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Wednesday, July 23, 2014

Health Care Reform Articles - July 23, 2014

Radio Interview at KEXP - Seattle Community Radio

This is a link to a radio interview I did this weekend on the "Mind Over Matters" show on KEXP radio in Seattle about health care reform and the need for single-payer.  I usually don't like listening to my own interviews, but this one seems to have come together pretty well and is, I think, worth listening to.

http://hotpotatomedia.com/mpgs/071914cf.mp3


Are we getting enough bang for our healthcare buck? Hardly.

By Dr. Philip Caper, Special to the BDN
Posted July 17, 2014, at 12:31 p.m.
The U.S. healthcare system costs each of us about twice as much as those in other wealthy countries. Are we getting our money’s worth? Not by a long shot.
According to the fifth and most recent of a series of reports spanning the past decade by The Commonwealth Fund, one of the world’s most respected independent health care think tanks, “the U.S. is last or near last on dimensions of access, efficiency, and equity” and last on overall quality of our system. The nations studied include Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.
Although the U.S. does have some advanced medical technology, as do most of the other countries studied, we do a lousy job of getting it to many of our people, leading to our poor scores on access.
We don’t compare particularly favorably when it comes to quality either. We score relatively poorly on safe and coordinated care, and while we score well on access to (lucrative) specialized care (but not primary care), that access does not translate into better outcomes. “The U.S. ranks last overall with poor scores on all three indicators of healthy lives — mortality amenable to medical care, infant mortality and healthy life expectancy at age 60.”
The Commonwealth report goes on to observe that, “The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes.”
Even though the Affordable Care Act does result in a modest expansion of coverage for many people, even if it were to work exactly as designed (which it won’t) it would leave 25 million to 35 million people uninsured. Many more are underinsured due to high deductibles and co-pays, and restrictive physician and hospital networks. Both impede access to timely care. This will still leave us trailing most if not all other wealthy countries in the overall performance of our healthcare system.
Which causes me to think about Medicare, the closest thing we have to a universal health insurance system. Once you qualify for Medicare, it is good for life without any means test, and without regard to age, health status, employment status, gender or place of residence.
That kind of security cannot be achieved through private insurance.
Medicare was enacted by Congress and signed by President Johnson on July 1, 1965. Because of its simplicity, Medicare was smoothly rolled out to 19 million beneficiaries on July 1, 1966. No confusing websites or glitchy software needed. Since then, it has proven to be one of the most effective and efficient federal programs ever enacted, and has become politically untouchable. Even the most conservative politicians refuse to attack it, although some try to make the spurious (and ridiculous) claim that it is not really a federal program.
By following Medicare’s example, we could do a lot better. It would be very nice if we lived in a political culture where we could simply improve the ACA by replacing it with Medicare for everybody. But we don’t and won’t — at least not yet. We will have to wait a few more years, until the bewildering complexity, unfairness and arbitrariness of the ACA become more apparent to more people.
That shouldn’t stop us from preparing for the inevitable. The next landmark in the evolution of U.S. health care policy could come as soon as 2017, when the ACA provides the states an opportunity to replace many of its provisions with a simplified and improved system of their own.
Vermont has already enacted legislation that starts it on the path to do just that. Maine could be in the next wave of states to follow their example. If the Legislature is unwilling or unable to do that, the people could, through our initiative process.
We should celebrate the 49th (and soon 50th) anniversary of Medicare by starting the process of furthering the national movement toward universal health care as a human right.
We could create a simpler, more efficient, more equitable and less costly healthcare system that would turn us away from our current system of money-driven medicine and back toward the goal of healthcare with the sole mission of preventing and healing disease.
It would be the right thing to do.
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.

