As policymakers in Washington look to solve the crisis of backlogged patients at Department of Veterans Affairs hospitals, health care leaders and politicians in Maine point to a small program that could serve as a model for reducing wait times.
In Aroostook County, veterans rave about how they can get care at the hospital in Caribou instead of the VA hospital in the Augusta area, saving them from traveling hours for treatment.
“It’s the best thing since peanut butter,” said Pete Miesburger, 77, a Korean War veteran.
Miesburger suffered a broken hip Jan. 30 when he fell at his home in Caribou, but he didn’t have to worry about a 250-mile ambulance ride to the Togus VA Medical Center.
“It was miserable outside, snowing, cold, a typical northern Maine winter day,” said Miesburger, a former Air Force firefighter who retired from the military in 1974. “God only knows what would have happened if I had to go to Togus.”
The four-hour drive to the Augusta area can easily extend to seven or eight hours in snowy weather. But Miesburger just went to Cary Medical Center in Caribou, thanks to a pilot program called Project ARCH, Access Received Closer to Home.
His friends and family were nearby so they could visit him in the hospital after his hip replacement surgery, something they couldn’t have done at Togus, he said.
Through the pilot program, veterans can get specialty care at Cary Medical Center and four other hospitals outside the VA system, in Farmville, Virginia; Pratt, Kansas; Flagstaff, Arizona; and Billings, Montana. The program costs $35 million a year. Veterans who meet certain criteria, including living far from a VA hospital, can be treated at a medical facility closer to home, which gets reimbursed at Medicare rates.
The VA had a primary care facility on the Cary Medical Center campus before the program started in 2011.
Project ARCH was hatched to solve a geography problem. If the program is expanded or a similar one is approved, it would have the potential to relieve backlogs, say Maine politicians, Cary Medical Center’s CEO and a veterans benefits expert.
“Conceptually, it should work. It has potential,” said Francis Jackson, an attorney in South Portland who belongs to a national veterans advocacy group and specializes in veterans benefits. “But I don’t think anyone really knows yet.”

Jackson said the program is too new and the scope is too limited to show whether it could have a dramatic impact on veterans’ wait times for care.
http://www.pressherald.com/2014/06/12/pilot-program-in-maine-could-be-model-to-ease-va-backlogs-nationally/

Blame for Michaud in VA scandal inflates his role

Posted June 13, 2014, at 9:17 a.m.
Blame is top of mind in political circles when it comes to the scandal surrounding appointment scheduling, hidden waitlists and delayed patient care at Department of Veterans Affairs health care facilities.
In Maine, that blame game has reached a fever pitch among some Republicans as they try to accuse U.S. Rep. Mike Michaud — the Democrats’ nominee for governor — of presiding over the agency’s malfeasance as the ranking Democrat on the House Veterans Affairs Committee.
Who knew a minority party member of Congress from Maine’s 2nd District had so much influence over day-to-day operations at the Department of Veterans Affairs?
The rush to blame Michaud is simplistic and distorts the nature of the numerous failures the Department of Veterans Affairs must address in order to better serve veterans and regain public confidence. Those failures clearly point to management missteps by top brass and internal shortcomings of individual health care facilities in the VA system.
At the Phoenix facility, where the current controversy got its start, the VA’s Office of the Inspector General found that 1,700 veterans were on a secret, unofficial waitlistfor doctors’ appointments. The shorter, “official” waitlist, with 1,400 veterans, made it appear as if the facility was scheduling appointments for patients faster than it actually was.
Based on the Phoenix facility’s “official” data, the average wait time for a 226-veteran sample reviewed by the inspector general was 24 days — 10 days longer than the VA’s stated 14-day goal. When the real data were factored in, the wait time for those 226 veterans grew to 115 days for a first primary care appointment.
The hidden waitlist practice obscures the full extent of one of the VA’s chief liabilities — limited access to care — making it easy for VA facilities entrusted with safeguarding veterans’ health to lose track of and neglect the needs of their patients.
The practice hasn’t been confined to the Phoenix facility — where, according to CNN, 40 veterans died while awaiting care. Rather, it points to a management failure emanating from the top. According to a VA care access audit released this week, the widespread manipulation is a direct result of the agency’s goal to schedule appointments for veterans within 14 days. The agency implemented the goal and attached financial incentives to it without taking the proper steps to determine whether the goal was attainable, given available resources.


