The link below will take you to an important edition of the NPR show "On Point" that was broadcast on April 4. The topic was the moral injury being inflicted on healthcare practitioners by our commodified, commercialized and corporatized for-profit health care system.
It's well worth your time to listening to it:
Editor's Note:
The accompanying Bangor Daily Column was written by me in 2015. It also touches on the issue of moral injury.
-SPC
How American health care turned patients into consumers
By Dr. Philip Caper, Special to the BDN
Posted March 19, 2015, at 11:05 a.m.
A clash of cultures is rapidly developing among those of us who see the mission of the health care system to be primarily the diagnosis and healing of illness and those who see it primarily as an opportunity to create personal wealth.
The concept of health care primarily as a business is uniquely American, and it has gained ascendancy during the last few decades. While there have always been a few greedy doctors, businessmen-wealth-seekers — not doctors — now dominate the medical-industrial complex. They include for-profit insurance, medical device and pharmaceutical companies as well as for-profit and nonprofit corporate providers of health care services, such as the three large hospital systems in Maine.
Partly because of the Affordable Care Act, they also include a rapidly growing army of lawyers, consultants and policy wonks who are creating lucrative businesses helping hapless “consumers” — formerly “patients” — “navigate” their way through the grotesquely byzantine maze our health care system has become.
This shift in emphasis from patient care to money profoundly has affected the practice of medicine and resulted in the clash of cultures within health care. As increasing numbers of “providers” — formerly “doctors” — become employees of large health care corporations — formerly community hospitals — we have come under increasing pressure to diagnose profitable diseases and order profitable tests and procedures without enough regard to the benefits or harm accruing to patients. Hospital “CEOs” — formerly “administrators” — trained in the ethics and practices of business rather than health care are incentivized to configure their “product lines” — formerly “services” — to produce the largest “profits” — formerly “margins.”
Those of us in the health care “business” — formerly “profession” — have been slow to react to this hijacking of our health care calling. Patients, despite sensing something is deeply wrong, feel helpless to push back. That now seems to be changing.
For the past three years The Lown Institute, founded by Dr. Bernard Lown, renowned cardiologist and advocate for universal health care, has held conferences designed to point out the growing problem of overtreatment in medicine. Recently they also have turned their attention to the equally disturbing problem of impaired access to health care and undertreatment. They now advocate for
RightCare — not too much treatment and not too little.
Arguably some of the most important effects of Obamacare have been the destabilization of our deeply dysfunctional health care system and an order-of-magnitude increase in the amount of attention given to its dysfunction by the media and the public. Elisabeth Rosenthal’s excellent New York Times series “Pay Till It Hurts” and Steven Brill’s Time magazine cover story and book titled “America’s Bitter Pill” are two of the most recent examples. These two factors have created an opportunity for real structural and cultural change.
There are many advocacy groups — Physicians for a National Health Program, HealthCare-NOW, Maine AllCare — trying to highlight these issues and to propose ways to turn this runaway train around.
While they are necessary, attempts at education and persuasion are not sufficient. Unlike past human rights movements, such as women’s suffrage and marriage equality, the fight for the right to health care for all Americans will require redirecting huge sums of money away from deeply entrenched, profit-oriented private corporations to not-for-profit programs that directly promote the public’s health and wellbeing.
The Institute of Medicine estimates that the convoluted American health care system wastes $750 billion per year in inefficiency and fraud, unnecessary administrative complexity and medical services, unjustifiably high prices and missed prevention opportunities. That waste creates a lot of jobs but does not pay for one Band-Aid or aspirin.
I attended the latest Lown conference, held last week in San Diego, to talk about the “Heal-In” held at Boston City Hospital in 1967 as an example of direct action taken by doctors, nurses and other healers to achieve a political goal without compromising patient care. The capstone of the conference was to announce the expansion of Lown’s mission, previously focused on education and discussion, to include creation of a national grassroots movement that will include direct action. Their first foray will be called RightCare Action week and is scheduled for the fall. Stay tuned.
