If you have the stomach for it, click on the hotline at the bottom of the following article. No, it's not from a Stephen King novel - it non-fiction.
- SPC
A Father’s Last Wish, and a Daughter’s Anguish
Fighting Health Care System for Simple Request: To Die at Home
Joseph Andrey was 5 years old in 1927 when his impoverished mother sold him to the manager of a popular vaudeville act. He was 91 last year when he told the story again, propped in a wheelchair in the rehabilitation unit of a nursing home where it seemed as though age and infirmity had put a different kind of price on his head.
Craning his neck, he sought the eyes of his daughter, Maureen Stefanides, who had promised to get him out of this place. “I want to go home, to my books and my music,” he said, his voice whispery but intense.
He was still her handsome father, the song-and-dance man of her childhood, with a full head of wavy hair and blue eyes that lit up when he talked. But he was gaunt now, warped like a weathered plank, perhaps by late effects of an old stroke, certainly by muscle atrophy and bad circulation in his legs.
Now she was determined to fulfill her father’s dearest wish, the wish so common among frail, elderly people: to die at home.
But it seemed as if all the forces of the health care system were against her — hospitals, nursing homes, home health agencies, insurance companies, and the shifting crosscurrents of public health care spending.
Her father had been discharged by a hospital to a nursing home like this one, supposedly for rehabilitation, so many times that even she had lost count. The stays, long or short, had only left him weaker, harder to care for at home with a shrinking allotment of help from aides and more prone to the infections that sent him back to the hospital.
This time she had fiercely opposed his being discharged to anywhere but home, a small walk-up apartment in Manhattan that her parents shared for half a century before her mother’s death. Yet over her protests and his own, he had been transferred here anyway, to Jewish Home Lifecare in Morningside Heights, a sprawling institution an hour from where she lived. Later, he would ask, “Are you sure you didn’t put me here?”
“No matter what I do, they want you in a nursing home,” Ms. Stefanides told him, promising the placement would be temporary. “I think they’re making money off you.”
Records would show that her father’s case let the nursing home collect $682.48 a day from Medicare, about five times the cost of a day of home care.
By now Ms. Stefanides was a veteran of battles with the health care system, but it still baffled her. A public-school teacher, she could not afford out-of-pocket home care, and though her father qualified for both Medicaid and Medicare, the flow of money seemed to bypass what he actually wanted at the end of life.
Home care agencies abruptly dropped or refused high-needs cases like her father’s as unprofitable under changes in the state’s Medicaid program. Hospitals, eager to clear beds, increasingly sent patients to nursing homes. The nursing homes were often too short-staffed to reliably change diapers but still drew premium Medicare rates, ordering hours of physical therapy and other treatment that studies showed wasoften useless or harmful.
Even hospice was limited. Now mostly for-profit, hospice companies would provide supervision and visits at home a few times a week through Medicare if a doctor certified that Mr. Andrey had only six months to live. The hidden catch: He would lose all Medicaid home care, the daily help he needed to be home at all.
Finding Humane Care at the End of Life
INTRODUCTION
As the story of Joseph Andrey’s last months shows, many Americans will end their lives in surroundings that only add to their misery. Those who hoped to die in their own beds are often forced into nursing homes, some of which mistreat patients. Even if home care is arranged, it too can be substandard, even abusive. And those who hope for government guidance can findunreliable information.
What can be done to ensure that the elderly get the care they want and need, particularly in their dying days?
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Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not
When Jennifer Hopper raced to the emergency room after her husband, Craig, took a baseball in the face, she made sure they went to a hospital in their insurance network in Texas. So when they got a $937 bill from the emergency room doctor, she called the insurer, assuming it was in error.
But the bill was correct: UnitedHealthcare, the insurance company, had paid its customary fee of $151.02 and expected the Hoppers to pay the remaining $785.98, because the doctor at Seton Northwest Hospital in Austin did not participate in their network.
“It never occurred to me that the first line of defense, the person you have to see in an in-network emergency room, could be out of the network,” said Ms. Hopper, who has spent months fighting the bill. “In-network means we just get the building? I thought the doctor came with the E.R.”
Patients have no choice about which physician they see when they go to an emergency room, even if they have the presence of mind to visit a hospital that is in their insurance network. In the piles of forms that patients sign in those chaotic first moments is often an acknowledgment that they understand some providers may be out of network.
ut even the most basic visits with emergency room physicians and other doctors called in to consult are increasingly leaving patients with hefty bills: More and more, doctors who work in emergency rooms are private contractors who are out of network or do not accept any insurance plans.
When legislators in Texas demanded some data from insurers last year, they learned that up to half of the hospitals that participated with UnitedHealthcare, Humana and Blue Cross-Blue Shield — Texas’s three biggest insurers — had no in-network emergency room doctors. Out-of-network payments to emergency room physicians accounted for 40 to 70 percent of the money spent on emergency care at in-network hospitals, researchers with the Center for Public Policy Priorities in Austin found.
