How Medical Care Is Being Corrupted
By PAMELA HARTZBAND and JEROME GROOPMAN
WHEN we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients.
But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.
Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.
Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.
By PAMELA HARTZBAND and JEROME GROOPMAN
WHEN we are patients, we want our doctors to make recommendations that are in our best interests as individuals. As physicians, we strive to do the same for our patients.
But financial forces largely hidden from the public are beginning to corrupt care and undermine the bond of trust between doctors and patients. Insurers, hospital networks and regulatory groups have put in place both rewards and punishments that can powerfully influence your doctor’s decisions.
Contracts for medical care that incorporate “pay for performance” direct physicians to meet strict metrics for testing and treatment. These metrics are population-based and generic, and do not take into account the individual characteristics and preferences of the patient or differing expert opinions on optimal practice.
For example, doctors are rewarded for keeping their patients’ cholesterol and blood pressure below certain target levels. For some patients, this is good medicine, but for others the benefits may not outweigh the risks. Treatment with drugs such as statins can cause significant side effects, including muscle pain and increased risk of diabetes. Blood-pressure therapy to meet an imposed target may lead to increased falls and fractures in older patients.
Physicians who meet their designated targets are not only rewarded with a bonus from the insurer but are also given high ratings on insurer websites. Physicians who deviate from such metrics are financially penalized through lower payments and are publicly shamed, listed on insurer websites in a lower tier. Further, their patients may be required to pay higher co-payments.
A Physician With a Troubled Conscience Puts Himself on the Couch
In ‘Doctored,’ Sandeep Jauhar Examines a Broken System
By SUSANNAH MEADOWS
In Sandeep Jauhar’s arresting memoir about the realities of practicing medicine in America, “Doctored: The Disillusionment of an American Physician,” he describes an interaction he has with a patient at Long Island Jewish Medical Center, where he is the director of the heart failure program. The patient has an abdominal mass and has been transferred to the medical center from another hospital for a preoperative evaluation. Dr. Jauhar tells her that there are some things he needs to figure out before sending her to the operating room.
“Like what is this mass,” he says. “Is it cancer? Has it spread?” Neither her paperwork nor the doctor from the other hospital had provided answers.
“Do you know if it has?” she asks, wondering if the cancer has metastasized. He does not. “No one knows what is going on,” she says, her eyes filling with tears.
And she is right, says Dr. Jauhar, whose writing has appeared in The New York Times and whose first book, “Intern,” chronicled that grueling year of his medical career. “It is hard to imagine such a thing happening in the era of ‘my doctor,’ ” he says, referring to the days when patients primarily had one doctor who knew them well.
It’s not news, of course, that our medical system has become dysfunctional. But Dr. Jauhar’s personal account shows that brokenness on a human scale, starting with the doctor-patient relationship, which is in tatters.
In his telling, being a caring doctor has become practically cost-prohibitive. Insurance companies don’t pay enough for spending time with patients. But they do for CT scans and stress tests — whether they’re warranted or not. While fear of lawsuits drives unnecessary tests, too, Dr. Jauhar sees our fee-for-service model as particularly poisonous.
Heart stents may call for longer use of blood thinner
By Marilynn Marchione
| ASSOCIATED PRESS NOVEMBER 17, 2014
CHICAGO — Millions of people with stents that prop open clogged heart arteries may need anti-clotting drugs much longer than the one year doctors recommend now. A large study found that continuing for another 18 months lowers the risk of heart attacks, clots, and other problems.
Even quitting after 30 months made a heart attack more likely, raising the question of if it’s ever safe to stop. It’s a big issue because the drugs can be expensive and bring risks of their own. The result also is a surprise, because the trend has been toward shorter treatment, especially in Europe.
‘‘It’s a wake-up call. It’s the opposite of where we’ve been going,’’ said Dr. Patrick O’Gara, clinical cardiology chief at Brigham and Women’s Hospital in Boston and president of the American College of Cardiology.
He had no role in the study, which was led by Brigham’s Dr. Laura Mauri, at the request of the Food and Drug Administration. The results were discussed Sunday at an American Heart Association conference and published online by the New England Journal of Medicine.
