Sunday, August 31, 2014

Health Care Reform Articles - August 31, 2014

Editor's Note:

I have embarked on an experiment and have created by own website at It contains links to my regular Bangor Daily News columns and to other articles I have written, as well as a link to a radio interview (about 30 minutes long) I did recently during a visit to Seattle and to the Maine AllCare website.

 In addition, I have devoted a page in the website to articles by others I think are especially important or well written (often both).

It is a work in progress, and other material will be added and some deleted as time goes on.

If you'd like, let me know what you think of it and please forward any suggestions you may have for improving it and making it more useful to me at


A Visit with a Neighbor
By Richard Dillihunt, MD

For decades, I have admired the Canadian health care system, first while at a remote Northern Quebec fishing camp. There, impromptu sick call was held for the Cree, local aboriginal people with rights to this remote land. Members of this tribe had various complaints that we treated with our medical chest. Despite the difference in language in the elderly, the shyness barriers were easily overcome. They seemed completely confident in our medical abilities.
We felt privileged as caregivers to be given such confidence and warm doctor-patient relationships came forth. Over the years we saw burns from campfire mishaps, an acute gallbladder, and a mangled hand injured beyond our medical capabilities. We made radio calls to regional flying services, and patients were fetched and flown to various medical centers. There were no lawyers or insurance companies involved. The only physical evidence of health care coverage was a small card that each patient guarded carefully. This card admitted them to their national health care system. It provided quality medical care covering all 35 million Canadians scattered across the second largest nation on earth.
The patient with the injured hand was emblematic of this system. A radio call summoned a floatplane, and the patient was loaded and lugged across and down the 150 km of the Peribonka River to the medical center in Chicoutimi. After treatment, he was returned by air. That little card had covered all medical care and transportation. Imagine what such a journey would cost us!
This system of universal health care came into being in 1946. It is attributed to a Canadian native son, Tommy Douglas. As premier of Saskatchewan, he established a universal single payer health care for all of Canada. After his death he was voted “Greatest Canadian” by the Canadian Broadcast Corporation viewers.
Although medical service for the Cree and Inuit have been difficult for the Canadian government to perfect, they have enjoyed great success. Given the vast territory, the nation does well to spread its resources over ten million square km, much of it being a harsh environment.
The Canadian system deserves careful scrutiny by every American who has concerns regarding our badly broken health care system. Inspection of how the Canadians have successfully developed their universal single payer form of health care uncovers features that the US needs to seriously consider. Just recently Danielle Martin, a brilliant young Canadian physician, called attention to the superior provisions of Canada’s public system in her testimony before Sen. Bernie Sanders’ committee in Washington. She showed that the Canadian system is based on need, not on the ability to pay. Her interaction with Sen. Burr (R-NC) went viral, generating over 700,000 views on YouTube across North America. Many major media outlets focused on her evidence-based, intelligent, and energetic defense of Canadian Medicare.
Canadians take great pride in their medicare-for-all system. They know that Canada’s life expectancy rates and maternal and infant mortality figures are superior to America’s, and their quality of care is equal to ours. They are aware that, traditionally, wait times have been a source of intense criticism of their system. They understand that this is largely overblown by stateside special interest groups whose propaganda has brainwashed America about horrendous waiting times for referrals and elective surgery. The facts show differently. Canada has addressed wait time issues with a Wait Time Alliance. Through this alliance there has been much improvement, and changes have been uncovered to correct this problem.
Two nations have developed, through different pathways, health care systems which are clinically similar and among the world’s best. When compared, Canada has taken the high ground, selecting a route featuring social justice and equality with a strong nationalism. Canadians are caring for one another. America’s profit- driven hard-nosed traditions and business practices have permeated the ways and means of the USA’s health care.
Lacking checks and balances, our system costs nearly twice that of Canada’s per capita, $8233 vs $4445 yearly. This accounts for 17.6% of America’s GDP while Canada’s health care expenditure is 11.4% of her GDP according to 2012 statistics. The most stunning statistic of all is this. Even with the ACA finally deployed, there are over 30 million uninsured American citizens, approximately equal to the entire population of Canada where everyone is covered by Medicare, and a simple little card replaces by comparison a vast array of paperwork that chokes our system.
The Canadian system is remarkably popular in America. Maine must pay attention to this surge. Because of our unique geographical location, we are surrounded by Canadian relatives, friends, and neighbors. Canada can provide us with more than frigid winds. We need to lead the way in acknowledging a very attractive Canadian healthcare system.

