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Monday, January 4, 2016

Health Care Reform Articles - January 4, 2015

Health expenses surging in Mass.

By Globe Staff 

The jumps in premiums come as insurers pass on the costs of rising drug prices, insurers and analysts said, and grapple with the cost of expanding coverage under the Affordable Care Act. Most of the state’s major health insurers are sharply raising premiums for individuals, small firms, and big businesses, according to a Globe review of figures provided by the insurers and the state Division of Insurance.
For many, the upward trend is troubling.
“People cannot sustain the amount of money they’re paying for health care, ” said Joshua Archambault, senior fellow at the Pioneer Institute, a right-leaning Boston think tank. “At some point, people really can’t afford it.”
The Division of Insurance will hold a two-day public hearing on the issue. Insurers will be called to discuss their rates at the first-of-its-kind hearing on Jan. 11, and members of the public can comment on Jan. 12.
“In the interest of transparency, we’re holding these [hearings] so insurers can explain the rates they say they need,” said Chris Goetcheus, a spokesman for the division.
The rise in health care costs for insurers — and subsequently consumers — comes after prices moderated in recent years. With the enactment of the Affordable Care Act, more people have coverage, and as a result they are using more medical services and prescription drugs, analysts said. In addition, they said, insurers may be passing along the costs of millions of dollars in taxes and fees to finance the expansion of health coverage.
Not all spending growth is surprising or troubling, said Michael E. Chernew, a professor of health care policy at Harvard Medical School.
Some spending growth is expected, given that locally and nationally, more people have gained insurance,he said. But other trends are concerning, he said, such as the move by many drug companies to put high price tags not just on innovative medicines but on long-established drugs as well. The prices of some common generic drugs have surged 15, 25, and even 75 times what they were just two years ago.
“Some of the increased spending is good,” Chernew said, “and some of the increased spending is bad.”
Several insurers and the state Division of Insurance, which approves rates for individual and small-business plans, attribute rising premiums in part to a controversial element of the federal health care law. That program, called risk adjustment, requires insurers with healthier members to make payments to companies with sicker members in order to share the risks and cost of insuring people with a lot of medical needs. It is designed to prevent insurers from boosting profits by enrolling only healthy members.
When the program went into effect in 2015, most insurers ended up paying money to their largest competitor, Blue Cross, which received more than $51 million in risk adjustment payments. Tufts Health Plan received more than $8 million.
The program aims to smooth and stabilize insurance rates, but some insurers say it is having the opposite effect. Companies, including Harvard Pilgrim, which made about $4 million in payments, Fallon, which paid about $11 million, and Neighborhood Health Plan, which paid about $28 million,said they raised rates more in 2016 because of risk-adjustment.
One portion of the market, health plans for individuals and small businesses, shows the steepness of some increases. Harvard Pilgrim raised premiums 8.7 percent for these plans in 2016, compared with a 1.4 percent decline in rates in 2015. Fallon’s rates are up 16.5 percent, compared with a 4.9 percent increase a year earlier. At Neighborhood Health, premiums rose 9.4 percent in 2016, compared to 5.9 percent a year earlier.
The national insurer United HealthCare raised rates 13 percent in 2016, after raising them 4.5 percent a year earlier.
Blue Cross, on the other hand, said the payments it received to help cover its higher population of sicker members helped it keep its premium increases modest: rates for individuals, small businesses, and large businesses are up about 5 percent this year, compared with 4.2 percent in 2015.
Even while increasing their rates, insurers said they are taking steps to rein in rising premiums.
At Tufts Health Plan, premiums for individual and small businesses plans are rising 6.8 percent in 2016, compared to 4.5 percent in 2015. But Tufts said it has redesigned some plans so members can keep premium increases to about 1 percent by opting to pay higher co-payments and deductibles for medical services.
“We’re developing new programs to try to control the costs customers are experiencing,” said Marc Spooner, Tufts’ president of commercial products. “We take our responsibility to control costs very seriously.”
http://www.bostonglobe.com/business/2016/01/03/health-care-costs-rising-faster/WUfquz4gBEjncURDm20b6L/story.html?s_campaign=email_BG_TodaysHeadline&s_campaign=


