The Aftermath of a Pandemic Requires as Much Focus as the Start
by Atuhl Gawande - NYT - March 16, 2023
By the end of 2021, Americans were dying three years sooner, on average, than they were before Covid-19, with life expectancy falling from 79 years to 76 years, according to the Centers for Disease Control and Prevention’s most recent statistics.
Such astonishing declines have occurred planet-wide — the first global reduction in life expectancy since World War II. Total deaths jumped 13 percent in the first two years of the pandemic. Estimates indicates that about 15 million more people died than would have been expected. Human development has been pushed into reverse.
Most of these deaths have been a direct result of the coronavirus. But the pandemic also killed people by damaging health care more broadly, which will itself have enduring consequences. Years of gains and investment have been wiped away. And we have only started to see the effects.
We can reclaim our lost ground and resume the past decades of advancement in human survival and health. But that requires holding on to our sense of urgency and doing more than simply hoping things will turn around. The aftermath of pandemics requires as much focus and response as the start. And the United States’ leadership is crucial. We rallied the world to invest in emergency relief. Now we must rally the world to invest in recovery.
Across the globe, including here at home, the pandemic diverted resources from essential health needs of all kinds. Routine immunization programs, sickness care for children and adults, cancer treatment, ambulance services, surgery capacity and mental health services have all been disrupted. Covid inflicted economic harm that led governments to slash even meager health budgets. It disrupted supply chains for basic medical supplies. And it has driven health workers, already in short supply, from the profession here and abroad.
The harm to health care has been wide, but the repair must start with the decimated and under-resourced ranks of primary health care workers — our first-line, community-based doctors, nurses and outreach workers. Attention in crisis tends to focus on hospitals and emergency responders. However, primary health workers deliver the vast majority of the services responsible for longer lives, including for stopping the next pandemic. They are the backbone of a functional and effective health system.
Decades of evidence show that primary care teams are also capable of remarkable improvements in health when they’re appropriately trained, paid and — this is crucial — given the capacity to reach out regularly to every household that they serve. Keeping people connected to the most important services for their health and survival, and working to make sure no one falls through the cracks, adds years of life.
When researchers in Ghana tested, in a randomized trial, the impact of financing neighborhood health clinics that included outreach workers and nurses who provided first-level care and offered preventive measures such as malaria nets and family planning, the results were dramatic. Child mortality fell by over 50 percent in three years and by nearly 70 percent in seven years. Women also markedly increased the spacing between births, which significantly reduces maternal mortality risk. In Costa Rica, investment over decades in such a primary care system has delivered an 80-plus-year life expectancy — one of the longest in the Americas despite Costa Rica having just one-sixth of the United States’ income per capita.
Here at home, during the pandemic, health leaders came to recognize the importance of investments incorporating, for the first time, large numbers of community health workers into local health systems, particularly where life expectancy is lowest. These workers were essential in getting 95 percent of older Americans vaccinated against Covid. Now they can also play a vital role in ensuring that gaps in access to other kinds of lifesaving care are closed.
The global primary care work force also provides critical capacity to detect future public health threats and deliver a response. When people have a weird rash, a nasty cough or a bad fever, it’s a local doctor or nurse whom they most depend on to recognize that it could be mpox (as monkeypox is now called), a new coronavirus variant or a deadly avian flu breaking out. And then it’s those same primary care professionals who deliver the needed testing, vaccinations and treatments to the community at large. Yet around the world, they are routinely among the most neglected and underfinanced part of the health care work force.
Which brings us back to the conditions that have driven the first global decline in life expectancy in generations. A doubling of human life span in less than a century, one of the greatest accomplishments in history, was achieved through worldwide cooperation on sustained efforts to address many individual causes of death and sickness — polio, H.I.V./AIDS, diarrheal illness, malaria and childbirth risks, to name just a few. These efforts have saved millions upon millions of lives, but they depend on primary health workers to achieve their impact. This work force is the same one we now must count on to incorporate management of future coronavirus variants into routine care.
A little over a year ago, when I took up my role at the U.S. Agency for International Development, where I oversee foreign assistance for global health, one of my great hopes was to help repair the systemic damage that’s been done. So I was thrilled when President Biden requested funding from Congress last year not only for these critical disease-driven programs and to prepare for future pandemics but also for a Global Health Worker Initiative. It would provide targeted investments abroad, such as in training and in digital tools, that advance the world’s efforts to rebuild the work force needed to restore health and survival. The omnibus budget that passed in the final weeks of the last Congress dropped this funding, however.
Last week, the president again put forward a budget to back this vital effort. Recovery has received far too little attention and resources, and Congress must do its part to change that.
In the meantime, I have worked with my U.S.A.I.D. team to do what we can. Starting with governments in seven countries that we assist — Ivory Coast, Ghana, Indonesia, Kenya, Malawi, Nigeria and the Philippines — we have set a goal to marshal resources to restore death rates to better than prepandemic levels by 2025 for, at minimum, children under 5 and women under 50. To accomplish this, we’re working country by country to analyze the gaps in essential health services and the underlying weaknesses in the primary health care work force upon which those services rest. We are also working to partner with governments and international institutions to focus resources on closing those gaps over the next two years.
As the World Health Organization has put it, we need countries “to make a radical reorientation of their health systems toward primary care.” This is how we will make a real recovery from the pandemic — and be prepared for the next one. And it is the only path we have back to a world of longer and healthier lives.
Atul Gawande is the assistant administrator for global health at the United States Agency for International Development.
https://www.nytimes.com/2023/03/16/opinion/pandemic-recovery-primary-care.html
Aggressive Medicare Advantage marketing floods TV and mailboxes with misleading ads. The Biden administration is cracking down
You may have seen a barrage of TV commercials urging viewers to sign up for Medicare Part C plans with so-called extra benefits and promises of no premiums. Maybe your mailbox has overflowed with similar come-ons. But those aggressive marketing campaigns for Medicare Advantage plans—private health insurers’ alternatives to traditional or original Medicare—may not be around much longer.
The huge rise in complaints about Medicare Advantage marketing has led the Biden administration to launch a crackdown. The Centers for Disease Control and Prevention reported more than 41,000 such complaints in 2021, double the number in 2020. Nevertheless, Medicare Advantage plans are hugely popular. More than 30 million Americans have them—roughly half of those eligible for Medicare.
“The Wild West” for Medicare Advantage marketing
“In a lot of ways, it’s the Wild West when it comes to selling these products,” says David Lipschutz, associate director of the Center for Medicare Advocacy. “That leads to situations where people are enrolled [in Medicare Advantage plans] without their knowledge, without their consent, or without the adequate information that they should have been given.”