Changing our health care system is as much about persuasion through power as it is about the power of persuasion. We as patients have power through the ballot box, and we as health care workers have power through our key roles in the “business” of health care to return and redirect its mission toward healing and away from its increasingly singular obsession with profitability.
All we have to do is summon the will and the courage to exercise that power.
Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com or through his website at philcaper.net.
http://bangordailynews.com/2015/03/19/health/blogs-and-columns/how-american-health-care- turned-patients-into-consumers/ printed on March 19, 2015
I'm re-posting the following article I posted in my March 9 blog. I'm about to read Nuila'a book, "The People's Hospital".
-SPC
American Health Care Is Dying. This Hospital Could Cure It.
A few months ago, I had to give a patient the worst news.
“It looks like your cancer has returned,” I said.
The man had religiously attended his chemotherapy and radiotherapy sessions in the city’s public health care system up until nine months before. Looking for a little more scheduling flexibility with his appointments, he took a step that seemed logical.
“I got health insurance,” he said, the eyeglasses on his forehead still for a moment. “Everything changed from there.”
Health insurance was supposed to improve his medical experience, but my patient couldn’t find an oncologist or hospital — even in the public system — that accepted his particular type. After months of searching, he grew discouraged; eventually he gave up. “A lot of this is on me,” he told me, ruefully.
This is the level of confusion and complexity we’ve come to accept as normal in our health care system.
I work as an internal medicine doctor at Houston’s Ben Taub Hospital, which is part of a public health system that treats Harris County’s most vulnerable patients, many of whom don’t have insurance. I often see the back end of our insurance fiasco: I’ve cared for dozens of patients who were sent to our E.R. hours after receiving inadequate treatment elsewhere. I’ve felt the injustice of a patient dying after he was dropped by his insurance. I’ve also seen patients hit with unexpected medical bills showing arbitrary prices after visiting the emergency room of a private hospital.
Visiting a hospital or clinic today feels like facing a firing squad, with rounds and rounds of bills coming from every direction. Fewer than half of Americans rate the quality of U.S. health care as excellent or good. We all have our stories. Whether through Twitter rants or opinion pieces or surveys quantifying how many of us grade the system as a failure — 56 percent at last count — we are fed up.
Patients are burned out. Nurses are leaving the profession. Doctors are demoralized. In the meantime, the people not sick or tending to sickness — the corporate middlemen in charge of insurance companies, private hospitals, doctor practices and pharmaceutical companies — are feasting. As Donald Berwick, a former administrator for the Centers for Medicare and Medicaid Services, noted, the “glorification of profit, salve lucrum, is harming both care and health.”
After listening to partisan rants on both sides that aim only to tweak rather than remake our system, I suggest we hold a national referendum on health care. Americans should vote yea or nay on a system that provides basic health care for all.
A federal ballot measure like this has never been held in our country. A referendum would ask Americans to focus on the proposal rather than on a candidate or political party. There’s reason to believe that a direct vote could help us solve our health care quagmire. In a recent survey, about two out of three Americans said it was the government’s responsibility to provide universal health coverage. Another study conducted in my home state showed the same, with seven out of 10 Texans declaring universal health coverage important.
It won’t be easy. Scholars have indicated that it may take multiple election cycles, along with volunteers collecting millions of signatures across the country, to achieve such a monumental feat. Americans are already split about how private insurance would figure into the equation. If history is any indication, those who benefit from our bloated system — the large corporations that keep American consumers in a stranglehold — would brew confusion about the plans in an effort to resist any change.
If the referendum resulted in a majority of “yes” votes, it would send a clear message to Congress and the president: Build us a universal health care system. The hard work of constructing that system and a way of paying for it would start there. Medicare for All, as proposed by Senator Bernie Sanders, would eliminate private insurance that duplicated what was offered in the single-payer system. This standard insurance would eliminate patients’ out-of-pocket expenses and make it harder for hospitals and doctors to cherry-pick those with more lucrative insurance. Multiple iterations of single-payer plans have sprung from Medicare for All, including some that would preserve private insurance. An altogether different plan, a public option, would preserve Americans’ choice to buy private insurance. The drawback would be that without a mandate, health care gaps would most likely still exist.
