is proposing a controversial plan for paring some of the $5.7 billion it owes in retiree health costs: pushing many of those too young to qualify for Medicare out of city-run coverage and into the new insurance markets that will soon be operating under the Obama health care law.
Officials say the plan would be part of a broader effort to save Detroit tens of millions of dollars in health costs each year, a major element in a restructuring package that must be approved by a bankruptcy judge. It is being watched closely by municipal leaders around the nation, many of whom complain of mounting, unsustainable prices for the health care promised to retired city workers.
Similar proposals that could shift public sector retirees into the new insurance markets, called exchanges, are already being planned or contemplated in places like Chicago; Sheboygan County, Wis.; and Stockton, Calif. While large employers that eliminate health benefits for full-time workers can be penalized under the health care law, retirees are a different matter.
“There’s fear and panic about what this means,” said Michael Underwood, 62, who retired from the Chicago Police Department after 30 years and has diabetes and Parkinson’s disease. Mr. Underwood, who says he began working for the city when employees did not pay into future Medicare coverage, is part of a group suing Chicago over its plan to phase many retirees out of city coverage during the next three and a half years. “I was promised health care for myself and my wife for life,” he said.
Unfunded retiree health care costs loom larger than ever for localities across the country, and the health law’s guarantee of federal subsidies to help people with modest incomes afford coverage has made the new insurance markets tantalizing for local governments. A study issued this year by the Pew Charitable Trusts found 61 of the nation’s major cities wrestling with $126 billion in retiree health costs, all but 6 percent of that unfunded.
“The Affordable Care Act does change the possibilities here dramatically,” said Neil Bomberg, a program director at the National League of Cities. “It offers a very high-quality, potentially very affordable way to get people into health care without the burden falling back onto the city and town.”
But if large numbers of localities follow that course, it could amount to a significant cost shift to the federal government. Authors of the health care law expected at least some shifting of retirees into the new insurance exchanges, said Timothy S. Jost, a law professor at Washington and Lee University who closely follows the law. “But if a lot of them do, especially big state and local programs,” he said, “that’s going to be a huge cost for the United States government, and it’s mandatory spending.”

Obamacare Canvassers Seek Out Florida's Uninsured

BOCA RATON, Fla. – Tammy Spencer did a double take when she read the address on her paper and looked at the house in front of her. 
Spencer, a volunteer with the nonprofit Enroll America, was spending a hot and humid Saturday morning knocking on doors in this mostly posh South Florida city looking for people without health coverage. She wanted to let them know about new online insurance marketplaces that open for enrollment Oct. 1.
The spacious house was on the Intracoastal Waterway, complete with its own boat dock. The woman who answered the door said she already had coverage through Medicare, and Spencer went on to the next house.
After two hours of canvassing, she found one uninsured woman and got contacts for three others. "It was worth it," said the 51-year-old insurance agent. "But next time, we need to go to a poorer area, or set up a table in the mall."
Spencer is one of hundreds of volunteers for Enroll America's "Get Covered America" campaign, which canvassed neighborhoods across Florida, New Jersey, Ohio and several other states Saturday to kick off several months of outreach efforts. The group, which is funded by health insurers, hospitals, philanthropies and others, has close ties to the Obama administration. It's trying to educate consumers about new insurance options and drive enrollment in the new marketplaces opening this fall for coverage that takes effect in January.