USC hospital sues Kaiser over nonpayment of bill



Two medical giants in Southern California are heading for a potentially bruising legal battle.
Keck Hospital of USC has sued Kaiser Permanente, accusing California's largest HMO of sending one of its patients to Keck for open-heart surgery and then refusing to pay the $544,000 hospital bill.
USC contends that Kaiser didn't disclose that its patient had already exhausted a $75,000 annual cap on insurance benefits when it asked Keck Hospital to perform the October 2013 surgery. Kaiser could have handled the procedure with its own surgeons but opted to transfer the patient to save money, Keck Hospital said in the lawsuit.
Kaiser declined to comment except to insist that USC knew about the limitations of the patient's insurance.
This legal battle between healthcare heavyweights highlights Kaiser's long-standing practice of using outside hospitals to see some patients who require more specialized care. It also provides a rare glimpse into the sometimes bitter disputes between health insurers and providers that are often handled behind closed doors.
Kaiser is both an insurer collecting premiums from customers and a medical provider treating them at Kaiser-run hospitals and physician offices. In some instances, Kaiser transfers patients to outside facilities for specialty care such as transplants, then covers the costs as any other insurer would.
In this case, Kaiser transferred the patient from the intensive care unit at its Los Angeles Medical Center to Keck Hospital knowing it would not cover the costs, USC said in the lawsuit, filed May 15 in Los Angeles County Superior Court.
The Kaiser representative who called Keck to arrange the surgery said the patient had active health coverage through Kaiser, the lawsuit said. With that assurance, USC authorized the surgery and treated the patient for 13 days at its hospital.
In December, Kaiser denied Keck Hospital's bill for the treatment, saying for the first time that the patient had exceeded the $75,000 cap on annual coverage, USC said. Those coverage limits were set by a state program Kaiser participates in for people who were denied coverage because of preexisting conditions.
Kaiser declined to discuss details of the lawsuit, but said in a statement, "We are confident that Keck's allegation that it was not informed about coverage limits is not accurate."
The lawsuit could tarnish a lengthy relationship between the healthcare giants. Keck, then known as USC University Hospital, and Kaiser first entered into an agreement in 1994 for the hospital to treat some Kaiser patients, with Kaiser paying the tab, USC said in the lawsuit.
Kaiser, a nonprofit based in Oakland, is California's largest HMO and one of the largest healthcare providers in the country. It reported $53.1 billion of operating revenue last year and $2.7 billion in net income.
Mark V. Pauly, a professor of healthcare management at the University of Pennsylvania's Wharton School, said a lack of communication about the patient's coverage appears to be at the center of the disagreement.
"It seems like somebody forgot to ask or somebody forgot to tell, which may be a sign of dysfunction in our healthcare system," Pauly said.

Californians gripe about Obamacare enrollment snags, lack of doctors


CHAD TERHUNE

Nearly 1,500 Californians have complained to state regulators in the last four months about their Obamacare coverage purchased through California's insurance exchange.
New data reveal the biggest category of complaints centers on getting confirmation of health plan enrollment and basic issues such as getting an identification card to obtain care.
Many consumers have also encountered difficulty finding a doctor who accepts their new coverage, as well as frustration with inaccurate provider lists, according to the California Department of Managed Health Care.
"If you have a medical condition and can't get care that is a very serious issue," said Marta Green, spokeswoman for the managed healthcare agency. "We are still working to resolve many of these cases."
Health insurers and officials at the Covered California exchange say they are working hard too to address consumers' gripes. They say some problems are inevitable from such a massive overhaul and that the number of complaints is a small fraction of the more than 1 million Californians who signed up under the Affordable Care Act.
Consumer frustration with smaller physician networks has drawn the most attention statewide.
About 12% of the 1,459 exchange customers who complained to the state cited an access to care problem, according to state figures. The data cover complaints received from Jan. 1 to April 30.
Not surprisingly, Green said, the two largest health plans in Covered California accounted for the most complaints overall and in the category of access to providers.
Anthem Blue Cross, a unit of industry giant WellPoint Inc., received 658 complaints through April and nearly 13% dealt with provider issues, state data show.
Blue Shield of California was next with 461 complaints and 17% focused on finding an in-network doctor.

