Hundreds of consumers trying to buy health insurance through the Massachusetts Health Connector continue to encounter snags, even as new leadership works to fix a balky system.
Louis Gutierrez, the Connector’s executive director, told the agency’s governing board Thursday his staff is conducting a top-to-bottom review of customer-service shortfalls and will submit plans to repair them within six weeks.
“We had several deeply problematic back-office operational deficits that led directly to unacceptable customer service for a significant number of customers,” Gutierrez said.
Gutierrez attributed the problems to the need for paper workarounds at key junctures in the insurance-buying process. That includes when consumers have selected a plan and that information is transferred to Dell Inc., the company that handles billing. Problems have also emerged when Dell then sends enrollment information to insurers.
The Connector’s software also lacks the ability to make some changes, such as adding a newborn child to coverage.
Gutierrez estimated that about 1 percent of Connector users are affected by these problems, but “when you have large numbers like we do that’s a lot of people.” About 1,000 people continued to wait for issues to be resolved Thursday, he said.
Even so, since February an additional 30,000 people have bought insurance through the Connector, a state agency serving people who do not obtain coverage through an employer, bringing to 141,585 the number of people who had enrolled as of April 6.
Although the open enrollment period for the Connector ended in February, there are many exceptions that permit people to sign up at other times.
http://www.bostonglobe.com/metro/2015/04/09/hundreds-massachusetts-health-connector-customers-still-encountering-snags/afRFHWW2TPbjS4m2woS44M/story.html

Medicare fix needs fixing

By Theodore R. Marmor
Philadelphia Inquirer (Philly.com), April 13, 2015
In recent weeks, reform legislation that proposes to change how Medicare pays physicians drew much attention. The prod to action was the imminent expiring of the present fee schedule.
For many years, Congress had failed to reach agreement about the rate of increase in physician payments under Medicare. This, in turn, prompted annual, ad hoc "fixes" while postponing decisions on how Medicare should operate as a "purchaser" of medical care.
The surprise of 2015 is that the House of Representatives did agree, in bipartisan fashion, on a remedy. After five years of persistent and contentious debate over the Obama health reform we now know as Obamacare, the sight of Speaker John Boehner (R., Ohio) embracing Minority Leader Nancy Pelosi (D., Calif.) over a health-care bill is indeed newsworthy.
But here, as in other instances, the problem is faulty reasoning from misleading assumptions.
Take the definition of what's wrong with our current payment arrangements. Many lawmakers say that Medicare should reject the fee-for-service method, the mode Medicare has used since its inception - and the way many industrial nations pay their doctors.
Instead, these lawmakers argue, Medicare should reward doctors for the "quality" rather than the "quantity" of their work, and reward "value" over "volume." Sylvia Burwell, secretary of Health and Human Services, has fervently embraced "value-based payment."
This seeming agreement on the need to do away with fee-for-service has prompted much discussion of alternative payment models, such as "capitation," "bundled payments," and monetary incentives for exemplary physician behavior.
Sounds plausible, doesn't it? But the problem is - as all other industrial democracies have learned in the last three decades - there is no single payment panacea. Each method of compensating doctors has the vice of its virtue.
If you pay physicians per capita - known as capitation, an annual or monthly amount for each patient signed up with a practice - the hope is that the doctors will care more about the health of their patients and less about the number of procedures they perform.
But there is little or no evidence to back up this hope. Many other countries use fee-for-service payments, but spend far less on health care than we do, and yet get decent results, without alarming problems of excess procedures.
Under Britain's National Health Service, physicians were once paid almost exclusively by capitation, and it generally served them well. Now general practitioners get paid partly per capita, partly by meeting targeted actions, and partly by the equivalent of a "salary" for being available on weekends and evenings. They are experimenting with a mix of payment methods.
So the international evidence shows there is no one obvious way to pay doctors. How to manage sensibly the mix of methods is the important challenge.
The celebration of paying for "value over quantity" assumes we know how to identify value and pay for it. Yet, there is considerable disagreement in modern medicine about how much one way of working is better than another.
For example, an attempt to establish a standardized cost-benefit analysis of treatments for Medicaid patients in Oregon in the late 1990s fell apart upon implementation. There was no agreed-upon list of what treatments were more valuable on grounds of both cost and quality, and physicians were rightfully indignant when their professional knowledge about what was best for their individual patients was upended by a rulebook.
In reading the bill that the Senate will soon vote on, I can't help but notice how the new prescriptions for physician behavior represent marketing jargon more than considered thought. For decades, one has seen prepaid group practice redefined as "managed care," while actually what was going on were mostly efforts to reduce the costs of care.
We have now seen a whole series of reforms celebrated for giving the patient financial "skin in the game," based on a vision of a medical-care marketplace where large deductibles force patients to make choices among goods and services that earlier forms of health insurance did not do.
As if these issues weren't enough to abandon this bill and start over, there are a couple of specific provisions that represent a Trojan horse for the further undermining of traditional Medicare. One is the imposition of deductibles on Medigap plans that the majority of Medicare beneficiaries buy to help with cost-sharing, a reform that will discourage seniors from seeking needed care. The other is a measure that would require wealthier people to pay higher Medicare premiums - a measure that could further erode universal political support for the program.
The Senate should take this legislation back to the drawing board.
Ted Marmor is a professor emeritus of political science and public policy at Yale University and a coauthor, with Rudolf Klein, of "Politics, Health and Health Care." He can be reached at theodore.marmor@yale.edu.
http://www.pnhp.org/print/news/2015/april/medicare-fix-needs-fixing