Controlling health care costs is a problem that has long confounded Americans. For this reason, I favor something different, a public health care system modeled after the one I’ve worked in for the past 12 years. The system provides health care directly — without the middleman of insurance — to nearly half its patients. When it bills a patient’s insurance, the system does so at a reasonable rate, on par with what Medicare pays.
As a resident, I rotated through private hospitals and saw how easy it is to default toward more expensive treatment. In a public system, doctors like me work on salary without financial incentives to overutilize tests or procedures, which further keeps costs in check and patient outcomes top of mind. The lack of a profit motive allows the system I work in to focus on providing quality care while cutting costs. In fact, in 2022, Ben Taub Hospital and the public system saved more than $1.8 billion in health care costs. This amounts to $2.30 in health care cost savings to Harris County taxpayers for every $1 in county taxes collected.
The public health care system in Harris County came into existence thanks to a local referendum in November 1965. The charity hospital that preceded it, Jefferson Davis Hospital, was notoriously underresourced and underfunded. When news spread of its deplorable conditions, citizens decided that the city’s standards had to be addressed. Health care had become a moral issue.
I’m not a specialist; I’m the hospital’s jack-of-all-trades, the doctor tasked with keeping care effective and efficient. As a hospitalist, I don’t have to spend time figuring out if an insurance company will authorize a patient’s treatment. Not worrying about reimbursements means I can focus on medicine. Ours are not easy jobs — our patients often arrive with undiagnosed diseases resulting in one or more organs failing — but at least we can provide good care to everyone. More than 50 years later, it remains as such. I take solace in knowing that I work for a system that tries to help all patients.
After the news sank in of his cancer’s return, my patient asked that I sit down with him. He had things on his mind, questions. He confided to me that his family didn’t know about his illness, and I told him how much I wished he had stayed at Ben Taub and that things had been different. I began to tell him what kind of treatments he might still expect. He stopped me. “I appreciate this hospital so much,” he said. “Y’all are here when no one else is.”
Millions on Medicaid May Soon Lose Coverage as Pandemic Protections Expire
by Noah Weiland - NYT - April 3, 2023
KANSAS CITY, Mo. — In a closet-sized windowless office, Kialah Marshall maintains an Excel spreadsheet with a prosaic title, “Medicaid Unwinding,” the source material for a mind-numbing routine.
Five days a week, she and a group of co-workers in a poor section of Kansas City, Missouri’s largest city, call 75 to 100 Medicaid recipients from a list of about 19,000 who receive care at Swope Health, a federally funded network of health clinics. Their assignment is straightforward: warning those patients that they could lose their health insurance for the first time in at least three years.
“Medicaid is on the line,” Ms. Marshall, once a recipient herself, said in that cramped office last week, describing how she delivers the potentially dire news.
As of Saturday, state officials around the country could begin removing people from Medicaid who no longer qualify — something they had been prohibited from doing under a provision in a coronavirus relief package passed by Congress in 2020.
That package offered states additional federal funding in exchange for guaranteeing that recipients of Medicaid, a joint federal-state program that serves low-income people, would retain their health coverage during the pandemic. In part because of that policy, the nation’s uninsured rate reached a record low early last year.
Medicaid and the Children’s Health Insurance Program have ballooned to cover roughly 90 million people, or more than one in four Americans — up from about 70 million people at the start of the pandemic. The guaranteed coverage amounted to an extraordinary reprieve for patients, preserving insurance for millions of vulnerable Americans and sparing them the hassles of regular eligibility checks.
The federal government has estimated that about 15 million people will lose coverage in the coming months, including nearly seven million people who are expected to be dropped from the rolls even though they are still eligible. Nearly half of those who lose coverage will be Black or Hispanic, according to federal projections.
The changes in eligibility could lead to more people signing up for private coverage through the Affordable Care Act’s marketplaces, where some people who lose Medicaid coverage will be eligible for free plans.