Many See I.R.S. Fines as More Affordable Than Insurance

By 


WASHINGTON — Clint Murphy let the deadline for getting health insurance by the new year pass without a second thought.
Mr. Murphy, an engineer in Sulphur Springs, Tex., estimates that under the Affordable Care Act, he will face a fine of $1,800 for going uninsured in 2016. But in his view, paying that penalty is worth it if he can avoid buying an insurance policy that costs $2,900 or more. All he has to do is stay healthy.
“I don’t see the logic behind that, and I’m just not going to do it,” said Mr. Murphy, 45, who became uninsured in April after leaving a job with health benefits to pursue contract work. “The fine is still going to be cheaper.”
Two years after the Affordable Care Act began requiring most Americans to have health insurance, 10.5 million who are eligible to buy coverage through the law’s new insurance exchanges were still uninsured this fall, according to the Obama administration.
That number appears to be shrinking: Administration officials said last month that about 2.5 million new customers had bought insurance through HealthCare.gov, the federal exchange serving 38 states, since open enrollment began on Nov. 1. The number of new enrollees is 29 percent higher than last year at this time, suggesting that the threat of a larger penalty may be motivating more people to get covered.
But plenty of healthy holdouts remain, and their resistance helps explain why insurers are worried about the financial viability of the exchanges over time. They say they sorely need more healthy customers to balance out the costs of covering the sicker, older people who have flocked to exchange plans.
People, like Mr. Murphy, who earn too much to qualify for federal subsidies that defray the cost of coverage may be most likely to opt out. A recent analysis by the Kaiser Family Foundation found that more than seven million people who are eligible for exchange coverage would pay less in penalties than for the least expensive insurance available to them. More than half would not qualify for subsidies, the analysis found.
Ben Wakana, a spokesman for the Department of Health and Human Services, said people would still be better off buying insurance.
“We understand some people may be thinking through their choice of coverage, but going without health insurance is a serious gamble that can be catastrophic if wrong,” Mr. Wakana said.
Many holdouts have made their decisions after meticulously comparing the cost of insurance premiums and deductibles with paying for doctor appointments, lab tests and prescriptions themselves. For some healthy people, the combined cost of premiums and deductibles, which can exceed $10,000, makes the penalty seem a better deal.
For 2016 and beyond, the penalty will be $695 per adult or 2.5 percent of household income, up from $325 per adult or 2 percent of household income last year.
Susan Reardon, 61, of Kalamazoo, Mich., said she was leaning toward going uninsured this year. She calculated that she would have to spend more than $12,000, including premiums of nearly $500 a month and a $6,850 deductible, to get anything beyond preventive benefits from the cheapest exchange plan available to her.
Ms. Reardon, whose husband is old enough to be covered by Medicare, said she would rather pay out of pocket for the drugs she takes for fibromyalgia and the handful of doctor appointments she tends to need each year.
If something catastrophic happens, she said, “I feel like it’s better just to die.”
As for the tax penalty, which could approach $1,500 for her?
“Come and get me,” Ms. Reardon said.


Heart doctors are listening for clues to the future of their stethoscopes

 
W. Reid Thompson, a pediatric cardiologist and an associate professor of pediatrics at Johns Hopkins School of Medicine, left, is a proponent of stethoscope training. (Ricky Carioti/The Washington Post)
The stethoscope is having a crossroads moment. Perhaps more than at any time in its two-century history, this ubiquitous tool of the medical profession is at the center of debate over how medicine should be practiced.
In recent years, the sounds it transmits from the heart, lungs, blood vessels and bowels have been digitized, amplified, filtered and recorded. Four months ago, the Food and Drug Administration approved a stethoscope that can faithfully reproduce those sounds on a cellphone app thousands of miles away or send them directly to an electronic medical record.
Algorithms already exist that can analyze the clues picked up by a stethoscope and offer a possible diagnosis.
But whether all this represents the rebirth of diagnostic possibility or the death rattle of an obsolete device is a subject of spirited discussion in cardiology. The widespread use of echocardiograms and the development of pocket-size ultrasound devices are raising questions about why doctors and others continue to sling earphones and rubber tubing around their necks.
“The stethoscope is dead,” said Jagat Narula, a cardiologist and associate dean for global health at the Icahn School of Medicine at Mount Sinai Hospital in New York. “The time for the stethoscope is gone.”
Not so, counters W. Reid Thompson, an associate professor of pediatrics at Johns Hopkins University School of Medicine. “We are not at the place, and probably won’t be for a very long time,” where listening to the body’s sounds is replaced by imaging. “It is valuable,” he said.

N.J. Factory Turns To Medicaid To Insure Lowest-Paid Employees


Butter-flavored popcorn oil is in high demand at Oasis Foods, a manufacturer of cooking oils, mayonnaise and other products that restaurants and distributors often purchase by the ton.