Hazards tied to medical records rush

Subsidies given for computerizing, but no reporting required when errors cause harm

By Christopher Rowland

Theresa Robertson’s bedside oxygen alarm sounded at 2:52 a.m., sending an urgent beep through the South Shore Hospital emergency room.
The alarm came as something of a surprise. The 46-year-old visual artist from Weymouth, who suffered from diabetes, congestive heart failure, and other serious health problems, had arrived at the nearby community hospital complaining of shortness of breath the previous afternoon. But by midnight, her vital signs were stable and she was resting peacefully.
Now, in the wee hours of Oct. 11, 2010, a new, more serious problem emerged. Four minutes after nurses responded to the oxygen alarm, Robertson had no pulse. The staff began pushing on her chest, racing to keep her alive.
The cause of Robertson’s crisis, it would later be learned, was a precipitous drop in her blood glucose — severe hypoglycemia. The deadly turn was the result of a medication error, lawyers for her family say, and that error can be traced in part to a major innovation in modern medical practice: electronic health records.
President Obama and Congress poured $30 billion in taxpayer subsidies into the push for digital medical records beginning in 2009, with only a few strings attached and no safety oversight of the vendors who sell the systems.
The move was touted as a way to improve patient care and help rein in medical costs. Five years later, the explosion in the use of the electronic records has created the potential for efficiencies and safety benefits but also new risks for patients, the scope of which still is not fully understood.
Academics, policy gurus, health care leaders, and patient safety advocates generally agree that the American medical system has long needed to abandon its old paper charts and catch up with the rest of the digital age. For instance, wider use of bar-coding in hospitals, matching patient wristbands with the drugs they are given, is creating a safer environment, specialists say.
But the scramble by doctors and hospitals to cash in on the incentives has thrust complex, balky, unwieldy, and error-prone computer systems into highly sensitive clinical settings at a record pace. From 2008 to 2013, the percent of US doctor’s offices with electronic health records rose from 17 to 48 percent. Growth in hospitals was even more dramatic, from 13 to 70 percent.

Deaths by medical mistakes hit records

The way IT is designed remains part of the problem

WASHINGTON |It's a chilling reality – one often overlooked in annual mortality statistics: Preventable medical errors persist as the No. 3 killer in the U.S. – third only to heart disease and cancer – claiming the lives of some 400,000 people each year. At a Senate hearing Thursday, patient safety officials put their best ideas forward on how to solve the crisis, with IT often at the center of discussions. 

Hearing members, who spoke before the Subcommittee on Primary Health and Aging, not only underscored the devastating loss of human life – more than 1,000 people each day – but also called attention to the fact that these medical errors cost the nation a colossal $1 trillion each year.  

"The tragedy that we're talking about here (is) deaths taking place that should not be taking place," said subcommittee Chair Sen. Bernie Sanders, I-Vt., in his opening remarks.

[See also: EHR adverse events data cause for alarm.]

Among those speaking was Ashish Jha, MD, professor of health policy and management at Harvard School of Public Health, who referenced the Institute of Medicine's 1999 report To Err is Human, which estimated some 100,000 Americans die each year from preventable adverse events. 
When they first came out with that number, it was so staggeringly large, that most people were wondering, 'could that possibly be right?'" said Jha. 

Some 15 years later, the evidence is glaring. "The IOM probably got it wrong," he said. "It was clearly an underestimate of the toll of human suffering that goes on from preventable medical errors."

It's not just the 1,000 deaths per day that should be huge cause for alarm, noted Joanne Disch, RN, clinical professor at the University of Minnesota School of Nursing, who also spoke before Congress. There's also the 10,000 serious complications cases resulting from medical errors that occur each day. 

Disch cited the case of a Minnesota patient who underwent a bilateral mastectomy for cancer, only to find out post surgery a mix-up with the biopsy reports had occurred, and she had not actually had cancer. 
http://www.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records

New Questions on Health Law as Rulings on Subsidies Differ


By 
WASHINGTON — Two federal appeals court panels issued conflicting rulings Tuesday on whether the government could subsidize health insurance premiums for millions of Americans, raising yet more questions about the future of the health care law four years after it wassigned by President Obama.
The contradictory rulings will apparently have no immediate impact on consumers. But they could inject uncertainty, confusion and turmoil into health insurance markets as the administration firms up plans for another open enrollment season starting in November.
By a vote of 2 to 1, a panel of the United States Court of Appeals for the District of Columbia Circuit struck down a regulation issued by the Internal Revenue Service that authorizes the payment of premium subsidies in states that rely on the federal insurance exchange.

A death blow for Obamacare?

