Thursday, August 29, 2013

Health Care Reform Articles - August 30, 2013

“Good” Patients and “Difficult” Patients — Rethinking Our Definitions

Louise Aronson, M.D.
N Engl J Med 2013; 369:796-797August 29, 2013DOI: 10.1056/NEJMp1303057
Four weeks after his quadruple bypass and valve repair, 3 weeks after the bladder infection, pharyngeal trauma, heart failure, nightly agitated confusion, and pacemaker and feeding-tube insertions, and 2 weeks after his return home, I was helping my 75-year-old father off the toilet when his blood pressure dropped out from under him. As did his legs.
I held him up. I shouted for my mother. As any doctor would, I kept a hand on my father's pulse, which was regular: no pauses, no accelerations or decelerations.
My mother was 71 years old and, fortunately, quite fit. She had been making dinner and said she dropped the salad bowl when I yelled for her. She took the stairs two at time. Something about my tone, she said.
Together, we lowered my father to the bathroom floor. I told her to keep him talking and to call me if he stopped, and then I dialed 911.
In the emergency department, after some fluids, my father felt better. My mother held his hand. We compared this new hospital with the last one where we'd spent so many weeks but which had been diverting ambulances elsewhere that evening. The doctor came in and reported no ECG changes and no significant laboratory abnormalities, except that the INR was above the target range. The doctor guessed the trouble was a bit of dehydration. He would watch for a while, just to be safe.
My mother waited with my father. The rest of us filed in and out, not wanting to crowd the tiny room. Then my father's blood pressure dropped again. I told the nurse and stayed out of the way. She silenced the alarm, upped the fluids, and rechecked the blood pressure. It was better. But less than half an hour later, we listened as the machine scanned for a reading, dropping from triple to double digits before it found its mark. The numbers flashed, but the silenced alarm remained quiet. I pressed the call button, and when the nurse arrived I asked her to call for the doctor. When no one came, I went to the nursing station and made my case to the assembled doctors and nurses. They were polite, but their unspoken message was that they were working hard, my father wasn't their only patient, and they had appropriately prioritized their tasks. I wondered how many times I had made similar assumptions and offered similar assurances to patients or families.
After weeks of illness and caregiving, it can be a relief to be a daughter and leave the doctoring to others. But I had been holding a thought just beyond consciousness, and not just because I hoped to remain in my assigned role as patient's offspring. At least as important, I didn't want to be the sort of family member that medical teams complain about. Now that I'd apparently taken on that persona, there was no longer any point in suppressing the thought. Although the differential diagnosis for hypotension is long, my father's heart was working well, I had adhered to the carefully calculated regimen that we'd received for his tube feeds and free water intake, and he did not have new medications or signs of infection. Those facts and his overly thin blood put internal bleeding like a neon sign at the top of the differential.
I rested my hand on my father's arm to get his attention and said, “Dad, how much would you mind if I did a rectal?”
We doctors do many things that are otherwise unacceptable. We are trained not only in how to do such things but in how to do them almost without noticing, almost without caring, at least in the ways we might care in different circumstances or settings. A rectal exam on one's father, of course, is exactly the same as other rectal exams — and also completely different. Luckily for me, my father was a doctor too. When I asked my crazy question, he smiled.
“Kid,” he replied, “do what you have to do.”
I found gloves and lube. I had him roll onto his side. And afterward, I took my bloody gloved finger out into the hallway to prove my point.
I realize that walking to the nurses' station holding aloft one's bloody, gloved hand is not an optimal tactic from a professionalism standpoint — but it worked. A nurse followed me back into my father's room, saw my panicked mother holding a bedpan overflowing with blood and clots, and called for help. Within seconds, the room filled, and minutes later, when the ICU team showed up, I stood back, a daughter again.
In retrospect, what is most interesting is how much more comfortable I felt performing an intimate procedure on my father than demanding the attention of the professionals assigned to care for him. Abiding by the unspoken rules of medical etiquette, I had quieted my internal alarms for more than 2 hours. Instead, I had considered how doctors and nurses feel about and treat so-called pushy or “difficult” families, and as a result, I had prioritized wanting us to be seen as a “good patient” and “good family” over being a good doctor-daughter.
Although many physicians would have made different choices than I did, the impetus for my decisions lay in a trait of our medical culture. When we call patients and families “good,” or at least spare them the “difficult” label, we are noting and rewarding acquiescence. Too often, this “good” means you agree with me and you don't bother me and you let me be in charge of what happens and when. Such a definition runs counter to what we know about truly good care as a collaborative process. From the history that so often generates the diagnosis to the treatment that is the basis of care or cure, active participation of patients and families is essential to optimal outcomes.
There will always be patients and families who are considered high maintenance, challenging, or both by health care providers. Among them are a few with evident mental illness, but most are simply trying their best to understand and manage their own or their loved ones' illness. That we sometimes feel besieged or irritated by these advocates speaks to opportunities for improvement in both medical culture and the health care system. Culturally, we could benefit from a lens shift toward seeing more-vocal patients and families as actively engaged in their health care, presenting new, potentially important information, and expressing unmet care needs. At the systems level, we need to both count (using specially designated sections of the medical record) and reward (through diagnostic and billing codes) the time that providers spend talking to patients and families.
I'll never know whether such changes would have altered my behavior or that of the medical staff on the night of my father's massive intestinal bleed, and fortunately we all acted in time. I do know that 8 years later, the most vivid image I have of that night is not my father wobbling in the bathroom surrounded by cold, hard tile and angular metal structures, or a mustard yellow bedpan filling with bright red blood. The image is this, a worst-case might-have-been scenario had I not been there, had I not had medical training, had I not spoken up: my parents, sleepy because it was by then late at night, snuggled up together at the top of the gurney, my mother resting her head against my father's chest, their eyes closed, their faces relaxed. His systolic blood pressure, usually 130, dropping to 80 and then 70. The monitors turned off or ignored. The lights dim. A short nap and they'd feel better. A little rest and maybe it would be time to go home.