How do people get enrolled in Medicare Advantage plans without consent?
They speak, or meet, with a third-party broker selling the plans, are sold the idea that the Medicare Advantage plan they’re in is subpar, and wind up signing up for a different one. Or brokers obtain signatures through inappropriate or fraudulent means, says Lipschutz.
“Medicare Advantage plans are engaging in more competitive marketing to differentiate themselves in terms of what they’re offering,” says Meredith Freed, senior policy analyst for the Program on Medicare Policy at the Kaiser Family Foundation. With nearly 4,000 Medicare Advantage plans available these days, she adds, “the pressure is increasing” to find new customers.
Incentives to switch and to sign up
Brokers earn commission when people buy, renew, or switch Medicare Advantage plans (maximum rates of up to $750 per member per year are set by the Centers for Medicare and Medicaid Services, or CMS). Selling incentives are highest for snagging first-timers; the top commission rates for Medicare Advantage switchers and renewals are 50% of those for first-time buyers.
A study by the Commonwealth Fund research group discovered that although Medicare Advantage premiums decreased from 2016 to 2020, agent compensation rose at a rate surpassing inflation.
And it’s not just brokers hawking Medicare Advantage plans that are earning a lot from seniors. Sen. Elizabeth Warren (D-Mass.) recently released an investigative report, Sales Before Seniors, which found that many Medicare supplement or “Medigap” plans—bought by people with original Medicare—offer “luxurious vacations and cash bonuses to agents and brokers, creating incentives for them to steer seniors to Medigap products that may not be the best fit for their financial and care needs” and that the incentives are not disclosed, pervasive, and minimally regulated.”
“These third-party groups have gotten very aggressive and creative,” says Ceci Connolly, president and CEO of the Alliance of Community Health Plans (ACHP), which represents mostly large, not-for-profit plans.
“During open enrollment this last season, Medicare Advantage plans seemed to depart from fact-based marketing, and some plans just made things up about what was covered and what was not,” says Philip Moeller, author of Get What’s Yours for Medicare and the “Get What’s Yours” columnist on Substack.
Lipschutz says his nonprofit has heard from savvy people who call the 800-number in a Medicare Advantage broker’s commercial, get enrolled, “and then find out they can no longer see the doctor they’ve been seeing for decades because that doctor does not contract with the plan’s network.” Unlike original Medicare, the Medicare Advantage plans have limited networks of doctors and hospitals.
An eye-opening Senate report
Last fall, Democratic staffers of the Senate Finance Committee released a scathing report, Deceptive Marketing Practices Flourish in Medicare Advantage, finding that Medicare beneficiaries were being “inundated with fraudulent and misleading communications across all modes of communication (in-person, television, telemarketer, and robocalls).”
In some cases, the report said, people would get mailers appearing to be from the U.S. government but that were actually from Medicare Advantage plans or their agents or brokers. Others were called 20 times a day from the same agent to switch plans.
There are also TV ads featuring celebrities claiming that older Americans were missing out on benefits, including higher Social Security payments, so viewers would call the broker hotlines.
The commercials sometimes play into FOMO, noting incredulously that there are people who have Medicare Parts A and B (traditional Medicare’s coverage for hospitals and doctor’s bills), but not Part C. In reality, if you choose traditional Medicare, that means you are getting Medicare Parts A and B. You would buy Medicare Part C only if you wanted a Medicare Advantage plan instead of traditional Medicare.
The commercials typically don’t expressly say who’s sponsoring them.
“Why do you want your old clunker?”
“Some of these abusive messages make it seem like no one in their right mind would ever want original Medicare—original Medicare is a loser. This is the Tesla of Medicare plans. Why do you want your old clunker?” says Moeller. “I happen to think traditional Medicare is a pretty good program, especially with a Medigap plan.“
The Alliance of Community Health Plans agrees with the Biden administration and the Senate Finance report that Medicare Advantage marketing needs reining in. “Too much of today’s Medicare Advantage marketing is inappropriate, confusing, misleading, or inaccurate, misrepresenting the choices available,” the group’s website says.
Notes Connolly: “We say it because we have received so many examples from our members around the country. This is a problem that has probably been percolating on a back burner, but in the last 12 months or so, it has really escalated.”
The government crackdown on Medicare Advantage marketing
Last fall, the Biden administration put Medicare Advantage plans and brokers on notice saying it would conduct more oversight of marketing materials and run “secret shopper” studies during the 2023 annual enrollment period.
Then it began reviewing TV ads to ensure they met CMS rules. “The plans were specifically told by Medicare to dial down the misleading celebrity endorsements,” says Moeller. Lipschutz believes this change “is having somewhat of an effect.”
In January 2023, CMS proposed rules for a comprehensive crackdown, including strengthening oversight of third-party organizations to detect and prevent the use of deceptive marketing tactics; restricting the use of Medicare’s logo; and ending improper comparisons between Medicare Advantage and traditional Medicare.
“There had been one [ad], for example, that said people could save up to $9,000 on their prescription drugs” with Medicare Advantage, says Freed. “That was in comparison to people who don’t have any prescription drug coverage. So it was making it seem like you’re saving a lot more than you might.”
The goal of these marketing changes, Freed says, “is to strengthen beneficiary protections when they’re choosing plans and provide them with transparent and accurate information around their Medicare choices to find coverage that meets their needs.”
Varying views of the proposals
The ACHP’s Connolly was “somewhat surprised and impressed” that CMS jumped on Medicare Advantage marketing problems as quickly as it did. Her group wants to see CMS restructure Medicare Advantage broker compensation and flag agents and brokers who have dis-enrolled many plan beneficiaries and reenrolled them in other plans.
But in a letter commenting on the government’s new proposals, the trade group for Medicare Advantage plans (AHIP) said some “could unduly inconvenience seniors and people with disabilities.” AHIP president and CEO Matthew Eyles said he believed these and earlier Biden administration changes to Medicare Advantage marketing “create more confusion and complexity for enrollees, family members, agent/brokers, and providers.”
American Hospital Association executive vice president Stacey Hughes, however, told CMS “we believe the proposed changes will go a long way in ensuring that Medicare beneficiaries have equal access to medically necessary care and consumer protections.”
Moeller says large Medicare Advantage plan providers such as Humana, UnitedHealthcare, Cigna, and Aetna are not the most abusive marketers. “I wouldn’t be surprised that when the dust clears on this, the big players are going to be even bigger. They know what the rules are, and from my experience, they really try to play within the rules.”