By Laurence H. Tribe

  |    JULY 18, 2014
The moment the Affordable Care Act was enacted in 2010, it became a litigation magnet. The lawsuits threatening to derail it were initially dismissed as ridiculous but became deadly serious by the time Chief Justice John Roberts’s decisive fifth vote two years later barely upheld the law’s individual mandate, while the Court’s decisive 7-2 vote left the health law’s Medicaid expansion in tatters.
Last month, the court struck a second blow to the ACA by allowing some for-profit corporations to opt out of offering contraceptive coverage they deemed religiously offensive. And even House Speaker John Boehner is joining in the litigation, using the administration’s efforts to make the law more palatable by delaying implementation of one of its provisions as the centerpiece of his threatened lawsuit against the president.

But while Boehner’s empty threat makes headlines, a far more serious threat could deliver the death blow that the law’s opponents have been seeking. This new round of litigation attacks the health insurance exchanges at the heart of Obamacare. Congress designed the exchanges as markets to offer new, comprehensive, and often-subsidized insurance options to supplement the private market. The exchanges are the law’s linchpin — its primary means of making quality insurance affordable for millions of Americans.
The ACA required each state to “establish” an “American Health Benefit Exchange” by Jan. 1. If a state didn’t do so, the Department of Health and Human Services would step in to set up and run the exchange on the state’s behalf. The ACA treats exchanges run by HHS the same as those run by the states themselves. That’s crucial, because 36 states have deferred to HHS to set up their exchanges.

Halbig Decision Puts Obamacare Back on the Front Burner and Will Give Republicans a Huge Political Headache

Today's 2-1 decision by the DC Court of Appeals striking down federal premium subsidies, in at least the 27 states that opted for the feds to run their Obamacare insurance exchanges, has the potential to strike a devastating blow to the new health law.

The law says that individuals can get subsidies to buy health insurance in the states that set up insurance exchanges. That appears to exclude the states that do not set up exchanges––at least the 27 states that completely opted out of Obamacare. Another nine states set up partnership exchanges with the feds and the impact on those states is not clear.

The response by supporters of the law, and the IRS regulation that has enabled subsidies to be paid in the states not setting up exchanges, hinges on the argument that the language is at worst ambiguous and the Congress never intended to withhold the subsidies in the federal exchange states.

But in the DC Court ruling one of the majority judges said, "The fact is that the legislative record provides little indication one way or the other of the Congressional intent, but the statutory text does. Section 36B plainly makes subsidies only available only on Exchanges established by states."

Will Judges Bring Down Obamacare?

BY 

What are we to make of the conflicting rulings, issued Tuesday by two federal courts, on an important part of the Affordable Care Act—taxpayer-financed subsidies for people buying insurance through the online federal exchange? My initial reading is that the rulings won’t amount to very much. If the Republicans truly want to put an end to Obamacare, they are going to have to do it through the ballot box and the Congress. The courts aren’t going to do it for them.
A three-judge panel of the U.S. Court of Appeals for the D.C. Circuit has ruled that the 2010 health-care-reform law authorized the provision of subsidies to people who buy insurance through state-run exchanges, such as Covered California and NY State of Health. But, citing the precise text of the law, the D.C. court maintains that the same authority was never extended to Healthcare.gov, which the federal government runs, and which covers thirty-six states that have refused to set up their own health-care exchanges. The ruling won’t go into effect immediately; in the first instance, the Justice Department is appealing to the full Court of Appeals. But if those judges and other courts were to uphold this ruling, it would clearly undermine the main goal of Obamacare, which was to reduce the number of uninsured Americans.
Cue a barrage of alarmist headlines and a vigorous denunciation of the ruling by Josh Earnest, the White House press secretary, who said, “You don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health-care costs, regardless of whether it was state officials or federal officials who were running the marketplace.”
That admonition from Earnest came shortly before a second appeals-court panel, this one based at the Fourth Circuit, in Richmond, issued a ruling pointing in the opposite direction. Citing an ambiguity in the law’s wording, the court said it would defer to the Obama Administration—which, after all, pushed the law through. The Administration, through the Internal Revenue Service, had issued a rule authorizing the payment of subsidies for policies purchased on Healthcare.gov. This rule was “a permissible exercise of the agency’s discretion,” the Richmond judges said.

