Health dollars wasted
A recent study of the hospital costs in eight different nations published in the September issue of Health Affairs has determined that hospital costs in the U.S. in 2011 were much greater than those in all of the nations studied. Lead author Dr. David Himmelstein, a professor at the CUNY/Hunter College School of Public Health and a lecturer at Harvard Medical School, stated, “We are squandering $150 billion each year on hospital bureaucracy and $300 billion is wasted every year on insurance companies’ overhead and the paperwork they inflict on doctors.” And our length of life and other parameters of the U.S. health care system are not as good as the seven other countries and many millions of Americans still have no or very limited insurance.
The evidence for a single payer health care system is getting stronger every day. We Americans simply have to become educated about why and how a single payer system works. Imagine that 450 billion of our “health care” dollars are spent needlessly and not on health care.
William Babson Jr. MD
Sinclair
Putting ‘Medicare for All’ on the Agenda
by John Nichols - The Nation
Don Berwick is making a vital point about the need for progressives to expand the discussion about healthcare reform.
Democratic and Republican strategists, and the candidates who let campaign consultants frame their range of opinion, are still engaging inpicayune debates about the strengths and weaknesses of the Affordable Care Act.
But Berwick, who for seventeen months headed the Medicare and Medicaid programs under President Obama, isn’t getting lost in the political weeds. He’s blazing a trail in the direction of what ultimately must be done—pushing at the constraints of the conversation and offering an illustration of why it is so important for progressives to get specific about the need for a “Medicare for All” fix.
Mounting an admittedly uphill campaign for the Democratic nomination for governor of Massachusetts, Berwick says, “I want us to be the first state in the nation to adopt single-payer health care—Medicare for All. With that one change, we can improve care and reduce costs for families and businesses. We can free up resources that will add tens of thousands of jobs all over Massachusetts. Single-payer health care— let’s lead.”
Berwick does not raise this issue casually. A Harvard Medical School graduate who practiced medicine serving low-income families before founding the nonprofit Institute for Healthcare Improvement, advised the World Health Organization and was so well regarded for his advice and counsel on improving Britain’s healthcare system that he was knighted by Queen Elizabeth II.
But being one of the best thinkers and doers in the area of healthcare reform does not always bring rewards. During his tenure as administrator of the Centers for Medicare and Medicaid Services, Berwick was a key player in implementing some of the best components of the Affordable Care Act, including initiatives “ensuring that young people can stay on their parents’ health plans until the age of 26, kids with preexisting conditions can no longer be denied the care they need, and insurance companies are subjected to new levels of transparency.”
Yet, as Berwick’s campaign now notes, “The toxic politics of Washington cut short Don’s time there. Right-wing pundits attacked his commitment to equality and health care for all. Glenn Beck labeled him the ‘second most dangerous man in America.’ Senate Republicans vowed to filibuster his confirmation. In the face of the same Republicans who blocked Elizabeth Warren’s confirmation to head the Consumer Financial Protection Bureau, Don was forced to step aside after only seventeen months leading Medicaid and Medicare.”
The experience did not sour Berwick on the fight for healthcare reform.
But it did cause him to refocus his considerable energies.
The physician returned to his home state of Massachusetts and began preparing for a gubernatorial run in which he has argued that the states can and must lead on real healthcare reform.
To that end, he says, he wants to build on the leadership role Massachusetts has taken on reform to make Medicare for All a reality.
“I know from my first-hand experience in Washington guiding the early implementation of the Affordable Care Act that all eyes in the nation are on Massachusetts. Champions of real health care reform are crossing their fingers for us to succeed; opponents are hoping for us to fail. It is crucial that we lead, and show the rest of the nation that treating health care as a right, not a privilege, is sensible and successful public policy,” explains Berwick in a statement on his website.
It is time to find a way to get to yes on a single payer system in Massachusetts. The complexity of our health care payment system adds costs, uncertainties, and hassles for everyone—patients, families, doctors, and employers. On day one, I will appoint a multi-stakeholder Single Payer Advisory Panel to investigate and report back within six months on how Massachusetts moves to a single payer health insurance system like Medicare for all.
Massachusetts is not the only state where single-payer healthcare reform is being placed in the agenda. In Vermont, Governor Peter Shumlin and his legislative allies have made significant progress on the issue. And they are not alone.
Last month’s “Organizing for Healthcare Justice in the Age of Obamacare” strategy conference in Oakland, California, brought together Labor Campaign for Single Payer, Healthcare NOW! and theOne Payer States group, as well as members of Physicians for a National Health Program and leading figures in National Nurses United, the California Nurses Association, the International Longshore and Warehouse Union and other labor groups. At the conference, much of the discussion was about state-based initiatives in Vermont, California, Minnesota, Oregon, Washington and other regions of the country.
