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Friday, January 24, 2014

Health Care Reform Articles - January 24, 2014


Hospital Chain Said to Scheme to Inflate Bills

By  and 
    Every day the scorecards went up, where they could be seen by all of the hospital’s emergency room doctors.
    Physicians hitting the target to admit at least half of the patients over 65 years old who entered the emergency department were color-coded green. The names of doctors who were close were yellow. Failing physicians were red.
    The scorecards, according to one whistle-blower lawsuit, were just one of the many ways that Health Management Associates, a for-profit hospital chain based in Naples, Fla., kept tabs on an internal strategy that regulators and others say was intended to increase admissions, regardless of whether a patient needed hospital care, and pressure the doctors who worked at the hospital.
    This month, the Justice Department said it had joined eight separate whistle-blower lawsuits against H.M.A. in six states. The lawsuits describe a wide-ranging strategy that is said to have relied on a mix of sophisticated software systems, financial incentives and threats in an attempt to inflate the company’s payments from Medicare and Medicaid by admitting patients like an infant whose temperature was a normal 98.7 degrees for a “fever.”
    http://www.nytimes.com/2014/01/24/business/hospital-chain-said-to-scheme-to-inflate-bills.html
    Sorry for this, but I just couldn't resist putting  links to a couple of my previous BDN columns in at this point. Please read the preceding article before you read these columns.
    -SPC

    Is medical care a good business?

    By Philip Caper, Special to the BDN
    Posted Oct. 20, 2011, at 4:42 p.m.
    For the past several decades, America has been experimenting with applying the principles of business to our health care system. Many believed that by unleashing the power of markets, health care costs would be controlled and access and quality improved.
    That experiment has been a spectacular failure. Today, a larger percentage of Americans lack health insurance or are seriously under-insured than at any time since the enactment of Medicare and Medicaid 46 years ago. That number is increasing every day.
    Health care costs are at levels never before seen anywhere in the world and are increasing in an uncontrolled and unsustainable way. Despite our high per-person costs — double those of other developed countries — tens of thousands of Americans die every year from lack of timely access to health care.
    The degree of interference with doctors’ and patients’ health care decisions that exists in America today would not be tolerated anywhere else in the world. “Death panels” do exist in America, but they are run not by government but by private corporations. Their purpose is to maximize profits.
    Americans are unique in the world in thinking about health care as a business. In no other country is that notion so widely and unquestioningly accepted.
    In his landmark 1983 book about the sociology of American medicine, Paul Starr describes its evolution throughout much of the 19th and 20th centuries as being driven primarily by mission — preventing illness when it could and diagnosing, treating, curing and comforting patients when it couldn’t. In the early 20th century, George Merck, founder of the large pharmaceutical company bearing his name, provided an example of this approach when he said “If we develop good medicine that cures people, money will take care of itself.” Mission, not money, motivated most of those involved in medical care.
    Starr’s book describes the successful efforts of physicians to block the creation of health care as a right of all Americans during the first half of the 20th century. They were afraid of a government takeover of medicine. But, Starr warned, the real threat to the autonomy of American doctors was not government, but corporations.
    Now, almost thirty years later, Starr’s warning has come true. Large corporations, many of them for-profit and publicly traded now dominate the financing and delivery of American medical care. As Melody Petersen has documented in her book “Our Daily Meds,” instead of embracing George Merck’s philosophy, pharmaceutical companies have become huge marketing machines. They now are focused far more on their profitability than on their healing mission. Producing medicine that cures diseases instead of just treating symptoms has become a bad business model. Once a disease is cured the customer disappears and profits decline.
    It was not always this way. Thinking about medicine shifted during the late 1970s due to the belief that what was needed to cure the rising costs and increasing numbers of uninsured was a more businesslike approach. Business schools began to offer courses in health care and doctors began to acquire MBAs.