Why Obamacare probably isn’t doomed

By Tom Goldstein July 22

The Affordable Care Act took a potentially serious hit today when the D.C. Circuit Court of Appeals struck down a rule that extended the law’s health-care subsidies to residents of the  three-dozen states where the federal government runs a health insurance exchange.
But the fact that another court of appeals upheld the same rule on the same day shows that the legal issue is very thorny and will very likely  be ultimately resolved by the Supreme Court. And the administration probably will come out ahead in the end.
The controversial part of the law says that the government can provide subsidies for health insurance bought on exchanges “established by [a] State.”
The argument against the administration’s rule is straightforward: if a state refuses to set up an exchange, forcing the federal government to operate it instead, then the subsidies aren’t available. That legal reading of the statute makes some sense, because Congress may have wanted to encourage states to create exchanges with the carrot of promising subsidies for the states’ residents.
But the courts are required to uphold the rule if the law is ambiguous and the administration’s position is reasonable. The Supreme Court will probably uphold the rule under that lax standard.
Here’s why. Other provisions of the statute reference an exchange “established by [a] State,” but really include the federal government. Another section of the law refers to a state-run exchange when everyone agrees that it means to include the federal government too. Also, the law actually requires every state to set up an exchange, and it refers to all the exchanges as having been established by states. So you can look at the statute as a whole and reasonably read it to extend the subsidies to residents of every state.
It also makes some difference that the section of the law cited by the rule’s opponents is a strange place for Congress to have limited the availability of subsidies, because that section states the formula for tax credits rather than core rules on who gets benefits under the Act. There also isn’t much evidence to suggest that Congress actually was intending to use the subsidies to encourage states to create exchanges.
We won’t have a final answer for a while. The parties can ask all the judges of both of the courts of appeals that issued today’s rulings to rehear the case. The administration has the better chance, because recent appointments to the court that struck down the rule tilt the court to the left. But it may be that both courts will see that Supreme Court review is inevitable and stand aside to let the Justices decide the issue.


Federal courts disagree over Obamacare, creating uncertainty about Mainers’ health insurance subsidies

by Jackie Farwell
Tens of thousands of Mainers could pay much more for health insurance if a legal blow dealt Tuesday to Obamacare by a federal appeals court is upheld.
The U.S. Court of Appeals for the District of Columbia Circuit ruled that the federal government can’t legally administer health insurance subsidies in Maine and 35 other states relying on the Healthcare.gov marketplace. But just hours later, another federal circuit court backed the subsidies in a separate ruling, leading to a day of dueling verdicts for the health reform law.
The success of the Affordable Care Act, President Barack Obama’s signature health reform law, hinges on the subsidies, which make health insurance affordable to millions of Americans.
In Maine, the courts’ decisions would affect all but a few of the thousands of people who signed up for private health insurance through Healthcare.gov. Eighty-nine percent of the 44,000 Maine consumers who enrolled qualified for tax credits to offset the costs of their monthly premiums. The premium for Maine consumers with tax credits averages $99 a month, according to federal figures.
Without that financial help, Maine consumers could pay nearly 80 percent more in monthly premiums, the figures show.
The tax credits are available to people with annual incomes of up to 400 percent of the federal poverty level, or $94,200 for a family of four.
Tuesday’s D.C. court ruling in Halbig v. Burwell, issued by a panel of three judges, has the potential to undermine health reform across the country. But the decision may not hold up.
The federal government is expected to ask the full D.C. Circuit, composed of 11 judges, to review the decision. With seven Democratic appointees and only four Republican appointees, the full court is expected to rule in the Obama administration’s favor.
Also on Tuesday, another federal circuit court reviewing a legal challenge to the subsidies reached the opposite conclusion. The Fourth Circuit Court of Appeals in Richmond, Virginia, upheld the subsidies struck down by the D.C. Circuit.
A Maine health reform expert says the subsidies will stay put, at least for now.
“Don’t panic,” Mitchell Stein, and independent health policy consultant, advised Maine consumers who qualified for subsidies.
If the Obama administration appeals Tuesday’s D.C. Circuit court ruling, as expected, the case could end up before the U.S. Supreme Court.
“It has no impact today,” Stein said. “It will be appealed so subsidies will continue to be paid. Nothing changes. Even if the full D.C. appellate were to agree with this decision, other appellate courts have found in the opposite direction.”
Kevin Lewis, CEO of Maine Community Health Options, a Lewiston-based startup insurer that attracted most of Maine’s new enrollees under the ACA, said the D.C. Circuit’s decision won’t affect its policyholders, given the legal hurdles ahead.