Video Nation
by Timothy Egan
The barbarians in Iraq and Syria had been beheading innocents, raping girls and slaughtering “infidels” well before a single awful video appeared of an American journalist being executed by a masked fanatic. The world shrugged.
Racism in the era of the first African-American president continued to drive the actions of police and festered in high places, well before Donald Sterling was caught on tape saying he didn’t want prominent black people appearing in public at games played mainly by blacks. Meh.
And about 1.3 million American women were assaulted by an intimate partner last year, with more than 150,000 of them being hit by a fist or something hard. It was just another stat in a jumble of disconnected figures — that is, until a professional football player was shown cold-cocking his fiancée.
We are roused to action by cruel realism, but only if it looks and sounds authentic. Reasoned calls to our better angels are no longer enough. It takes the YouTube snuff films of gangsters with a religious cause, or the fuzzy images captured by an elevator robo-cam, to move a nation.
Against this backdrop, President Obama on Wednesday tried to convince a fickle country, its citizens driven to their smartphones by national attention deficit disorder, to kill some bad guys. Kill, in a sort of war, at the ragged edge of a longer war nobody except John McCain defends anymore. For the moment, we’re with the president. But trust me: It will all change with fresh pictures.
Don’t expect the video of the commander in chief’s address to the nation to go viral. We got calm reassurance: “America is safer” than it’s been for some time, thanks to targeted strikes against key terrorist leaders, he said. We got explanation. The nihilists of ISIS “are not Islamic,” he said. The vast majority of their victims are Muslim. And a plan: The United States will lead “a broad coalition against these terrorists,” with increased airstrikes and training of allies in the region.
Fine. Good. Solid. And forgettable. It’s not entirely his fault. A crisis now follows something that pops up on TMZ or is released by hackers. After the slick smoking-gun-as-mushroom-cloud casus belli theater of the last president, we don’t trust the official version of anything. And not just in matters of war and peace.
“If you watch the nightly news it feels like the world is falling apart,” Obama said at a fundraiser last month. He’s half correct. Not many people watch the actual nightly news anymore, but millions watch the cinéma vérité of horrible things, from punching a loved one to beheading a journalist.
The president understands this dynamic, yet he seems helpless to do anything about it. He’s as reactive as the rest of the world. Nearly 200,000 people have died and three million refugees are wandering in despair because of the Syrian conflict. But the American public was resolute in not wanting any part of it until the beheadings of two of our citizens appeared.
“All you need to do is see the videos of the beheadings and we’re not worried about mission creep,” said Senator Bill Nelson, Democrat of Florida, this week, in making an argument for military engagement. That’s it in a nutshell: public policy driven by visceral reaction to videos.
And for the cherry on top of that dollop of honesty, consider the candid cynicism of Representative Jack Kingston, of Georgia, explaining the Republican strategy on Obama’s initiative. “We can denounce it if it goes bad, and praise it if it goes well, and ask him what took him so long,” he said.
The National Football League, the top-rated source of entertainment in the land, has tolerated any manner of wife-beaters and even accused murderers in its employ. In the league’s cozy moral universe, it’s all pink cleats for breast cancer victims and salutes to the troops. But knocking out a loved one — eh, how about a two-game suspension. In the starting lineup Sunday for the San Francisco 49ers was Ray McDonald, who was arrested on suspicion of battering his pregnant fiancée. No TMZ money shot yet, so McDonald plays.
No person of conscience could watch the Ray Rice video without feeling revulsion. But that shouldn’t be the new standard for outrage and action. Trying to sway someone with an old-fashioned appeal — e.g., figures on the number of women who are kicked cold every day — is largely fruitless.
The other day, a leading scientist asserted for the zillionth time, after it was reported that the volume of greenhouse gases in the atmosphere hit a record in 2013, that we are on a path to global disaster with climate change. At the same time, the National Audubon Society released a report that warmer temperatures will disrupt half the bird species of North America, causing many to go extinct.
Do we need to see trumpeter swans falling from the sky or a three-toed woodpecker dropping dead in a fire-charred forest for this threat to seem real?
President Obama can’t go on vacation following a beheading because he’s not allowed to go off the video mood of the moment. Yet Dwight Eisenhower could golf his way through the scariest period of the Cold War, and Franklin Roosevelt could paddle around the waters at his refuge of Warm Springs, while crushing the Nazi war machine.
“The world has always been messy,” said Obama, a smart man, making a smart observation to a public that doesn’t reward that trait. “In part we’re just noticing now because of social media and our capacity to see in intimate detail the hardships that people are going through.”