Lipschutz expects some version of the Biden administration’s proposed changes will take effect this spring and in the 2024 Medicare Advantage plan year.
“The administration deserves some credit for reversing the course of regulation over the last few years and starting to focus more on consumer protections,” he says. “And we’re going to continue to urge them to go farther.”
https://fortune.com/well/2023/03/06/biden-administration-cracking-down-on-medicare-marketing/
Denied by AI: How Medicare Advantage plans use algorithms to cut off care for seniors in need
by Casey Ross and Bob Herman - STAT - March 13, 2023
An algorithm, not a doctor, predicted a rapid recovery for Frances Walter, an 85-year-old Wisconsin woman with a shattered left shoulder and an allergy to pain medicine. In 16.6 days, it estimated, she would be ready to leave her nursing home.
On the 17th day, her Medicare Advantage insurer, Security Health Plan, followed the algorithm and cut off payment for her care, concluding she was ready to return to the apartment where she lived alone. Meanwhile, medical notes in June 2019 showed Walter’s pain was maxing out the scales and that she could not dress herself, go to the bathroom, or even push a walker without help.
It would take more than a year for a federal judge to conclude the insurer’s decision was “at best, speculative” and that Walter was owed thousands of dollars for more than three weeks of treatment. While she fought the denial, she had to spend down her life savings and enroll in Medicaid just to progress to the point of putting on her shoes, her arm still in a sling.
Health insurance companies have rejected medical claims for as long as they’ve been around. But a STAT investigation found artificial intelligence is now driving their denials to new heights in Medicare Advantage, the taxpayer-funded alternative to traditional Medicare that covers more than 31 million people.
Behind the scenes, insurers are using unregulated predictive algorithms, under the guise of scientific rigor, to pinpoint the precise moment when they can plausibly cut off payment for an older patient’s treatment. The denials that follow are setting off heated disputes between doctors and insurers, often delaying treatment of seriously ill patients who are neither aware of the algorithms, nor able to question their calculations.
Older people who spent their lives paying into Medicare, and are now facing amputation, fast-spreading cancers, and other devastating diagnoses, are left to either pay for their care themselves or get by without it. If they disagree, they can file an appeal, and spend months trying to recover their costs, even if they don’t recover from their illnesses.
“We take patients who are going to die of their diseases within a three-month period of time, and we force them into a denial and appeals process that lasts up to 2.5 years,” Chris Comfort, chief operating officer of Calvary Hospital, a palliative and hospice facility in the Bronx, N.Y., said of Medicare Advantage. “So what happens is the appeal outlasts the beneficiary.”
The algorithms sit at the beginning of the process, promising to deliver personalized care and better outcomes. But patient advocates said in many cases they do the exact opposite — spitting out recommendations that fail to adjust for a patient’s individual circumstances and conflict with basic rules on what Medicare plans must cover.
“While the firms say [the algorithm] is suggestive, it ends up being a hard-and-fast rule that the plan or the care management firms really try to follow,” said David Lipschutz, associate director of the Center for Medicare Advocacy, a nonprofit group that has reviewed such denials for more than two years in its work with Medicare patients. “There’s no deviation from it, no accounting for changes in condition, no accounting for situations in which a person could use more care.”
Medicare Advantage has become highly profitable for insurers as more patients over 65 and people with disabilities flock to plans that offer lower premiums and prescription drug coverage, but give insurers more latitude to deny and restrict services.
Over the last decade, a new industry has formed around these plans to predict how many hours of therapy patients will need, which types of doctors they might see, and exactly when they will be able to leave a hospital or nursing home. The predictions have become so integral to Medicare Advantage that insurers themselves have started acquiring the makers of the most widely used tools. Elevance, Cigna, and CVS Health, which owns insurance giant Aetna, have all purchased these capabilities in recent years. One of the biggest and most controversial companies behind these models, NaviHealth, is now owned by UnitedHealth Group.
It was NaviHealth’s algorithm that suggested Walter could be discharged after a short stay. Its predictions about her recovery were referenced repeatedly in NaviHealth’s assessments of whether she met coverage requirements. Two days before her payment denial was issued, a medical director from NaviHealth again cited the algorithm’s estimated length of stay prediction — 16.6 days — in asserting that Walter no longer met Medicare’s coverage criteria because she had sufficiently recovered, according to records obtained by STAT.
Her insurer, Security Health Plan, which had contracted with NaviHealth to manage nursing home care, declined to respond to STAT’s questions about its handling of Walter’s case, saying that doing so would violate the health privacy law known as HIPAA.
Walter died shortly before Christmas last year.
NaviHealth did not respond directly to STAT’s questions about the use of its algorithm. But a spokesperson for the company said in a statement that its coverage decisions are based on Medicare criteria and the patient’s insurance plan. “The NaviHealth predict tool is not used to make coverage determinations,” the statement said. “The tool is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home.”
As the influence of these predictive tools has spread, a recent examination by federal inspectors of denials made in 2019 found that private insurers repeatedly strayed beyond Medicare’s detailed set of rules. Instead, they were using internally developed criteria to delay or deny care.
But the precise role the algorithms play in these decisions has remained opaque.
STAT’s investigation revealed these tools are becoming increasingly influential in decisions about patient care and coverage. The investigation is based on a review of hundreds of pages of federal records, court filings, and confidential corporate documents, as well as interviews with physicians, insurance executives, policy experts, lawyers, patient advocates, and family members of Medicare Advantage beneficiaries.
It found that, for all of AI’s power to crunch data, insurers with huge financial interests are leveraging it to help make life-altering decisions with little independent oversight. AI models used by physicians to detect diseases such as cancer, or suggest the most effective treatment, are evaluated by the Food and Drug Administration. But tools used by insurers in deciding whether those treatments should be paid for are not subjected to the same scrutiny, even though they also influence the care of the nation’s sickest patients.
In interviews, doctors, medical directors, and hospital administrators described increasingly frequent Medicare Advantage payment denials for care routinely covered in traditional Medicare. UnitedHealthcare and other insurers said they offer to discuss a patient’s care with providers before a denial is made. But many providers said their attempts to get explanations are met with blank stares and refusals to share more information. The black box of the AI has become a blanket excuse for denials.
“They say, ‘That’s proprietary,’” said Amanda Ford, who facilitates access to rehabilitation services for patients following inpatient stays at Lowell General Hospital in Massachusetts. “It’s always that canned response: ‘The patient can be managed in a lower level of care.’”