Maine gubernatorial candidates react to split ACA verdicts

By Jackie Farwell, BDN Staff
Dueling court verdicts issued Tuesday over the legality of financial subsidies provided to Americans under the Affordable Care Act elicited quick response from Maine’s gubernatorial candidates.
The U.S. Court of Appeals for the District of Columbia Circuit ruled that the federal government can’t legally administer health insurance subsidies in Maine and 35 other states relying on the Healthcare.gov marketplace. Hours later, another federal circuit court in Virginia — in a separate case — upheld the subsidies in a conflicting ruling.
Republican Gov. Paul LePage said Maine couldn’t afford to pick up the cost of the subsidies, which are funded by federal taxpayer dollars.
“First the federal government forced people to buy health insurance,” LePage said in a statement. “Now, if this ruling holds up, these people would lose their federal subsidies to pay for that health insurance. Their premiums could skyrocket for plans that in some cases might be more expensive than their previous plans, which were canceled as a result of the law, making their health insurance unaffordable.”
LePage, who is running for re-election, urged Mainers to “call on those in Congress who voted for this scheme to get to work and fix this law immediately.”
LePage’s statement Tuesday reinforced his position as a staunch opponent of the Affordable Care Act. He’s often criticized Democratic President Barack Obama and Democrats in Congress for enacting the health reform act — and five times vetoed Democratic legislators’ proposals to expand Medicaid eligibility in Maine as outlined by the Affordable Care Act.
His Democratic challenger, U.S. Rep. Mike Michaud, voted in favor of the Affordable Care Act in 2010. Michaud said the D.C. court’s ruling undermined the intent of the law to provide quality, affordable health coverage to all Americans and stem rapidly rising healthcare costs.
“I remain committed to working with my colleagues on both sides of the aisle to find bipartisan fixes for the Affordable Care Act that will ensure as many Americans as possible have access to efficient, quality and affordable healthcare,” he said in a statement.
Michaud also reiterated his past support for establishing a state-run health insurance marketplace.
Tuesday’s court rulings don’t affect subsidies in states that opted to establish their own marketplaces, also called exchanges.
Brent Littlefield, LePage’s senior political consultant, highlighted the troubled and costly rollout of some state-run marketplaces, such as in Oregon, Massachusetts, Hawaii and Vermont.
Other state exchanges exceeded expectations.
Eliot Cutler, the independent candidate in Maine’s gubernatorial race, said Maine could have avoided any potential fallout from the D.C. court ruling if the state had established its own exchange. As a direct consequence of LePage’s opposition to a state-run exchange, roughly 39,000 Mainers now must wonder about how to afford health care, he said.
“Had Maine set up its own exchange, these people would not be living today with the uncertainty that this decision has created,” Cutler said in an interview.
Maine could still opt to set up its own exchange. Cutler said such legislation would be among the first bills he would send to the Legislature as governor.
Federal funding offered to states to set up their own exchanges, however, expires in October, before Maine’s Nov. 4 gubernatorial election.
As governor, LePage had a responsibility to ensure Maine people have access to quality care, when they need it, at an affordable price, Cutler said.
“Turning your back on that fundamental responsibility is, I think, a terrible, terrible mistake,” Cutler said.