“It’s very common and there’s little consumers can do to prevent it and protect themselves — it’s a roll of the dice,” said Stacey Pogue, a senior policy analyst with the nonpartisan center and an author of the study.
Number of Latinos with insurance coverage surges under healthcare law
By NOAM N. LEVEY
By NOAM N. LEVEY
The federal healthcare law has dramatically increased coverage among Latinos, according to a new report that provides a comprehensive look at the effects of the Affordable Care Act on a historically underinsured community.
Overall, the percentage of Latinos ages 19 to 64 lacking health coverage fell from 36% to 23% between summer 2013 and spring 2014.
That parallels a broader increase in coverage that has taken place since insurance marketplaces opened last fall and states began expanding Medicaid under the healthcare law.
The overall uninsured rate for U.S. adults under 65 plummeted from 20% to 15% in the same period, according to the Commonwealth Fund, a nonprofit group that studies U.S. and global health systems. Other surveys have shown similar declines.
But many of the health law's supporters were concerned that the expansion in coverage would not reach Latinos and other groups that have traditionally struggled to access regular medical care.
"The Affordable Care Act appears to be working for millions of Latinos who, as a group, have long faced the nation's highest uninsured rates," said the Commonwealth Fund's Michelle Doty, the report's lead author. "These substantial improvements will mean better health and healthcare for millions of people."
Underinsured Enrollees Flood Community Health Centers
Some low-income consumers who bought bronze plans with low premiums but high deductibles are discovering they still can't afford health care and are turning to the community health centers which cannot turn anyone away. Meanwhile, a study finds insurance costs for small businesses are lower through the SHOP exchanges, and South Dakota lifts a $2M cap on employees' lifetime health costs.
Modern Healthcare: Underinsured ACA Enrollees Strain Community Health Centers
Obamacare enrollees are straining the finances of community health centers around the country, some health center leaders say. The issue is that many lower-income patients with insurance coverage through the federal and state exchanges bought bronze-tier plans with lower premiums but high deductibles, coinsurance and copayments and no federal cost-sharing subsidies. When these patients face high out-of-pocket costs for care that falls below the deductible, they can't afford it. So the centers are subsidizing that care by offering them means-tested sliding-scale fees. When the centers, which are not allowed to turn away patients for inability to pay, try to get the insurers to pay, the claims are usually denied, and the centers have to write it off as uncompensated care (Dickson, 9/25).
Obamacare enrollees are straining the finances of community health centers around the country, some health center leaders say. The issue is that many lower-income patients with insurance coverage through the federal and state exchanges bought bronze-tier plans with lower premiums but high deductibles, coinsurance and copayments and no federal cost-sharing subsidies. When these patients face high out-of-pocket costs for care that falls below the deductible, they can't afford it. So the centers are subsidizing that care by offering them means-tested sliding-scale fees. When the centers, which are not allowed to turn away patients for inability to pay, try to get the insurers to pay, the claims are usually denied, and the centers have to write it off as uncompensated care (Dickson, 9/25).
The Washington Post: Obamacare’s Small Business Exchanges Offer Cheaper Health Coverage, Study Shows
During the lead-up to the rollout of the health care law a year ago, President Obama was adamant that new insurance marketplaces for small businesses would provide a start-to-finish online shopping experience for employers, where they could compare and buy plans with the click of a mouse. In addition, he said, by placing rates from different insurers side-by-side and offering tax breaks, the marketplaces would provide less expensive plans that what had been available to small companies. ... It appears, based on one new study, that the exchanges are delivering [on the second promise] (Harrison, 9/24).
During the lead-up to the rollout of the health care law a year ago, President Obama was adamant that new insurance marketplaces for small businesses would provide a start-to-finish online shopping experience for employers, where they could compare and buy plans with the click of a mouse. In addition, he said, by placing rates from different insurers side-by-side and offering tax breaks, the marketplaces would provide less expensive plans that what had been available to small companies. ... It appears, based on one new study, that the exchanges are delivering [on the second promise] (Harrison, 9/24).
Kaiser Health News: Debate Grows Over Employer Plans With No Hospital Benefits
As companies prepare to offer medical coverage for 2015, debate has grown over government software that critics say can trap workers in inadequate plans while barring them from subsidies to buy fuller coverage on their own. At the center of contention is the calculator -- an online spreadsheet to certify whether plans meet the Affordable Care Act’s toughest standard for large employers, the ‘minimum value’ test for adequate benefits (Hancock, 9/26).