The Register's Editorial: Why tie insurance to jobs?

UPS continues the trend of employers cutting costs

In many households, one spouse buys health insurance through a job for the entire family. Now United Parcel Service Inc. has announced it intends to cut this coverage for working spouses of nonunion employees next year. About 15,000 spouses will need to obtain coverage through their own jobs.
The change will not affect those spouses who cannot get their own coverage because their employers do not offer it or the families of about 250,000 UPS workers who belong to unions.
A UPS spokesman said the change is necessary to keep costs down. Companies certainly can save money by no longer subsidizing health insurance for employees’ husbands and wives. That trend predates passage of the Affordable Care Act, and saving money is why such a policy is becoming more common.
According to one survey, about 6 percent of companies with more than 500 workers exclude spouses from coverage if that individual can obtain it elsewhere. That’s a rate that has doubled in recent years. Many workers now pay an additional monthly charge simply to have a spouse on the family plan.

ObamaCare's architects reap windfall as Washington lobbyists

By Megan R. Wilson 08/25/13 12:06 P
ObamaCare has become big business for an elite network of Washington lobbyists and consultants who helped shape the law from the inside.

More than 30 former administration officials, lawmakers and congressional staffers who worked on the healthcare law have set up shop on K Street since 2010.
Major lobbying firms such as Fierce, Isakowitz & Blalock, The Glover Park Group, Alston & Bird, BGR Group and Akin Gump can all boast an Affordable Care Act insider on their lobbying roster — putting them in a prime position to land coveted clients.

“When [Vice President] Biden leaned over [during the signing of the healthcare law] and said to [President] Obama, ‘This is a big f'n deal,’ ” said Ivan Adler, a headhunter at the McCormick Group, “he was right.”
Veterans of the healthcare push are now lobbying for corporate giants such as Delta Air Lines, UPS, BP America and Coca-Cola, and for healthcare companies including GlaxoSmithKline, UnitedHealth Group and the Blue Cross Blue Shield Association.
Ultimately, the clients are after one thing: expert help in dealing with the most sweeping overhaul of the country’s healthcare system in decades

Workers facing the thorny problems of healthcare and retirement

Are Americans best served by relying primarily on the private sector for health coverage and for benefits in their sunset years? Experts' opinions vary.

David Lazarus
4:02 PM PDT, August 29, 2013
Like most employers, Trader Joe's is grappling with how to look after the well-being of its workers amid difficult financial circumstances.
In May, the head of the privately held Monrovia company, with stores nationwide, sent a confidential memo to employees notifying them of changes to their health coverage, retirement program and wages.
"In these increasingly complex times, it has become necessary to relook at our programs," wrote Dan Bane, the chief executive and chairman. "We do not do this review lightly."
He pledged to reduce workers' healthcare costs 10% for the remainder of the year while the company determines its response to changes under the Affordable Care Act.
Bane said Trader Joe's would scale back its contribution to employees' retirement plans, though the company's contribution would remain generous by industry standards. He also set new limits on employee raises.
A Trader Joe's spokeswoman declined to comment on the memo, which was provided to me by a company employee.
As Labor Day approaches, it's worth noting that the challenges faced by Trader Joe's are shared by most U.S. businesses, large and small.
Meeting workers' present and future social-welfare needs has become a crucial and highly complex issue as healthcare costs continue to outpace inflation and secure retirements grow increasingly out of reach for many people.
These issues highlight the vulnerabilities of a system in which people's social safeguards are tied to their employment and workers are largely fending for themselves in financial markets.
Put succinctly: Are Americans best served by relying primarily on the private sector for health coverage and for benefits in their sunset years? Or would it make more sense to pool our collective risks and look to a greater role for public programs such as Social Security and state pension plans in providing safety nets?
"If you start with the premise that Trader Joe's doesn't want to be a bad guy but can't afford these benefits — and you see that being replicated over and over again with other companies — it necessitates looking at some non-private-sector responses," said Bob Bruno, a professor of labor and employment relations at the University of Illinois.
Not all economists would agree with that.