A Tale of Two Patients

By Joseph Eichenseher, M.D.
Sonoma County (Calif.) Gazette, April 10, 2015
In previous columns in this newspaper you’ve heard a myriad of reasons why single payer, or Improved Medicare for All, benefits Americans and provides for a better and less expensive solution to the debacle of our current healthcare situation. While Canada and all developed countries have ongoing problems with healthcare, and none pretend to be perfect, the seriousness of our current crisis, in the form of out-of-control costs and unnecessary suffering, has reached epic proportions, casting us in a shameful light. Tens of thousands of Americans die each year due to lack of insurance, and there are millions of other examples of avoidable suffering. I see many of them daily as a primary care physician here in Sonoma County. The following are two examples of how our dysfunctional health system impacts local lives.
Patient #1 - “Bob.”  Robert M. is a 50-year-old carpenter experiencing daily chest pain at work.  He copes by doing less of the activities that cause the pain, but the symptoms are worsening over time. He works three part-time jobs, none of which provide health insurance.  He comes to my community clinic office because we have a sliding scale, and the visit costs him $40, as opposed to a private office that would charge over $200. He states that he can’t afford to spend more, as he is supporting three children and his invalid mother. Upon my exam it is determined that he needs a referral to a cardiologist and a possible heart procedure. The initial visit to the cardiologist will cost $300 (and they won’t see him if he doesn’t pay first), and any procedure will likely cost a minimum of $40,000. He understands he needs care, but refuses to follow my recommendations due to his inability to pay. We try to convince him that if he doesn’t go to the hospital or a specialist soon he will continue to suffer and possibly have a heart attack. He leaves our office downtrodden.
Patient #2 - “Cindy.”  Cynthia R. is a 61-year-old daycare worker with similar symptoms as Bob. When with the children, doing strenuous activities, she has sharp chest pains. She is one of the fortunate Americans to have insurance, but with a $5,000 deductible. This situation of “underinsurance” increasingly affects tens of millions of people. When we recommend that she seek treatment for her heart condition she likewise refuses, stating that she can’t afford to pay the deductible. We plead with her to seek appropriate care, yet she declines, and leaves my office more stressed, adding to her risk of a heart attack.
Both Bob and Cindy’s situations are common in today’s America. They are hardworking people who continue to suffer unnecessarily. Due to untreated medical conditions they are likely to miss many days at work and leave family responsibilities unfulfilled. The knowledge that treatment is available, yet financially challenging to obtain, also causes stress in their lives and worsens health outcomes. They will likely die younger or experience an emergency situation, causing more suffering and costing hundreds of thousands of dollars, potentially creating insurmountable debt. Medical bills are now the number one reason for individual and family bankruptcy in America.
The rest of the world has figured out that healthcare is a right for all people. They don’t tolerate for-profit health insurance companies and they find ways for everybody to be covered less expensively with better health outcomes. Society benefits if all people are treated with dignity. If either Cindy or Bob lived in Canada, Singapore, Australia, Costa Rica, or France they would receive timely specialist treatment and avoid unnecessary suffering. They would be happier, more productive citizens. The United States of America is a great country that offers so much opportunity and possibility. It is time for us to be part of the 21st-century civilized world.  Please consider joining us in Sonoma County to fight for healthcare justice: “Expanded, improved Medicare for All.”