New Novartis Drug Shows Striking Efficacy in Treating Heart Failure

Friday, August 29, 2014

Health Care Reform Articles - August 29, 2014

The Study You’ll Never Hear About
According to a new Commonwealth Fund
sponsored study published in
Health Affairs,
“Small Primary Care Physician Practices Have
Low Rates Of Preventable Hospital
The study of over one thousand
practices of various sizes and ownerships,
conducted by some of the most respected names
in health care, found that the smallest
independent primary care practices, that are
physician owned, provide better care at lower
overall cost. Considering the current, and rather belligerent, advocacy and policy efforts to eradicate small independent medical practice, and the massive move of physicians from private practice to hospital employment in the name of efficiency, quality, value and economies of scale, this study should have created quite the furor. It has not, and chances are excellent that it never will.

The study, consisting of 1045 practices and 284,000 patients, is a combination of survey responses regarding practice characteristics, and Medicare claims data used to calculate rates of ambulatory care-sensitive admissions (ACSA). As the title implies, Lawrence Casalino and colleagues found that practices with one or two physicians had 30% lower rates of these presumably preventable admissions. But this was by no means the only finding, because in general, physician owned practices, as opposed to hospital owned practices, regardless of size, had lower ACSA rates. Furthermore, the study also found that all sorts of innovative practice models foisted on physicians nowadays have marginal and sometimes negative effects on ACSA rates: “Neither the patient-centered medical home score, nor pay-for-performance incentives, nor the acceptance of risk for the cost of hospital care for the practice’s patients was significantly associated with the ambulatory care–sensitive admission rate ... . Practices exposed to public reporting had somewhat higher rates.” 

Expansion of Mental Health Care Hits Obstacles

by Abby Goodenough
LOUISVILLE, Ky. — Terri Hall’s anxiety was back, making her hands shake as she tried to light a cigarette on the stoop of her faded apartment building. She had no appetite, and her mind galloped as she grasped for an answer to her latest setback.
In January, almost immediately after she got Medicaid coverage through the Affordable Care Act, she had called a community mental health agency seeking help for the depression and anxiety that had so often consumed her.
Now she was getting therapy for the first time, and it was helping, no question. She just wished she could go more often. The agency, Seven Counties Services, has been deluged with new Medicaid recipients, and Ms. Hall has had to wait up to seven weeks between appointments with her therapist, Erin Riedel, whose caseload has more than doubled.
“She’s just awesome,” Ms. Hall said. “But she’s busy, very busy.”
The Affordable Care Act has paved the way for a vast expansion of mental health coverage in America, providing access for millions of people who were previously uninsured or whose policies did not include such coverage before. Under the law, mental health treatment is an “essential” benefit that must be covered by Medicaid and every private plan sold through the new online insurance marketplaces.
The need is widely viewed as great: Nearly one in five Americans has a diagnosable mental illness, according to the Department of Health and Human Services, but most get no treatment. If the law’s goal is met, advocates say, it will reduce not only personal suffering but also exorbitant economic costs, like the higher rate of general health problems among those with mental illnesses, and their lost productivity.
Kentucky has been trying to overhaul its mental health system, partly by allowing private psychologists and social workers to accept Medicaid patients for the first time. The change is crucial, state officials say, because 85 percent of the 521,000 Kentuckians who got coverage through the state’s new insurance exchange this year were poor enough to enroll in Medicaid. Previously, only psychologists and social workers at community health centers like Seven Counties, which are quasi-governmental agencies, could provide outpatient therapy to Medicaid recipients here. Now, more than 1,000 private mental health providers statewide have signed up to treat Medicaid enrollees, according to the state.