Anthem's Maine network plan draws scores of critics

Posted: August 29
Updated: Today at 12:22 AM

At a central Maine hearing, state officials are told the insurance setup with Maine Med will cause financial and physical hardship.

AUBURN – Hundreds of central Maine residents turned out for a public hearing Thursday to criticize the pending partnership between Anthem Blue Cross and Blue Shield and the parent company of Maine Medical Center.
Anthem, the state's largest health insurer, and MaineHealth, the state's largest network of hospitals and care providers, are planning to offer an insurance network on the health care exchange to be created in Maine under the federal Affordable Care Act.
The network will include 32 of the state's 38 hospitals, excluding only the three hospitals owned by Central Maine Healthcare of Lewiston, Parkview Adventist Medical Center in Brunswick, York Hospital in York and Mercy Hospital in Portland.
Anthem and MaineHealth already have approval from the Maine Bureau of Insurance for the plan to partner on the health insurance exchange. Their provider network and pricing have also been approved.

Hundreds at hearing rip Anthem state insurance plan that excludes three hospitals

Posted Aug. 30, 2013, at 6:10 a.m.
AUBURN, Maine — For more than three hours, they were angry and they were heard.
Hundreds of people packed Kirk Hall at Central Maine Community College on Thursday night for a comment session on Anthem Blue Cross and Blue Shield’s controversial new insurance proposal that would force individual policy holders into a network with MaineHealth providers.
Under the plan, patients who bought individual policies after March 2010 could no longer see doctors at Central Maine Medical Center in Lewiston, Bridgton Hospital or Parkview Adventist Medical Center in Brunswick.
Speakers ripped Anthem and MaineHealth for proposing it and the state for considering it.
They questioned the increased drive times, abandoned long-term patient-doctor relationships, increased waits, risk of losing local jobs and having choice taken away.
Mary Dempsey said her mother, who has battled cancer, could have to leave CMMC, home to the Patrick Dempsey Center for Cancer Hope & Healing that her son helped found.
“My mother is a very strong lady, and to see her break down in tears because she might have to go somewhere else is not acceptable,” Dempsey said. “Not acceptable.”
Daniel Rausch, a medical oncologist, said CMMC is the only Lewiston hospital that offers radiation therapy. He’d have to tell sick patients to drive five days a week to Portland or Augusta.
“I don’t know how that qualifies as comparable care,” he said.
Allan Ingraham, recently retired head of vascular surgery at the CMMC heart center, said he was “disgusted and disappointed” that the state’s second-largest metropolitan area was getting such short shrift.
“To coin one of the governor’s famous statements, you should pass out some Vaseline to everybody in this area,” he said. “It is ignoring all of the achievements that have happened at Central Maine Medical Center.”
The state’s first breast care center. The state’s first helicopter service.
Comment after comment drew hoots and applause. Many CMMC employees and supporters in the audience wore lime-green “Please Keep Care Local” T-shirts. Another hundred people who couldn’t fit in the auditorium waited outside in the hall.
The Rev. Naomi King drove her electric wheelchair to the front of the packed room and introduced herself as Stephen King’s daughter. Her family, she said, has Anthem policies.
After her father’s horrific car accident in 1999, “it was Bridgton Hospital that stabilized him and Central Maine Medical Center that treated him,” King said. These changes would affect people who “helped him walk again and write great books and tell great stories.”
She said she’d put off some care if forced to travel 90 minutes from Western Maine to see a doctor.
“It is going to increase suffering in our community, enormously and economically,” King said.
Bill Young, CMMC’s former, longtime CEO, said he was “perplexed” that the state was considering the plan but understood why MaineHealth, Maine Medical Center’s parent, wanted it.
In the 1970s, CMMC was small and Maine Med was huge. People drove there for specialized care. In the mid-1970s, Young said, CMMC made a concerted effort to grow, and every specialist hired drew patients away from Maine Med.

St. Joseph's renovating to get fewer MaineCare users
Updated: 12:25 AM

The Portland diocese says the care facility it sponsors needs more private payers to stay financially healthy – bad news for some facing discharge.

PORTLAND – The Roman Catholic Diocese of Portland acknowledged Thursday that the assisted-living unit at St. Joseph's Rehabilitation & Residence will be renovated to attract more private-pay residents and help offset the cost of residents covered by MaineCare.

The diocese finally responded to mounting criticism of the way 34 residents of the unit – 28 of them MaineCare recipients – are being discharged to make way for a $750,000 to $1 million renovation, without the promise of being allowed to return.
David Twomey, chief financial officer for the diocese and Bishop Richard Malone's delegate on St. Joseph's board of directors, said it's uncertain whether St. Joseph's will accept MaineCare residents when the renovated unit opens in 2014.