    The ills of money-driven medicine

    By Philip Caper, Special to the BDN
    Posted May 17, 2012, at 11:57 a.m.
    A couple of weeks ago, nine medical specialty societies released a list of 45 medical tests and procedures they believed are significantly overused. On the heels of this announcement was a conference on “Avoiding Avoidable Care” attended by about 150 experts, mostly physicians. I attended.
    We spent two days discussing the reasons for and ethics of unnecessary medical care in the U.S. Instead of blaming others (such as patients or malpractice lawyers), the doctors at this conference mostly agreed that “If you’re looking for an explanation for medical care overuse — too many tests, procedures and prescriptions — follow the money.”
    The amount of overuse was estimated to be around 30 percent of all medical care. We spend $2.7 trillion annually on medical care in the U.S. Thirty percent of a big number is still a big number, about $800 billion in this case. In our industrialized health care system, moving “product” is important, whether or not it is really necessary.
    The World Health Organization reported earlier this month that the U.S. ranks poorly in our rate of premature births. Our rate of prematurity has risen around 30 percent since 1981. We are now on a par with Turkey, Kenya, Thailand and Honduras at about 12 percent. Canada, Australia and Europe all fare significantly better with rates around 7 percent.
    The high U.S. rate is attributed to a variety of factors. Lack of prenatal care tied to poor health insurance coverage is prominent among them. Many of these premature births could be prevented, and have been in many other countries, through better primary care and inexpensive public health measures. Many in Congress are now trying to eliminate such programs — to save money.
    The BDN recently reported that 750 people showed up last month in Machias for free dental care offered by volunteers. The lack of dental care in rural Washington County was attributed largely to economic barriers made worse by poor economic times, such as lack of dental insurance, and to diets filled with cheap “soda, sweets and junk food.”
    But don’t worry, your health care dollars are at work in other ways. Documents released earlier this month by the Minnesota attorney general detailed the increasingly desperate tactics employed by hospitals as unpaid debts mount. They are attempting to collect money owed by patients seeking emergency care, sometimes by threatening denial of services. Accretive Health, the company employed by the hospitals to collect the bills, reported a $29.2 million profit last year. Accretive Health saw its stock decline 19 percent after the papers were released.
    The real tragedy in these stories is that the dysfunction in each is mostly avoidable. They are all the result of applying the principles of business and the techniques of industrialization to health care, where they don’t belong.
    During the past several decades, clinical decision-making, from lab tests to pharmaceutical prescribing to procedures (including some highly invasive ones), have become subject to “market forces.” Most Maine doctors are now employed by large corporations that hold them to “productivity (profit) targets,” achieved mainly by ordering tests and procedures, in order to meet “business objectives.”

     Why Oncologists Should Support Single-Payer National Health Insurance
    By Ray E. Drasga, MD, and Lawrence H. Einhorn, MD
    St Clare Clinic for the Indigent, Crown Point; and Indiana University School of Medicine, Indianapolis, IN
    Oncologists face growing difficulties in caring for patients be- cause of the rising cost of treatment coupled with the high prevalence of uninsurance and underinsurance. A diagnosis of cancer is often the single most catastrophic health care event in an individual’s life. The stress of the situation increases expo- nentially when patients realize the burden of cost on themselves and their families.
    Oncologists face the dilemma of advising a treatment schema that the patient can afford. Therapies may need to be compromised as a result of the patient’s inability to pay. Pa- tients often present with more advanced disease because they have never had cancer screenings because of a lack of insurance or concerns about cost. Meanwhile, the prices of cancer-related drugs are rising sharply, prompting some oncologists to sound the alarm.1
    Different insurance plans have their own procedures for use review and benefit determinations, making it difficult for providers to interpret whether cancer treatment will be cov- ered. The average patient finds it frustrating to navigate the bureaucracy with his or her life and financial security on the line. This article will outline the scope of these issues and offer an evidence-based case for single-payer national health insurance.
    http://org.salsalabs.com/o/307/images/Drasga%20Einhorn%20authors%20proof-edited%20(1).pdf