"We get a rush this time of year with all the movie-going at the holidays," says Duke Gillingham, president of Oasis, at his factory in Hillside, N.J., just west of Newark Liberty Airport.
The company's health insurance coverage is not as popular as its popcorn oil. Oasis offered health insurance to all employees for 2015, to comply with a new Affordable Care Act mandate. And while some employees did sign up for the insurance — the company doubled the number of people on its health plan over previous years — about two-thirds of the employees declined the coverage. With monthly premiums of roughly $350 for a family of four, and with a $2,500 annual deductible, it was too expensive for factory workers, many of whom earn between $10 and $15 an hour.
Gillingham says he hasn't been able to find decent insurance much cheaper than that, and he cannot afford to significantly raise his employees' wages.
"The sad fact is we're in a very competitive business," he says. "We wish we could make [insurance] more affordable, but it's essentially what the business can bear. If we don't watch what we're doing, we can be high-cost, and that doesn't serve any of the employees well."
Companies Look To Avoid Penalties
Oasis Foods, a subsidiary of a Swedish food manufacturer, has about 180 workers. As of Jan.1, smaller firms — those that employ between 51 and 100 workers — are being phased into the same mandate that Oasis faced in 2015. Companies must offer affordable coverage to all employees, and will be subject to a penalty if their workers instead turn to the health exchange to buy subsidized coverage.
There's no penalty for companies, it turns out, if workers qualify for Medicaid — though there could be controversy.
At firms like Oasis, low-wage workers are candidates more often for Medicaid than for the state or federal insurance exchange.
To qualify for Medicaid, applicants may earn no more than 138 percent of the federal poverty level — or roughly $16,000 for a single person and around $33,000 for a household of four.
Employers have not historically played a significant role in helping workers enroll in Medicaid. But Gillingham's insurance broker told him about a startup called BeneStream, which is based in New York City and facilitates enrollment in the government program.
Company Shifts Insurance Costs To The Government
Founded two years ago with seed money from the Ford Foundation, BeneStream now helps more than 6,500 workers at 125 companies across the country get Medicaid. CEO Benjamin Geyerhahn says moving workers from private insurance to Medicaid helps firms shift their costs to the government.http://www.npr.org/sections/health-shots/2016/01/01/460944790/n-j-factory-turns-to-medicaid-to-insure-lowest-paid-employees

By Scott Thistle, Sun Journal
Posted Dec. 28, 2015, at 2:34 p.m.
AUGUSTA, Maine — Hoping to tap federal funding that could help fight Maine’s heroin addiction crisis, a pair of Republican state senators is again proposing legislation to expand Maine’s Medicaid eligibility.
Sen. Tom Saviello, R-Wilton, who previously has supported an expansion of the state and federally sponsored health insurance program for low-income families and individuals, said his bill — essentially a “placeholder” that was carried over from 2015 — will go before the Legislature when it convenes in January.
One of a handful of Republican lawmakers who support Medicaid expansion in Maine, Saviello said Monday he knows his legislation, co-sponsored by fellow moderate Republican Sen. Roger Katz of Augusta, faces an “uphill fight.”
Expanding Medicaid in Maine as allowed by the federal Affordable Care Act would add an estimated 60,000 people to the state’s Medicaid rolls.
Meanwhile, the number of documented drug overdoses from heroin or other opioids, including prescription painkillers, has reached its highest level since state medical officials have been keeping track.
Earlier this month, in a letter to the state’s top medical professionals urging them to use greater caution in prescribing painkilling medications, Maine Attorney General Janet Mills noted that on average, five Mainers a week are dying from overdoses.
Democrats in the Legislature have been united in their support of expansion, which President Barack Obama’s administration has touted as a key component of health care reform. But Republican Gov. Paul LePage has five times since 2013 vetoed bills that would have expanded the state’s Medicaid program, and legislative Republicans have voted to sustain those vetoes.
Supporters of expansion — who note that the federal government would fund at least 90 percent of the eligibility expansion — have been unable to muster two-thirds support in both chambers of the Legislature, which would be needed to override another expected LePage veto.
“As Yogi Berra said, ‘It’s deja vu all over again,’” Adrienne Bennett, a spokeswoman for LePage said in a message to the Sun Journal. “The results were disastrous for Maine when it expanded this kind of welfare in 2002, and it is now blowing holes in state budgets around the country.”
Bennett said Illinois, Rhode Island, Ohio, New Mexico and California all saw their budgets decimated by Medicaid expansion.
“We rejected Medicaid expansion five times, and we will reject again, no matter how many times liberal politicians push for it,” Bennett said. “Unfortunately, there are some politicians using a real addiction pandemic to push welfare expansion to score political points in an upcoming election year. The governor doesn’t play that game.”
Given Maine’s addiction crisis, Saviello said it’s time the state takes advantage of federal funds meant to provide health insurance to individuals with incomes less than 138 percent of the federal poverty level or about $16,105 a year for a single person.

AG Healey finds mixed progress at Steward Health Care

Health care firm lost $75m in 2014

By  GLOBE STAFF  
Steward Health Care System has maintained important medical services for elderly and low-income patients, but its mounting losses raise concerns about the for-profit hospital company’s financial stability, Attorney General Maura Healey said in a new report Wednesday.
The company lost $75 million on operations in 2014, up from $55 million in 2013 and $22 million in 2012, according to the report. The company also has large amounts of debt and $369 million in unfunded pension liabilities.
“Steward acquired hospitals that were experiencing financial difficulties, and Steward has continued to experience challenges in its financial performance,” the report said. “Its ability to meet the requirements of its lenders and investors may be an important challenge for Steward.”
The attorney general is required to monitor Steward and issue reports on the health system’s progress as part of the 2010 deal that allowed Steward to buy several struggling Caritas Christi hospitals run by the Archdiocese of Boston. Steward, backed by the New York private equity firm Cerberus Capital Management, now operates nine hospitals in Eastern Massachusetts, including St. Elizabeth’s Medical Center and Carney Hospital in Boston.
The report noted that the Steward story is still unfolding. When Steward launched five years ago, residents and state officials were concerned that, as a for-profit company, it would close hospitals, raise prices, or cut less profitable services such as psychiatric care. But the report said: “The most dire of these concerns have not come to pass. Steward has kept the former Caritas system intact and operated the system as it had proposed, albeit in a health care market that remains challenging and dynamic.”
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Steward spokeswoman Brooke Thurston said the loss in 2014 was largely due to the financial struggles and eventual closing of Quincy Medical Center, a 196-bed hospital Steward shuttered at the end of 2014. Thurston added that the company has spent heavily to upgrade its technology and health care facilities.