The FDA said it is reviewing the results and that doctors should not change practice yet.
http://www.bostonglobe.com/business/2014/11/17/heart-stents-may-require-longer-blood-thinner-use/asQGgrougvFmd3I9diAnBN/story.html?s_campaign=email_BG_TodaysHeadline
Top insurers overstated doctor networks, California regulators charge
By CHAD TERHUNE
Salon, Nov.14, 2014
Starting tomorrow, November 15, millions of Americans will go online to obtain or re-enroll in health coverage through the Patient Protection and Affordable Care Act’s (ACA) insurance marketplaces. Working families once again will try to pick a health plan that works for them. Yet this year, the task will be particularly difficult.
A quirk in the ACA, coupled with the expiration of a national children’s health insurance program, will put family coverage out of reach for many. This means that up to 3 million low-income children may lose their insurance because family coverage is too expensive for low-income parents.
A solution exists. But first, let’s explore the ACA problem. Under the law, employers need to provide insurance only for workers – not workers’ families. This has created the so-called “family glitch.” Although premiums paid by workers are capped, there is no limit on the employee’s share of premiums for family members, and these often cost three times as much as an individual’s coverage.
So what are parents to do? What about the Children’s Health Insurance Program (CHIP)? It was expressly designed to help families in these circumstances. Since 1997, CHIP has provided insurance for children 18 and under in families slightly over the poverty level, and all kids in families that can’t afford private insurance.
CHIP is now up for congressional reauthorization. Congress is debating how long to extend the program given that the ACA helps provide private and Medicaid coverage for many children. The ACA’s “family glitch” adds new complications in health care. Politics permitting, Congress hopes to quickly renew the successful program by the end of the year.
But CHIP isn’t a panacea either. Many children eligible for CHIP still lack insurance and access to care. Why? CHIP is a federal block grant. States implement CHIP in their own way. Some create waiting lists when the coffers run empty.
CHIP also struggles to enroll and cover all eligible kids. Many eligible children have parents that are undocumented who are hesitant to get coverage. Application assistance, language access and geography determine the success of outreach of CHIP or any other health program’s enrollment.rtisement
Top insurers overstated doctor networks, California regulators charge
By CHAD TERHUNE
Bolstering a chief complaint about Obamacare coverage, California regulators said two major health insurers violated state law by overstating the number of doctors available to patients.
More than 25% of physicians listed by Anthem Blue Cross and Blue Shield of California weren't taking Covered California patients or were no longer at the location listed by the companies, according to state reports released Tuesday.
In some cases, these errors led to big unforeseen medical bills when patients unwittingly ventured to out-of-network doctors for medical tests or a surgery.
The results of the five-month investigation come at a critical juncture as the second year of health law enrollment gets underway and more than 1.2 million Californians are shopping in the state's insurance exchange.
"We found the provider directories made available to the public had significant errors," said Shelley Rouillard, director of the California Department of Managed Health Care. "When you have a quarter or more of physicians that aren't available, that is significant."
Anthem and Blue Shield account for nearly 60% of enrollment in Covered California. The two industry stalwarts have long catered to patients wanting the widest selection of physicians.
As a result, their narrower networks and more restrictive policies were a jolt to many people and often came to light only when they were getting treated. The insurers compounded the problem with inaccurate provider lists, mislabeled insurance cards and false assurances about coverage, according to patients, doctors and regulators.
The latest findings could spark fresh criticism of Covered California, which has been faulted for going easy on its biggest health plans. Exchange officials said they welcomed the audit and insist they have pushed health plans hard to fix these persistent network problems.
LePage signals that legal battle with feds over Medicaid is not over
By Mario Moretto, BDN Staff
Posted Nov. 18, 2014, at 6:15 p.m.
AUGUSTA, Maine — Gov. Paul LePage’s administration seems likely to appeal a federal court ruling that the state cannot end Medicaid coverage for low-income 19- and 20-year-olds.
In an interview with MPBN, LePage said he expects the lawsuit will end up at the U.S. Supreme Court.
“I don’t know about the rest of the people on the staff, but I thought from the first time this would end up on [Chief Justice John] Roberts’ lap,” LePage told MPBN’s Mal Leary. “This has to be decided at the Supreme Court, and we are just going through the process.”
Adrienne Bennett, LePage’s press secretary, said Tuesday that if any litigation were pending, she could not comment. However, she said LePage “signalled” he did not expect the legal fight was over.
In 2012, the state sought to drop non-disabled young adults from coverage. But the federal government denied the request, citing provision of the Affordable Care Act, or “Obamacare,” which requires states to maintain the same eligibility requirements in place in 2010 until 2019.