Brian Moore, a physician and advocate for patients denied access to care at North Carolina-based Atrium Health, recalled visiting a stroke patient who was blocked from moving to a rehabilitation hospital for 10 days. “He was sitting there trying to feed himself. He was like, ‘I just never thought when I signed up for Medicare Advantage that I wouldn’t be able to get the care I need,’” he said. “He was drooling and crying.”
The cost of caring for older patients recovering from serious illnesses and injuries, known as post-acute care, has long created friction between insurers and providers. For decades, facilities like nursing homes racked up hefty profit margins by keeping patients as long as possible — sometimes billing Medicare for care that wasn’t necessary or even delivered. Many experts argue those patients are often better served at home.
The enactment of the Affordable Care Act in 2010 created an opportunity for reform. Instead of paying for care after the fact, policy experts proposed flipping the payment paradigm on its head: Providers would be paid a lump sum upfront, incentivizing them to use fewer resources to deliver better outcomes.
At the time, most Republicans in Congress were wringing their hands over the new law and its subsidies to help low- and middle-income Americans pay for health insurance. Tom Scully, the former head of the Centers for Medicare and Medicaid Services under George W. Bush, shared those concerns. But he also saw something else: a potential billion-dollar business.
Scully drew up plans for NaviHealth just as the new law was taking effect. Its payment reforms aligned perfectly with the Medicare Advantage program he had played a pivotal role in creating during the Bush administration.
Scully knew how those insurance plans worked. He also knew they were taking a financial beating in post-acute care.
“Look, I love the nursing home guys, but there were a lot of patients coming out of hospitals spending 20 days in a nursing home in MA,” because that’s what Medicare’s rules allowed, Scully said on a podcast in 2020. “It was just like Pavlov’s bell.”
As a well-connected partner at the private equity firm Welsh, Carson, Anderson & Stowe, Scully heard of a small shop called SeniorMetrix that was working on this type of post-acute data and analytics. The firm quickly won him over. “They had an algorithm,” Scully said on the podcast. “I saw it and said, ‘This is it.’”
He wrote a $6 million check to buy the company, which he rebranded to NaviHealth. Scully then raised $25 million from wealthy friends and companies, including the health system Ascension and the rehabilitation hospital chain Select Medical, and coaxed another $25 million from Welsh Carson.
NaviHealth started making its sales pitch to Medicare Advantage plans: Let us manage every piece of your members’ care for the first 60 to 90 days after they are discharged from the hospital, and we’ll all share in any savings.
The sweetener was the technology. One of the company’s core products is an algorithm called nH Predict. It uses details such as a person’s diagnosis, age, living situation, and physical function to find similar individuals in a database of 6 million patients it compiled over years of working with providers. It then generates an assessment of the patient’s mobility and cognitive capacity, along with a down-to-the-minute prediction of their medical needs, estimated length of stay, and target discharge date.
In a six-page report, the algorithm boils down patients, and their unknowable journey through health care, into a tidy series of numbers and graphs.
The product was a revelation to insurers, giving them a way to mathematically track patients’ progress and hold providers accountable for meeting therapy goals. By summer 2015, NaviHealth was managing post-acute care for more than 2 million people whose insurance plans had contracted with the company. It was also working with 75 hospitals and clinics seeking to more carefully manage contracts in which they shared financial responsibility for holding down costs. At the time, spending on post-acute care accounted for $200 billion annually.
That same year, Scully sold NaviHealth to the conglomerate Cardinal Health for $410 million — roughly eight times the investment. In 2018, another private equity firm, Clayton, Dubilier & Rice, upped the ante and paid $1.3 billion to take over NaviHealth. Then in 2020, UnitedHealth — the largest Medicare Advantage insurer in the country — decided to make the hot commodity its own, buying NaviHealth in a deal valued at $2.5 billion.
In an interview with STAT, Scully said the concept behind NaviHealth is “totally correct,” because it roots out wasteful spending. And he did not believe the algorithms restricted necessary care. But when presented with reporting that showed NaviHealth was at the center of voluminous denials and overturned appeals, Scully said he wasn’t in a position to comment on what may have changed since he sold his stake.
“The NaviHealth decision tool as I knew it — again, this is eight years ago — has a place and is valuable. If [it] overdoes it and is inappropriately denying care and sending people to the wrong site of service, then they’re foolish, and they’re only hurting themselves reputationally,” Scully said. “I have no idea what United’s doing.”
Providers told STAT that as NaviHealth was changing hands and enriching its investors, they started noticing an increase in denials under its contracts — that the pendulum had now swung too far in the other direction in an effort to prevent overbilling and make sure patients weren’t getting unnecessary services.
Patients with stroke complications whose symptoms were so severe they needed care from multiple specialists were getting blocked from stays in rehabilitation hospitals. Amputees were denied access to care meant to help them recover from surgeries and learn to live without their limbs. And efforts to reverse what seemed to be bad decisions were going nowhere. Atrium Health’s Moore, who leads a team that specializes in reviewing medical necessity criteria, started taking a deeper look at the denials.
“It was eye-opening,” he said. “The variation in medical determinations, the misapplication of Medicare coverage criteria — it just didn’t feel like there [were] very good quality controls.”
He and many other providers began pushing back. Between 2020 and 2022, the number of appeals filed to contest Medicare Advantage denials shot up 58%, with nearly 150,000 requests to review a denial filed in 2022, according to a federal database.
The database fails to capture countless patients who are unable to push back when insurers deny access to services, and only reflects a portion of the appeals even filed. It mostly tracks disputes over prior authorization, a process in which providers must seek insurers’ advance approval of the services they recommend for patients.
In comments to federal regulators and interviews with STAT, many providers described rigid criteria applied by NaviHealth, which exercises prior authorization on behalf of the nation’s largest Medicare Advantage insurers, including its sister company UnitedHealthcare as well as Humana and several Blue Cross Blue Shield plans.
“NaviHealth will not approve [skilled nursing] if you ambulate at least 50 feet. Nevermind that you may live alon(e) or have poor balance,” wrote Christina Zitting, a case management director for a community hospital in San Angelo, Texas. She added: “MA plans are a disgrace to the Medicare program, and I encourage anyone signing up..to avoid these plans because they do NOT have the patients best interest in mind. They are here to make a profit. Period.”
Federal records show most denials for skilled nursing care are eventually overturned, either by the plan itself or an independent body that adjudicates Medicare appeals.