It’s all about the optics. If Republicans repeal the new health care law, it won’t hit home until we actually see a cancer patient being denied insurance because of a pre-existing condition — death panel live! Not a bad idea.
Former insurance lobbyist educates seniors on how to avoid Medicaid for end-of-life care
Posted Sept. 12, 2014, at 8:17 a.m.
PORTLAND, Maine — Chris Orestis has attracted millions in investment to Life Care Funding, the company he started in 2007, but the veteran insurance industry lobbyist is counting on old skills to grow the still-young venture nationally.
State legislators are the next battleground for the company, which buys life insurance policies primarily from middle-class people who, instead of supporting dependents after they die, need to cash out the policy to pay for long-term and end-of-life care.
A bill to encourage seniors to consider that option was tabled last year in Maine, after Maine’s Department of Health and Human Services and the American Council of Life Insurers said the matter required further study before law or regulatory changes are considered.
Orestis said his company is planning another push.
“We’re waiting to see what happens with the governor’s race and then trying to bring that back in the state of Maine,” Orestis said.
So far, Texas and Kentucky have passed such laws. Maine is one of 10 states where similar legislation has been proposed.
Perhaps the one thing less pleasant than thinking about end-of-life care is thinking about how to pay for it, but it’s a concern destined to be on the mind of more and more people and caregivers, especially in oldest-in-the-nation Maine.
“At midnight in 2011, the very first second of 2011, the first baby boomer turned 65 and they have since been turning 65 at a rate of about 10,000 a day,” Orestis said. “When the [stock] market collapsed and baby boomers just kept coming and coming — but running out of ways to pay for care — we were standing there with a way to access a massive pool of assets.”
The company buys life insurance policies for an average of 45 percent of the value of the death benefit, paid when the policyholder dies. On a $100,000 policy, that means the policyholder would have about $45,000 placed in a secured account to pay for care.
Orestis said that setup, opposed to getting cash for a policy through what’s called a life settlement, is more secure for the policyholder and helps prevent financial elder abuse.
Life Care then holds onto the policy, paying the required premiums, until the policyholder dies. All told, Life Care aims to make about 10 percent on each purchased policy.
Orestis said the benefit for policyholders is they have more options paying privately than going onto Medicaid.
“You’d have more options as a private-pay person,” said Rick Erb, president of the Maine Health Care Association, which supported the mandatory disclosure bill last year. “Even if the facility does accept MaineCare [Maine’s version of Medicaid], it might not accept [MaineCare] for all of the beds.”
That’s the case at Avita at Stroudwater, a Scarborough assisted living facility designed specifically for housing people with memory loss. The facility has 70 apartments, 10 of which are MaineCare beds and, accordingly, come with a longer waiting list.
Lea Rust, the facility’s marketing coordinator, said converting life insurance policies to pay for care is relatively new to caregivers, but provides another option she thinks has promise for patients looking at care where they’d pay privately.
“It’s our job to educate people because I don’t think that families are even thinking about it,” Rust said. “I think they’re just looking for money where they can find it.”
Difference between hospital admission, observation can be pricy
Posted Sept. 11, 2014, at 12:40 p.m.
An increasing number of seniors who spend time in the hospital are surprised to learn they were not “admitted” patients, even though they may have stayed overnight in a hospital bed and received treatment, diagnostic tests and drugs.
Because they were not considered sick enough to require admission but were not healthy enough to go home, they were kept for observation care, a type of outpatient service. The distinction between inpatient status and outpatient status matters: Seniors must be admitted as patients for three consecutive days to qualify for Medicare coverage for follow-up nursing home care, and no amount of observation time counts for that three-day tally. That leaves some observation patients with a tough choice: Pay the nursing home bill themselves — often tens of thousands of dollars — or go home without the care their doctor prescribed and recover as best they can.
Angry seniors have sued Medicare and appealed to Congress to change the rules they say make no sense. Medicare officials recently began experimenting with limited exemptions, but they have been unable to resolve the problem.
Most observation patients with private health insurance don’t face such tough choices. Private insurance policies generally pay for nursing home coverage whether a patient had been admitted or not.
Here’s a primer comparing how Medicare and private insurers handle observation care.
Does observation care coverage vary by insurance policy?
Regardless of what type of insurance they have, patients are kept for observation for the same reason — so doctors can decide whether they need care only the hospital can provide. They also may receive diagnostic tests and, in some cases, treatment.
Medicare and most private insurers consider observation care an outpatient service — like a doctor’s visit or a lab test — even though observation patients may spend a night or more in a hospital room.
What does it cost?