At that point, Maine was still providing coverage to 19- and 20-year-olds with incomes 156 percent or more under the federal poverty level. The Legislature approved the plan to end coverage for 19- and 20-year-olds, which was estimated to save $3.7 million in state funds and $6.9 million in federal matching funds.
The federal government held that such a change in the state’s Medicaid law would violate the maintenance of effort provision of the Affordable Care Act and threatened with an elimination of all Medicaid funding. LePage claimed the feds were forcing Maine’s hand with an unfunded mandate and filed a lawsuit against the federal government.
A U.S. Appeals Court on Monday ruled against the state. Medicaid coverage for roughly 6,000 low-income 19- and 20-year-olds in Maine has remained intact during the legal battle between state and federal government.
Maine Attorney General Janet Mills refused to represent the state in the case, citing her agreement with the federal government’s interpretation of the law. LePage designated $100,000 from his executive contingency fund to pay for outside counsel to represent the state in court.
Information about how much of that $100,000 has been spent so far was unavailable Tuesday afternoon.
Maine Obamacare advocates trumpet health insurance options
By Jackie Farwell, BDN Staff
Posted Nov. 18, 2014, at 3:10 p.m.
PORTLAND, Maine — David Cousens used to worry about his three sons hauling lobster traps without the security of health insurance. Commercial lobster fishing — the country’s second most dangerous profession, after logging — carries a risk of injury that can threaten a lobster fisherman’s livelihood, he said, as medical bills stack up and fishing comes to a halt.
“We’ve got enough to worry about when we’re on the water,” Cousens, president of the Maine Lobstermen’s Association, said. “I don’t need to worry about health insurance, too.”
Cousens and his adult sons, who all fish out of South Thomaston, signed up for coverage through HealthCare.gov, the federal government’s health insurance marketplace created under the Affordable Care Act. The plans are affordable with good benefits and offer him a little peace of mind, said Cousens, who used his plan Tuesday morning for a doctor’s appointment. His copay was $40, he said.
Maine health advocates are highlighting lobster fishermen among success stories from across the state as the second open enrollment period under the ACA gets off the ground. After HealthCare.gov’s botched rollout, advocacy groups hope to reassure consumers of a improved sign-up process for plans taking effect in 2015.
Cousens joined Portland Mayor Michael Brennan, U.S. Department of Health and Human Services’ regional official Christie Hager and others at an ACA kickoff event Tuesday at Becky’s Diner in Portland.
“Lobstermen aren’t a group that like a lot of change, but they’ll also embrace something if it works,” Cousens said.
HealthCare.gov was designed to simplify the process of shopping for a plan, allowing consumers to go online to compare options, see whether they qualify for lower costs and choose affordable coverage that best meets their needs. The site’s geared toward those who purchase their own health coverage in the “individual market,” such as self-employed and part-time workers, rather than those who get insurance through work or government programs.
The Obama administration has said the site will work better, handling twice as many shoppers as it did on the busiest day of the first enrollment period, which officially ended in March. The second enrollment period opened Saturday and ends Feb. 15, 2015.
With a few exceptions, consumers who buy coverage through HealthCare.gov must enroll or re-enroll during that time or go without insurance until next year’s open enrollment period. If consumers want coverage to begin Jan. 1, 2015, they must sign up by Dec. 15.
More than 44,000 Maine residents signed up for private coverage through HealthCare.gov during the first open enrollment period. While technical glitches initially stunted sign-ups, Maine went on to enroll about 36 percent of eligible residents, ranking eighth nationally, according to the Kaiser Family Foundation.
In Maine, 90 percent of enrollees qualified for tax credits to offset the costs of their monthly premiums or discounts on out-of-pocket costs, according to the U.S. Department of Health and Human Services.
April Gilmore, ACA enrollment counselor for the Maine Lobstermen’s Association, said enrollment is going more smoothly this time. Consumers who are renewing their plans can navigate the site faster, with much of their information stored from last year, she said. Assisters also are helping enrollees with the stumbling block of setting up new passwords, which the site requires, she said.
“I was able to log in myself on the 15th [of November], so I thought that was a really good sign, considering,” said Gilmore, who helped Cousens and his sons sign up. “I think people were wary from what happened last year, but we’re encouraging people to call us if they run into trouble.”