But even patients who win authorization for nursing home care must reckon with algorithms that insurers and care managers like NaviHealth use to help decide how long they are entitled to stay. Under traditional Medicare, patients who have a three-day hospital stay are typically entitled to up to 100 days in a nursing home.
With the use of the algorithms, however, Medicare Advantage insurers are cutting off payment in a fraction of that time.
“It happens in almost all these cases,” said Christine Huberty, a lawyer in Wisconsin who provides free legal assistance to Medicare beneficiaries. She said Medicare Advantage patients she represents rarely stay in a nursing home more than 14 days before they start receiving payment denials.
“But [the algorithm’s report] is never communicated with clients,” said Huberty, who often only finds the report after filing a legal complaint. “That’s all run secretly.” NaviHealth said the findings of the algorithm, if not the report itself, are routinely shared with doctors and patients to help guide care.
A director at one post-acute facility said denials from UnitedHealthcare and NaviHealth are now the norm for many of their patients, even if they are clearly sicker than what the algorithm projects.
“They are looking at our patients in terms of their statistics. They’re not looking at the patients that we see.”
Medical director of a post-acute care facility
“They are looking at our patients in terms of their statistics. They’re not looking at the patients that we see,” said the director, who asked not to be named to avoid jeopardizing relationships with Medicare Advantage plans.
And when insurers deluge providers with denials, “they’re hoping that their endurance is greater than ours,” the director said.
NaviHealth has not published any scientific studies assessing the real-world performance of its nH Predict algorithm. And to the extent it tests its performance internally, those results are not shared publicly.
Additionally, regulators do not monitor these algorithms for fairness or accuracy, but the industry-wide blowback has forced the government to consider acting. Federal Medicare officials proposed new rules in December that say Medicare Advantage insurers can’t deny coverage “based on internal, proprietary, or external clinical criteria not found in traditional Medicare coverage policies.” Insurers also would have to create a “utilization management committee” that reviews their practices every year.
But even these proposals would still allow insurance companies to “create internal coverage criteria,” as long as they are “based on current evidence in widely used treatment guidelines or clinical literature that is made publicly available.”
Major lobbying groups for health insurance companies — America’s Health Insurance Plans, the Better Medicare Alliance, and the Alliance of Community Health Plans — did not make anyone available for interviews. Instead, the groups referred to comments they sent to Medicare supporting some, but not all, of these government proposals. AHIP, for example, urged Medicare “to not adopt policies that would place limits on plan flexibility to manage post-acute care.” Final regulations are due this spring.
If concerns about the algorithms have begun to surface in legal filings and public letters to Medicare, they remain almost entirely out of sight for patients like Dolores Millam, who fell and broke her leg on a summer day in 2020.
After surgery, she began her stay in a Wisconsin nursing home on Aug. 3. Like many older patients, Millam arrived with a complicated medical history, including coronary artery disease, diabetes, high blood pressure, and chronic pain, according to court records. Her doctor had ordered that she stay off her leg for at least six weeks.
Nevertheless, an algorithm used by her insurer, UnitedHealthcare, predicted she would only need to stay for 15 days, until about Aug. 18, according to records obtained by STAT.
Just a couple days after that date, Millam received notice that payment for her care had been terminated. It was 4 p.m. on a Friday.
“I must have made — I’m not kidding — 100 phone calls just to figure out where she could go [and] why this was happening,” said Millam’s daughter, Holly Hennessy, who also received the notice.
She said she couldn’t fathom UnitedHealthcare’s conclusion that her mother — unable to move or even go to the bathroom on her own — no longer met Medicare coverage requirements.
“You try to call and reason with somebody and get explanations, and you’re talking to somebody in the Philippines,” Hennessy said. “It’s simply a process thing to them. It has nothing to do with care.” UnitedHealthcare declined to discuss its handling of Millam’s care, asserting that doing so would violate federal privacy rules.
When she received the denial, Millam could not put weight on her left leg and was being moved with a Hoyer lift, a large, freestanding harness used to transport patients who can’t use their legs. She also required 24-hour care to help with dressing, eating, and other basic tasks, according to court records.
In a note filed after payment was denied, a speech therapist wrote, “Pt. is not yet safe to live independently. She will need assistance with medication administration and supervision with ADLS [activities of daily living] due to memory deficits making her unsafe.”
Hennessy said she had no choice but to keep her mother in the nursing home, Evansville Manor, and hope the payment denial would get overturned. By then, the bills were quickly piling up.
Medicare rules call for a five-stage appeal process. The first appeal goes directly to the insurer. If denied, the patient can ask an outside entity known as a “quality improvement organization” to reconsider.
Hennessy and her mother were denied at both levels, forcing them to consider an appeal to a federal judge, a process that takes months and requires filling out reams of paperwork. Somewhere in her blitz of phone calls, Hennessy heard about the Greater Wisconsin Agency on Aging Resources, which agreed to take up her case.
In late October, Millam returned home from the nursing home after a nearly three-month recovery. The bill was almost $40,000. A few days later, her appeal came before a judge.
Hennessy, who was driving to Florida at the time, recalls pulling over for the hearing, which was held via Zoom.
The judge only asked a handful of questions of the family and representatives from the nursing home. If there was any participation from UnitedHealthcare, its opinions were not mentioned in the official record. Court documents only reference a finding from the quality improvement organization, Livanta, which had asserted that Hennessy’s mother had no “medical issues to support the need for daily skilled nursing care” when the payment denial was issued in early August.
The final ruling, issued on Nov. 25, found instead that it was the insurer that hadn’t given any good reason to deny care for a patient who was still “a safety risk.” The judge said her treatment should be paid for in full.
In the months afterward, Hennessy herself crossed the age threshold into Medicare eligibility. She said a friend who sold Medicare Advantage plans had always expected to get her business when she turned 65.
“I just told him, ‘I can’t do it. I’ve lived this nightmare,’” Hennessy recalled. The conversation ended their friendship, until the neighbor called back a couple years later following a struggle with his own Medicare Advantage insurer over a knee replacement.
“He called me to apologize for having gotten so bent out of shape,” Hennessy said. “I’ve still got friends who say, ‘Oh, I’ve got UnitedHealthcare Advantage, and it’s wonderful.’”
“Well, it is,” she said. “Until you need the big stuff.’”
This story is part of a series examining the use of artificial intelligence in health care and practices for exchanging and analyzing patient data. It is supported with funding from the Gordon and Betty Moore Foundation.