Loving and Hating Obamacare With One Muddled Mind

E.J. Dionne has a nice column pointing out that while “Obamacare” remains unpopular, most of the provisions are well-liked, and thus Democrats should run on the issue. As regular readers know, I certainly agree that the individual components of reform are far more popular than reform overall. However, the column's headline -- “Obamacare has growing support, even if its name does not” -- isn't really buttressed by the article. Actually, support for key provisions of the law, including coverage of pre-existing conditions, health-insurance exchanges offering subsidies to middle-income policy holders and Obamacare's Medicaid expansion, have always polled well.
Moreover caution is always in order with issue polling. When these kinds of polls show public opinion fractured, it’s tempting to believe that one side or the other represents voters' “true” support. That’s the wrong way to interpret such polls. Yes, the ACA polls badly while most of its components poll well. But that doesn’t mean that the ACA is genuinely unpopular (as most opponents suggest) or that it’s genuinely popular (as most supporters contend). There is no underlying truth to be excavated from the results; the best we can do is say that public opinion is inconsistent.
Well, that’s the best we observers can do. Campaign operatives, in contrast, can counsel their candidates to stress whatever is popular. What those operatives shouldn't do is to fall for their own spin, or let their candidates fall for it. That applies both to Republican consultants encouraging candidates to bash Obamacare, and Democratic consultants urging candidates to highlight the law's most popular provisions.

What Doctors Can’t Do

Wednesday, August 27, 2014

Health Care Reform Articles - August 27, 2014

Leader of Connecticut’s Health Marketplace Is Named to Run Federal Program
WASHINGTON  —  The  Obama  administration  on  Tuesday  named  Kevin  J. Counihan,  who  ran  Connecticut’s  successful  health  insurance  marketplace, as  the  chief  executive  of  the  federal  marketplace  serving  consumers  in  36 states.
Mr.  Counihan  will  start  on  Sept.  8,  a  little  more  than  two  months  before the  next  sign-­up  period  for  health  insurance  begins  on  Nov.  15.  Sylvia Mathews  Burwell,  the  secretary  of  Health  and  Human  Services,  hired  Mr. Counihan  for  the  new  position  of  chief  executive  as  part  of  an  effort  to improve  management  of  the  federal  marketplace  and  to  avoid  the technological  failures  that  paralyzed  its  website,,  last  fall.
Ms.  Burwell  said  Mr.  Counihan  would  be  “a  clear,  single  point  of  contact for  streamlined  decision-­making.”
Although  he  comes  to  the  federal  marketplace  with  a  record  of  success —  enrollment  in  health  plans  exceeded  expectations  in  Connecticut  under his  watch,  and  the  state’s  online  marketplace  ran  relatively  smoothly  —  Mr. Counihan  now  faces  a  far  bigger  challenge.  He  will  be  under  pressure  to  get millions  more  Americans  signed  up  for  insurance  during  the  three-­month enrollment  period,  even  as  millions  who  already  bought  plans  through  the online  marketplaces  will  need  to  renew  them  or  switch  to  new  coverage.

Covered California officials, insurance chief clash over Prop. 45

by Chad Ternune

California's Obamacare exchange and the state insurance commissioner are on a collision course over Proposition 45, a popular ballot measure aimed at reining in health insurance rates.
Covered California officials lashed out at the statewide ballot initiative this week and warned that it could be disastrous to the state's implementation of the federal healthcare law.
In November, voters will decide whether to give Insurance Commissioner Dave Jones veto power over rate increases for about 6 million Californians who have individual and small-business policies. Without this authority, Jones says, consumers will keep being subjected to excessive rate hikes and Obamacare won't be affordable.
Until now, the state-run exchange had largely avoided a public clash over Proposition 45 with Jones, a Democrat who supports the health law. That restraint disappeared at an exchange board meeting Thursday, and officials there will take up a vote next month to formally oppose it.
These moves thrust Covered California into the middle of what's expected to be a highly contentious and costly campaign.
Anthem Blue Cross, Kaiser Permanente and other companies have already contributed more than $37 million to defeat the measure. Insurers argue that the initiative is unnecessary because the Affordable Care Act already imposes new rules to protect consumers.
The ballot fight starts with broad support for Proposition 45. A Field Poll released this week found 69% of California voters favored the proposition. That support may wane once ads attacking the measure ramp up.