As companies prepare to offer medical coverage for 2015, debate has grown over government software that critics say can trap workers in inadequate plans while barring them from subsidies to buy fuller coverage on their own. At the center of contention is the calculator -- an online spreadsheet to certify whether plans meet the Affordable Care Act’s toughest standard for large employers, the ‘minimum value’ test for adequate benefits (Hancock, 9/26).
The Associated Press: State Lifts $2M Cap On Employee Health Care Costs
South Dakota can no longer limit how much it pays out in health care coverage over the lifetime of state employees, but officials say for now that shouldn't raise costs. Laurie Gill, the commissioner of the state's Bureau of Human Resources, briefed legislators this week on how changes mandated by the Affordable Care Act will affect the state's health plan. The Affordable Care Act prohibits health care plans from capping the amount of benefits employees incur over a lifetime. South Dakota had capped lifetime expenses at $2 million per individual, meaning any health care costs incurred over that amount weren't covered. The change means the state could end up paying out more, but Tom Steckel, the state's director of employee benefits, said in the past it's been rare for an employee to reach the $2 million limit. Steckel said his office has been looking into how many workers surpassed the cap. So far, he said, he wasn't aware that any had reached it last year (Burbach, 9/25).
South Dakota can no longer limit how much it pays out in health care coverage over the lifetime of state employees, but officials say for now that shouldn't raise costs. Laurie Gill, the commissioner of the state's Bureau of Human Resources, briefed legislators this week on how changes mandated by the Affordable Care Act will affect the state's health plan. The Affordable Care Act prohibits health care plans from capping the amount of benefits employees incur over a lifetime. South Dakota had capped lifetime expenses at $2 million per individual, meaning any health care costs incurred over that amount weren't covered. The change means the state could end up paying out more, but Tom Steckel, the state's director of employee benefits, said in the past it's been rare for an employee to reach the $2 million limit. Steckel said his office has been looking into how many workers surpassed the cap. So far, he said, he wasn't aware that any had reached it last year (Burbach, 9/25).
Too Many People Die In Hospital Instead Of Home. Here’s Why.
TOPICS: DELIVERY OF CARE, STATES
By Fred Mogul, WNYC
SEP 22, 2014
This story is part of a partnership that includes WNYC, NPR and Kaiser Health News. It can be republished for free. (details) Special thanks to WNYC's Data Team.
It was September 2012 and it was life-long smoker Paula Faber's third cancer in a decade, but she did not hesitate.
"She was going to fight it every inch of the way," says her husband Ron Faber.
By August 2013 after much fighting, Paula Faber died at age 72. Ron Faber now regrets the intervening 11 months of chemotherapy, radiation, painkillers and side effects that reduced his wife to 67 pounds of frayed nerves. Instead, the pain could have been managed so she could focus on the quality of life.
"I would have rather have had a really okay four-and-a half months than this endless set of treatments," the stage actor said.
As they confronted Paula's terminal diagnosis, the decision the Fabers made is among the most difficult anyone can make. But it turns out that in the New York metropolitan region, patients opt for aggressive treatment much more often than other Americans.
"New York City continues to lag in serious ways with regards to providing patients with the environment that they want at the end of life," says Dr. David Goodman, who studies end-of-life care at Dartmouth College's Geisel School of Medicine.
The reasons they do this are many, but most experts agree that it has less to do with the unique characteristics and desires of people in New York and New Jersey than the health care system and culture that has evolved here.
The result: More people dying in the hospital, often in an intensive care unit on a ventilator or feeding tube; more doctor visits leading to tests, treatments and drug prescriptions; and more money being spent by the government, private insurers and patients themselves.
Specialists at the Dartmouth Healthcare Atlas maintain that one of the main drivers of this phenomenon is quantity: people end up in hospitals here so often, they say, because this region simply has a lot of hospital beds.
"One of the truisms of healthcare is that whatever resources are available, or whatever beds are built, they tend to get filled," Goodman says.
A second driver is that every region has its own medical "culture," and the one in New York is built around highly trained specialists and sub-specialists who see it as their job to cure illness. Dr. Diane Meier says that means, "that if there's a cancer it needs chemotherapy, that if there's heart failure, it needs a procedure."
Meier is a geriatric specialist at Mount Sinai and the director of the Center to Advance Palliative Care
http://www.kaiserhealthnews.org/Stories/2014/September/22/Too-Many-People-Die-In-Hospital-Instead-Of-Home-Heres-Why.aspx?utm_source=khn&utm_medium=internal&utm_campaign=viewed
The Woman’s Heart Attack
By MARTHA WEINMAN LEAR
IN medical circles, they call it the Hollywood Heart Attack. You’ve seen it: grimace of agony, clutching of chest, sudden collapse, the whole purple-prose panoply.
For my husband, Harold Lear, a doctor who became a patient just that suddenly, it was the first stop in a five-year medical odyssey, one cardiac crisis after another, ending with the ultimate stop in 1978.