Keep Things Simple For A Healthy, Long Life


I'm often asked for medical advice by friends, family members, even new acquaintances: What about this diet? What should I do about this symptom? What about this medication?

People are usually disappointed when I don't share their enthusiasm about the latest health fads. Members of my family, in particular, are often underwhelmed by my medical advice.
I'll be the first to admit that I don't always do a great job of conveying why I'm skeptical about the newest medical technology, reports of the latest health news and fashions and even people's symptoms. Mostly it's because in my experience so much about health just isn't that simple.
Most symptoms, after all, aren't explainable, at least to the level of detail we all seem to want. "What's causing my symptoms?" friends, family and patients ask me. Is it a virus? Bacteria? Arterial blockage?
In spite of all the science and technology in medicine, what we doctors do is more about making educated guesses. Especially in primary care, it's often a matter of playing the probabilities than providing precise diagnostic information.
But prevention is different. We know a lot about it, based on huge bodies of epidemiological research. Most of prevention is fairly straightforward. You've heard the advice again and again. In fact, the repetition may make it easy to tune out.
I'll risk it, though, and tell you again that there really aren't shortcuts to health. Here's what you need to do:
  • Get enough sleep.
  • Move your body throughout the day.
  • Eat well — a healthy assortment of foods. Mostly plants, and not too much. (An idea popularized by author Michael Pollan.)
  • Interact socially. Isolation is not good for the body, soul or mind.
  • Take some time to reflect on what you are grateful for.
Recently I've come across a couple of sources that do a good job of conveying these messages. One is a set of books and ideas about the world's so-called Blue Zones. If you haven't heard about them, Blue Zones are the places in the world where people both have the healthiest and longest lives.
People in these communities often live well beyond 100 years:
  • Okinawa, Japan
  • Ikaria, Greece
  • Sardinia, Italy
  • Nicoya, Costa Rica
  • Loma Linda, Calif.
In these places, people have preventive medicine baked into their lives, mostly without even having to think about it. Their daily activities involve eating healthful diets rich in local plants, walking most places and lots of intergenerational social interaction.
Interestingly, folks in these communities generally do drink alcohol. But they limit it to 1 or 2 drinks a day. Also, they typically do eat meat — but not very often and in small portions. (Loma Linda may be a bit of an exception, with its large populationof Seventh-Day Adventists.)
One thing that probably won't surprise you: Blue Zoners do not eat refined sugars. They skip the convenient packaged foods that we're trained to eat because they're cheap and widely available.
Summarizing these themes visually in under two minutes is another gem from the idea lab of Dr. Mike Evans from Toronto. You've seen some of his other videos here. I love them. Just watch the one below, and follow his advice. That's what I'm trying to do in my own life.


More Maine Seniors Are Being Pushed Into Poverty 

By  • DEC 31, 2015

LEWISTON, Maine — Seniors are typically the least likely age group to be chronically poor, under the federal government's official formula for measuring poverty. 

Jay Field concludes his multi-story report on poverty in Maine.
But a recent study, by researchers from the University of New Hampshire, found that increasing numbers of Maine seniors are being pushed into poverty by rising medical and cost of living expenses.
The situation is especially perilous for those entering older age without any savings.
In the final part of our series on poverty in Maine, the story of a woman in Lewiston, struggling to survive on social security, after a long-term disability forced her to stop working. 
"This will take me a minute. There's wifi in the building and it doesn't always work well," says Robyn Rosser, who is trying to log into her bank account on her labtop.
It's early November and we're inside Rosser's small, subsidized apartment at Bates Mill, the refurbished, former textile factory in Lewiston. The days immediately after Rosser gets her monthly social security check are the most agonizing. The money comes in on the third — $1,362 that's supposed to last the entire month. Rosser's account comes up on the screen.
Jay Field: "Today's the 6th." Robyn Rosser: "I have a lot more than I thought I did. $1,032."
Rosser's electric and car insurance bills have been paid. But her $500 rent check still needs to clear. When that happens, she estimates she'll have around $300 for food and other bills for the rest of the month.
"Try not to spend anymore than you have. You get into the laundry money," Rosser says. "You go through your car to get the change."
It's a level of chronic desperation that Rosser could hardly imagine, growing up in an affluent family in the suburbs of Cleveland, Ohio. Rosser says her dad was an advertising executive.
"I was taught all about money when I was younger," she says. "How to invest it. How to save it. My father made me get a checking account when I was 15 and learn how to use it. And, you know, you get an education, you get a job, and everything is going to be okay."
And for a long time, things were okay. Rosser worked for years in creative services at a TV station. She bought a small house on a lake — a nest egg that she hoped would be there for her, when she retired. She had a daughter.
"Child went to good schools," Rosser says. "And them I was disabled, due to unfortunate genetics, at age 49."
Rosser was diagnosed with a serious mental illness and was advised not to work. She says she'd started saving for retirement during the latter part of her career. She used that money up during her first year out of work. Rosser applied for social security disability benefits. And for the next fifteen years or so, she lived primarily off those benefits and the equity in her house.
"I was using my house for a bank account," she says. "The equity in the house was a good thing. I hated to have to give it up that way."
Along the way, Rosser was diagnosed with another serious health condition, a lung disease that requires her to be on oxygen and pay for air conditioning round the clock during the summer, which pushes her electric bill as high as $180 a month. A little less than three years ago, Rosser decided time had come to sell her house. She had debts to pay off and her lung condition was making it difficult to continue going up and down flights of stairs.