    Abundance Doesn’t Mean Health


    The relatively new notion that around a third or more of the world’s population is badly (“mal”) nourished conflates hunger and diet-spawned illnesses like diabetes, both of which are preventable.
    Both result from a lack of access to quality food, which in turn can result from a lack of money. No one with money starves, and the obesity-diabetes epidemic afflicts predominantly people on the low end of the income scale. With money comes good food, food that creates health and not “illth,” to use John Ruskin’s word. With a lack of money comes either not enough food or so-called empty calories, calories that put on pounds but do not nourish.
    This is made very clear in Oxfam’s “Good Enough to Eat” index, a snapshot of the state of eating in 125 countries released last week. The index attempts to determine the best and worst countries in which to eat, by measuring levels of undernourishment and underweight in children; asking “do people have enough to eat?”; measuring costs of food versus other goods and services, to see whether food is affordable; looking at the diversity of people’s diets and the availability of safe water; and monitoring diabetes and obesity levels to learn whether the diets are healthy.
    The results for the United States make a fine case for American exceptionalism, though not in the way chauvinists will find pleasing.
    We rank first in food affordability; food is cheap compared with other things we buy, and prices are relatively stable. We also rank highly (4th) in food “quality,” which is measured by (potential) diversity of diet, though access to good water is shockingly low (tied for 41st, about a third of the way down the list).
    Then the hammer falls: When it comes to healthy eating as measured by diabetes and obesity rates, we’re 120th: sixth from the bottom, better off only than Saudi Arabia, Kuwait, Jordan, Fiji and our unlucky neighbor Mexico. (Canada fares a little better; it’s 18th worst.) We’re also in a tie (with Belarus and other powerhouses) for 35th in “enough to eat.” Really.

    Preventive Medical Care Can Come With Unexpected Costs

    by MICHELLE ANDREWS

    Preventive health care services are supposed to be covered under the Affordable Care Act so that people don't have to pay out of pocket to get recommended screening tests. But some people are discovering that these supposedly free services can be costly.
    Take colonoscopy. The procedure is recommended for people age 50 and older by the U.S. Preventive Services Task Force, and thus should be covered under the law. But there's a hitch. Although insurers generally pay for the procedure itself, they may not pick up the hospital facility fee or the anesthesia charges, leaving patients on the hook for sometimes more than $1,000 in additional charges. Talk about a rude awakening.
    Contraception is another sticky area. Most health plans are supposed to pay for all methods ofbirth control approved by the Food and Drug Administration without charging women anything out of pocket. But some insurers have not been paying for some forms of contraception, according to a recent study by the Guttmacher Institute, a sexual and reproductive health research and education organization.

    Midwives and nurses are as good as docs -- and sometimes better, WHO finds

    Maggie Fox NBC News
    Oct. 31, 2013 at 6:32 PM ET
    Midwives, nurse practitioners, physician assistants and other non-doctors do as good a job as MDs in the care they deliver — and patients often like them better, a World Health Organization team reported on Thursday.
    These non-physicians are especially effective in delivering babies, taking care of people infected with the AIDS virus, and helping people care for chronic diseases such as diabetes and high blood pressure, the team reported in a WHO bulletin.
    The findings extend from the poorest nations to the United States and Europe, they said. While some physician groups have resisted wider use of such professionals, they should embrace them because they are often less expensive to deploy and are far more willing to work in rural areas, the WHO experts said.
    “There are some obvious advantages in terms of relying on mid-level health workers,” WHO’s Giorgio Cometto told NBC news in a telephone interview.
    “They take less time to be trained. Typically, they cost less to remunerate. In some countries they are more likely to be retained in rural areas.”
    David Auerbach, a researcher at the Rand Corp., says other studies have shown the same thing. “There’s really not much difference you can find in the quality,” he said.