STAT is investigating denials and appeals in Medicare Advantage, and the role that technology plays in those decisions. If you have an experience with Medicare Advantage denials, please share your story with us. We will not share your name or story without your permission.
https://www.statnews.com/2023/03/13/medicare-advantage-plans-denial-artificial-intelligence/?utm_medium=email&utm_source=pocket_hits&utm_campaign=POCKET_HITS-EN-DAILY-RECS-2023_03_15&sponsored=0&position=5&scheduled_corpus_item_id=3088b5c4-55ea-4a76-b070-df0398aaa13a?sponsored=0&utm_medium=email&utm_source=pocket_hits&utm_campaign=POCKET_HITS-EN-DAILY-RECS-2023_03_15
Socialism is in retreat in the Democratic Party
Remember Medicare-for-all? Just a few years ago, it was the Democrats’ hottest idea. Now it has nearly fallen out of public discussion. Socialism, which was noisily advancing in the Democratic Party, is silently beating a retreat.
A new dawn for socialism had appeared to begin with Sen. Bernie Sanders’s (I-Vt.) strong insurgent campaign for the Democratic presidential nomination in 2016. Its centerpiece proposal was to replace all private health insurance with a government-run program By 2018, 124 House Democrats, more than three-fifths of all of them, were co-sponsoring the Medicare-for-all bill.
The 2018 elections saw the rise of a slew of self-proclaimed socialists. The most mediagenic of them, Rep. Alexandria Ocasio-Cortez, beat a longtime incumbent Democrat. A moderate Democrat from yesteryear criticized her as she took office. “New party, who dis?” was her response. By the time Democrats began their presidential debates in 2019, Medicare-for-all was the leading subject, with Sen. Elizabeth Warren (D-Mass.) and then-Sen. Kamala D. Harris(D-Calif.) joining Sanders in advancing variants of it. Writers on the left celebrated what they called “a progressive policy arms race” led by Warren and Sanders.
But then Joe Biden, who opposed the proposal, won the nomination. His spoonful of sugar for the advocates was a promise to take several large steps toward Medicare-for-all. He said he would create a new “public option” to let working-age Americans above the poverty level get insurance coverage from the federal government. He also promised to lower the eligibility age for Medicare from 65 to 60 and to have it cover dental and vision care.
Once in office, though, Biden has walked away from these initiatives. His new budget includes no public option and doesn’t let 60-year-olds into Medicare, perhaps because these policies would have been costly and disrupted many people’s current health-care arrangements. The White House released accompanying verbiage about working with Congress to strengthen dental and vision benefits, but the budget reserves no money for it.
The dashing of progressive hopes on health care should put in perspective the much-discussed shift of the Democratic Party, and the country as a whole, to the left.
Today’s Democrats are indeed more left-wing than their forebears in many ways. Biden’s budget foresees record levels of federal spending and debt. He has signaled more hostility to bipartisan entitlement reform than the two previous Democratic presidents did. And Republicans are eager to highlight the party’s socialist turn, if only to denounce it.
But it turns out the party’s left wing has spent much of the past few years fooling itself about its ascendancy. Sanders did well in the 2016 primary because he was running against Hillary Clinton. He fizzled in 2020, when she wasn’t in the race as a foil. Ocasio-Cortez and her closest allies in the House are in liberal districts where, as then-House Speaker Nancy Pelosi (D-Calif.) remarked a few years ago, “a glass of water” with a D next to its name could win an election. They represent the voters Democrats already have, not the ones they need to win.
Which helps explain why Medicare-for-all has languished. When Democrats had a House majority, from 2019 through the start of this year, it was because they prevailed in moderate districts. The number of co-sponsors for the legislation actually dropped a little.
A major reason moderates shunned the bill: It requires raising taxes on the middle class, as Sanders readily admits. (He says the middle class will save more on medical bills than they pay in taxes.) Biden, like the other two Democrats who have been president in the past 40 years, has ruled that out.
And that constraint on Democratic ambitions is getting tighter. In 1993, President Bill Clinton signed a bill raising taxes on couples making more than $140,000: about $300,000 in today’s money. Biden has an even more expansive definition of the middle class: He says only couples making more than $450,000 should pay higher tax rates.
If they’re willing to raise taxes only on a small slice of the population, Democrats might not be able to keep financing the government we have. They certainly cannot finance a European-style social democracy.
Fans of Medicare-for-all can, however, take comfort that they will have one champion in the 2024 presidential race: Marianne Williamson.
https://www.washingtonpost.com/opinions/2023/03/13/biden-budget-socialism-lost/
You Don’t Have to Be a Doctor to Know How Much Trouble the N.H.S. Is In
Allyson Pollock and
On Dec. 15, nurses walked out and began the largest nurses’ strike in the history of Britain’s National Health Service. They were protesting working conditions that have left them burned out and stretched thin — and compromised patient safety — and wages that fell in the last decade in real terms. Ambulance workers joined them. This week, thousands of junior doctors went on strike for three consecutive days.
“I come to work and can see that there’s a patient waiting eight hours to see a doctor. There are some days where I finish my shift, come back the next day and then I see the same patient still sat waiting in A&E” — the emergency room — “the next day,” Dr. Kiara Vincent, one of the doctors striking, told the BBC on Monday.
But you don’t have to work in a hospital to know that Britain’s N.H.S. is in the most serious crisis of its history; you just have to be injured, or ill. Thousands of people are estimated to have died in the last year because of overwhelmed ambulance and emergency services. There are 7.2 million people in England, more than 10 percent of the population, on waiting lists for treatments like hip or knee replacements, back surgery or cataract operations. And hundreds of thousands of people have had a doctor’s referral for outpatient care at a hospital rejected because there are no available appointments — they are simply bounced back to the doctor to begin the process again.
That the flagship health care service of one of the wealthiest countries in the world is in such a state is shocking, but not without explanation. Decades of marketization, 10 years of Conservative austerity and a pandemic have hollowed out the N.H.S. so much that people who can afford to, and increasingly those who can’t, are having to pay for health care.
A two-tier system with more and more in common with American health care is taking shape. It’s not working, and we’ll soon be at the point where it’s too late to do anything about it.
The damage to the N.H.S. was inflicted in three main waves.
In the late 1980s and early ’90s, a Conservative government introduced the internal market and closed long-stay hospitals — where care was free — under the euphemistic banner of “care in the community.” Private nursing homes backed by equity investors took over provision for older people, and care became chargeable and means-tested, mirroring Medicaid “spend down” rules.
