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Wednesday, January 13, 2016

Health Care Reform Articles - January 13, 2016

Note from the editor:

This is a clippings blog. I post the first few paragraphs from articles I find to be of interest from newspapers and other sources. Occasionally, I will make a short comment about one of the articles.
Due to a recent formatting change by Google Groups blogs, the emails I send out sometimes appear to be of articles or comments I have written. Some readers have evidently thought (erroneously) that I've written the paragraphs that are actually from articles I have clipped from other sources.

If I'm distributing an article I have written via the blog, it will say " by Philip Caper, M.D." following the headline.

 If I am making a comment about an article, it will be attributed to "-SPC", and usually precede the article I'm referencing.

Otherwise, it will have come from one of the stories I'm quoting, not from me. 

Each email I send notifying readers of a new blog post contains a hot-link to the web version of the daily post, usually at the top of the email. It is best, when you receive an email notification, to use that line to get to the web version of the new post. That contains the post in its entirety, with the date it was posted at the top.

I hope that clears things up  a bit.

-SPC

Junior Doctors’ Strike in England Disrupts Care for Thousands

by Stephen Castle

LONDON — Hospital doctors in England staged their first strike in four decades on Tuesday, disrupting treatment for thousands of patients in the National Health Service and escalating political tensions over a publicly funded health care system so revered that it was once likened to a national religion.
Operations were postponed and appointments canceled in a bitter dispute over pay and working hours between employers and junior doctors, a term that covers medical professionals with as much as a decade of experience.
With the junior doctors offering only emergency care, about 3,500 operations had been affected by Tuesday afternoon, including routine procedures for knee and hip replacements — prompting a warning from Prime Minister David Cameron that the labor action would create “real difficulties for patients, and potentially worse.”
Yet the dispute over the health system carries risks for the government. The National Health Service, which is funded by taxes and payroll deductions but has faced years of financial strain, delivers most treatment without charge. Despite regular funding crises, there has been no similar strike since 1975.
Mr. Cameron’s Conservative Party has always found it hard to make changes to the health service, which was created by the Labour Party in the 1940s and is now creaking under the strain of an aging population and tightened budgets.
In his memoirs, Nigel Lawson, a chancellor of the Exchequer under Prime Minister Margaret Thatcher, wrote that health practitioners regarded themselves as “a priesthood,” making the sector “extraordinarily difficult to reform.”
The National Health Service, he wrote, “is the closest thing the English have to a religion.”
It is also a significant presence in national life, employing 1.6 million people which, it says, puts it in the top five of the world’s largest work forces, alongside the United States Defense Department, McDonald’s, Walmart and the Chinese People’s Liberation Army.