    Maine Medical Association urges lawmakers to compromise on Medicaid expansion

    AUGUSTA — A band of health care providers speaking on behalf of the Maine Medical Association urged lawmakers Thursday to reach a bipartisan compromise to expand the state's Medicaid program to cover a larger group of low-income residents.
    Doctors and a nurse practitioner speaking during a news conference at the State House said they favor expanding access to health care because it would save lives and money.
    Kenneth Christian, an emergency room physician at Maine Coast Memorial Hospital in Ellsworth, said too many Mainers depend on emergency rooms for their medical care.
    "When the ill or injured show up at our doors, they get access to the attention and the care they deserve," Christian said. "But as good of a job as we do serving the public, I certainly wish that far fewer Mainers needed to rely on emergency rooms as their first, last and only access to health care services."
    Expanding Medicaid would eventually see those individuals flowing into less costly and more efficient primary care practices, Christian said.
    Others in the group, including Rhonda Selvin, a nurse practitioner and the associate medical director of Maine Quality Counts, said expanding access to health care could in the long run save money, but more important, it would save lives.
    Selvin outlined a list of pilot programs designed to redirect low-income people to primary care practices. But many still seek medical care in emergency rooms, which often leads to duplication of effort or expensive diagnostic tests that may not be necessary.
    "Having a CT scan one week and another CT scan the next week doesn't save costs," Selvin said. "And when we don't have providers that have access to this information, these types of patterns will continue. Primary care is the essential place where we need to develop both the communication and the service and the care for our patients, and without access none of these programs will follow through because they hinge on the fact that all of our patients have primary care."
    Other speakers said they agreed with Maine lawmakers who support an expansion of MaineCare, but they wanted it to include reforms to help contain costs and create a culture of personal responsibility.

    State’s clinicians join growing chorus of groups calling on lawmakers to expand Medicaid

    By Mario Moretto, BDN Staff
    Posted Jan. 23, 2014, at 12:43 p.m.
    AUGUSTA, Maine — Doctors with the Maine Medical Association on Thursday urged lawmakers in Augusta to work together to make Medicaid expansion the law of the land this year.
    Their voices joined a growing chorus of statewide groups urging the Legislature to accept federal dollars related to expanding Medicaid, known as MaineCare in the state, to roughly 70,000 low-income Mainers.
    It’s not just the usual liberal lobbying groups, either: Earlier this month, the Maine Hospital Association made its pro-expansion stance clear, and the Maine State Chamber of Commerce is also pushing a deal to tie Medicaid expansion to cost-saving measures within the program.
    Republican leadership, including Gov. Paul LePage, are unequivocally opposed to the expansion. They point to a controversial study commissioned by DHHS that says expansion would cost $807 million over 10 years.
    But the existence of back-door negotiations between Democratic leaders and a handful of moderate Republicans is, at this point, an open secret, and the Maine Medical Association wants to encourage that dialogue.
    With the other nonpartisan groups involved, that could provide political cover for Republicans who want to buck party leadership.
    “MMA and providers across Maine welcome these deliberations and hope an accord can be reached,” said Dr. Amy Madden, a family doctor and chairwoman of the group’s legislative committee, during a news conference Thursday at the State House.
    The current version of Medicaid expansion being pushed by Democrats would expand the program for just three years — the length of time the federal government says it will cover 100 percent of the cost for newly eligible, low-income beneficiaries. It also allows the state to opt out of the program if the feds renege on their promise to pay, and includes a provision that would make Medicaid patients pay the highest co-payment allowed by federal law.
    House Speaker Mark Eves, D-North Berwick, the lead sponsor of that bill, says it’s an effort to compromise by addressing fears voiced by Republicans last year that the program would be too costly. Republicans, however, point out that the bill is substantially the same as one rejected by lawmakers last year, and hardly counts as a new effort at bipartisan collaboration.
    Madden and others with MMA said their support for expanding Medicaid is an extension of their desire as health care providers to help patients get the care they need. Many said that without access to Medicaid, many low-income people have only one source of health care: emergency rooms.
    “As good a job as we do, I certainly wish fewer Mainers had to rely on the emergency room for their first, last and only source of services,” said Dr. Kenneth Christian, an ER doctor at Maine Coast Memorial Hospital in Ellsworth.