Maine Health Care Advocates: Don't Panic Over Dueling Subsidy Rulings

By 
Health care officials in Maine spent the day analyzing the potential impact of two, conflicting federal appeals court rulings on a key part of the Affordable Care Act.
Jay Field reports on today's dueling appeals court rulings on Affordable Care Act subsidies.
One said that tax credits used to buy coverage under the law can only be given to residents of states that set up their own health insurance exchanges. But another argued that the Affordable Care Act's language is vague and that the government is free to offer subsidies in all states.  
In Maine, health care consumers are wondering how the decisions will affect them. Maine is one of 27 states that opted out of the Affordable Care Act and declined to set up its own health insurance exchange. Most of these states have Republican governors, like Paul LePage, who oppose the ACA.
Consumers in Maine who want to buy coverage under the law get federal subsidies and use the federal exchange - healthcare.gov - to shop for plans. "People who are currently getting tax credits that help them afford health insurance coverage should not panic," says Emily Brostek, associate director at Consumers for Affordable Health Care.
In Maine, 44,000 people signed up for coverage under the Affordable Care Act during the first enrollment period, which ended March 31. In one of the decisions issued today, the D.C. Circuit Court of Appeals, in a 2 to 1 ruling, said that only states with their own health exchanges could get subsidies from the federal government to help middle- and low-income people buy coverage.
But Bostick says the D.C. decision is based on a very narrow reading of the law, "which we don't believe is likely to be agreed upon by other courts."
Indeed, shortly after Emily Brostek spoke these words, a second ruling came out - this one from a federal appeals court in Richmond, Virginia. It it, a three-judge panel ruled unanimously that the Obama administration could, in fact, offer subsidies in states using the federal health care exchange.

Missouri Alone in Resisting Prescription Drug Database
By 
SIKESTON, Mo. — On his office phone at L & S Pharmacy, Richard Logan listened as a doctor’s office detailed how a patient had just left with her third prescription for painkillers in only nine days — and was quite possibly getting more, illegally, elsewhere.
Mr. Logan, 61, holstered two guns, slipped on a bulletproof vest and jumped into his truck. Because in his small corner of America’s epidemic of prescription drug abuse, Mr. Logan is no ordinary pharmacist. He is also a sheriff’s deputy who, when alerted to someone acquiring fraudulent drug prescriptions, goes out to catch that person himself.
“I’m only one guy, and for every person we get to, there are probably 100 who we can’t,” Mr. Logan said. “How many people have to get addicted and die for us to do what everyone else is doing about it?”
His frustration stems from this: Missouri is the only state in America that has declined to keep a prescription drug database — the primary tool the other 49 states use to identify people who acquire excess prescriptions for addictive painkillers and tranquilizers, as well as the physicians who overprescribe them.
A Dearth in Innovation for Key Drugs
There is clearly something wrong with pharmaceutical innovation.
Antibiotic-resistant infections sicken more than two million Americansevery year and kill at least 23,000. The World Health Organization has warned that a “post-antibiotic era” may be upon us, when “common infections and minor injuries can kill.” Even the world’s tycoons consider the proliferation of antibiotic-resistant bacteria one of the crucial global risks of our times, according to a survey by the World Economic Forum.
Yet the enthusiasm of the pharmaceutical industry for developing drugs to combat such a potential disaster might be best characterized as a big collective “meh.”
No major new type of antibiotic has been developed since the late 1980s, according to the W.H.O. From 2011 to 2013, the Food and Drug Administration approved only three new molecular entities to combat bacterial diseases — the lowest rate since the 1940s. “No sane company will develop the next antibiotic,” said Michael S. Kinch, who led a team at the Yale Center for Molecular Discovery tracking the evolution of pharmaceutical innovation over the last two centuries.
And this is hardly the drug industry’s only problem. Antibiotics, Professor Kinch told me, “are the canary in the coal mine.”
This is particularly striking at a time when the pharmaceutical industry is unusually optimistic about the future of medical innovation. Dr. Mikael Dolsten, who oversees worldwide research and development at Pfizer, points out that if progress in the 15 years until 2010 or so looked sluggish, it was just because it takes time to figure out how to turn breakthroughs like the map of the human genome into new drugs. The pipeline today, which includes tailored treatments for cancer, newfangled vaccines and therapies for tough diseases like hepatitis C, is robust.

White House working on new birth control insurance rule


The Obama administration plans to make another change in the rules governing how employer healthcare plans cover birth control, one in a long series of efforts to accommodate religious objections to some contraceptives.
Details of the new rules will not be set for a few weeks, a senior administration official told reporters in Seattle, where President Obama was attending Democratic fundraisers Tuesday. The Justice Department announced the general outline of the change in a filing with a federal appeals court earlier in the day. 
Nonprofit religiously affiliated employers such as colleges, hospitals and charities are required to provide contraceptive coverage as part of whatever health plans they offer. But if the organization objects on religious grounds to some or all methods of birth control, the current rules provide an exemption.
The rules require the employer to file a form with the government giving notice of its objection as well as the name of its insurer. The insurance company is then supposed to step in to offer the birth control coverage on its own at no extra cost to covered individuals.

