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Wednesday, April 9, 2014

Health Care Reform Articles - April 9, 2014

It Took a Digital Village: How a Times Series Was Built

By ELISABETH ROSENTHAL
 

Elisabeth Rosenthal has been writing a series of articles about the high cost of health care in the United States.
Deepika Singh got three stitches for a gash on her knee, generating a bill of $2,229 in San Francisco. Deirdre Yapalater’s colonoscopy, performed in under an hour at an outpatient surgery center on Long Island, resulted in charges of $6,385. Michael Shopennacquired an artificial hip manufactured in Indiana and flew to Belgium to have it installed, costing him $13,660, a small fraction of the $100,000 his local hospital in Seattle would have charged.
When Kim Little had a small lesion removed from her cheek, the total bill came to over $25,000. Renee Martin called her local hospital to get an estimate for her pregnancy, which was not covered by her insurance, and was told that it would be between $4,000 and $45,000. She asked: “How can you not know this, you’re a hospital?”
These patients all shared their stories with The Times through various interactive tools, providing me with a new, valuable reporting strategy.

For more than a year now I’ve been working on a continuing series, “Paying Till It Hurts.” I focused not on the very expensive drugs or end-of-life care that American medicine is known for, but instead the high price tag of common procedures or treatments, which amounts to an even more significant share of the nation’s $2.7 trillion annual health care bill. Everyone knows that American medicine is expensive, but how do routine treatments end up costing so much? What financial incentives lead to the extraordinary, ordinary bills?
I had trained as an internist before “converting” to journalism 20 years ago, about the time of the Clinton health care reform effort. And although I had not covered health care for The Times since 1997 (I was a correspondent in Beijing and then covered the environment), these questions gnawed at me over years. They gnawed at me most when I opened one of my own Explanation of Benefits statements and was agog at the charges.
So when debates over the Affordable Care Act refocused attention on the dysfunctional American health care system, I pestered the top editors here to allow me to write a series about how and why medicine in the United States commands bills that are the highest in the world.
After some wonky months of reading journals and interviewing health care experts across the country, I had a pretty good understanding of the market failures I wanted to highlight – and a list of procedures to focus on. But how would I identify compelling patient narratives to anchor my articles? In the old days, I might have turned to doctors and patient advocates or stood in hospital parking lots accosting random patients (yes, I’ve done that!).
And I initially tried that, with frustrating results. Patient advocates and doctors all had a bias, and the yield of standing in parking lots is low. I thought social media might be able to provide fresher, more uncensored voices. I was already somewhat familiar with the tools: For a short time I had developed and anchored a travel blog at The International Herald Tribune (now The International New York Times) called Globespotters, where we solicited readers’ tips about cities. So for my first attempt to gather some patients using social media, I wrote a short post on our Well Blog about a small study showing that it was nearly impossible for patients to find out the price of a hip replacement at a United States hospital. We included a prompt: “Have you had a hip replacement or other procedure? Tell us about your costs and bills.” In a few hours we had 513 comments, and the series was off and running.
Subsequently, The Times’s social media team helped me exploit this powerful medium more fully. In each article, on blogs and on Twitter/Facebook, we encouraged readers to share their medical experiences and bills. Each comment served as a tip.



Study Finds Sicklier Enrollees in Earliest Stage of Health Law

By 
People who signed up early for insurance through the new marketplaces were more likely to be prescribed drugs to treat pain, depression and H.I.V. and were less likely to need contraceptives, according to a new study that provides a much-anticipated look at the population that signed up for coverage under the new health care law.
The health of those who enrolled in new coverage is being closely watched because many observers have questioned whether the new marketplaces would attract a large share of sick people, which could lead to higher premiums and ultimately doom the new law.
The study, to be released Wednesday by the major pharmacy-benefits manager Express Scripts, suggests that early enrollees face more serious health problems and are older than those covered by their employers. The study also showed a higher use of specialty drugs, which are often used to treat diseases like cancer and rheumatoid arthritis; the use of such drugs could hint at more costly medical problems.
Over all, early users of marketplace plans appeared to be filling prescriptions for drugs at rates similar to people with coverage through their employers. Another pharmacy-benefit manager, Prime Therapeutics, said it was seeing slightly higher rates of prescription-drug use among its marketplace customers.
“I think this gets under the hood of not only who is enrolling, but what kind of health care challenges do they have,” said Karen M. Ignagni, president of America’s Health Insurance Plans, which represents insurers. “Pharmacy claims are often an indicator for medical claims, and it’s often the case that they provide a real insight into overall trends.”
Still, she and others cautioned that it was too early to properly evaluate the health of those who were signing up. The study by Express Scripts looked at a sample of 650,000 consumers who received coverage in January and February and did not capture information about those who signed up closer to the enrollment deadline. Insurers have said anecdotally that those who signed up later tended to be younger and were presumably healthier.
http://www.nytimes.com/2014/04/09/business/study-looks-at-earliest-health-law-enrollees.html?hp&_r=0