Your health records are supposed to be private. They aren’t.


The federal law that protects health information is violated often and easily, and it's hardly ever enforced.

by Charles Ornstein

Seven years ago, I sat across from Farrah Fawcett in the living room of her Los Angeles condo. In what would be her last media interview before she died in 2009, the actress described her suspicion that an employee at UCLA Medical Center had shared details of her cancer treatment — and the setbacks along the way — with the National Enquirer.
Whenever she sought treatment there, the tabloids were quick with a story, even if it wasn’t right. “I actually kept saying for months and months and months, ‘This is coming from here,’ ” Fawcett told me. “I was never more sure of anything in my life.”
To prove her theory, Fawcett had set up a sting: In May 2007, she withheld news of her cancer’s return from nearly all of her relatives and friends. Within days, the story was in the Enquirer. “I couldn’t believe how fast it came out,” Fawcett said. A UCLA employee was caught and charged with selling information to the tabloid. She pleaded guilty but died before she was sentenced.
In 2008, prompted by Fawcett’s experience and those of other celebrities, California passed a law authorizing fines on hospitals that fail to protect patient privacy. Gov. Arnold Schwarzenegger signed it; his then-wife, Maria Shriver, was one of those whose records had been accessed inappropriately at UCLA.
The Office for Civil Rights of the U.S. Department of Health and Human Services produced this video about changes to the Health Insurance Portability and Accountability Act. (HHS)
At the time, I thought that this was a problem largely confined to the People magazine world of celebrities and that this law would quash the prurient interest in their medical records.
I was wrong.
After spending the past year reporting on loopholes and lax enforcement of the Health Insurance Portability and Accountability Act, the federal patient-privacy law known as HIPAA, I’ve come to realize that it’s not just celebrity patients who are at risk. We all are.
Over the course of my reporting, I’ve talked to hundreds of people who say their medical records were hacked, snooped in, shared or stolen. Some were worried about potential consequences for themselves and their families. For others, the impact has been real and devastating, requiring therapy and medication. It has destroyed their faith in the medical establishment.