Obamacare chief in California gets $53,000 bonus

By Chad Terhune
California's health insurance exchange awarded its executive director a one-time bonus of $53,000 after the state enrolled 1.2 million people in Obamacare coverage.
Covered California's board chairwoman, Diana Dooley, said Peter Lee had not received a raise in three years, so the exchange granted the executive director a 20% incentive award based on his annual salary of $262,644.
Lee, a former healthcare official in the Obama administration, was instrumental in building California's state-run marketplace.
Consumer advocates credited him with securing lower-than-expected rates from health insurers in his first two years on the job, and with surpassing the state's enrollment goals.
California accounted for about 15% of the overall U.S. enrollment of 8 million people in individual policies under the Affordable Care Act.
The state also avoided many of the online glitches that plagued the federal exchange at and other state sites.
Several state exchange directors didn't survive the rollout of Obamacare this year. Officials in Oregon, Minnesota and Maryland all resigned as troubles mounted.
Lee hasn't been immune to criticism. On Thursday, after his bonus was announced at a meeting of the exchange's board, two state lawmakers faulted him for low enrollment among African Americans.

Beware siren song of private-payer care

In the U.S., the doctor is in, but maybe financially unavailable

By Jessica Schorr Saxe, M.D.
Vancouver Sun, Aug. 25, 2014
The middle-aged woman came to my family medicine practice for a routine visit to check her high blood pressure. It was the highest I’ve ever seen in the office: 280/180. I told her to go to the emergency department for probable admission to the hospital.
Her eyes crinkled, and tears fell silently. I thought she was crying because I had frightened her about the urgency of her condition. I was wrong.
“I can’t go to the hospital,” she said, “I can’t afford it.”
I have practised for more than 30 years in a health centre that cares for low-income patients in Charlotte, N.C. As is typical in the United States, our patients rely on a hodgepodge of funding sources. Almost all patients face some financial barriers to care.
A few have private insurance (increasingly with high co-pays and deductibles), many have Medicare (for the elderly) or Medicaid (for some of the poorest of the poor), and many are uninsured. Of the uninsured, some are “self-pay” and some qualify for sliding-scale charges pegged to their income.
While my patient with extreme hypertension is deeply etched into my mind, I could tell you many similar stories.
The typical new patients in my practice have not had health care for months or years. In many cases, they once had employer-based insurance and access to private doctors, then lost their job and thus their coverage and their physicians. Some cry when they talk about the interruption of these long-term relationships with their doctors.
One such patient had been hospitalized with severe congestive heart failure and had lost his full-time job because of his illness. Although he continued to work part-time, he was uninsured and could no longer see his usual doctor.
It took months for him to see me. When he did, I promptly sent him to a cardiologist who prescribed open-heart surgery. He received it, but he could have died waiting for care, as thousands of Americans do every year.
The constant churning of patients in and out of coverage, or in and out of private insurance plans (each with a restrictive network of providers), is cumbersome and costly. Such transitions require patients to seek out new doctors who request and scrutinize old records and sometimes order tests, not realizing they have already been done.
The U.S. system creates other challenges to providing good care. Some patients miss appointments simply because they don’t have enough money for their insurance co-pays.
I approach each patient with an algorithm. This patient has Blue Cross/Blue Shield and has these options, this one has Medicare and another set of options for referrals and medications, this patient is on sliding scale and another set: oops, no options here for certain services. It is even more complicated, because the options change.
Unlike many other places in the U.S., we are fortunate at my health centre to have many services for the uninsured, but there are still many gaps. Elective orthopedic surgery, for example, is not even an option.
I have a patient with a painful hand condition and several patients who need knee or hip replacements. Many of them would be able to work if they could afford the recommended surgery, but instead they live in pain and poverty.
I know some people in Canada decry excessive waiting times for elective procedures. The waiting times for patients on the U.S. side are sometimes infinite or until they reach the age of 65 (decades away for some), when they finally receive our Medicare.
Medical care in the United States costs twice as much per capita as in Canada, yet we have tens of millions who are uninsured, two million people a year who are victims of medical bankruptcy, and some of the worst health statistics in the developed world.