Health Care Reform Articles - August 29, 2013

Lessons in Maryland for Costs at Hospitals

CUMBERLAND, Md. — This hardscrabble city at the base of the Appalachians makes for an unlikely hotbed of health care innovation.
Yet Western Maryland Health Systems, the major hospital serving this poor and isolated region, is carrying out an experiment that could leave a more profound imprint on the delivery of health care than President Obama’s reforms.
Over the last three years, the hospital has taken its services outside its walls. It has opened a diabetes clinic, a wound center and a behavioral health clinic. It has hired people to follow up with older, sicker patients once they are discharged. It has added primary care practices in some neighborhoods.
The goal, seemingly so simple, has so far proved elusive elsewhere: as much as possible, keep people out of hospitals, where the cost of health care is highest. Here, the experiment seems to be working.
Hospital admissions here are down 15 percent. Readmissions have fallen, too. In 2011, 16 percent of people who had been discharged went back into the hospital. Now, that figure is 9 percent. Many patients report that they are happier with the care.
And Western Maryland has reaped financial rewards. In the fiscal year ending in June, the system made an operating profit of $15 million on about $370 million in revenue, said Barry P. Ronan, the chief executive. That’s a spectacular return, given that the average margin at hospitals across the state is a meager 0.8 percent.
Western Maryland’s initiatives to take charge of people’s health, rather than simply provide services for a fee, fit a core objective of federal health care reform: changing hospitals and related facilities into something resembling an Accountable Care Organization.
Yet the innovations taking place in this corner of Appalachia rest on a policy that the architects of President Obama’s health care reforms never tried to emulate. Indeed, this innovation was only possible because in Maryland, hospital fees are subject to government price controls.
Western Maryland Healthcare System is one of 10 rural hospitals that agreed with the state’s Health Services Cost Review Commission to accept a guaranteed budget every year to take charge of the health care of the community they serve.
If revenue comes in under the budget one year, the hospitals are allowed to increase prices the next to make up for the deficit. If revenue exceeds the budget, however, they must reduce prices to give the surplus back.

Death Panels: This Time, Maybe Not So Scary

Give Representative Earl Blumenauer, an nine-term Democrat from Oregon, credit for two things. First, a sense of humor: He began an op-ed piece he wrote for The New York Times a few years back with, “I didn’t mean to kill Grandma.” He sometimes adopts the very phrase he got slurred with in 2010, referring to himself, ironically, as “the death-panel guy,” just as the president and his administration now embrace “Obamacare.”
Yes, it was Mr. Blumenauer who, as part of the effort to overhaul health care, introduced into the legislation an unremarkable provision requiring Medicare to cover voluntary discussion with a physician about advance directives and treatment preferences at the end of life. These consultations would take place every five years, more often if a patient’s health declined substantially.
Critics of our health care system frequently lament that providers are paid to do things — order tests, perform procedures — but not simply to talk with patients. Mr. Blumenauer, with co-sponsors and supporters in both parties, intended to change that. He’d been dismayed by the dreadful Terry Schiavo case in Florida. “One family’s tragedy turned into a political spectacle,” Mr. Bluemenauer told me. “This was something that was entirely preventable.”
Opponents of Obamacare seized on this modest idea — asking patients what they want really shouldn’t be so controversial — as the embodiment of evil. The falsehoods — that the provision was mandatory (no), that it advocated or enabled euthanasia (no) — spiraled, culminating in Sarah Palin’s denunciation of “death panels.”
So let’s give Mr. Blumenauer credit, secondarily, for nerve: He and several co-sponsors, again from both parties, have introduced the Personalize Your Care Act of 2013, which once more would provide for Medicare and Medicaid coverage of voluntary discussions of advance care planning. His initial effort “derailed in the heat of the debate about health care reform, the superheated rhetoric, the Tea Party frenzy,” he said. Now, “the hysteria has died down.”
This time, Mr. Blumenauer has vowed to meet with all 435 members of the House to explain his idea and seek their support, and has passed the 100-member mark. Even so, he doesn’t think the bill can pass this year. By 2014 or 2015, he thinks, “the time will be right.”

Wal-Mart to Offer Health Benefits to Domestic Partners

Wal-Mart Stores will extend its health care benefits to its American workers’ domestic partners, including those of the same sex, starting Jan. 1.
The company, the nation’s largest private employer, has been a target of attacks by labor groups for what they call substandard wages and benefits. It said Tuesday that the changes were made so it could have a uniform policy for all 50 states at a time when some states have their own definitions of what constitutes domestic partnerships and civil unions.
Employees can enroll their domestic partners from Oct. 12 through Nov. 1.
Wal-Mart defines domestic partners as spouses of the same-sex or opposite gender. They must be unmarried partners who are not legally separated, who have lived together for at least 12 months, are not married to anyone else, are in an exclusive relationship and plan to continue sharing a household indefinitely, said Randy Hargrove, a Wal-Mart spokesman.
“States have different definitions,” Mr. Hargrove said. “We are going to have our own definition that will apply to our associates.”