The Hidden Financial Incentives Behind Your Shorter Hospital Stay
by Austin Frakt - NYT
After one of her operations, my sister-in-law left the hospital so quickly that she couldn’t eat for days; after other stays, she wasn’t discharged until she felt physically and mentally prepared. Five days after his triple heart bypass surgery, my stepfather felt well enough to go home, but the hospital didn’t discharge him for several more days.
You undoubtedly have similar stories. Patients are often left wondering whether they have been discharged from the hospital too soon or too late. They also wonder what criteria doctors use to assess whether a patient is ready to leave.
“It’s complicated and depends on more than clinical factors,” said Dr. Ashish Jha, a Harvard physician who sees patients at a Boston Veterans Affairs hospital. “Sometimes doctors overestimate how much support is available at home and discharge a patient too soon; sometimes we underestimate and discharge too late.”
Changing economic incentives — which are not always evident in individual cases — have also played a role in how long patients tend to stay. Recent changes to how hospitals are paid appear to be affecting which patients are admitted and how frequently they are readmitted.
What is clear is that hospital stays used to be a lot longer. In 1980, the average in the United States was 7.3 days. Today it’s closer to 4.5. The difference isn’t because hospitalized patients are becoming younger and healthier; by and large, today’s patients are older and sicker. Yet they’re being discharged earlier.
One big reason for the change came in the early 1980s. Medicare stopped paying hospitals whatever they claimed their costs were and phased in a payment systemthat paid them a predetermined rate tied to each patient’s diagnosis. This “prospective payment system,” as it is called, shifted the financial risk of patients’ hospitalization from Medicare to the hospital, encouraging the institutions to economize.
One way to economize is to get patients out of the hospital sooner. The prospective payment system pays a hospital the same amount whether a Medicare patient stays five days or four. But that extra day adds costs that hit the hospital’s bottom line.
So it’s in a hospital’s financial interest to encourage doctors to discharge patients sooner. A physician who practices at a Boston-area teaching hospital told me that hospital administrators exert social pressure on doctors by informing them that their patients’ stays are longer than that of their peers. It’s now easier for doctors to discharge patients sooner to a skilled nursing facility — where they’ll be monitored and professionally cared for — because so many more of them have been built in recent years.
Almost since the prospective payment system started, experts have raised concerns that it would lead to higher rates of readmissions. After all, patients discharged more quickly may tend to be sicker, more prone to complications or require a level of care that’s harder to provide outside the hospital. It seems logical, therefore, that more of them would need to return to the hospital. Evidence backs this logic. In the United States and other nations, when lengths of stay decline, readmissions rise.
Until recently, hospitals did not suffer financially when a patient was readmitted, so long as it was more than 24 hours after discharge. Indeed, readmission represented only additional revenue. If reducing lengths of stay increased readmissions while decreasing costs of each stay, hospitals benefited financially on both ends of the equation.
But Medicare and private insurance companies picking up the tab lose money when a patient is readmitted. In some cases, a longer initial hospital stay that avoids a readmission is worth the additional upfront investment.
The federal government has created several new programs that penalize hospitals for readmissions. Under Medicare’s Hospital Readmissions Reduction Program, hospitals now lose up to 3 percent of their total Medicare payments for high rates of patients readmitted within 30 days of discharge. This fiscal year — the fourth one of the program — Medicare will collect $420 million from 2,592 hospitals that had readmission rates higher than deemed appropriate.
Since 2010, when almost one in five Medicare hospital patients returned within 30 days, hospital readmissions have fallen considerably. Though this fact was highlighted by the Obama administration, some people are seeing evidence that hospitals are gaming the metric. For instance, patients who are placed under “observation status” are not counted in the readmissions metric even though they may receive the same care as patients formally admitted to the hospital. Likewise, patients treated in the emergency room and not admitted to the hospital do not affect the readmissions metric either. As readmissions have fallen, observation status stays and returns to the emergency department after a discharge have risen.
“When asked by hospital administrators to keep patients in observation status, many physicians comply,” Dr. Jha told me. “Some hospitals’ electronic medical systems will alert emergency physicians when a patient has been recently discharged, and they’re encouraged to keep them in the emergency department and not readmit them.”
The influence of hospital financing is hardly perceptible to an individual patient. But the record is clear: Financing matters, and it affects both hospital admission and discharge decisions.

Physicians are burning out, and patients must rally around them

It is only a slight oversimplification to compare the treatment of doctors to the treatment of teachers

By Kip Sullivan, J.D.
Star Tribune (Minneapolis), Dec. 29, 2015
A silent epidemic is ravaging our health care system — an epidemic of burnout among doctors. A paper published in the December issue of Mayo Clinic Proceedings reports that the percent of physicians admitting to at least one symptom of burnout rose from 46 percent in 2011 to 54 percent in 2014. By contrast, burnout in the general population over that period stayed at about 25 percent, way below the rate among doctors.
Other research has confirmed this problem. The Star Tribune reported in May that a national survey showed a 21 percent increase in burnout among doctors between 2011 and 2014.
The media, including the Star Tribune, is doing a good job of reporting on the problem and its immediate causes — more paperwork and less autonomy. But the media is not explaining why paperwork is going up and autonomy is going down. Why are doctors spending more time at their computers? Why are so many people who don’t belong in the examining room looking over the shoulders of doctors to second-guess them, grade them and subject them to financial incentives based on their grades?
It is only a slight oversimplification to compare the treatment of doctors to the treatment of teachers. Just as teachers have been subjected to deprofessionalization — and to some extent demonization — in the name of improving education, so doctors have been deprofessionalized and subjected to grossly unfair and inaccurate criticism in the name of improving medicine.
The main difference between the campaigns to rob teachers and doctors of their autonomy is that parents and students have rallied to defend their teachers. The No Child Left Behind (NCLB) law, and the obsession with measurement that it reflected, provoked a backlash among parents. No similar movement has arisen among patients to defend doctors.
That’s because the methods used to rob doctors of their autonomy are much less visible than the methods used to deprofessionalize teachers. The NCLB forced students to spend more time taking tests and teachers to spend more time “teaching to the test.” These consequences were quite visible to anyone who wasn’t living in a cave.
But the consequences of the physician deprofessionalization movement — let’s call it the No Patient Left Behind movement — are harder to see. Although patients are the ultimate victims of the obsession with micromanaging doctors that has constipated the minds of the health policy elite, we do not see the injury being inflicted on our doctors. For that reason, and because the injuries we as patients suffer as a result of physician burnout are also hard to perceive, we are not outraged by the No Patient Left Behind movement as parents and students were by the NCLB.
We should be.
The micromanagement of doctors, directly through “utilization review” by bureaucrats and indirectly via financial incentives tied to report cards, has taken a dreadful toll. By turning medicine into “factory work,” as the Star Tribune put it in its May article, proponents of micromanagement are driving doctors into early retirement and degrading the quality of services delivered by the physicians who remain in practice. Micromanagement buffs are also driving up costs (all of those computers, all of that data entry, all of that number-crunching and all of that third-party supervision have to be paid for somehow).
So what can we as ordinary patients do? We must stick our noses into a debate that has for too long gone on over our heads. Over the last half century, an unholy coalition of large employers and insurance companies has persuaded leaders of both political parties that U.S. health care costs are double those of other industrialized nations because U.S. doctors order too many services for their patients.
Never mind that underuse of medical care is far more common than overuse, even among those of us with insurance. Never mind that people in other industrialized nations use just as much health care as we do. Never mind that insurance company bureaucrats don’t know how to reduce overuse without aggravating underuse and driving up administrative costs.
The unholy alliance made up its mind that overuse — not excessive administrative costs, not excessive profits and prices — was the reason why U.S. health care costs are high, and that someone had to force doctors to stop ordering all those unnecessary services.
The solution the unholy alliance adopted came to be called “managed care” by the late 1980s. The terminology that managed-care advocates use has changed over the intervening decades, but the basic tactics remain the same: Micromanage doctors directly by vetoing their decisions or making them get approval for a treatment from insurance industry bureaucrats, and micromanage them indirectly by exposing them to the risk of financial penalties if their patients cost “too much” or if patients with one of a dozen diseases don’t get “quality” care as the bureaucrats define it.
These counterproductive efforts to control physician behavior are what are burning doctors out. They are also driving doctors into the arms of large hospital-clinic chains called “accountable care organizations” (ACOs), where their autonomy is even further reduced. (ACOs are HMOs on training wheels). Both problems — the rising physician burnout rate and the takeover of our health care system by a few enormous corporations — have occurred with no public debate.
The deliberations of the Minnesota Health Care Reform Task Force are typical of the problem. The task force is supposed to issue a report to the Legislature in January on how to improve our health care system. But it has devoted no time to the physician burnout problem. It has, however, spent many hours discussing more measurement of doctors and pushing more doctors into ACOs.
If Minnesota patients remain oblivious to the physician burnout problem, we will soon regret it. We should let our legislators know that we want the problem addressed. And we don’t mean massages and therapy for our doctors. We mean a restoration of physician authority to make decisions based on evidence and patient values, and an end to the managed-care tactics that are burning out our doctors.
Kip Sullivan is a nonphysician member of the board of the Minnesota chapter of Physicians for a National Health Program.