Oregon: State Sues Over Health Website

by Reuters

The state sued Oracle America Inc. and six of its top executives on Friday, accusing the software giant of fraud for failing to deliver a working website for the Affordable Care Act program. The lawsuit, filed in Marion County Circuit Court, claims that fraud, lying and “a pattern of racketeering” by Oracle cost the state and its Cover Oregon program hundreds of millions of dollars. Oregon paid Oracle about $240.3 million for a system that never worked, the suit said. Oracle issued a statement saying that the suit “is a desperate attempt to deflect blame from Cover Oregon and the governor for their failures to manage a complex I.T. project.” It added, “The complaint is a fictional account of the Oregon health care project.” The company said it expected to prevail in both the state court lawsuit and in a breach of contract suit it filed against Cover Oregon two weeks ago in federal court.

Part D Gains May Be Eroding

by Paula Span

In 2003, when President George W. Bush signed the major Medicare expansion that would establish prescription drug coverage, he called it “a promise, a solemn promise, to America’s seniors.”
Medicare Part D, which took effect in 2006, initially made plenty of people angry. Some Congressional Democrats had argued that it would “privatize Medicare” by relying on insurance companies, while a number of Republicans insisted that the nation couldn’t afford the new program. Ordinary older adults learned to fear falling into the infamous “doughnut hole” coverage gap.
But in its first few years, national data shows, Part D did help elderly Medicare beneficiaries make modest progress. Out-of-pocket costs decreased. Better able to afford their medications, seniors were less likely to stop taking them for financial reasons. And they were less likely to do without other basic needs — like food and heat — in order to pay for drugs.
“I expected that to keep going,” said Jeanne Madden, a health policy analyst at Harvard Medical School. Instead, as she and a team researchers from Harvard and the University of Massachusetts report in the most recent issue of Health Affairs, those downward trends took a U-turn in 2009. “Things improved after Part D, continued to improve for a few years, and then reversed,” she said in an interview.

Obamacare has growing support, even if its name does not

by E.J. Dionne, Jr. 

The Affordable Care Act was supposed to be a slam-dunk issue for Republicans in this fall’s elections. Karl Rove told us so in April, writing that “Obamacare is and will remain a political problem for Democrats.”
So how’s that Obamacare thing working out for the GOP?
The most significant bit of election news last week was the decision of Sen. Mark Pryor, the embattled Arkansas Democrat, to run an ad touting his vote for the health care law as a positive for the people of his increasingly Republican state.
Pryor’s ad is so soft and personal that it’s almost apolitical. After his dad, the popular former senator David Pryor, tells of his son’s bout with cancer, he notes that “Mark’s insurance company didn’t want to pay for the treatment that ultimately saved his life.” The picture has widened to show Mark Pryor sitting next to his father. “No one should be fighting an insurance company while you’re fighting for your life,” he says. “That’s why I helped pass a law that prevents insurance companies from canceling your policy if you get sick, or deny coverage for preexisting conditions.”
Who knew a law that critics claim is so dreadful could provide such powerful reassurance to Americans who are ill?
Democrats have never fully recovered from the Obama administration’s lousy sales job for (and botched rollout of) what is, legitimately, its proudest domestic achievement. That’s one reason Pryor doesn’t use the word “Obamacare” in describing what he voted for. Another is that, in many of the states with contested Senate races this year, most definitely including Arkansas, President Obama himself is so unpopular that if you attached his name to Social Security, one of the most popular programs in American history would probably drop 20 points in the polls.

No Link Found for Deaths and Veterans’ Care Delays

by Richard A. Oppel, Jr.

An investigation by the watchdog office for the Department of Veterans Affairs has been unable to substantiate allegations that 40 veterans may have died because of delays in care at the veterans medical center in Phoenix, according to a letter from the new secretary of Veterans Affairs.
The allegations of deaths created a national scandal that eventually led to the ouster of the previous secretary of Veterans Affairs, Eric Shinseki.
Outrage over the manipulation of waiting list data in Phoenix and other veterans medical centers also led to passage by Congress of a $15 billion plan to improve access to medical providers. The director of the Phoenix hospital, Sharon Helman, has been placed on leave and the department has begun the process of firing her.
A report by the department’s office of inspector general is expected to be released this week that will describe findings from its investigation into Phoenix. Officials from the inspector general’s office have declined to comment on what the report will say.
However, a letter sent from the new Veterans Affairs secretary, Robert A. McDonald, to the inspector general responding to the report’s findings states that the investigation was unable to prove a link between the deaths of 40 veterans and delays in care.