Through all the years that followed, it remained my assumption that the Hollywood Heart Attack was it: the paradigm, the norm, the way heart attacks are supposed to happen.
I was relieved of this assumption two years ago, when I had one of my own.
Mine went like this: altogether well one moment, vaguely unwell the next; fluttery sensation at the sternum, rising into the throat; mild chest pressure; then chills, sudden nausea, vomiting, some diarrhea. No high drama, just a mixed bag of somethings that added up to nothing you could name. Maybe flu, maybe a bad mussel, maybe too much wine, but the chest pressure caused me to say to my second husband, “Could this be a heart attack?” “Of course not,” he said. “It’s a stomach bug.”
Still, that pressure, slight but there, nagged at me. I called my doctor and reported my symptoms. The mention of diarrhea, almost never a presenting symptom in heart attacks, skewed the picture. He said, “It doesn’t sound like your heart. I can’t say a thousand percent that it’s not, but it doesn’t seem necessary to go racing to the emergency room with the way you feel now. Just see it through and come in for an EKG in the morning.”
The pressure eased. I slept, and woke the next morning feeling well. I went for the test mainly because I had said that I would, fully expecting to be told that I was healthy. First the EKG and then the echocardiogram told a different story: a substantial heart attack, “less than massive,” my doctor said, “but more than mild.” We were both stunned.
Suddenly I found myself living in a sequel: same hospital where Hal had worked and died, same coronary unit, same cardiologist, same everything; different husband wheeling me in my wheelchair through the corridors where I had wheeled Hal in his. Ghosts in every corner.
With a stent implanted in an occluded artery, I recovered fast and was cleared to leave in four days, but a bad hospital-acquired infection kept me there four weeks — time enough for a revelatory education about women and hearts.
Surprise No. 1: The biggest killer of American women is not breast cancer, as many people believe. It is heart disease. Should I have been surprised? Of course not. The American Heart Association keeps telling us about our hearts and we keep not listening, possibly because we are so fearful of cancer that we have no fear to spare, as we lie on our beds dutifully palpating ourselves for the lumps that we pray not to find.
Our hearts kill more of us than all kinds of cancer combined.
Obamacare doctor networks to stay limited in 2015
Obamacare doctor networks to stay limited in 2015
Finding a doctor who takes Obamacare coverage could be just as frustrating for Californians in 2015 as the health-law expansion enters its second year.
The state's largest health insurers are sticking with their often-criticized narrow networks of doctors, and in some cases they are cutting the number of physicians even more, according to a Times analysis of company data. And the state's insurance exchange, Covered California, still has no comprehensive directory to help consumers match doctors with health plans.
This comes as insurers prepare to enroll hundreds of thousands of new patients this fall and get 1.2 million Californians to renew their policies under the Affordable Care Act.
Even as California's enrollment grows, many patients continue to complain about being offered fewer choices of doctors and having no easy way to find the ones that are available.
Some consumers have been saddled with huge medical bills after insurers refused to pay for care deemed out of network. These complaints have sparked a state investigation and consumer lawsuits against two big insurers.
Mary Edwards, a 63-year-old librarian in Mar Vista, was excited about a Health Net PPO she picked out last fall because it offered a wide selection of doctors at a reasonable price. But it turned out that several physicians listed on her plan didn't accept the insurance or weren't taking new patients.
"This is part of the Affordable Care Act that doesn't quite work yet," Edwards said. "This game of who's in and who's out is tiresome."
More than 80,000 medical providers are participating in Covered California next year, according to a Times analysis of health plan information. The data, current through August, were submitted to state regulators and obtained under the Public Records Act.
Altogether, the 10 insurers in Covered California have contracted with an estimated 75% of California's licensed physicians, or nearly 90% of those considered active in the state. However, many of those doctors are available in just one or two health plans.
All of these insurance networks for individual policies are subject to change and regulatory review before taking effect Jan. 1. The next open enrollment under the Affordable Care Act runs Nov. 15 to Feb. 15.
Anthem Blue Cross, Blue Shield of California, Health Net and Kaiser Permanente dominated the first year of Obamacare enrollment in California, accounting for 94% of the individual market.
Health Net has proposed the most dramatic change for 2015, the data show. It's dumping the PPO network that Edwards and others purchased and switching to a plan with 54% fewer doctors and no out-of-network coverage, state data show.
Yet premiums for that stripped-down policy are going up as much as 9% compared with pricing for the PPO. State regulators have questioned the company's moves.
Health Net said its cutbacks were necessary to avoid even steeper rate hikes and it's confident the smaller network will be sufficient. Its separate HMO network is unchanged for 2015 after about 4,000 doctors were added this year.
The insurer is following the lead of its two rivals Anthem and Blue Shield, which opened last year with sharply limited networks.