In the late 1990s and early 2000s, Labour, under Tony Blair, built dozens of new hospitals with money from partnerships with private investors. The new hospitals were saddled with enormous loan and interest repayments — around $60 billion is still owed.
In 2010, the Conservatives, back in power — alongside the Liberal Democrats until 2015 — embarked on a decade of austerity. A government-commissioned report released last year called the years between 2010 and 2020 the N.H.S.’s “decade of neglect.”
The cumulative effect was devastating: In the three decades that preceded the pandemic the number of NHS beds in England was more than halved. Shortages — of beds, ventilators or intensive care specialists — in early 2020 were not unique to Britain, but Britain had fewer per capita beds than comparable countries. There was a palpable sense of panic about how Britain and its health service were going to manage.
Britain did manage. And it was because of the dedication of the people who work for the N.H.S., and the retired staff who came out of retirement to help. Britons know this: Research from the spring of 2022 suggests that the British public still overwhelmingly support the founding principles of the N.H.S., even as their satisfaction with it sinks to the lowest level in decades. (Nurses and ambulance workers have the most public support of all of the workers who have been staging strikes in Britain this winter.)
But people are also tired of waiting — or not able to wait — and more and more are paying for private treatment.
There was a 35 percent increase in people choosing to self-fund care between 2019 and 2021, with “market-beating growth” reported in the self-pay market since the Covid pandemic. The number of people self-funding operations like hip and knee replacements more than doubled.
And there are indications that some of the people paying for private treatment are doing so not because they can afford to, but because they can’t afford to wait: Between 2019 and 2021, as self-funding increased, the number of people paying with private insurance decreased; people are reportedly taking out loans to pay for operations and, in a development that will be familiar to Americans but is something quite new in Britain, more and more people are turning to GoFundMe to raise money for medical treatment.
The government has done plenty to encourage this shift: In 2012, the Conservatives increased the cap on what percentage of an N.H.S. hospital’s income could come from treating private patients to 49 percent.
An investigation by The Guardian newspaper in January found that some N.H.S. hospitals with private divisions were promoting self-pay for people who “don’t want to wait for an N.H.S. referral,” while warning N.H.S. patients that services were “extremely busy.” And it’s well established that doctors who work for the public and the private sector have a conflict of interest and can game the system, telling patients that they’ll have to wait months for N.H.S. treatment one week and then treating them privately the next.
More private patients is supposed to mean more money for the service. But since the profit margins on the income from private patients are treated as confidential, researchers have not been able to verify whether private patient units have created more money for N.H.S. patients, whether they make any profit or even lose money.
What we do know is Britons who want to use the N.H.S. are finding it increasingly hard to do so. It doesn’t have to be this way, but change won’t be easy.
In the short term the N.H.S. should stop treating private patients and use public funds to increase the numbers of beds and staff. And sooner rather than later, doctors should be required to choose between working for the public system or the private sector.
There have been four attempts to introduce a bill — that we co-authored — that would reinstate the N.H.S. as a planned system of universal public health care in England in the House of Commons since 2015 — and all four have failed, the last one in 2018. The prospects of any future attempt would depend on the next government.
On Thursday, after months of rolling strikes, the government increased its pay offer to nurses and ambulance workers. Three of the largest health unions agreed to recommend the offer to their members. Junior doctors went back to work, but their dispute is far from over.
The N.H.S. as Britons have known it — accessible, free at the point of use, cherished — is becoming something else. But as long as there are still people willing to fight for it, it’s not too late to save it.
Allyson Pollock is a clinical professor of public health at Newcastle University. Peter Roderick is a principal research associate at Newcastle University and a lawyer.
https://www.nytimes.com/2023/03/17/opinion/nhs-britain-privatization.html
Lawmakers, administration argue over rescue plan for Maine’s struggling EMS providers
The Mills administration raised concerns and urged changes to the stopgap measure, which is one of several proposals this session to shore up EMS services that are losing money and struggling to attract new workers.
A $25 million proposal to rescue struggling emergency medical response agencies prompted a testy exchange Monday between a Mills administration official and a Democratic committee chairwoman.
The bipartisan bill would provide emergency funding primarily to rural EMS providers at risk of shutting down. It is one of several bills aimed at saving local EMS providers around the state, which have long struggled with increasing call volumes, reimbursement rates that don’t cover service costs and a workforce shortage driven by demanding work and low pay.
Supporters of the bill, which is sponsored by House Speaker Rachel Talbot Ross, D-Portland, and co-sponsored by House Minority Leader Billy Bob Faulkingham, R-Winter Harbor, argued that the one-time allocation is a much-needed lifeline for struggling EMS services, especially in rural areas.
“I’m standing before you begging you to support (the bill),” said Renee Gray, the Lubec town administrator and an advanced emergency medical technician and service chief for a small ambulance service covering Jonesport and Beals Island. “The lives of our communities and loved ones depend on it.”
But a Mills administration official suggested setting conditions for the funding.
Maine EMS Director Sam Hurley, testifying on behalf of the agency and the Department of Public Safety, urged the committee to consider making the funding available through grants to ensure spending accountability and transparency. He recommended attaching conditions, including aligning the funds with the state EMS board’s soon-to-be-released strategic plan.
Hurley said the funding should be used to engage local agencies about regionalizing ambulance services, which would undoubtedly lead some providers to shut down.
“We have to force those conversations with them,” Hurley said. “I don’t like saying the government has to force something but I think that’s the only future way through.”
Hurley’s suggestion to align the funding with the as-yet unpublished strategic plan prompted a stern response from Rep. Suzanne Salisbury, committee co-chair and bill co-sponsor, who worried that a grant process would be irresponsible and create red tape for service providers. She was also frustrated by what she believed were mischaracterizations of the bill, including a suggestion that providers would use the funding to drastically increase pay or purchase additional equipment, such as an ambulance.
“I feel it’s very out of touch with the original proposal, which is essentially sending a lifeline to services in danger of closing,” she said, adding that the EMS strategic plan doesn’t contemplate shifting to a new system until more than a decade from now. “I’m very frustrated. We cannot wait for the strategic plan of EMS for 2035, because people will die.”
The interaction highlights the challenges of restructuring the state’s EMS system to ensure it is sustainable and equitable throughout the state. It will likely require a balancing act between the state’s history of local control and the cost efficiencies that come with regionalization.
As of January, 276 entities were licensed to provide emergency medical services: 173 fire departments, 41 nonprofits, 35 independent municipalities, 11 private companies, 11 hospital companies, three colleges, two tribal agencies and one airborne medical service. They are divided into six regions of the state.