Our healthcare system: Can we afford it for much longer?

By Dwight Michael, M.D.
Gettysburg Times, April 9, 2015
We are five years into the Affordable Care Act (ACA), and yet we truly do not know how this very complicated bill will ultimately affect the affordability of healthcare in our country.
Prior to passage of the ACA, the cost of medical care for the average American was spiraling upwards at an ever-increasing rate. Presently, $3 trillion a year, 17% of the U.S. gross domestic product, is spent on healthcare in our country. This is nearly twice the amount that any other country spends on healthcare.
Despite the fact that we outspend other developed countries nearly 2:1, our clinical outcomes such as infant mortality rates, maternal mortality rates, and life expectancy are mediocre at best.
Although there are many facets to the excessive cost of healthcare in our nation, patients’ out-of-pocket cost for their prescription drugs is one of the most upsetting to me. Why do we have to pay so much?
At the core of excessive American healthcare costs, our political system allows money to “buy” legislators and legislation.
In his recent book "America’s Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System," Steven Brill reveals that our legislators needed to cut deals with several powerful players in healthcare if there was any hope of passage of the ACA.
As early as 2003, under the leadership of congressman Billy Tauzin, Congress passed a bill that forbid Medicare to negotiate drug prices with the pharmaceutical industry, costing Medicare patients and taxpayers literally billions of dollars.
Six years later, from March to July of 2009, the same Billy Tauzin-now lead lobbyist for PhRMA (Pharmaceutical Research and Manufacturers of America) at $2 million a year-led the way in a backroom deal with negotiators from Max Baucus’s Senate Finance Committee and eventually the White House.
The ACA deal: The pharmaceutical industry would give up $80 billion over 10 years by paying an additional tax based on market-share, give Medicaid patients deeper discounts on the costs of their drugs, and reduce the “doughnut-hole” costs of drugs for Medicare patients. White House analyst Tony Clapsis had calculated that the pharmaceutical industry would reap an additional $200 billion due to the increased number of Americans with health insurance. By his estimate, Big Pharma was giving up less than half of its increased revenues.
In return, Max Baucus and the White House gave the pharmaceutical industry four major gifts: 1. Medicare was still forbidden to negotiate drug prices with the pharmaceutical industry. 2. Importation of drugs from other countries such as Canada remained illegal. 3. There were to be no draconian cuts in Medicaid payments for drugs. 4. Biologic drugs would have 12 years of patent protection, markedly improving their profits during that timespan. These promises were made to gain the pharmaceutical industry’s support of this legislation.
Who really pays for this? Everybody in the United States who buys a prescription drug pays for this. Last year, we spent $309 billion for prescription medications.
Other countries in the industrialized world have a central health authority that negotiates drug prices with the pharmaceutical industry. Because we have no such agency, it is estimated that our country spends anywhere from 35 to 50% more for prescriptions drugs.
Even at a conservative 30% extra, this is an additional $93 billion a year handed over to the pharmaceutical industry. These companies claim they require such revenues for research and development of new drugs. Their profit margins (10-43%), however, are better than those of any other industry. In 2008 the top 10 pharmaceutical companies in the world made profits of $51.6 billion. In 2014 this figure had increased by $38.2 billion to $89.8 billion. This is profit after all other expenses are paid!
Think about it. Because of money’s influence on our political process, the pharmaceutical industry has used its vast riches to influence our legislators, who then produce legislation that essentially causes the United States -- you, me and all other Americans -- to pay for the massive profits of these international corporations. We are paying 35-50% more for our prescriptions than any other country. In effect, our government’s legislation has allowed Big Pharma to pad its profit margin with our money, while these companies give the rest of the world discounted prices. It does not seem fair to me. Does it to you?
One of my conservative partners at Gettysburg Family Practice has suggested that he could support a law that would limit the charge for any prescription to no more than the average of what other nations pay for that drug. If we did this, we could cut American prescription drug costs by $93 billion a year.
In our present healthcare climate of ever-increasing deductibles, co-pays, and other out-of-pocket costs, I often spend time with my patients looking for an affordable option for a drug they need. This happens on a daily basis.