A network of consumer assistance groups, including the Maine Lobstermen’s Association, Western Maine Community Action and other organizations, are again providing free assistance in person and over the phone to help Mainers sign up for coverage.
Saco man who killed family, self, had stopped taking antidepressants when he lost his insurance
By Seth Koenig, BDN Staff
Posted Nov. 18, 2014, at 2:18 p.m.
SACO, Maine — In the 13 months before police say he murdered his family and then killed himself, Joel Smith repeatedly visited doctors seeking help for stress and anxiety, but stopped taking prescribed medication because he lost his insurance, according to documents released this week by the state medical examiner’s office.
The night of July 26, police say Smith, 33, shot his wife, 35-year-old Heather Smith, 12-year-old stepson Jason Montez, and biological children Noah Montez, 7, and Lily Smith, 4, with a shotgun before turning the weapon on himself in the family’s Saco apartment.
On Monday, the medical examiner’s office released its reports on all five individuals in response to a Freedom of Access Act request filed by the Bangor Daily News in August.
According to an account by Saco police officer Megan Tibbetts that accompanied the reports, Joel Smith was angry at his wife for staying out until 10:30 p.m. on the night in question, drinking with neighbors in the Water Street apartment complex where they lived.
Within the next hour, neighbors said they heard what sounded like fireworks going off.
Heather Smith had recently returned to the apartment after treatment for heroin and oxycodone abuse, Tibbetts’ account read, in part. Three days before the incident, on a Wednesday, Joel and Heather Smith went to pick up the three children from their paternal grandfather, with whom they’d been staying during Heather’s rehabilitation stint.
The night before the crime, Heather Smith passed a drug test, but abruptly left a group therapy session halfway through the meeting with no explanation. Police would later report that on the same night, Joel Smith threatened suicide, although it is unclear whether, or in what way, the two circumstances are related.
According to the medical examiner’s report, Joel Smith had visited doctors at least four times between June 2013 and February 2014 seeking help for stress and anxiety, among other things. Those visits came on the heels of what the report suggested were numerous previous attempts to seek medical help since 2008, when Smith told doctors he lost his job and his anxiety became “intolerable.”
“He had done well on [the antidepressant] sertraline, but lost his insurance and had not been taking sertraline for several months. His anxiety had returned with panic symptoms, obsessive worrying and difficulty sleeping,” read the medical examiner’s recounting of Joel Smith’s Feb. 28 appointment with his primary care physician. “He rarely drank and denied recreational drugs. He denied depression and suicidal and homicidal ideation. The impression was generalized anxiety and panic disorder. Sertraline, 50 mg daily, was prescribed. He was to return in one month. There were no further visits.”http://bangordailynews.com/2014/11/18/news/portland/saco-man-who-killed-family-self-had-stopped-taking-antidepressants-because-he-lost-his-insurance/print/
Bill Nemitz: A post-ordeal debriefing, in the words of nurse Hickox
by Bill Nemitz
The health care worker, who never had Ebola, has moved to Here’s a surprising fact about Kaci Hickox: Before she became the poster woman for Ebola hysteria across the United States, she had hoped to land a job as an epidemiologist for the Maine Center for Disease Control and Prevention.
Here’s a not-so-surprising update: Hickox no longer wants the job.
“I would not work for the state health department here. Sorry,” Hickox said during a visit, along with her boyfriend, Ted Wilbur, to the Portland Press Herald on Monday. “And they probably would not hire me.”
Which, believe it or not, is our loss.
With the Maine CDC currently running on fumes – no state epidemiologist, no deputy epidemiologist, no hepatitis coordinator and more than a quarter of the state’s 50 public health nurse positions vacant – Hickox is far more qualified to run the state’s infectious-disease unit than CDC Director (and acting state epidemiologist) Dr. Sheila Pinette.
Pinette, an internist, had no public health experience whatsoever before she was appointed by Gov. Paul LePage back in 2011.
Hickox, on the other hand, has a master’s degree in public health and nursing from Johns Hopkins University, two years of training as an epidemiology intelligence officer with the U.S. CDC, and more on-the-ground experience dealing with the deadly Ebola virus than anyone else in the state she still calls home.
That’s right. Nurse Hickox is still here. And for the time being, she’s staying put.
“I don’t have a job yet,” said Hickox. “I’m still searching.”