Unequal TreatmentLas Vegas tries new tactic to improve city's notorious healthcare



Teresa Garcia, weak and in pain, had all but given up on doctors when she came to a small clinic next to a former wedding chapel on the Strip.
"I never thought I would get better," the 55-year-old housekeeper said, recalling years of perfunctory physician visits that generated countless prescriptions but did little to slow the dangerous advance of her diabetes.
Today, under intense care from a team of social workers, nurses and a doctor who, like her, emigrated from Mexico, Garcia has learned to change her diet and closely monitor her disease. She has regular checkups. She has cut her blood sugar in half. She no longer needs to inject herself with insulin.
The model of medical care that is helping Garcia is built on a highly personal approach to patients and a high-tech system to track quality — something that is new for this city. A grim joke here long held that the best place to go for good healthcare was the airport.
Now, Las Vegas is emerging as a test of how much a community can improve chronically poor health by expanding insurance coverage and using models of medical care pioneered in healthier places.
"We are a prime example of what people see as problematic about the American healthcare system," said Larry Matheis, the former longtime head of the Nevada State Medical Assn. "That makes a lot of the ideas in health reform very attractive. … The challenge is going to be figuring out how to make it all work."
Starting this year, the Affordable Care Act guarantees insurance to tens of thousands of Las Vegas residents once effectively shut out of the health system. And leading hospitals, physician groups, unions and businesses are seeking to improve care by taking advantage of the coverage expansion.
The clinic Garcia visits has already inspired a similar facility in nearby downtown. And the Culinary Health Fund, a union health plan that runs Garcia's clinic, plans to build three more across the city.
Under another initiative in the city, a team of highly trained nurses is working to enhance medical care in nursing homes so fewer residents end up in the hospital.
Poverty and obesity are not as widespread here as in some of America's other least healthy communities. Nevertheless, improving care in Las Vegas is an immense task.
Before Nevada expanded its Medicaid program under the new health law, nearly 30% of working-age adults in greater Las Vegas lacked insurance. By comparison, in U.S. communities with the best health outcomes, fewer than 1 in 10 are uninsured.
The area also has a critical shortage of primary care doctors — half as many relative to the population as healthier regions of the Northeast and upper Midwest.

 

When a Stressful Hospital Stay Makes You Sick

By DAVID H. NEWMAN, M.D.
 

The woman was rolled into the emergency department by paramedics. Struggling to breathe, she bent forward, hands on her knees, using gravity to help expand her chest.
“This all started when she was admitted, and now she’s worse,” her husband told me. A few weeks earlier, pneumonia had put her in the hospital for five days. When her oxygen levels improved she was discharged, but at home she struggled to get out of bed, and couldn’t shake a deep fatigue. The day I saw her in the E.R., her breathing was becoming increasingly labored.
Her lungs sounded quiet and clear, but her heartbeat was rapid. Her forearms were covered with red and purple bruises, the aftermath of daily blood tests. Her face was gaunt; her lips were dry. According to her husband she rarely slept, and ate poorly, while in the hospital. She was losing weight.
Her husband’s description led me to a diagnosis that my colleagues and I are increasingly recognizing: post-hospital syndrome.
It’s long been known that hospitals can be the source of illness — 1.7 million Americans develop hospital-acquired infections each year. But post-hospital syndrome is something different and more ominous.
In a 2013 paper, Dr. Harlan Krumholz, a professor of medicine and public health at Yale School of Medicine, described a syndromethat emerges in the days and weeks after a hospital stay: “Physiologic systems are impaired, reserves are depleted, and the body cannot effectively avoid or mitigate health threats.” He called this period of vulnerability “post-hospital syndrome.”
http://well.blogs.nytimes.com/2014/06/12/when-a-stressful-hospital-stay-makes-you-sick/?_php=true&_type=blogs&emc=edit_tnt_20140612&nlid=1311158&tntemail0=y&_r=0