Americans oppose withholding funds for health law, poll shows

By Noam N. Levey
3:00 AM PDT, August 28, 2013
WASHINGTON -- While Americans remain deeply divided over President Obama’s healthcare law, a clear majority opposes withholding funding to implement the 2010 law, a new national survey indicates.
Fifty-seven percent of Americans say they disapprove of cutting off funding for the Affordable Care Act, while just 36% say they would approve such a move, according to the most recent poll from the nonprofit Kaiser Family Foundation.
Making suspension of the healthcare law a condition for future funding of the federal government has emerged this summer as a favored strategy by many Republicans looking for ways to derail final implementation of the law.
A large group of GOP lawmakers on Capitol Hill has urged Republican leaders to reject any government appropriations legislation this fall that continues to provide money for the law, even if the move would lead to the shutdown of the federal government.
But nearly 7 in 10 Americans who oppose this tactic said in the recent poll that “using the budget process to stop a law is not the way our government should work.”

‘Breaking Bad’ Is Fully Dependent on Our Broken Health-Care System

By Tricia Romano
The Daily Beast, August 27, 2013

When Breaking Bad first aired on AMC in January 2008, the country wasn’t yet in a recession and Obamacare wasn’t a word, but the health-care debate was front and center.
Though candidates Barack Obama and Hillary Clinton differed on the specifics, they agreed that the U.S. health-care system, which was bankrupting so many people, needed an overhaul. (John McCain, of course, didn’t support anything resembling single-payer or universal health care.)
By the time Breaking Bad’s second season premiered, everything had changed. The unemployment rate was skyrocketing, and people were losing their homes. Obama had just been sworn in and promised to reform the health-care system. Fixing health care wasn’t just a pie-in-the-sky dream; it now had a renewed urgency.
Walter White (Bryan Cranston)’s initial foray into making meth was about paying for his cancer treatment and keeping his family from going broke. And he was a manwith health insurance. Imagine his desperation had he been without it, as 55 million Americans are, according to the Commonwealth Fund.
In Breaking Bad’s first few seasons, Walt struggled to come up with the cash to pay for his treatment. The $5,000 deposit at the oncology center was a fraction of the overall expense, which would total $90,000, a number only the rich could afford. Forget about a high school chemistry teacher. Later his hospital stay runs up another $13,000 tab. And while Walt grumbles to Skyler (Anna Gunn) about stealing from his pension, he does the math—it’s going to take a lot of meth to make a dent in his financial hole.
On Sunday night, during White’s gross, false videotaped “confession,” he talked about how he was afraid the cancer diagnosis would “bankrupt his family.” He spoke of paying for his brother-in-law Hank (Dean Norris)’s health care—$177,000—which Hank called the “last nail in the coffin” preventing him from going to the DEA and spilling the beans.
In what other country would “I paid for your health care” be a menacing bribe?
If Breaking Bad had aired the ’80s, it would have read as a giant “Just Say No” campaign. But in 2013, with health-care costs rising and Obamacare on the brink of becoming a reality, the show’s main takeaway isn’t “meth is bad,” “money is evil,” or “people can’t change their nature.” Breaking Bad almost seems to be saying good health care is worth killing for.
Walter White finds other reasons to continue his downward spiral into madness—he’s a prideful, resentful, ego-driven sociopath, after all. Skyler was asking Walt how much money would be enough to feed his ego and desire for power when she took him to the storage unit and showed him a bed of cash. But though his cancer had receded at that point, Walt’s bed of money is a good reminder of how much money Americans really need to cover their health-care expenses, for cancer in particular. According to the National Cancer Institute, national cancer-care costs were $124 billionin 2010—$12.12 billion of that just for lung-cancer costs.‘breaking-bad’-is-fully-dependent-on-our-broken-health-care-system

The Register's Editorial: Why tie insurance to jobs?

In many households, one spouse buys health insurance through a job for the entire family. Now United Parcel Service Inc. has announced it intends to cut this coverage for working spouses of nonunion employees next year. About 15,000 spouses will need to obtain coverage through their own jobs.
The change will not affect those spouses who cannot get their own coverage because their employers do not offer it or the families of about 250,000 UPS workers who belong to unions.
A UPS spokesman said the change is necessary to keep costs down. Companies certainly can save money by no longer subsidizing health insurance for employees’ husbands and wives. That trend predates passage of the Affordable Care Act, and saving money is why such a policy is becoming more common.