It’s been eight days since Hickox’s battle of wills with the LePage administration – and before that, with New Jersey Gov. Chris Christie – ended quietly with the expiration of a court order suggesting (but not requiring) that she keep a low profile at her and Wilbur’s rented home in Fort Kent. The 21-day period since Hickox’s last exposure to the Ebola virus in Sierra Leone ended Nov. 10, vindicating her claim since Day One that she was not sick and thus should not be treated like a modern-day leper.
Owner of Becky’s Diner hopes to serve up health insurance for employees
As the new round of Obamacare insurance sign-ups begins, small businesses look into coverage for workers and a help network in Maine gets slammed with calls.
by Joe Lawlor
Becky Rand would like to offer health care coverage for employees at her restaurant – Becky’s Diner on the Portland waterfront – so she’s crunching the numbers to see if it’s financially possible.
“I’m looking into coverage for the whole restaurant. I’m hoping this is the year,” said Rand, who hosted an Affordable Care Act event Tuesday at the diner. “I believe it’s important. I would love it if everyone could have insurance.”
On hand at the diner to tout the ACA were Mayor Michael Brennan and Christie Hager, regional director for the U.S. Department of Health and Human Services.
Up to now, Rand has been gently encouraging her 30 full-time and 20 part-time employees to consider buying coverage through the ACA’s health insurance marketplace, which kicked off its second open enrollment period on Saturday. People can sign up on the marketplace through Feb. 15.
The marketplace is where those without insurance – including those who work but can’t obtain coverage from an employer – can purchase subsidized individual insurance.
“The kids never think they’re going to get sick,” Rand said. “But you never know what’s going to happen to you.”
The marketplace enrolled 44,000 Mainers for coverage this year – 7.1 million nationwide – and health care advocates hope thousands more uninsured Mainers will obtain benefits for 2015. Emily Brostek, executive director of Consumers for Affordable Health Care, an Augusta nonprofit that advocates for reforms and helps people purchase insurance on healthcare.gov, said the statewide network of groups that helps people sign up has been “slammed” with calls this week from potential enrollees.
America’s new healthcare bind: How to overcome the “family glitch”
Due to a quirk in the law, 3 million low-income kids could soon lose their insurance. Here's the best, only way out
By Vijay DasSalon, Nov.14, 2014
Starting tomorrow, November 15, millions of Americans will go online to obtain or re-enroll in health coverage through the Patient Protection and Affordable Care Act’s (ACA) insurance marketplaces. Working families once again will try to pick a health plan that works for them. Yet this year, the task will be particularly difficult.
A quirk in the ACA, coupled with the expiration of a national children’s health insurance program, will put family coverage out of reach for many. This means that up to 3 million low-income children may lose their insurance because family coverage is too expensive for low-income parents.
A solution exists. But first, let’s explore the ACA problem. Under the law, employers need to provide insurance only for workers – not workers’ families. This has created the so-called “family glitch.” Although premiums paid by workers are capped, there is no limit on the employee’s share of premiums for family members, and these often cost three times as much as an individual’s coverage.
So what are parents to do? What about the Children’s Health Insurance Program (CHIP)? It was expressly designed to help families in these circumstances. Since 1997, CHIP has provided insurance for children 18 and under in families slightly over the poverty level, and all kids in families that can’t afford private insurance.
CHIP is now up for congressional reauthorization. Congress is debating how long to extend the program given that the ACA helps provide private and Medicaid coverage for many children. The ACA’s “family glitch” adds new complications in health care. Politics permitting, Congress hopes to quickly renew the successful program by the end of the year.
But CHIP isn’t a panacea either. Many children eligible for CHIP still lack insurance and access to care. Why? CHIP is a federal block grant. States implement CHIP in their own way. Some create waiting lists when the coffers run empty.
CHIP also struggles to enroll and cover all eligible kids. Many eligible children have parents that are undocumented who are hesitant to get coverage. Application assistance, language access and geography determine the success of outreach of CHIP or any other health program’s enrollment.rtisement
What about Medicaid? Can that help parents? Not necessarily. Although it covers nearly 36 million children, and Medicaid and CHIP combined insure more than half of America’s children, many working parents make too much money to qualify or live in states that did not expand Medicaid.
http://www.pnhp.org/print/news/2014/november/america’s-new-healthcare-bind-how-to-overcome-the-“family-glitch”
http://www.pnhp.org/print/news/2014/november/america’s-new-healthcare-bind-how-to-overcome-the-“family-glitch”
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