But hundreds of thousands of people could end up in the so-called coverage gap in states that have not expanded Medicaid under the Affordable Care Act, with incomes too low for subsidized coverage through those marketplaces but too high to qualify for Medicaid.
The speed and mechanics of what Ms. Marshall and state and federal health officials are calling the “unwinding” will vary by state. A majority of them plan to take 12 to 14 months to complete the eligibility verifications, with many states beginning to remove people from Medicaid rolls by late spring or early summer. Only five states — Arizona, Arkansas, Idaho, New Hampshire and South Dakota — were expected to begin axing people from Medicaid this month, according to the federal government.
Some state officials have argued that the program is merely retreating to its intended size and shape. “We’ll be able to go back in there and say, ‘OK, do you belong? Do you not belong?’” Gov. Michael L. Parson of Missouri, a Republican, said in February.
Annual eligibility checks can save states money by relieving their Medicaid programs of spending on participants who no longer qualify for coverage. But they often result in a cycle that health policy experts call churn, or when people eligible for Medicaid lose their insurance in the confusing, intimidating bureaucracy of enrollment verification, then eventually re-enroll.
“Those people don’t have anywhere else to go,” said Jennifer Tolbert, an associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. She added that the consequences would be severe for people with chronic health conditions for whom a week or a month without insurance could be especially risky.
Researchers have found that most people who lose Medicaid coverage often go without insurance for some period of time, while about four in 10 regain Medicaid coverage within a year.
In Missouri, where state officials have warned that as many as 200,000 people may lose coverage, the unwinding could result in a boom-and-bust cycle.
The state expanded Medicaid under the Affordable Care Act during the pandemic, resulting in more than 300,000 new adults with coverage. It now has about 1.5 million Medicaid recipients, half of whom are children.
That growth makes the state a proverbial canary in the coal mine for the rest of the country during the unwinding, said Timothy D. McBride, a health policy expert at Washington University in St. Louis and the former chair of an oversight committee for the state’s Medicaid program. He pointed to a controversial period in 2018 and 2019, when officials used a new process for verifying Medicaid eligibility to remove over 100,000 people from the rolls, many of them children. That led to complaints of unjust removals.
“Have we learned lessons from that period?” Dr. McBride asked.
Medicaid eligibility rules vary by state. They can depend on a family’s income, whether someone is raising a child and whether a person has a disability. Millions of children and pregnant women benefit from the program.
For states, tracking down those who are on Medicaid will be daunting, experts say. Some people will have moved, and some will have died. Phone numbers will have changed, making some people hard to reach. Others will be earning more, making them ineligible for coverage.
Researchers at the Kaiser Family Foundation and the Georgetown University Center for Children and Families found different strategies among states, some of them with spottier technology that could hinder efficient re-enrollment. Most states, the researchers found, were using databases from other government programs, such as food stamps or Social Security, to verify eligibility for Medicaid automatically and save people the hassle of filling out paper forms. Missouri has adopted that strategy.
The so-called continuous enrollment policy requiring that Medicaid recipients retain their coverage was initially set to end with the expiration of the public health emergency for the pandemic, which the Biden administration is planning to allow to lapse in May. But before the administration announced its plans to end the emergency, a spending package that Congress passed in December separated the Medicaid policy from the emergency declaration and established an April 1 starting point for the unwinding.
When lawmakers set that date, they attached guardrails to encourage states to undertake the work gradually. The legislation mandates that states report data monthly to the Department of Health and Human Services on how many people have been taken off Medicaid. It also allows the department to intervene if a state does not comply with federal requirements.
Missouri is starting with people whose coverage would be up for renewal in June, a group of about 100,000. The state is leaning on managed care organizations to work with Medicaid recipients on renewals, but the effort required of the state is still immense. Kim Evans, the official overseeing the Medicaid unwinding in Missouri’s Department of Social Services, said she had about 1,200 government workers available to help.