In Congress, a Bid to Undo Dialysis Cuts

WASHINGTON — Eight months ago, Congress ordered the Obama administration to eliminate a stark example of federal government waste: more than $500 million a year in excessive drug payments being sent to dialysis clinics nationwide.
But in a demonstration of just how hard it is to curb spending in Washington, more than 100 of the same members of Congress who voted in January to impose the cut are now trying to push the Obama administration to reverse it or water it down.
The conflicting message is due in part to the lobbying muscle of an industry dominated by two companies — DaVita Healthcare Partners of Denver and Fresenius, based in Germany — both of which have seen their bottom lines improve since 2011, when the federal government first started making the excessive payments.
While most of Washington has been on vacation, industry lobbyists aligned with nonprofit groups that in many cases they helped set up or finance have orchestrated a textbook campaign to protect the payments. They argue that the potential cut of $29.52 per patient visit from the previously planned $246 reimbursement for next year would force them to close or curtail services at some of the more than 5,000 dialysis centers nationwide.
At issue is how the government reimburses dialysis clinics. Until 2011, the government paid clinics for each dosage of an anti-anemia drug administered, a practice that led to concern that clinics were overusing the drug. But after adopting a flat fee for dialysis, the use of the drug plunged, while the dialysis companies’ earnings margins rose. That prompted Congress to order a cut in the drug fee. 
Some outside experts say the industry is now effectively enlisting patients and members of Congress as a lobbying tool to protect their payments. The real problem, they say, is that the industry continues toopen or acquire new clinics even as growth in the number of patients on dialysis nationwide has slowed.
“Patients should not be used as pawns in a series of scare tactics to protest a change in a payment,” said Richard Berkowitz of Skokie, Ill., who said he was repeatedly pressured when he recently visited his dialysis clinic to sign a petition protesting the cuts, even though he routinely does dialysis on his own at home.
The industry — which lists dozens of lobbyists, including former Representative Earl Pomeroy, Democrat of North Dakota, and Thomas A. Scully, who ran the Medicare program from 2001 to 2004 — has proved its clout in Washington before. It persuaded Congress to pass legislation that as of 2011 allowed the industry to receive an annual adjustment in its reimbursement rate, which it will get in the coming year. That will slightly reduce the impact of the other proposed cut.
The federal government for decades has covered the cost of what is called end-stage kidney disease, the only chronic disease that has this automatic coverage. The benefit has cost the government more than $32.9 billion a year, the biggest part of it for dialysis. The result is that about 90 percent of the dialysis patients served by a company like DaVita rely at least in part on federal insurance.
Company officials say the drug payments should be maintained because they help the companies with other costs not sufficiently covered by the federal reimbursements.

States find new ways to resist health law

Several Republican-led states at the forefront of the campaign to undermine President Obama’s health-care law have come up with new ways to try to thwart it, refusing to enforce consumer protections, for example, and restricting federally funded workers hired to help people enroll in coverage.
And in at least one state, Missouri, local officials have been barred from doing anything to help put the law into place.
The actions have drawn less attention than congressional efforts to cut off funding for the law, or earlier state decisions to refuse to set up online insurance marketplaces or reject an expansion of Medicaid, which sharply limited the law’s reach.
But the moves could impede Obama’s most significant domestic accomplishment, which, despite having withstood a Supreme Court challenge and a presidential election, still faces doubts about its viability. And they could affect implementation at a crucial time, just as some of the major provisions of the law, also known as Obamacare, are set to go into effect.

Maine tackles the rising cost of health care

Updated: 9:19 AM

The state, ranked fifth in per-capita health spending, is devising strategies for efficiencies when Obamacare arrives.

By Joe Lawlor
Staff Writer
States have begun tackling an issue that has vexed employers, individuals and governments at all levels for years: trying to control the rapidly rising cost of health care. Maine has an especially difficult task because it ranks fifth among the states for per-capita health care costs, according to 2009 federal statistics.

"We are a very rural state, we are the oldest state in the nation, and older people have higher per-capita health care costs. And we don't have a lot of competition in our health care markets," said Mitchell Stein, public policy director for Maine-based Consumers for Affordable Health Care.
Maine's health care costs averaged $8,521 per person in 2009, the most recent year for which statistics are available from the Centers for Medicare and Medicaid Services.

Choosing Wisely in Maine: Be Prepared with the Right Health Care Information

A guest post from Choosing Wisely in Maine

Life happens. As it does, it’s inevitable that you’ll see the inside of a doctor’s office. Although most of these visits will be routine scheduled checkups, some might be more serious.
Whatever the reason, it’s important to be prepared with the right information before you talk with your health care provider.

Choosing Wisely in Maine
Choosing Wisely®, a national initiative led by the American Board of Internal Medicine (ABIM) Foundation in partnership with Consumer Reports, is helping patients and health care providers have more informed conversations. Did you know you have access to dozens of fact sheets and tips available through the Choosing Wisely in Maine Campaign? All of these are made available from Consumer Reports, a trusted source of research and reporting since 1936. Together, the Choosing Wisely in Maine Campaign, the ABIM Foundation and Consumer Reports have one goal: to help you have more informed conversations with your doctor/health care provider.
What you should be asking your health care provider
Ask your doctor/health care provider these five questions before any medical test or procedure at your next appointment:

Portland working hard to combat homelessness, but changes to MaineCare could make problem worse anyway