Answers to Tough Questions About Dying

By PAULA SPAN
 

Lots of people want to encourage you to have the Conversation with aging family members about their wishes at the end of life, and then to help you document those preferences in an advance directive.
You can log onto the Conversation Project, for example. Established two years ago by the former syndicated columnist Ellen Goodman, it will guide you through discussions of fears, values, medical options. Or you can turn to Prepare, created last year by a geriatrician, Dr. Rebecca Sudore of the University of California, San Francisco. Readers here have also recommended the Five Wishes document.
And to be sure doctors follow your or your relatives’ wishes precisely, a P.O.L.S.T. form is your strongest protection when frailty or illness becomes advanced.
But then what? There is still scant discussion, except from experienced hospice staff members, about what to expect when death comes very close. How do you deal with pain, everyone’s great fear? What is dyspnea (answer: shortness of breath), and what can be done to ease it? How is palliative care different from hospice care, and which do you need? What are the actual signs, physical and emotional, of approaching death?
Families and friends need to know these things, especially when they are trying to help a loved one die at home — where most people say they want to die, although only a minority do.
http://newoldage.blogs.nytimes.com/2014/04/07/answers-to-tough-questions-about-dying/?action=click&contentCollection=Business%20Day&region=Footer&module=Recommendation&src=recg&pgtype=article

Sliver of Medicare Doctors Get Big Share of Payouts

By  and SARAH COHEN
A tiny fraction of the 880,000 doctors and other health care providers who take Medicare accounted for nearly a quarter of the roughly $77 billion paid out to them under the federal program, receiving millions of dollars each in some cases in a single year, according to the most detailed data ever released in Medicare’s nearly 50-year history.
In 2012, 100 doctors received a total of $610 million, ranging from a Florida ophthalmologist who was paid $21 million by Medicare to dozens of doctors, eye and cancer specialists chief among them, who received more than $4 million each that year. While more money by far is spent for routine office visits than any other single expenditure, one of the most heavily reimbursed procedures — costing a total of $1 billion for 143,000 patients — is for a single treatment for an eye disorder common in the elderly.
The Medicare data — all for 2012 and the subject of an intense legal battle — provides an unprecedented look at the practice of medicine across the country, shedding fresh light on the treatment decisions physicians and other practitioners make every day. It will also provide consumers with an ability to compare doctors and treatments in a way they have never had until now.
Fraud investigators, health insurance plans, researchers and others will spend weeks poring over the information about how many tests were ordered and procedures performed for every provider who received Medicare payments under Part B, which excludes payments to hospitals and other institutions. The Centers for Medicare and Medicaid Services is making the data publicly available on Wednesday. While total Medicare spending — including hospitals, doctors and drugs — is approaching $600 billion a year, payments to individual doctors have long been shrouded in secrecy. For decades, the American Medical Association, the powerful doctors’ group, and others have blocked the release of the information, citing privacy concerns and the potential for misuse of the information. But a federal judge ruled last year that the information could be made public.
http://www.nytimes.com/2014/04/09/business/sliver-of-medicare-doctors-get-big-share-of-payouts.html?emc=edit_tnt_20140409&nlid=1311158&tntemail0=y&_r=0

Doctor With Big Medicare Billings Is No Stranger to Scrutiny

By 
MIAMI — The doctor who bills the most for Medicare in the country is a South Florida ophthalmologist whose offices were twice raided last year by the FBI and whose generous political contributions and cozy relationship with a New Jersey senator, Robert Menendez, are under investigation by federal public corruption prosecutors, a New York Times analysis of Medicare data shows.
Data released Wednesday by the Centers for Medicare and Medicaid Services show Dr. Salomon E. Melgen, 59, who moved to Florida from the Dominican Republic in the late 1970s, received $21 million in Medicare reimbursements in 2012 alone. The doctor billed mostly for Lucentis, a medication used to treat macular degeneration made by a company that pays generous rebates to its doctors.