Doctors Unionize to Resist
the Medical Machine

An Oregon medical center’s plan to increase efficiency by outsourcing
doctors drove a group of its hospitalists to fight back by banding together.
By NOAM SCHEIBER
Early in the morning on Aug. 12, 2015, a 68-year-old man named Barry turned up at PeaceHealth Sacred Heart Medical Center in Springfield, Ore., confused and feverish.
The case was not a candidate for even a minor subplot on “House.” The admitting doctor stopped one of the patient’s medications and inserted an IV to deliver fluids, and by late the next morning, he had largely recovered.
Still, Dr. Rajeev Alexander, the hospitalist who took over his care, was determined to make an accurate diagnosis.
For nearly half an hour, Dr. Alexander, a perpetually rumpled man, chatted with Barry and Linda, his sister, about the events that had landed him in the hospital, the food processing plant where he once worked, the stroke that had impaired his mind. “It was a very scary night last night,” Linda, his caretaker, said. “He was just sitting on the floor, like you would sit a 6-month-old when they haven’t got their balance.”
Dr. Alexander considers it proper technique to review each mundane detail with a patient. He is full of scorn for the eureka style of medical diagnosis depicted on television, and by his own admission, he reads a CT scan with the sophistication of a barber.
Eventually, Dr. Alexander would discard the more exotic theories that had crossed his mind — meningitis, or possibly a condition known as serotonin syndrome — and settle on a far simpler malady: dehydration, which aggravated a chronic kidney problem.
He was nonetheless unapologetic about the time he had invested.
“Real life is all about the narrative,” he said. “It’s sitting down and talking about bowel movements with a 79-year-old woman for 45 minutes. It’s not that interesting, but that’s where it happens.”
Dr. Alexander’s method is at the center of an emotional debate in medicine, in which the imperative to increase efficiency in a high-cost health care system is often at odds with the deference traditionally accorded to doctors.
It’s a debate that came home to Sacred Heart in the spring of 2014, when the administration announced it would seek bids to outsource its 36 hospitalists, the hospital doctors who supervise patients’ care, to a management company that would become their employer.
The outsourcing of hospitalists became relatively common in the last decade, driven by a combination of factors. There is the obvious hunger for efficiency gains. But there is also growing pressure on hospitals to measure quality and keep people healthy after they are discharged. This can be a complicated data collection and management challenge that many hospitals, especially smaller ones, are not set up for and that some outsourcing companies excel in.
“They assure you of relief of some headaches,” said Dr. John Nelson, a past president of the Society of Hospital Medicine. He compared outsourcing doctor groups to a management company to hiring a lawn service. “You’re relieved of having to get the mower out. You’re not necessarily assured that you’re happier with your yard.” In recent years, according to the society, 25 to 30 percent of hospitalists have worked for multistate management companies, which also employ doctors in other disciplines, like anesthesiology and emergency medicine.
Outsourced hospitalists tend to make as much or more money than those that hospitals employ directly, typically in excess of $200,000 a year. But the catch is that their compensation is often tied more directly to the number of patients they see in a day — which the hospitalists at Sacred Heart worried could be as many as 18 or 20, versus the 15 that they and many other hospitalists contend should be the maximum. (Mark Hamm, executive vice president of EmCare, a physician services firm based in Dallas that has no connection to Sacred Heart, said the hospitalists employed by many staffing companies typically see 15 to 18 patients a day, though he said that was true of those who were directly employed by hospitals as well.)
It was the idea that they could end up seeing more patients that prompted outrage among the hospitalists at Sacred Heart, which has two facilities in the area, with a total of nearly 450 beds. “We’re doctors, we’re professionals,” Dr. Alexander said. “Giving me a bonus for seeing two more patients — I’m not sure I should be doing that. It’s not safe.” (A hospital representative said patient safety was “inviolate.”)
Some Sacred Heart hospitalists left for other jobs, and the rest formed a union, one of the first of its kind in the country.
To everyone’s surprise, Sacred Heart’s administration agreed to junk its outsourcing plan, but this retreat did not usher in a love fest. Instead, there has been a long, grinding negotiation with the administration over the proper role of the hospital doctor, which continues to this day.
Dr. Alexander and his colleagues say they are in favor of efficiency gains. It’s the particular way the hospital has interpreted this mandate that has left them feeling demoralized. If you talk to them for long enough, you get the distinct feeling it is not just their jobs that hang in the balance, but the loss of something much less tangible — the ability of doctors everywhere to exercise their professional judgment.

Insurers Say Costs Are Climbing as More Enroll Past Health Act Deadline 

By 


WASHINGTON — Eager to maximize coverage under the Affordable Care Act, the Obama administration has allowed large numbers of people to sign up for insurance after the deadlines in the last two years, destabilizing insurance markets and driving up premiums, health insurance companies say.
The administration has created more than 30 “special enrollment” categories and sent emails to millions of Americans last year urging them to see if they might be able to sign up after the annual open enrollment deadline. But, insurers and state officials said, the federal government did little to verify whether late arrivals were eligible.
That has allowed people to wait until they become ill or need medical services to sign up, driving up costs broadly, insurers have told federal health officials.
“Individuals enrolled through special enrollment periods are utilizing up to 55 percent more services than their open enrollment counterparts” who sign up in the regular period, the Blue Cross and Blue Shield Association, whose local member companies operate in every state, told the administration.
In a notice published recently in the Federal Register, the administration said it had “heard concerns that these special enrollment periods may be subject to abuse,” and asked for evidence. The insurance companies obliged.
“Many individuals have no incentive to enroll in coverage during open enrollment, but can wait until they are sick or need services before enrolling and drop coverage immediately after receiving services, making the annual open enrollment period meaningless,” Steven B. Kelmar, an executive vice president of Aetna, said in a letter to Sylvia Mathews Burwell, the secretary of health and human services.
A quarter of the applications that Aetna received in the health law’s public insurance marketplace last year came through special enrollment periods, he said.
Administration officials said they wanted to prevent any misuse or abuse of special enrollment periods, and they are expected to outline their plans this week. But, they said, people must be able to sign up late when they have a legitimate reason. And many have.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, said nearly 950,000 people used special enrollment periods to get coverage through HealthCare.gov from late February to the end of June 2015. That, he said, shows the marketplace is working to meet people’s needs.
In a typical email in September, federal officials told consumers: “You may still be able to get 2015 coverage. Certain life changes like losing your coverage, having a child, turning 26, moving or getting married may qualify you for a special enrollment period. See if you qualify.”
And people have been helped.