Staffing and funding challenges mean people seeking emergency medical help in their homes, in public or at the scene of an accident may have to wait longer for aid to arrive. It also makes it difficult for hospitals to transfer patients from one facility to another, causing a backlog of patients in emergency rooms, according to testimony Monday.
The previous Legislature formed the Blue Ribbon Commission to Study Emergency Medical Services. The commission issued a report in December outlining recommendations that include the proposed $25 million in emergency funding to prevent additional services from closing, and $70 million a year over the next five years to maintain the current system of providers.
“EMS in the state is in crisis,” the report says. “EMS services in Maine are at the edge of a cliff, or over it, and changes must occur to ensure that when someone calls with a medical emergency, EMS services are able and ready to assist.”
The state’s EMS board, which is appointed by the governor, is doing its own strategic planning and is expected to vote on a final plan at its next meeting April 5.
EMS providers urged lawmakers to support the emergency funding while acknowledging the need to regionalize services that are now provided by municipalities, nonprofits and hospitals. Providers say insurance only covers a percentage of the cost of transporting patients to hospitals. And insurance companies provide no reimbursement for calls in which a patient declines transportation to a hospital.
An amended version of the rescue fund bill, L.D. 526, presented Monday would allow services in danger of closing to receive $15,000 to $500,000. Eligibility would be based on need, “rurality” of the service area and a department’s number of responses. Recipients would have to file an annual report each May and services responding to fewer than 2,000 calls a year would have to explore other EMS models.
Dr. Erik St. Pierre, emergency medical director at Northern Maine Medical Center and the director of two ambulance services in Fort Kent and Madawaska, said the EMS system is in the worst shape he’s seen in his 11 years working in the state. Recently, he said, he was unable to find an ambulance to transport three pediatric patients, resulting in parents transporting two kids and a nurse and a clinician transporting another.
St. Pierre, who testified by video from Aroostook County, said last Friday he placed 13 calls over a 12-hour period to find an ambulance to transport a patient to a major hospital. By the time he secured transportation, he said, the hospital had assigned the bed to someone else.
“That is a story we hear over and over again up here,” St. Pierre said. “For us in the rural community up here it is a crisis and it is serious.”
St. Pierre suggested lawmakers examine the system in New Brunswick, Canada, which centralizes EMS dispatch and allows for more efficient coverage of communities.
Robert “Butch” Russell, director of the Maine Ambulance Association and CEO of Northeast Mobile Health in Scarborough, urged the committee to approve the onetime funding measure, saying the current system is at a “breaking point.” He also thinks communities and providers should discuss regionalization, although he hesitated to suggest what that might look like.
“It’s not a popular word in our industry,” Russell said. “I don’t want to define regionalization. That means different things to different people. But when we talk about services only doing 100 calls a year, we’ve got to come up with ways of doing that different.”
Talbot Ross presented lawmakers with an amended version of the bill Monday, saying she continues to work with the governor’s office to address concerns, including accountability and oversight by the state EMS board. But she continued to stress the importance of the emergency funding.
“Put it this way: Today you are taking out the defibrillator and ensuring this system gets a chance at a full recovery,” she said. “Our next steps will require a full care plan and regular maintenance – there is no option here. For too many, this is quite literally a life or death option.”
The committee is expected to take up the bill in a work session in the coming weeks before sending a recommendation to the full Legislature.
A doctor shortage is expected to get worse. Here is what it means for patients.
The Association of American Medical Colleges projects that by 2034 the U.S. will see shortages of between 17,800 and 48,000 primary care physicians.
by Amanda Hill - News Center Maine - March 21, 2023
PORTLAND, Maine — Have you noticed it takes longer to schedule an appointment with your primary care physician? Or, once there, you feel more rushed through it? Dr. John Rodriguez said it's a problem nationwide, but it's impacting every community, especially small ones.
"I see a lot of my primary care friends have called it quits, and they’ve either left the scene already or they’re joining big groups," Rodriguez said. "Or they’ve left health care, and they’re working for insurance companies."
Why? It's largely because of doctor burnout.
Rodriguez is a chief medical officer of a direct primary care office. Essentially, it’s a practice that either has a membership fee or takes direct payment from the patient, removing the need for an insurance company. It’s not an affordable option for everyone, but Rodriguez said it does afford a more intimate relationship with patients and cuts down on overwhelming paperwork, which have become two reasons for doctor burnout.
Rodriguez said larger offices pay bonuses when doctors see more patients, but as they stuff in more appointments, those appointments become shorter. They're also spending more time interacting with insurance companies and filling out paperwork for certain medical mandates, which are meant to protect the patient, but still take time away from the in-office visit.
"Your visit appointments are now down to seven minutes on average, right? That’s fine if it’s a head cold. But if you’re dealing with three or four medical problems like diabetes, high blood pressure, and heart disease, it’s impossible to keep up with that in proper form," Rodriguez said.
That shortened time can lead to things that are missed or the wrong diagnosis. Waiting for an appointment or bouncing from one doctor to another can lead to a patient giving up or not receiving the screening they need.
"Sometimes I’m a second opinion doc, so I’ll see patients from other offices," Rodriguez said. "And as well-intended as they were, their diagnosis was off, and we come up with a different diagnosis. They were in a hurry to get the patient on. The patient had a few complaints they didn’t think were important, but they were."
The Association of American Medical Colleges projects that in 2034 the U.S. will have shortages of between 17,800 and 48,000 primary care physicians. Some of that is the high cost of schooling, preventing some students from entering the field, along with an aging field of physicians who will soon retire.
About five years ago we met Dr. William Medd, who worked well beyond his retirement years in the town of Norway, because he couldn’t find a replacement. He worried about what would happen to his patients if they didn't have a general care physician in town.
By 2019, Medd found a replacement, thanks in part to a program he helped create with MaineHealth called RIMM: Rural Internal Medicine Maine Track. The idea is to dedicate at least one resident in medical school to a rural part of the state for three years, incorporating them into the community hoping they choose to build a life there.
It's something, along with new creative ways to rebuild relationships with patients like direct primary care, but the track of physicians in general isn't looking good, Rodriguez said.
"It’s going to get worse, and really the issue is you need the quarterback," Rodriguez said. "You need someone who knows the health care system and how to maneuver through that, and if you don’t have that it’s chaos."
In the meantime, if you're losing your primary care physician, it's worth asking the practice or physician themselves if they'd refer you to someone else.
For a list of direct primary care physicians in Maine, click here.
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