The release of the Medicare figures was the latest in a series headline-grabbing disclosures that have dogged the doctor since January of last year. The millionaire surgeon, who lives in a 5,000 square foot home in North Palm Beach and travels by private jet, is better known as the generous campaign contributor whose close relationship with Mr. Menendez, a Democrat, has been scrutinized by federal prosecutors.
http://www.nytimes.com/2014/04/10/business/doctor-with-big-medicare-billings-is-no-stranger-to-scrutiny.html?emc=edit_tnt_20140409&nlid=1311158&tntemail0=y

Release of Medicare doctor payments shows some huge payouts

Some physicians received more than $10 million in 2012, data show, but the government and doctors warn the figures can be misleading.



April 8, 2014, 9:00 p.m.
Ending decades of secrecy, Medicare is showing what the giant healthcare program for seniors pays individual doctors, and the figures reveal that more than a dozen physicians received in excess of $10 million each in 2012.
The Obama administration is releasing a detailed account Wednesday of $77 billion in government payouts to more than 880,000 healthcare providers nationwide that year. The release of payment records involving doctors has been legally blocked since 1979, but recent court rulings removed those obstacles. No personal information on patients is disclosed.
The two highest-paid doctors listed in the Medicare data are already under government review because of suspected improper billing. They include an ophthalmologist in the retiree haven of West Palm Beach, Fla., who topped the list by taking in more than $26 million to treat fewer than 900 patients. That is 61 times the average Medicare payout of $430,000 for an ophthalmologist.
A Florida cardiologist received $23 million in Medicare payments in 2012, nearly 80 times the average amount for that specialty. One California doctor was in the top 10 nationwide: a Newport Beach oncologist who was paid $11 million that year.
The overwhelming majority of doctors billed the government very modest amounts. Overall, 2% of healthcare providers accounted for 23% of the Medicare fees, the federal data show.
Medicare officials said disclosing physician payment data marks an unprecedented opportunity to make the nation's healthcare system more transparent for consumers and accountable to taxpayers. Many consumer advocates and employers applauded the move.
"Providing consumers with this information will help them make more informed choices about the care they receive," Jonathan Blum, Medicare's principal deputy administrator, said last week. Medicare plans to post the data online.

http://www.latimes.com/business/la-fi-medicare-doctor-pay-20140409,0,6562889.story#axzz2yO849ZDS

Medicare making some doctors rich; one got $18 million

Officials hope to uncover fraud by releasing data that show how much physicians billed the government.

By Peter Whoriskey, Dan Keating
The Washington Post
And Sandhya Somashekhar 
The Medicare program is the source of a small fortune for many U.S. doctors, according to a trove of government records that reveal unprecedented details about physician billing practices around the nation.
The government insurance program for older people paid nearly 4,000 physicians in excess of $1 million each in 2012, according to the new data. Those figures do not include what the doctors billed private insurance companies.
The release of the information gives the public access for the first time to the billing practices of individual doctors nationwide. Consumer groups and news outlets have pressured Medicare to release the data for years. And in doing so Wednesday, Medicare officials said they hope the data will expose fraud, inform consumers and lead to improvements in care.
The American Medical Association and other physician groups have resisted the data release, arguing that the information violates doctor privacy and that the public may misconstrue details about individual doctors.
COSTLY SPECIALTIES, COSTLY BILLS
Among the highest billers were a cardiologist in Ocala, Fla., who took in $18.1 million, mainly putting in stents; a New Jersey pathologist who received $12.6 million performing tissue exams and other tests; and a Michigan vascular surgeon who got $10.1 million.
Some of the highest billing totals may simply reflect a physician who is extremely efficient or who has an unusually large number of Medicare patients.
The highest numbers also may reflect a physician who specializes in procedures that require costly overhead, and in those cases, a large portion of the money may wind up not with the doctor but with pharmaceutical companies or makers of medical devices.
But in some instances, the extremely high billing totals could signal fraudulent doctor behavior, as government inspectors have previously found.
Indeed, three of the top 10 earners already had drawn scrutiny from the federal government, and one of them is awaiting trial on federal fraud charges.
The greatest tallies also may signal that the Medicare payments for some procedures are too high for the amount of work involved or that perverse incentives lead doctors to overuse a procedure.