    True Single-Payer Healthcare System Being Considered in New York Assembly

    New York State Assemblyman Richard Gottfried, who represents the Chelsea and Hell's Kitchen sections of Manhattan (D-75th District), has introduced a bill to implement a true single-payer healthcare system in New York State. Although the legislation made it out of the healthcare committee of the Assembly last year, it then was basically stonewalled from going much further.
    Gottfried, chair of the health committee, told BuzzFlash at Truthout, the bill was re-introduced at the beginning of this session on January 8th of 2014.
    What makes Gottfried's bill distinct is that it would -- if implemented in its ideal configuration -- be a true single-payer healthcare system for all New Yorkers (except Veterans, who receive care through a government-administered system of providers employed by the Veterans Administration.)
    This differs from what is called the Vermont "single-payer" system, which is a laudable one coming down the pike. But the Vermont healthcare insurance program would more accurately be called a comprehensive coverage system than a true single-payer.
    Gottfried's bill (A5389-A/S2078-A) would create the New York Health Trust Fund and all New Yorkers -- in theory -- (except veterans) would eventually receive care through the fund. They would carry a "New York Health" card for all their medical needs. Although still far from being enacted, what would make Gottfried's bill a near seamless single-payer, if passed and implemented in its ideal form, is that the federal government would (and that is something, alas, unlikely to see for the time being given current DC private insurance control of politicians) pay Medicare and other federal programs directly into the state health insurance program. (Medicaid is already paid to states to administer the program within each state -- but Gottfried's bill would make Medicaid party of the pool of money funding "New York Health.") There are still some gaps and exceptions that would be closed at a later time were the bill ever to be passed and the feds were to provide waivers, but it puts the first stage of a state single-payer on the map of consideration even if it is a political long shot.
    Here is the key paragraph (in section 2 of the bill) that makes Gottfried's bill such a milestone in setting the bar on state single-payer:
    It is the intent of the Legislature to create the New York Health program to provide a universal health plan for every New Yorker, funded by broad-based revenue based on ability to pay. The state shall work to obtain waivers relating to Medicaid, Family Health Plus, Child Health Plus, Medicare, the Patient Protection and Affordable Care Act, and any other appropriate federal programs, under which federal funds and other subsidies that would otherwise be paid to New York State and New Yorkers for health coverage that will be equaled or exceeded by New York Health will be paid by the federal government to New York State and deposited in the New York Health trust fund. Under such a waiver, health coverage under those programs will be replaced and merged into New York Health, which will operate as a true single-payer program.
    http://truth-out.org/buzzflash/commentary/item/18434-true-single-payer-healthcare-system-being-considered-in-new-york-assembly?tmpl=component&print=1