Busy Doctors, Wasteful Spending

By SANDEEP JAUHAR
    OF all the ways to limit health care costs, perhaps none is as popular as cutting payments to doctors. In recent years payment cuts have resulted in a sharp downturn in revenue for many hospitals and private practices. What this has meant for most physicians is that in order to maintain their income, they’ve had to see more patients. When you reduce the volume of air per breath, the only way to maintain ventilation is to breathe faster.
    As our workdays have gotten busier, we doctors have had less time to devote to individual patients. An internist I know in private practice used to see 15 patients a day. “Now reimbursement is so low I have to see at least 30,” he told me. “If I stay in the room more than 10 minutes, my assistant will call me and tell me to hurry up.”
    Racing through patient encounters, we practice with an ever-present fear that we will miss something, hurt someone and open ourselves up to legal (not to mention moral) liability. To cope with the anxiety, we start to call in experts for problems that perhaps we could handle ourselves if we had more time to think through a case. The specialists, in turn, order more tests, scans and the like.
    And therein lies the sad irony of the health cost containment paradigm in this country. There is no more wasteful entity in medicine than a rushed doctor.
    The Institute of Medicine, a federally funded research group in Washington, has estimated that wasteful health care spending — i.e., spending that does not improve health outcomes — costs about $750 billion in the United States every year. Excessive paperwork and administrative costs explain some of this waste, but unnecessary or inefficiently delivered services, especially in hospitals, account for by far the largest chunk. Total payments to physicians, in comparison, are much smaller, making up a fifth or less of the money this country spends on health care.
    But even though physicians’ salaries account for a relatively small fraction of health care costs, physicians’ decisions may affect upward of 80 percent of total health spending. We order tests, prescribe drugs, hospitalize patients and — one of the costliest decisions a doctor can make today — call specialists for help.
    http://www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html?emc=edit_tnt_20140720&nlid=1311158&tntemail0=y&assetType=opinion&_r=1&assetType=opinion&gwh=D0D3829F0BA108EE5BEF6E9231C38C03&gwt=pay&assetType=opinion


    Health Care Spending Slowdown: The Consumer Paradox
    Executive Summary
    Submitted to:
    Federation of American Hospitals (FAH)
    Submitted by:
    Dobson|DaVanzo
    Al Dobson, Ph.D.
    Gregory Berger, M.P.P.
    Kevin Reuter
    Phap-Hoa Luu, M.B.A.
    Joan E. DaVanzo, Ph.D., M.S.W.
    Wednesday, July 23, 2014 — Final Report
    Dobson DaVanzo & Associates, LLC Vienna, VA 703.260.1760 www.dobsondavanzo.com

    Executive Summary
    In recent reports we have outlined the continuing historic slowdown in the growth rate of health care spending driven in large part by emerging structural changes in the health care system.1,2 Recent evidence suggests that the cost curve has continued to bend, with health care spending declining in the first quarter of 2014. Despite this continuing trend in health care spending growth, consumers are increasingly concerned that they are ever-more financially burdened by spending on their own health care.
    This consumer perception is largely a factor of the “new normal” being established through health insurance, which includes:
    • Benefit plan designs, used by employers and insurers to shift greater financial risk to consumers through higher out-of- pocket spending (i.e., deductibles, co-payments, and co- insurance); and
    • Health insurance premiums, which continue to rise faster than the average person’s income.
      This trend of growth in out-of-pocket spending combined with increases in health insurance premiums that outpace increases in wages is not sustainable over the long term, and harms both patients and providers. However, the slowing growth of national health care spending has eased this burden to some degree, and if it continues, will ultimately benefit consumers. The savings from the health care spending slowdown have been and will continue to be passed onto consumers through lower costs than would otherwise have been the case and greater value in the services they use.
      http://fahpolicy.org/wp-content/uploads/2014/07/Dobson-DaVanzo-Federation-Cost-Sharing-Executive-Summary.pdf