Those whose status the state is still uncertain about after automatic checks will be mailed letters early next month, and they will have until the end of June to complete renewal forms. If they miss that deadline, they will lose their insurance, but they can still challenge the decision and be re-enrolled if state officials determine them to be eligible.
Ms. Evans called the work an “all-out assault” to reach people who might otherwise slip through the cracks.
Sidney D. Watson, a health law professor at Saint Louis University, said the unwinding could be particularly damaging to the many seasonal agricultural workers in rural stretches of the state, like in the Ozarks. “Everyone is on high alert here,” she said, adding that Medicaid coverage among those seasonal workers was important to keeping smaller hospitals and clinics running.
Clinics like Swope Health are especially critical to warning Medicaid recipients about the unwinding policy, since their doctors and other health providers often know people affected by the policy change. Swope has run radio ads and placed billboards in and around Kansas City, which have increased calls from Medicaid recipients inquiring about how to preserve their insurance, said Tamika Reliford, one of Ms. Marshall’s co-workers who helps patients with their coverage.
Almost half of Swope’s roughly 40,000 patients are covered by Medicaid or the Children’s Health Insurance Program, meaning the clinics rely on Medicaid funds. “We still have to employ the providers, the nurses and administrators here to do the hard work,” said Jeron Ravin, Swope’s chief executive.
For some Swope patients unaware of the unwinding, it takes a lucky encounter. Unable to get Medicaid to cover his eye-drop prescription for glaucoma in recent weeks, Derrick Smith learned something more important when he asked Swope for help: He could eventually lose his coverage altogether.
Checking Mr. Smith’s Medicaid status, Ms. Reliford noticed he had moved, making him vulnerable to missing a mailing about the unwinding if one was sent to his previous address. Mr. Smith had not heard about the eligibility check.
“I was real close on it,” he said sheepishly while visiting a Swope clinic last week, adding that losing his insurance would have been an “easy mistake” for him to make.
Mr. Smith was one of the hundreds of thousands of adults who secured Medicaid coverage when Missouri expanded the program under the Affordable Care Act during the pandemic. But like others who gained coverage that way, he will be getting his first glimpse of annual scrutiny of his eligibility.
Ms. Marshall, the Swope employee working through the Medicaid spreadsheet, said she worried about sending patients into a state of “frantic panic” when she reaches them to warn about the possibility of losing coverage. “This is something that a person needs,” she said, “for their family, for their children.”
https://www.nytimes.com/2023/04/03/us/politics/medicaid-enrollment-pandemic.html
Millions of Americans May Soon Lose Medicaid Coverage. Here’s How to Prepare.
As pandemic protections expire, states are redetermining which people are eligible for the health insurance program.
by Dani Blum - NYT - March 31, 2023
Throughout the pandemic, millions of Americans on Medicaid have been shielded from losing health care coverage. Medicaid provides health coverage for low-income Americans; for the past three years, states suspended their typical process of redetermining whether someone remained eligible for coverage.
States must now reverify that every Medicaid recipient still qualifies for the program within the next 14 months.
Many people will continue the same Medicaid coverage they’ve had for years, but millions could lose access to their current coverage — either because they don’t qualify for Medicaid anymore, or even if they do continue to qualify, because the administrative hurdles to renew their coverage are so high. In particular, people with disabilities, people who are not native English speakers and people who changed addresses during the pandemic may struggle to wade through the red tape, said Lindsay Allen, a health economist and Medicaid policy researcher at Northwestern Medicine.
States can begin the process of disenrolling people who are not eligible on April 1, and they have 14 months from that date to complete the redetermination process, with people losing coverage intermittently throughout. Each state will have a slightly different process, and most will take a full year to work their way through every Medicaid enrollee.
“There’s 92 million people in our country that need to fill out paperwork all at once, in a very confined amount of time,” said Dr. Jose Francisco Figueroa, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health.
Who will be affected?
Some people will get kicked off Medicaid because they make significantly more income than they previously did. Some health policy experts are worried about those who remain eligible but don’t have the time or resources to complete what can be a cumbersome renewal process.