    The only way out

    By Louis Balizet, M.D.
    Health Policy Solutions (Denver), Jan. 9, 2014
    The Affordable Care Act, while providing some short-term benefits, is, on the whole, unworkable. Quite apart from website failures, its approach to health care is fundamentally flawed. It is exceedingly complex. It perpetuates and entrenches the inefficient insurance model of payment for health care. It does nothing to address the rapacious pricing of pharmaceuticals. It ignores hospitals’ “medical arms race,” in which they expand facilities and services based not on community need, but on potential for profit. It still burdens doctors and hospitals with multiple payers, abstruse coding and insecurity about payment for delivered services. It is subject to state-by-state sabotage. At its most optimistic projection it leaves at least 25 million people uncovered.
    Despite three years of preparation, the Affordable Care Act (ACA) is beset by delays, multiple exemptions and computer failures. The Obama Administration celebrates the enrollment of 2.1 million persons in private insurance through the exchanges.
    The Centers for Medicare and Medicaid Services, meanwhile, has been cagey about how many of these 2.1 million have actually established a contractual arrangement with an insurance company. This has led to speculation that the number is quite small.
    As recently as two months ago, the digital conduit that connects exchanges to insurance companies was described as “under construction.” Repeatedly postponed deadlines have insurance companies scrambling to send bills, register payment and validate coverage. With opening day now behind us, it is likely that hundreds of thousands will find themselves stranded at second base – exchanges negotiated, but insurance not issued.
    Many of those who have secured coverage will discover that it is very thin coverage indeed, especially those with bronze plans. These plans approximate “junk insurance”: prohibitively high deductibles and co-pays combined with shrinking provider lists. Insurance companies that have elected to participate in the exchanges may find themselves in actuarial hot water and will raise premiums, further trim provider lists or fold altogether (especially the newly-formed co-ops). This year and especially 2015, may make October through December 2013 look like halcyon days.
    The multiple failures of the ACA should come as no surprise to anyone familiar with its sordid political history. Sen. Ted Kennedy’s untimely death deprived the U.S. Senate of a powerful member who was at once its chief expert on health care policy and a decades-long advocate for universal health care. Health care leadership defaulted to Montana Sen. Max Baucus, ill-suited by inclination and background to fashion true reform.
    Barack Obama acted less like a president and more like a community organizer as he failed to propose a coherent plan of his own. Into this policy breach stepped special interests, most prominently insurers and Big Pharma; any pretense of universal coverage and bona fide cost controls soon disappeared. What emerged was the euphemistically entitled the Patient Protection and Affordable Care Act, a Rube Goldberg contraption that befuddles experts to this day while richly rewarding those who got in on the ground floor.
    What are the alternatives if the ACA craters? This is not a hard question to answer; examples of much better systems abound.
    http://www.pnhp.org/print/news/2014/january/the-only-way-out

    Teaching Doctors the Art of Negotiation

    By DHRUV KHULLAR
    By the time I rushed to his room, my patient had already ripped out his I.V., packed his knapsack and was making his way to the door, his hospital gown, on backward, flapping like a cape over the jeans he had hurriedly slipped on. He told me he felt fine now, after coming in feverish and sweating a few nights back, and despite his poorly controlled H.I.V. and the strong possibility that the lump in his neck was lymphoma. We had been waiting several days for the biopsy results, but now he had had enough.
    “I’ve got things to do,” he declared. “Call me when you know.”
    “Wait! We, uh, almost…” I stammered. He glared at me and continued his bare-chested charge toward the door.
    Just then the attending physician arrived and calmly approached the patient. He offered him a glass of water and asked if they could chat for a few minutes. Patients leaving A.M.A., or against medical advice, were not uncommon on this floor. The attending had practice. It showed.
    He said he understood the patient’s frustration, apologized for the delay and promised to  call the doctors in the pathology department to see why the test results were taking so long. He asked where the patient was planning to go, why he felt it so important to leave and offered to connect him with social services that could help take care of things outside the hospital. He grabbed a napkin and drew a quick sketch explaining how his disease would likely progress and the many risks of leaving without treatment.
    “All right doc, I’ll give you a couple more days,” the patient finally said. Together — in white coat and gown-cape — they strode back to his room.
    http://well.blogs.nytimes.com/2014/01/23/teaching-doctors-the-art-of-negotiation/
    Maine Medical Association Presses for Medicaid Expansion
    01/23/2014   Reported By: Patty B. Wight
    As lawmakers consider the merits of expanding Medicaid under the Affordable Care Act, some groups are urging compromise on an issue that runs largely along party lines. Today, physicians from the Maine Medical Association held a press conference to express their support for such a deal. But as Patty Wight reports, it's still not clear whether any Republicans at the State House would get behind a modified approach to Medicaid expansion.



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