      In Effort to Foster Competition in Health Care, Common Threads Emerge Among State Laws

      First-of-its-Kind, Comprehensive Report from National Academy of Social Insurance and Catalyst for Payment Reform

      For Immediate Release: July 17, 2014
      WASHINGTON, D.C. and SAN FRANCISCO – Today, the National Academy of Social Insurance (NASI) and Catalyst for Payment Reform (CPR) released a comprehensive evaluation of state laws addressing the power of health care providers to negotiate higher prices. This report, State Policies on Provider Market Power (PDF), catalogues the laws and regulations state governments are using to maintain or increase competition in health care markets, which the recent wave of mergers among hospitals and other consolidation among providers has significantly reduced.
      The report reveals a number of common strategies states are using, including laws and regulations pertaining to: antitrust; price and quality transparency; competition in health plan contracting; price regulation; the development of Accountable Care Organizations (ACOs); expanding the authority of state Departments of Insurance; and facilitating the entry of new providers into the marketplace. Key findings include: 
      • Forty-two states have laws related to price transparency, mandating that hospitals and/or providers share some type of price information publicly. However, the information is frequently not available in a format that is highly useful or accessible to consumers.
      • Eighteen states have attempted to limit providers’ influence through banning most favored nation contracting clauses (which can prevent other health plans from entering local markets, stifling competition).
      • A growing number of states are forming regulatory bodies to monitor health care prices. Delaware, Maryland, and Massachusetts, among others, have legislation establishing health care commissions to monitor and review health care prices.
      • Texas is the only state that has passed legislation that supports market competition during the development and implementation of ACOs; other states that have passed legislation supporting the development of ACOs (e.g., Alabama) have included provisions intended to grant provider groups exemptions from state antitrust laws and immunity from federal antitrust laws through the state action doctrine.
      • Five states currently have Certificate of Public Advantage statutes that permit exemption from antitrust provisions for providers merging or consolidating for the purposes of cooperation and health care delivery improvements.　
      The report also highlights the approaches of states with active policy strategies for fostering competition, including California, Massachusetts, New Hampshire, New York, Pennsylvania, and Rhode Island. "This review shows that states active in this space have devoted significant resources to creating and maintaining a competitive market," said Lee Goldberg, Vice President for Health Policy at NASI.
      "Balancing the desire for more coordinated and continuous health care with the benefits of market competition is a challenge facing the nation and every state," said Suzanne Delbanco, Executive Director of CPR. "We hope this report will help states learn from one another about policy approaches to maintaining and fostering competition as the provider landscape undergoes dramatic changes."
      The report is a part of a larger NASI project on "Addressing Pricing Power in Health Care Markets." Support for this project is provided by the Robert Wood Johnson Foundation, The California HealthCare Foundation based in Oakland, California, and the Jayne Koskinas Ted Giovanis Foundation for Health and Policy.

      Download a PDF of the Full Report

      Study: 52k More Primary Care Physicians Needed by 2025

      Written by Molly Gamble
      With the Patient Protection and Affordable Care Act in place, the country will need roughly 52,000 more primary care physicians by 2025 to cover the law's preventive care provisions and general population growth, according to a new study from the Annals of Family Medicine. 

      The total number of office visits to primary care physicians is projected to grow from 462 million in 2008 to 565 million in 2025 — an increase driven by population growth and aging, according to the study.

      Population growth will demand 33,000 additional physicians by 2025, while another 10,000 will be needed to accommodate the aging population. The healthcare reform law's insurance expansion will call for another 8,000 physicians — a 3 percent increase in the current workforce. 

      Study authors said that in addition to increasing the supply of primary care physicians, policymakers must also consider physician distribution. "Our estimates do not account for the uneven distribution of services whereby some areas experience pervasive shortages. The newly insured will only exacerbate this maldistribution if they cluster in physician-scarce areas," according to the study. 

      The authors urged for more research on the association between workforce ratios and outcomes, where uninsured populations are located and where access to primary care is limited. 
      http://www.beckershospitalreview.com/hospital-physician-relationships/study-52k-more-primary-care-physicians-needed-by-2025.html






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