PORTLAND, Maine — The city has been touting its recent efforts to combat homelessness, but some say the problem remains serious and is about to get worse.
In November, the City Council adopted the recommendations of a task force it appointed to come up with ideas for reducing and preventing homelessness. The recommendations included centralizing the intake process for emergency shelters, expanding case management services, and building new facilities to house homeless individuals.
The city is now using a seven-pronged strategy to implement the recommendations, and the results are starting to show.
For example, 300 adults who used city shelters have found stable housing this year, an increase of 30 percent over the same period in 2012, according to the city’s Department of Health and Human Services.
And after seeing steep increases year after year in the number of clients its shelters serve, the city saw a slight decrease last month: 439 people, down from a record-high 444 in July 2012.
“We’re still at an unprecedented level, but the trend is starting to reverse,” said Douglas Gardner, the department’s director.
At an Aug. 15 news conference, Mayor Michael Brennan hailed the work of the 18-member task force, social service organizations such as Preble Street and United Way, city staff and others for the progress that’s been made.
“We have pulled together a diverse group of partners who are working in tandem to seek solutions. This collaboration has become the catalyst to success best demonstrated by the hundreds of men, women and families who now have a home to call their own,” Brennan said.
Preble Street Executive Director Mark Swann agrees. “I think in all my years here, this has been the most focused, targeted and collaborative effort we’ve made to put a dent in the problem [of homelessness],” he said Monday.
There’s no single reason for the progress that’s been made, according to Gardner. Homelessness is a complex problem with many contributing causes, he said. But he cited a few of the seven prongs that are already helping.
The Portland Housing Authority is now providing rent vouchers so that homeless individuals can be rapidly rehoused. And case management has become a major focus. For example, clients coming into any city shelter now must meet with a case manager to develop an individualized plan to secure housing.
Services on the street have been expanded, too. Outreach workers now canvas city streets and campsites to help homeless individuals, 12 hours a day, six days a week.
“We’re really trying to meet folks where they are,” Gardner said.
Other prongs will not show results immediately. For example, the city has allocated $50,000 to fund siting and other pre-development work to build additional permanent housing for homeless individuals. And city planners are working to determine how zoning regulations may need to be adjusted in order to build a housing facility.
Meanwhile, a new challenge looms on the horizon: imminent changes in MaineCare, the state’s Medicaid program.

The unsteady rollout of Obamacare

By Caroline Poplin, M.D.
McClatchy-Tribune News Service, Aug. 26, 2013
Any program as large and complex as Obamacare (not to mention one facing such entrenched opposition) is going to encounter some turbulence on its shakedown cruise. But the recent glitches are as important for what they tell us about reform, as for what they do.
Obamacare (more formally, the Patient Protection and Affordable Care Act) will cover millions of currently uninsured Americans as advertised -- but with as little disruption to corporate profits as possible. Patients and taxpayers are to shoulder most of the additional cost.
The administration will delay for one year -- until 2015 -- the requirement that large employers offer their employees decent insurance, or pay a small penalty (the so-called "employer mandate"). There was no corresponding delay of the individual mandate, the requirement that all citizens sign up for insurance coverage starting in 2014, the most unpopular provision of ACA. This means that next year employees of the recalcitrant firms will have to buy health insurance without any contribution from their employers.
The Congressional Budget Office estimates this delay could affect up to a million people. If families cannot afford the insurance offered on the new exchanges, and fall below 400 percent of the poverty line, taxpayers will pick up part of the tab. The Kaiser Foundation calculates that about half the uninsured will qualify for Federal subsidies.
Congressional Republicans (and some Democrats) passed a bill to delay the individual mandate also. However, no one in Washington really wants that; it would hurt the insurance companies, who are adamant that young, healthy individuals be required to enroll so as to cover the costs of the sick, who will sign up right away.
The administration also quietly postponed for a year ACA annual and lifetime limits on out-of-pocket costs in some employer-sponsored plans. This delay will fall hardest on the sickest -- patients with diseases like cancer, multiple sclerosis, or HIV, where the costs of drugs alone can easily exceed $100,000 a year.
Democrats winced and largely remained silent. Republicans chortled, passed another symbolic bill, and continue to obstruct the ACA wherever they can.
Business contended -- and the administration apparently agreed -- that these two provisions were too complicated to implement on time. However, these are large corporations that deal with complex matters all the time -- and they had three years to plan. By contrast, figuring out the new exchanges, benefit packages and tax subsidies will be at least as difficult for individuals, who get just three months to plan; most exchanges will not be up until October, and people must enroll by January.
Is there something wrong with this picture?