Because observation care is provided on an outpatient basis, patients usually have co-payments for doctors’ fees and each hospital service. And they need to pay extra for routine drugs they take at home if the hospital provides them during the observation period. For seniors who do not have a supplemental insurance policy that helps cover these expenses, the bill can be oppressive, according to Terry Berthelot, a senior attorney at the Center for Medicare Advocacy, a public interest law firm based in Connecticut.
Like Medicare beneficiaries, privately insured patients usually are responsible for a share of the cost of each treatment or test they receive when hospitalized for observation.
Those bills can add up, according to a study by the Health Care Cost Institute, a nonprofit, nonpartisan research organization. Privately insured people receiving observation and other outpatient services in the hospital paid about four times as much out of pocket as admitted patients in 2012 — an average of $47 per admitted person compared to $199 for an outpatient.
How do you know if you’ve been admitted?
Ask your doctor or hospital officials to be sure, because patients in observation care usually are treated in the same units and rooms as admitted patients and might not know they have not been admitted. Most find out when they get a bill.
Medicare does not require beneficiaries be notified when they are on observation status, but at least two states — Maryland and New York — have passed laws compelling hospitals to tell patients when they are under observation care and, as the Maryland notice warns, “that may increase the patients’ out-of-pocket costs for their stay.”
“Knowledge is power,” said Maryland Sen. Delores G. Kelley, D-Baltimore County, who introduced the notice legislation last year.
Maine Insurers Take Different Approach to Paying Doctors, in Effort to Cut Costs
Patty Wight reports on insurers' effort to provide better patient care by paying primary care physicians upfront.
PORTLAND, Maine - Insurance companies are starting to pay primary care physicians in Maine a little differently, in an effort to improve care, and reduce expensive hospitalizations. They're giving doctors reimbursements upfront, to cover the cost of outreach and forms of care that come outside a patient visit. Some health policy experts say these programs are another step in the right direction.
Years ago, Portland internist Dr. Tom Claffey says he noticed a problem with the way patients with chronic conditions were being treated. Their care was sporadic and reactionary.
"The delivery of care needed to change from engaging patients when they came to see us, to outreach and monitoring people and looking at their chronic conditions and managing those on a continuous basis, rather than an intermittent basis," Claffey says.
So Claffey, who is also the president of Intermed, says the physician group decided to try something new. They had nurse practitioners and physician assistants review medical records to identify the sickest patients. They'd call those patients to remind them about important screenings. They'd meet with them to identify any social or domestic issues affecting health. They extended office hours into evenings and weekends.
But Claffey says this kind of outreach wasn't covered by insurance. "And so it was something, essentially, we funded for a while, 'til we had conversations with insurance companies that showed them there was value in what we were doing."
Now, some insurance companies are putting money into the approach.
"What we're trying to do is to transform how practices actually deliver care to their members, and also pay them differently so they can accomplish those changes," says Dr. Jeff Holmstrom, a practicing family physician, and also the medical director at Anthem, which last year launched its so-called Enhanced Personal Health Care Program in Maine. It pays primary care physicians a set amount per month - around $3 per patient - to invest in infrastructure to deliver quality care.
"We give them money upfront so they can hire a nurse practitioner or a care coordinator, or maybe have a relationship with a mental health provider in their office," Holmstrom says, "things that traditionally primary care couldn't afford the way it was paid."
Income checks throw Californians off health plans
Covered California not sure how many are affected
SACRAMENTO, Calif. —Some Californians who purchased individual health coverage through the state's insurance exchange are suddenly being dropped or transferred to Medi-Cal, the program for the poor that fewer doctors and providers accept.
Covered California, which is responsible for determining and directing Californians to an appropriate health plan, has no estimate of how many people are affected, saying only that the changes are occurring as incomes are checked to verify the policyholders can purchase insurance through the exchange.
Since the shifts often happen without warning, there's confusion and anger among policyholders.
Glendale resident Andrea Beckum learned last month that she and her husband had been shunted to Medi-Cal only after getting a call from their insurance broker telling them their Anthem Blue Cross policy had been canceled. It's a mystery because they make above the $21,707 threshold for two people to qualify for Medi-Cal, she said.
When the couple met with Los Angeles County social service workers, they were told they make too much to qualify for Medi-Cal. Now they are uninsured and considering an appeal.
"That's the crazy part," said Beckum, 35, a part-time neuropsychology researcher. "Even if we were in Medi-Cal, we don't qualify for Medi-Cal."
Covered California launched the online marketplace in October 2013 as part of the state's implementation of the federal Affordable Care Act. The exchange offers sliding-scale subsidies for private coverage to lower-income and middle-class people with no access to health care on the job, and directs the poor to county social service offices for Medi-Cal.