How the Koch brothers are killing Medicaid expansion in Maine

State Politics
By 
In December of last year, Maine Representative Brian Duprey (R-Hampden) posted a photo to Facebook from a presentation at the American Legislative Exchange Council (ALEC) conference he was attending Washington D.C. ALEC is a secretive organization that serves as a pipeline into state legislatures for corporate-backed policies.
“Watching my good friend Tarren Bragdon moderate a panel on Obamacare and Medicaid expansion,” Duprey captioned the photo, which shows Bragdon behind an ALEC-branded podium. The post was “liked” by Maine House Minority Leader Ken Fredette.
Fredette, Duprey, and most of their fellow Republicans in the Maine House and Senate have so far been unwilling to join Democrats in sufficient numbers to overcome a gubernatorial veto and accept federal health care funding made available through the Affordable Care Act to expand health care coverage in Maine. Enough of them have stuck with Governor Paul LePage despite the popularity of the issue and its economic, budgetary and health care benefits that even a compromise bill advanced by Republican Senator Roger Katz faces an uncertain legislative future following its likely veto by LePage today.
Why is this the case, when Republicans have been willing to ignore the increasingly-marginalized LePage on other issues, including rejecting his budget recommendations for two years in a row? The Facebook post by Duprey, which may seem at first to be just one more inconsequential social media interaction, actually points us toward the answer to that question.
Bragdon, a former Maine legislator, former head of the conservative Maine Heritage Policy Center (MHPC) and former co-chair of LePage’s transition team, now heads a Florida-based organization called the Foundation for Government Accountability (FGA). His office in Naples is a nexus in a national network of conservative groups and causes funded by large corporations and some of the wealthiest conservative donors in the country, including billionaire oil magnates and arch-libertarians Charles and David Koch. The Kochs and their close allies are responsible for creating and underwriting much of the current right-wing establishment. (For instance, they sit on ALEC’s corporate board and are likely responsible for a significant amount of its funding.) They’ve spent millions fighting health care reform and the debate over Medicaid expansion in Maine is a convenient battlefield in their wider war against the Affordable Care Act and any government involvement in ensuring access to health coverage.

Nearly 4 Million Seriously Mentally Ill Still Without Insurance

TOPICS: HEALTH DISPARITIES, MENTAL HEALTH, PUBLIC HEALTH
By MICHAEL OLLOVE, STATELINE
APR 09, 2014
This story comes from our partner Stateline, the daily news service of the Pew Charitable Trusts.
Some might consider Kelly Troyer of South Carolina lucky. She isn’t one of them.
Thanks to the generosity of her church and family members, she receives some treatment for the depression and post-traumatic stress disorder she suffers as a result of the sexual assault she endured in 2012. But Troyer, 45, said her lack of health insurance and other uncovered medical costs, including a hospitalization and all her medications, has forced her into personal bankruptcy.
She lives in one of the 24 states that chose not to expand their Medicaid programs, offered under the Affordable Care Act. Those decisions have left about 3.7 million Americans with serious mental illness, psychological distress or a substance abuse disorder without health insurance, according to a recent report from the American Mental Health Counselors Association (AMHCA), a group that represents mental health professionals.
In states that agreed to expand Medicaid, about 3 million people who have those conditions and were uninsured are now eligible for coverage, according to the report.
It makes no sense that this state would not accept the Affordable Care Act, Troyer said. Don’t say no and then don’t offer another option. There are people who are homeless now because they don’t have health insurance. I could be one of them.
Option Offered
Medicaid, the federal-state health care program for the poor, is the primary means by which states pay for mental health care for the poor. Medicaid beneficiaries are entitled to comprehensive care for mental illness and substance abuse.
Originally, the federal health care law enacted in 2010 required  all states to expand Medicaid benefits to adults with annual incomes below 138 percent of poverty or $15,521 for an individual in 2014.
A 2012 U.S. Supreme Court decision gave states the option of not participating in the eligibility expansion. Most, but not all, states with Republican governors or Republican-controlled legislatures opted out, even though the federal government is paying 100 percent of the costs of the expansion in the first three years before tapering down to 90 percent after 2019.
The federal health law could have added as many as 18.7 million more Americans to the Medicaid rolls. With only 26 states now participating, that number is down to about 8.1 million. If the 24 states that opted out of the Medicaid expansion continue to do so, they will forgo a total of $61.9 billion in federal revenues by 2022, according to a December Commonwealth Fund report. Governors in those states say they don’t trust the federal government to come up with the promised money and worry the states will be left having to make up the difference.
It is really a tragedy, said Joel Miller, executive director of AMHCA. When uninsured people with mental health conditions, such as depression, gain Medicaid coverage, they become healthier and life expectancy increases, but in states that refuse to expand Medicaid, citizens will see their hopes dashed for a better life and better health.
The report gives state-by-state numbers of people with serious mental illness or substance abuse disorders who would have received Medicaid if their states had opted in to Medicaid expansion. The report covers 25 states, although since it was published, one of them, New Hampshire, decided to reverse course and join the expansion states.


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