“We’re worried that many people, when they go try to schedule an appointment with their doctor, somebody’s going to tell them, ‘Oh, you don’t have insurance anymore,’” Dr. Figueroa said.
If you have moved, your current state’s Medicaid program may have a harder time reaching you.
“We know whenever these sorts of moments happen, it’s people of color, it’s kids, it’s people that don’t speak English that are always hit the hardest,” said Natalie Davis, a founder and the chief executive of United States of Care, a nonpartisan advocacy organization that supports expanding access to health care.
How can you prepare?
It’s critical to make sure your contact information is up-to-date with your state Medicaid office. In many states, you can create an account on your state Medicaid website, where you can verify that your information is accurate and update your communication preferences. And you can always locate the phone number of your state’s Medicaid office to call and confirm, although call centers may be particularly bogged down during this period.
Watch for communication from your state Medicaid office — notices in the mail, phone calls, emails. Some states have already begun contacting people to inform them about the renewal process.
While all states must begin contacting enrollees by April, most people won’t receive this renewal notice for months, said Jennifer Tolbert, an associate director of the Program on Medicaid and the Uninsured at the Kaiser Family Foundation. “I do worry that there’s all this urgency around April 1 and when nothing big happens in April that everyone just breathes this big sigh of relief and says, ‘Oh, I’m fine, I don’t have to worry about this.’ But that’s not going to be the case.”
Different states may require different documentation, but in general, they will want to verify your income, address and whether you’ve had a change in the number of dependents, said Ms. Davis. You may receive a notice asking to confirm or update your financial or other information; people typically are given 30 days to respond, Ms. Tolbert said.
“Everyone who’s on Medicaid today: Expect to fill out paperwork,” Dr. Figueroa said.
What should you do if you lose Medicaid coverage?
If you’re notified that your Medicaid coverage has been terminated but you think you continue to qualify, the first thing you should do is find out if you lost coverage inappropriately, Ms. Tolbert said. Contact your state Medicaid office — although keep in mind that call centers are likely be swarmed, she advised.
“Don’t give up if you can’t get through via the phone,” she said. “Stick with it.” You can request what’s known as a fair hearing process, to appeal the state’s decision to terminate your Medicaid benefits.
You can find a directory of organizations that can help you navigate Medicaid renewal at Localhelp.healthcare.gov.
What are the options if I’m no longer eligible for Medicaid?
If you are no longer eligible for Medicaid, your best bet is to seek out subsidized insurance by going to the online Affordable Care Act marketplaces either operated by your state or available at HealthCare.gov. The American Rescue Plan expanded insurance subsidies, so people who lose access to Medicaid may still be able to find an affordable plan, Ms. Tolbert said. But some people in the 10 states that have not previously expanded Medicaid will be left in a coverage gap, she said, not eligible for subsidized insurance but also unable to qualify for Medicaid.
If you are employed, you may be able to get coverage from your employer. Reach out to your H.R. department within 60 days of losing coverage — the sooner, the better — to ask about coverage. If you’re married, your spouse may want to ask their employer about potential coverage options that can apply to you; if you’re an adult under the age of 26, you may also be able to switch to your parents’ insurance.
And if you’re a parent, just because you’ve lost coverage doesn’t always mean your child will. Any notification that you’re no longer eligible for Medicaid should explain if your child retains coverage, Ms. Tolbert said — but if you’re unsure of your child’s status, get in touch with your state Medicaid office.
It’s the compounding weight of these intricacies — uncertainty over which plan covers which family member, confusion over what information someone needs to qualify for Medicaid — that policy experts worry will further burden Medicaid recipients. The extra stress of redetermination adds a “mental tax,” Ms. Davis said.
But as the redetermination process kicks off, tracking down contact information for state agencies you can turn to in advance and watching for important communications can help you prepare. “If you’re proactive, you can minimize the chance of a gap in your coverage,” Dr. Allen said.
https://www.nytimes.com/2023/03/31/well/live/medicaid-health-insurance-eligibility.html
No comments:
Post a Comment