With LePage, Maine becomes more of an outlier

by David Farmer

On his first day in office earlier this week, Louisiana Gov. John Bel Edwards took steps to expand access to health insurance for 300,000 people in his state.
Fulfilling a campaign promise, Edwards’ decision will improve the lives of hundreds of thousands of people and give his state’s economy a shot in the arm.
In Maine, things were a little different — and much more depressing.
Two reports issued by the Maine Health Access Foundation on Monday point to the failure of the state to take care of its people and the consequences of refusing to use federal dollars to expand access to health care through MaineCare.
And the burden for that decision is carried by young adults, people with less education, men and residents of rural areas. Many of them are working, but they just aren’t making enough money to afford health insurance even with the subsidies included in the Affordable Care Act, or Obamacare.
According to one of the reports, while about 27 percent of adults in Maine ages 18-64 had incomes less than $25,000, 57 percent of the uninsured in 2014 fell into that category.
Across the country, the rate of people without insurance is declining. In Maine, that’s not the case. Gov. Paul LePage’s policies and his vetoes have stood in the way of reform that would help as many as 70,000 Maine people live healthier, happier and more productive lives.
In an op-ed published at the beginning of the year in the Portland Press Herald and teasing the reports, Barbara Leonard of Maine Health Access Foundation put it this way: “Over the past two years, the number of uninsured Maine people having difficulty paying medical bills has increased by about 10 percent, while nationally, the rate of those pressed to pay for health care has declined.”
Governors Get Smarter on Medicaid
By 
Republican and Democratic governors in several states that have refused to expand their Medicaid programs are now seeking to do so, but will need approval from Republican-dominated legislatures. Even if they are not moved by humanitarian concerns to improve health care for their poorest citizens, recalcitrant legislators should at least see the folly of rejecting extremely generous matching funds. The federal government will pay 100 percent of the cost for newly eligible enrollees in 2016 and 95 percent in 2017, phasing down to 90 percent in 2020 and subsequent years.
Thus far 30 states and the District of Columbia have expanded their Medicaid programs and 20 have not, although several of them are debating whether to do so. Some of the states that expanded were given federal waivers to use conservative approaches, like using Medicaid money to pay for private insurance. In several states that have not expanded or are still debating, pragmatic Republican governors find themselves at odds with ideologues in Congress and with right-wing groups that want to destroy Obamacare at all costs.
Gov. John Kasich of Ohio, now seeking the Republican nomination for president, was one of the first to see the wisdom of expanding Medicaid to bring in billions of dollars in federal matching funds. When Republicans who dominated the legislature balked, he bypassed them with a tactical maneuver that allowed a separate board to expand the state’s Medicaid without legislative approval. He calls this the right thing to do, fiscally and morally, as it surely is. No governors should deny health coverage for people just because they are ideologically opposed to federal entitlement programs.
The Republican governors of South Dakota and Wyoming and the Democratic governor of Virginia have included Medicaid expansion in their state budgets, suggesting a strong desire to get their hands on federal matching funds if only they can wrest approval from their legislatures. Virginia appears a lost cause, but the other two states are up for grabs.
In Louisiana, term-limited Gov. Bobby Jindal blocked expansion last year, but was succeeded by a Democrat who vows to quickly enroll about 300,000 more people on top of the 1.4 million already enrolled. In Arkansas, where a centrist Democratic governor used federal money to buy private coverage for more than 200,000 people in 2013, his Republican successor wants to continue the expansion. In Kentucky, a new Republican governor who vowed to roll back the big expansion ordered by his Democratic predecessor is having second thoughts now that he is responsible for the health of his constituents.
Elsewhere the forces of reaction remain busily at work. In Utah, a Republican governor who had futilely tried to get expansion approved by the Legislature gave up this year and did not include expansion in his budget. Both Republican senators from Utah are opposed to expansion.
And in Florida, where the Legislature has blocked expansion, there is a campaign to amend the state Constitution to require the state to accept federal funds for expansion. It is considered a long shot whether the campaign can gather almost 700,000 signatures by Feb. 1 to put the measure on the ballot during the 2016 presidential campaign. It appears to be the last hope for hundreds of thousands of poor Floridians.