Tuesday, August 27, 2013

Health Care Reform Articles - August 27, 2013

How to Charge $546 for Six Liters of Saltwater

It is one of the most common components of emergency medicine: an intravenous bag of sterile saltwater.
Luckily for anyone who has ever needed an IV bag to replenish lost fluids or to receive medication, it is also one of the least expensive. The average manufacturer’s price, according to government data, has fluctuated in recent years from 44 cents to $1.
Yet there is nothing either cheap or simple about its ultimate cost, as I learned when I tried to trace the commercial path of IV bags from the factory to the veins of more than 100 patients struck by a May 2012 outbreak of food poisoning in upstate New York.
Some of the patients’ bills would later include markups of 100 to 200 times the manufacturer’s price, not counting separate charges for “IV administration.” And on other bills, a bundled charge for “IV therapy” was almost 1,000 times the official cost of the solution.
It is no secret that medical care in the United States is overpriced. But as the tale of the humble IV bag shows all too clearly, it is secrecy that helps keep prices high: hidden in the underbrush of transactions among multiple buyers and sellers, and in the hieroglyphics of hospital bills.
At every step from manufacturer to patient, there are confidential deals among the major players, including drug companies, purchasing organizations and distributors, and insurers. These deals so obscure prices and profits that even participants cannot say what the simplest component of care actually costs, let alone what it should cost.
And that leaves taxpayers and patients alike with an inflated bottom line and little or no way to challenge it.
A Price in Flux
In the food-poisoning case, some of the stricken were affluent, and others barely made ends meet. Some had private insurance; some were covered by government programs like Medicare and Medicaid; and some were uninsured.
In the end, those factors strongly (and sometimes perversely) affected overall charges for treatment, including how much patients were expected to pay out of pocket. But at the beginning, there was the cost of an IV bag of normal saline, one of more than a billion units used in the United States each year.
“People are shocked when they hear that a bag of saline solution costs far less than their cup of coffee in the morning,” said Deborah Spak, a spokeswoman for Baxter International, one of three global pharmaceutical companies that make nearly all the IV solutions used in the United States.
It was a rare unguarded comment. Ms. Spak — like a spokesman for Hospira, another giant in the field — later insisted that all information about saline solution prices was private.
In fact, manufacturers are required to report such prices annually to the federal government, which bases Medicare payments on the average national price plus 6 percent. The limit for one liter of normal saline (a little more than a quart) went to $1.07 this year from 46 cents in 2010, an increase manufacturers linked to the cost of raw materials, fuel and transportation. That would seem to make it the rare medical item that is cheaper in the United States than in France, where the price at a typical hospital in Paris last year was 3.62 euros, or $4.73.

Obamacare endangers Obamacare

By Jennifer Rubin, Updated: 

The best thing opponents of Obamacare have going for them is Obamacare. The implementation glitches and the ensuing delays have created a perverse system: Individuals must purchase insurance with no out-of-pocket cost cap while employers are under no obligation to provide insurance. Aside from the gross unfairness and the difficulty in rolling out the plans (e.g. exchanges aren’t set up, there is no guarantee personal information will be protected, the centrality of a corrupted IRS) Obamacare’s debut is bringing home several unpleasant realities.
 In January, a study by Kurt Giesa and Chris Carlson in the magazine of the American Academy of Actuaries estimated that 80 percent of Americans below the age of 30 in the individual market would find themselves with higher premiums next year than this year, even after subsidies. Early data from the states suggest this estimate may not be far off the mark. . . .The young and healthy are expected to enable that system to function in two ways: They will pay significantly higher rates than they do now, and more of them will buy coverage. But there is an obvious contradiction between these two expectations. If the cost of something goes up, why would more people buy it?
Obamacare’s promise of universal, affordable health-care insurance is illusory; it will be neither universal nor affordable.
Second, young and healthy voters will be getting a raw deal and they know it. If they behave rationally and take up Supreme Court Chief Justice John Roberts offer — don’t insure and just pay the tax — the system will collapse. The pool of covered people in the exchanges will be older (although Medicare remains in place for those 65 years and over) and sicker, the costs will increase, and the alternative will be to squeeze care (i.e. ration) or hugely increase taxes. Levin sums up: “Its mistreatment of the young and healthy is therefore actually a huge problem for the law, and points to the core of the new system’s economic irrationality, or rather to its failure to contend with how people understand their economic options.”
The other adverse consequences (stifling medical device companies, over-pricing the cost of labor, increases in part-time work) will also be felt as Obamacare works its will on the economy by taxes, mandates and more taxes.
It is a misnomer then to call the problems ones of “implementation.” Even if states get their exchanges up and even if the government prevails in laws challenging the obligations of religious-based employers and even if the exchanges manage to secure personal data, the underlying assumptions on which Obamacare rests — young and healthy people can be corralled into the system to subsidize old and sick people is illogical. If you are under 26 years old then you likely stay on your parents’ plan. If you’re over 26 and are making little income you probably qualify for expanded Medicaid insurance. And if you are over 26 and have an income but no employer-based coverage you probably pay the fine and sign up for subsidized care when and if you get very ill or seriously injured. Besides all that, you’d still have the impact on hiring and the part-time work boom.

Health law coverage can be tough sell in some states

Group’s experience in Texas underscores resistance, uncertainty