Assemblyman Richard Pan, D-Sacramento, who chairs the Assembly Health Committee, said he will hold a hearing later this month and look, among other things, at why people are losing coverage and what can be done to reduce interruptions.
"Implementing the Affordable Care Act, clearly it's not something that just stops at the end of open enrollment," Pan said. "There are ongoing issues."
Officials at Covered California acknowledged that a number of people are being shifted around during income checks and eligibility updates.
"It will happen continually," spokesman Dana Howard said.
A California solution for a Medicaid quirk
The 2010 federal healthcare reform law required virtually all adult Americans to carry insurance, starting this year. And to help make policies affordable, it offered subsidies to lower-income households while expanding the Medicaid insurance program to more of the poorest residents. But there's a key difference between those two groups: Only those in the Medicaid program may find their estates billed after they die to pay back some of the aid.
The Obama administration recognized how unfair this was, and it urged states to rein in their efforts to recover from the estates of Medicaid enrollees. The California Legislature responded by passing a bill (SB 1124) that would stop Medi-Cal, the state's version of Medicaid, from trying to collect repayment for routine medical care and insurance premiums. The measure now awaits action by Gov. Jerry Brown, whose Department of Finance opposes the bill because it would cost Medi-Cal an estimated $30 million a year. Although those funds are important to Medi-Cal, Brown should sign the bill.
Because Medicaid was meant for people with few resources, federal law requires states to seek from the estates of those who did have assets reimbursement for nursing home, in-home and community-based care. California law goes further, requiring Medi-Cal to seek reimbursement for the cost of any care delivered to an enrollee age 55 or older, provided that the enrollee did not have a surviving spouse or minor or disabled children. The law allows heirs to obtain an exemption from the recovery if they can show it would cause them substantial hardship, such as forcing them to remain on public benefits.
In theory, that's not a bad way to limit Medi-Cal's benefits to the poorest Californians. In practice, though, the recoveries are unfairly applied. More sophisticated families evade recovery by shifting assets to relatives of Medi-Cal enrollees before they die. And those with slightly more income can buy subsidized insurance at extremely low cost through Covered California, the state's insurance marketplace, without having to repay the subsidies after they die.
Glitch in health care law allows employers to offer substandard insurance
By Jay Hancock
A flaw in the federal calculator for certifying that insurance meets the health-care law’s toughest standard is leading dozens of large employers to offer plans that lack basic benefits, such as hospitalization coverage, according to brokers and consultants.
The calculator appears to allow companies enrolling workers for 2015 to offer inexpensive, substandard medical insurance while avoiding the Affordable Care Act’s penalties, consumer advocates said.
Insurance pros are also surprised such plans are permitted.
Employer insurance without hospital coverage “flies in the face of Obamacare,” said Liz Smith, president of employee benefits for Assurance, an Illinois-based insurance brokerage.
At the same time, a kind of Catch-22 bars workers at these companies from subsidies to buy more comprehensive coverage on their own through online marketplaces. No federal tax credits for health coverage are available to people with workplace plans approved by the calculator.
The calculator is used by self-insured employers, which include most large firms.
Like insurance companies, self-insured employers must certify that their plans pass the law’s standards for consumer value.
One official way to do that is to get a passing score on the Health and Human Services Department’s “minimum-value” calculator, an online tool.
An employer checks boxes on the screen indicating what benefits are offered — such as hospitalization, mental health care and pharmacy coverage — as well as workers’ share of the cost. The calculator then determines whether the plan covers enough potential medical costs to be considered adequate insurance.
“There are a lot of errors in the calculator,” said Shannon Demaree, director of actuarial services at Lockton Cos., a large broker. “It allows more plans to pass as qualifying coverage than we believe really do.”
It’s unclear which companies, or how many, are offering calculator-approved coverage without hospital benefits. Retailers, temp agencies and other lower-wage employers that have not traditionally offered comprehensive insurance are the most likely to sign up, brokers say.
“There is very high interest” among Lockton’s clients, Demaree said.
About 35 employers working with Assurance intend to offer such coverage, Smith said. The American Worker Plans, another Illinois firm, is advising about 30 companies considering that type of coverage, said Jon Duczak, the company’s senior vice president.
While they offer such plans because employers ask for them, Assurance and the American Worker Plans said they are cautioning them about their use. They did not identify the employers.
HHS is aware of potential problems with the calculator but has not changed it, industry authorities said.
“I think they were somewhat naive in not realizing that people were going to game the heck out of it,” said Hobson Carroll, an independent actuary who works closely with self-insured employers.
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