A Single-Payer System: Best for Doctors and Patients Alike?

By Neil Chesanow
Medscape, Dec. 21, 2015
Recently, Medscape published two provocative articles on the viability of a single-payer healthcare system in which experts took opposing views on the issue. In one article, one group argued why it would save US healthcare; in the other, another group made the case that adopting a single-payer system would be the ruin of US healthcare.
In the article on why a single-payer system would be our salvation, Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and an architect of the Affordable Care Act (ACA), contended that although the ACA has been "a step forward for the country," it "does not deal with the problem of waste and complexity in the system," as he feels a single-payer system would.
And James Burdick, MD, a transplant surgeon at Johns Hopkins University School of Medicine and author of the forthcoming book "Talking About SINGLE PAYER," argued that a single-payer system is "a more economical way to use healthcare resources. You could reduce expenses and still improve quality. That's a tremendous opportunity that you don't have in many other fields."
Of course, as the article pointed out, this would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000. But Dr Burdick believes it would likely restore doctors' authority. And those who favor single-payer say that for all practices, administrative costs would plummet because there would be only one set of payment rules. Prior authorizations, narrow networks, and out-of-pocket payments would be eliminated, proponents of a single-payer system maintain.
The article also pointed to evidence of growing physician support for a single-payer system. For example, a 2014 survey of Maine physicians conducted found that nearly 65% of respondents preferred the single-payer option over trying to fix the current system—up from 52% in a 2008 survey. Physicians in general seem more open to a single-payer system.
Americans are warming up to the idea too. A tiny majority (51%) support Medicare for all, according to a national poll released in January. Many experts believe that the movement for a single-payer system may start at the state level, although the public's abiding mistrust of government must still be overcome.
The article ignited impassioned arguments about the pros and cons of a single-payer system among the well over 100 physicians who responded with comments. Several doctors proposed thoughtful alternatives to "Medicare-for-all."
"Commercial insurance is a failure and a joke," one doctor opined. "Families pay more than $15,000 per year for health insurance and still have $2500 in deductibles, plus high copays. Patients are reluctant to get healthcare in outpatient settings, since private insurance does not cover anything unless a catastrophic event occurs. Many doctors no longer accept private insurance owing to their numerous administrative burdens. We easily forget that the primary goal of private insurance in capitalism to make a profit for the CEOs of insurance companies and the shareholders who own stock in them. Personally, I would prefer a 100% Medicare practice."
"Medical insurance is supposed to be only for catastrophic events, like car insurance," another physician shot back. "Can you imagine if Americans wanted insurance to pay for routine maintenance and fuel for their cars? The healthcare system is broken. You solution is to break it some more. My solution for my family is to live within our means, never go into debt for more than 30 days at a stretch, and never purchase health insurance—except very high-deductible, catastrophic-event insurance. Emergency rooms are for broken bones, gushing wounds, anaphylaxis, and other genuine emergencies, not sniffles and sprains. A full medicine chest and a bit of common sense is our family's strategy."
"A government-run single-payer system is without a doubt the only way to provide effective medical health therapeutic and management, a doctor contended. "For those who desire a higher level of care—and can afford it—there will be a concierge and private-pay system. As medicine advances technologically, this will become a necessity. The loss of jobs in the insurance industry will be partially offset by an increase in the added positions in the government medical system."
"Obamacare barely passed through Congress with Democrat-only votes, and only with the assistance of bribes, threats, and lies," an anesthesiologist fumed. "It has never garnered more than 30% public approval; and it has been changed over 40 times by the Obama regime illegally, without benefit of legislation by the legislative branch. The clowns who thought it was such a terrific idea back then are the same clowns braying for single-payer now. Why we are supposed to trust them this time? Why is it that the only answer to failed socialist government programs is more socialist government programs?" 
"Single-payer reform would be an audacious step," a radiologist observed. "It would virtually eliminate the entire commercial insurance industry—with $730 billion in revenues and a workforce of 470,000—and replace it with one unified payer. EXCEPT that when the government takes over, it will cost $1.4 trillion and require a 900,000-person workforce."
"A one-payer system will not be like 'Medicare-for-all'; it will be end up becoming more like 'Medicaid-for-all,'" a pulmonologist warned. "How many of you in private practice could make a living if 100% of your patients were on Medicaid?"
"Yes, turn it over to the government," a doctor acerbically wrote. "They will make our lives easier and reduce our paperwork and the onerous documentation requirements during patient encounters. Oh wait! They are the ones doing now that with Medicare. Never mind."
"I don't see one valid point against single-payer in these comments, just the usual 'anticommunist' stuff," another doctor reasoned. "A number of comments trashed the Veterans Administration (VA). The VA system has a lot going for it, considering the level of acuity of the population it serves—starting with a functional electronic health record. Do the detractors think that a random assortment of for-profit HMOs would do a better job serving the high-utilization health needs of veterans? Basic healthcare is like a utility—something everyone needs, and in the best interest of our society to make sure everybody gets." 
"Why does it have to be a single-payer?" one doctor wanted to know. "Why not a government payer for essential care and let private payers compete for the rest?"
"Why not allow anyone to buy Medicare as their insurance, rather than just those over 65?" another doctor counter-proposed. "Young, healthy people could get Medicare, and the premium would be much less than commercial insurance. Their utilization of medical services is generally lower, so the money generated would be a net to Medicare. If commercial insurance wants to compete, it would have to lower its rates. This would generate competition among Medicare and commercial insurers and drive premiums down. If you want Medicare, then get it. If you want commercial insurance, then get it. Let the individual decide, but give the option of Medicare."