Private Health Care Exchanges Enroll More Than Predicted


By
    Employers are moving more quickly than forecasted to offer health insurance to their workers through private exchanges, according to new data from Accenture, a consulting firm.
    Three million people signed up for workplace health coverage for this year through private exchanges, Accenture said. That’s roughly three times the number of people the firm had estimated last fall would enroll for coverage through the private exchanges — online systems that are separate from the state and federal health insurance marketplaces.
    The growth was driven largely by smaller and midsize companies — those with no more than 1,000 employees, said Rich Birhanzel, who leads Accenture’s health administration services. Beginning last fall, significant numbers of employers offered coverage through private exchanges for the first time, and the firm had predicted that about one million would enroll. “What we’re seeing is that adoption is happening faster than we anticipated,” he said.
    Accenture estimates that total enrollment in private exchanges by active employees will reach about 40 million by 2018, surpassing the number of people enrolling through state and federally funded exchanges. (Currently, the federal government says eight million people have signed up for health insurance through the public exchanges set up by the Affordable Care Act).
    Accenture released the findings at the annual conference of America’s Health Insurance Plans, an industry group. The number was gleaned from publicly available corporate filings, as well as insights Accenture gained through its role as a consultant to employers, health insurers and exchange operators, Mr. Birhanzel said.
    Private exchanges are similar to the public marketplaces, but are offered by employers to their employees. Consulting companies, including Aon Hewitt, Mercer, Towers Watson and Buck Consultants, operate private exchanges, and some insurers also offer their own versions. Walgreen and Sears, for instance, participate in Aon Hewitt’s offering, known as the Corporate Health Exchange.
    Some employers are shifting employees to the exchanges to control costs and reduce administrative burdens, and to give workers more plans to choose from. (The idea is that offering plans from multiple insurers will help lower costs through competition.) While details of the exchanges vary, companies typically allocate a specific amount for employees to spend on health insurance, and then workers choose from a menu of options.
    Roughly a quarter of employees who signed up through the private exchanges ended up with less coverage than they had under employer plans, Mr. Birhanzel said. They might have chosen to lower their monthly premiums or chosen to trade off some health coverage for other types of coverage — like disability insurance or life insurance — offered through the exchanges.
    Lowering health insurance premiums generally means higher deductibles — the amount you must pay for care before coverage begins. High-deductible plans typically come with lower monthly premiums, but employees are responsible for more out-of-pocket costs.
    http://www.nytimes.com/2014/06/12/your-money/private-health-care-exchanges-enroll-more-than-predicted.html?contentCollection=your-money&action=click&module=NextInCollection&region=Footer&pgtype=article

    Empty beds, empty coffers: Why Maine’s rural nursing homes are facing an uncertain future