Uncommon sense on health care

By Alan Bavley
The Kansas City Star, March 29, 2015
Joshua Freeman is chief of family medicine at the University of Kansas Hospital and an inveterate blogger.
He started his “Medicine and Social Justice” blog in 2008 calling for universal health care coverage and has returned repeatedly to the subject. That’s because even though the Affordable Care Act makes coverage available to many people, Freeman doesn’t think it goes far enough.
And while politicians dare not speak its name, Freeman isn’t shy about what he thinks we need: A single-payer, Canadian-style system covering everyone.
Freeman recently gave me an advance copy of his new book, “Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System,” laying out his arguments.
It’s a fine primer on the tangled web of special interests and ultimately futile regulation that passes for a health care system in this country. (Truth in punditry: Freeman cites my reporting in his chapter on the role of profit in health care.)
Freeman provides telling anecdotes: His experience treating uninsured patients whose chronic illnesses were out of control because they couldn’t afford care. His discovery in New Orleans of a safety-net clinic sponsored by Qatar — which means America, the richest nation on Earth, accepts foreign aid to care for its poor.
He’s also good at taking points often made by others and making connections. Yes, we know we spend more on health care than other wealthy nations and despite that, our people aren’t particularly healthy. But the U.S. also spends less on social services, he observes, the kinds of things that elevate people from the poverty that degraded their health in the first place.
But the poor don’t have political clout. Health care providers and insurers do. So that’s where the money goes. “We have a health care system that is designed to make profit rather than health,” Freeman says.
According to Freeman, a single-payer system — basically, Medicare for all — would go a long way toward putting the focus back on patients. It would eliminate the crazy quilt of insurance plans that drive up administrative costs. And it would set more equal and rational payments for medical services. Providers could still compete, Freeman says, but it would be on the basis of quality or personal style.
Perhaps Freeman’s most compelling argument is that a system covering everyone would unite us all, rich and poor. We would all have an equal stake in making sure providers were adequately paid and delivered high-quality care, and that everyone had access to that care.
But Freeman sees health care as a basic human right. That’s still a subject for debate in the United States.

The Tangle of Coordinated Health Care


More specifically, who coordinates the proliferating number of health care helpers variously known as case managers, care managers, care coordinators, patient navigators or facilitators, health coaches or even — here’s a new one — “pathfinders”?
Rachel Schwartz, a licensed clinical social worker for close to 20 years, came face to face with this quandary earlier this month. Employed by a home care agency in Virginia, she visited a woman in her late 70s who had recently come home from the hospital.
The patient, who lives with her husband and daughter, has diabetes and dementia. Ms. Schwartz, during the scant one to three social work visits that Medicare will cover, planned to help her sign up for community services like Meals on Wheels.
“We’re trying to keep people at home and out of hospitals,” she said.
But the woman also had a care manager through her Medicare Advantage program, her daughter reported, handing over a business card. Not wanting to duplicate those efforts, Ms. Schwartz left the care manager a message, then later texted a former colleague who worked for the same program. Did she know this care manager? They should collaborate.
No, the colleague didn’t know her. She might not be a field case manager, she texted back; she might be a telephonic manager.
Telephonic? “I thought, ‘Gosh, I don’t even know what that is,’ ” Ms. Schwartz said.
It wasn’t her first encounter with this sometimes puzzling new approach to health care. Recently, intending to arrange home care through Veterans Affairs for an older veteran, Ms. Schwartz learned that his Medicare Advantage care manager had already helped him apply for Medicaid home care. A younger patient’s “mental health case worker” had already submitted paperwork for the same Medicaid program Ms. Schwartz was about to recommend.

Study Finds Broad Rise in Medication Use by Those Newly Joining Medicaid

By