UNDER OBAMACARE, MEDI-CAL BALLOONED TO COVER 1 IN 3 CALIFORNIANS


CALIFORNIA OFFICIALS NEVER ANTICIPATED HOW MANY PEOPLE WOULD SIGN UP FOR STATE-RUN HEALTH INSURANCE UNDER OBAMACARE.

THE STATE'S HEALTH PLAN FOR THE POOR, KNOWN AS MEDI-CAL, NOW COVERS 12.7 MILLION PEOPLE, 1 OF EVERY 3 CALIFORNIANS.

IF MEDI-CAL WERE A STATE OF ITS OWN, IT WOULD BE THE NATION'S SEVENTH-BIGGEST BY POPULATION; ITS $91-BILLION BUDGET WOULD BE THE COUNTRY'S FOURTH-LARGEST, TRAILING ONLY THOSE OF CALIFORNIA, NEW YORK AND TEXAS.
"WHEN THE FINAL NUMBERS STARTED COMING OUT, WHERE A THIRD OF THE POPULATION WAS ON MEDI-CAL, IT WENT WAY PAST ANYONE'S EXPECTATIONS," SAID STATE SEN. ED HERNANDEZ (D-WEST COVINA), WHO CHAIRS THE SENATE HEALTH COMMITTEE.
EXPANDING MEDI-CAL WAS A KEY PART OF THE AFFORDABLE CARE ACT, THE NATIONAL LAW THAT OVERHAULED THE HEALTHCARE SYSTEM AND REQUIRED NEARLY ALL AMERICANS TO HAVE INSURANCE STARTING IN 2014. UNDER THE LAW, MEDI-CAL — HISTORICALLY A HEALTH PROGRAM FOR POOR FAMILIES AND THE DISABLED — WAS OPENED TO ALL LOW-INCOME CALIFORNIANS STARTING TWO YEARS AGO, WITH THE FEDERAL GOVERNMENT PAYING FOR THOSE NEW ENROLLMENTS.
THOUGH A SURPRISE, THE HIGH MEDI-CAL ENROLLMENT IS GENERALLY HAILED AS A SUCCESS. CALIFORNIA'S UNINSURED POPULATION HAS BEEN CUT IN HALF SINCE OBAMACARE, IN LARGE PART BECAUSE SO MANY CALIFORNIANS SIGNED UP FOR MEDI-CAL, WHICH IS FREE FOR BENEFICIARIES.


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