    By Jackie Farwell, BDN Staff
    Posted June 13, 2014, at 10:17 a.m.
    When a nursing home in Calais abruptly closed its doors two years ago, the effects reverberated throughout the small Washington County community. Nearly 100 people lost their jobs. Local businesses said goodbye to paying customers. The town suffered the departure of a major taxpayer, which affected everything from sewer rates to real estate prices.
    For Martha Baker, the closure meant losing her home. In her mid-90s, Baker was forced to move to a nursing facility in Lubec, an hour away from the staff she had come to consider family, her son and his wife, Town Manager Diane Barnes.
    “We weren’t able to go down and see her as often as we wanted to,” Barnes said. “It was hard on her as well with us not being around and the people she was accustomed to taking care of her.”
    Baker understood she was moving but not the reason why, Barnes said.
    “She said, ‘Why are you taking me away from my home?’ … I can’t explain it, unless you actually go through it, how hard it is on the elderly, especially at that age, to make that type of a transition,” Barnes said.
    Some families needed to travel even further, finding placements at nursing homes in Bangor and Ellsworth, she said.
    Baker received excellent care in Lubec before she died in November, Barnes said, but the uprooting took a toll on her mother-in-law.
    Barnes, who will soon leave Calais to become Lisbon’s town manager, hopes legislation designed to shore up nursing home funding will spare other families and communities from the same fate. The newly passed bill aims to address $30 million in accumulated underpayments to nursing homes under the state’s Medicaid program.
    “It’s a little too late for us here in Calais, but I’m hoping that it’s going to help some of the other facilities so we can still maintain access around the state,” said Barnes, who served on a long-term care committee last fall, which proposed added funding for nursing homes. “Especially in the rural communities.”
    Maine’s 7,000 nursing home residents are among the neediest in the country. Fifty-six percent are diagnosed with dementia — the second-highest rate in the nation. Maine ranks fourth highest in the number of nursing home residents who need help with tasks of daily living, such as bathing, grooming and eating. Maine nursing homes also must meet some of the most stringent staffing ratios of any state.
    Despite the challenges, Maine’s facilities boast one of the lowest rates in the nation of deficiencies, such as mistreating patients or high infection rates, which is a reflection of nursing home quality. Without adequate funding, however, Maine seniors and their families will suffer, experts say.
    “Maine nursing homes have for the most part, with some outliers, maintained quality,” said Brenda Gallant, who works on behalf of nursing home residents as the state’s long-term care ombudsman. “And that is critical. But I think we’re at a turning point.”

    Did anyone take the Alexander Group report seriously?

    By Trish Callahan, Special to the BDN
    Posted June 11, 2014, at 2:33 p.m.
    Reports of plagiarism have supporters of consultant Gary Alexander on the run. Gov. Paul LePage is begging for privacy while he cleans up his mess, and nationally Rep. Paul Ryan, R- Wisconsin, backpedaled on an invite for Alexander to speak before the House Budget Committee. What took them so long to start running? Reading the now-infamous Alexander Group report for the Maine Department of Health and Human Services should have been the starting gun.
    The last sentence in a description of the report says it all. The last of this series of self-aggrandizing, run-on sentences reads:
    “Deploying cost-effective savings methodologies to ensure a value-, transparent-, and efficiency-based system, our reforms drive innovation, improve service quality and performance, incentivize accountability and consumer engagement, modernize operations, and root out fraud, waste, and abuse.”
    First, what is up with that sentence? Second, root out fraud, waste and abuse? This report is an abuse of taxpayer dollars in and of itself. What is the going hourly rate forcutting and pasting? Or overly inundating a report with readily available statistics with limited substantive context? Or making recommendations drawn from assumptions and flawed math? Paying $925,000 for those couple hundred pages is a bit of a stretch.
    One sentences actually says, “Assuming that each case was a single individual receiving $200 per month in benefits amounts to $2,400 per case over the course of twelve months,” without identifying the basis for this presumption. Critical thinkers call this technique a baseless assumption.
    The report recommends subsidizing and mandating jobs for certain benefit recipients. At the beginning of the report, though, the authors acknowledge that a working single parent of three would have to earn $16 an hour to equal the standard of living provided at $8 an hour with government assistance.
    A quick scan of median wages for Maine at the Bureau of Labor Statistics shows most of the entry-level jobs available to recipients fall below that $16-per-hour mark. The point of financing jobs that will not free recipients from government assistance and forcing jobs that statistics show will not cover basic expenses is unclear.
    It is clear the recommendation is useless for Maine’s poor, unless it comes with an increased minimum and/or living wage law. The MIT Living Wage Calculator estimates that a single parent of three in Maine needs to earn more than $31 an hour to cover basic expenses absent government assistance. Maybe some of our recipients could get jobs with the Alexander Group.
    The report itself undermines the group’s recommendation that the state apply for a “global waiver” to administer its MaineCare program. The state currently administers the program utilizing six different waivers, which the report finds cumbersome in their individual bureaucracies and regulations. One “global waiver” would give the administration greater flexibility and authority in redesigning the entire program.