Our View: Anti-expansion stance keeps Maine’s uninsured rate from falling

Evidence continues to mount regarding the benefits of expanding Medicaid eligibility for low-income Mainers.
BY THE EDITORIAL BOARD

The passage of the Affordable Care Act was supposed to reduce the number of working-age adults without health insurance. But in Maine, according to recent research, the ranks of the uninsured haven’t diminished over the past few years. That doesn’t mean it’s the Affordable Care Act that’s not working.
To make a huge, positive difference in the lives of the thousands of Mainers who still lack coverage, legislators should pass the latest proposal before them to take full advantage of the federal program and expand Medicaid eligibility.
The report on uninsured rates in Maine was released Monday by the Maine Health Access Foundation. The number of Mainers enrolling in insurance plans under the ACA started strong in 2014 and continues to grow, reaching nearly 75,000 last year.
But the rate of uninsured Mainers has held steady since 2013 at about 15 percent, the nonprofit advocacy group concluded, based on an annual state survey of Mainers’ health habits. During the same period, the number of Mainers receiving Medicaid shrank as tighter standards were put in place.
Those most likely to be uninsured? Men, young adults, people without a high school diploma and residents of rural areas, the report found.
The downsides to lacking insurance? Compared to people with coverage, the uninsured are more likely to put off preventive care or skip it altogether. So when they do get treated, caring for them is more expensive and more complicated.
The ACA’s solution? Providing states with funds to expand Medicaid eligibility. The U.S. government would pick up 100 percent of the tab through 2016, gradually reducing that to 90 percent by 2020.
Gov. LePage and most Republicans in Augusta have staunchly resisted expanding Medicaid eligibility, citing concerns that Maine will be left holding the bag after federal officials back out of the deal. But the argument that the federal share could be cut is based on “pure speculation,” concluded the fact-checking service PolitiFact. What’s more, opponents of expansion aren’t taking into account its benefits.


‘I Am Drowning.’ The Voices of People With Medical Debt.

By 
Lauren Shields, 60, at home in University City, Mo. Ms. Shields, a computer project manager, whose husband has lymph node cancer, chose her current job four years ago based on health insurance coverage. They have high incomes and insurance through Medicare, but have still taken on $5,000 in credit card debt.“We don’t go to the movies. We don’t go out for breakfast on Saturday morning. None of our pets are going to the vet this year for a checkup. I’m cutting back on Christmas presents this year because the money’s not there.” Whitney Curtis for The New York Times
For many readers, the added burden of medical bills meant cutting back on daily expenses or changing long-term financial plans. These sorts of sacrifices were the most common among our survey respondents, too. For families with tight family budgets, a bill for hundreds or thousands of dollars can ripple through lives and reshuffle financial priorities.
http://www.nytimes.com/interactive/2016/01/11/upshot/12up-medicaldebt.html?em_pos=small&emc=edit_up_20160111&nl=upshot&nlid=1311158&ref=headline&_r=0

More Hospitals Are Ditching Antibiotics In The Meat They Serve 

By  •
Every year some 2 million Americans get infections from antibiotic-resistant bacteria, and 23,000 of them die from these superbugs. 
Superbugs are mostly a hospital problem: They're where these pathogens are often born and spread, and where the infected come for help. But hospitals are not where the majority of antibiotics sold in the U.S. are used. 
Food and Drug Administration data show that 62 percent of antibiotics important for human health are sold to food animal producers and used on farms. And in December, the agency noted that antibiotics for use on the farm increased in 2014, including antibiotics important in human medicine. 
Concern about the livestock industry's overuse of antibiotics has led a number of health care institutions to start choosing meat from animals raised without antibiotics whenever they can. According to Practice Greenhealth, a nonprofit that's helping the health care industry on this issue, more than 400 U.S. hospitals are working toward a goal of making 20 percent of their meat purchases "antibiotic-free." And around a dozen hospitals have already switched the majority of their chicken purchases to antibiotic-free. 
"Health care is really voicing their demand for [antibiotic-free meat] products," says Hillary Bisnett, a food expert for Practice Greenhealth and Health Care Without Harm. "Hospitals understand antibiotic resistance, and they're being asked to steward their own use of antibiotics. So it's very easy for them to say, 'Livestock producers need to be doing their part, too.' " 
Is meat from animals raised without antibiotics really better? Public health groups who follow this issue, like the Pew Charitable Trusts, say it can be safer. Of greatest concern is that when chicken, hog or cattle farmers use drugs to promote growth or prevent disease in their animals, they'll overuse the drugs and create resistant bacteria, like Salmonella and Campylobacter, that could make people sick. 


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