Texas Medical Association News Clips

(CNNMoney.com) -- One of the keys to the various health reform plans kicking around Washington is "pooling." The proposal floated by President Obama during the campaign, for instance, would establish a National Health Insurance Exchange designed to help small businesses and individuals reduce their premiums.

Pooling is a great idea in theory. But historically, it hasn't succeeded at significantly expanding affordable coverage.

The premise is simple: Set up a system to allow individuals and small employers to band together to join group plans that they would otherwise not have access to. These "pooled" plans can then negotiate with insurers and cut the same preferential deals that major corporations are able to. By pulling thousands of people together, the pools mimic the economics of scale that let large companies negotiate lower costs from insurers for their employees' coverage.

"The basic idea goes way, way back," explains Elliot Wicks, a senior economist with the hospital network Health Management Associates who has studied pooling proposals for more than a decade.

In 1989, economists Alain Enthoven and Richard Kronick proposed a network of "public sponsors" that would help manage and regulate the private purchasing of health insurance. This embryonic attempt at providing cheaper insurance through expanded pools ended up as the core of Hillary Clinton's ill-fated 1993 "managed competition" plan.

Even as it was failing on the federal level, though, the notion of government-established insurance pools was being experimented with at the state level. Following a popular pooling plan created by Cleveland's Council of Small Employers in the 1970s, about a dozen states created state-organized plans to gather small employers together into purchasing pools. The most successful of these was the Health Insurance Plan of California, created in 1993, which at its peak four years later covered about 7,000 participating employers representing 134,000 enrollees.

California's HIPC ultimately fizzled, though, for a couple of reasons. First off, one of the main attractions of the plan to small employers - that each of their employees could choose from any insurance package, rather than an entire business having to pick a one-size-fits-all plan - was a turn-off for insurers. As Wicks puts it, "They were all worried that they were going to get all the sick employees."

More problematic was that HIPC didn't, in the end, cut costs. A 1999 study by the California HealthCare Foundation, in fact, found that it would cost small businesses about 6% less to buy coverage outside HIPC than via the state-sponsored plan.

The problem was that even as the largest state health insurance pool, HIPC still only commanded a tiny share of the state's small businesses and individuals.

"You have a dilemma here: you can only be effective as a bargainer, the way large businesses do, if you have enough business to make the insurers give you a favorable price," Wicks says. "But unless you have a better price, it's very hard to attract the number of enrollees to get that mass. So without something that puts a lot of people into these, it's hard to have much bargaining power."

Compelling coverage

The solution, say pooling advocates, is to find some way to either force or strongly encourage people to join pools, in order to create a force that insurance companies can't ignore. It's what Massachusetts did in creating its Commonwealth Connector in 2006, for example, by requiring that everyone in the state either procure health insurance or pay fines.

It's one reason many observers believe we're likely to see mandatory health coverage become national law. Though Obama opposed mandates during the campaign, Sen. Max Baucus and others have more recently incorporated required health coverage into their Congressional health reform plans.

Mandatory coverage is also something the insurance industry is insisting on in exchange for allowing individuals to get insurance without regard for prior medical history. Their concern isn't solely getting a guaranteed market for their products, say health care experts. There's also the legitimate worry that if pre-existing conditions are no longer a bar for coverage, young, low-risk individuals will forgo getting insurance until they become sick - draining the system of the healthy payers who help to keep premiums low for everyone else.

Even then, though, most observers agree that pools by themselves won't do the trick without substantial government subsidies to go along with them. It's a lesson that Massachusetts, for one, has learned the hard way. It severely underestimated the numbers of individuals who would qualify for subsidies - any state residents earning less than triple the federal poverty line, or about $63,000 for a family of four, are eligible - and had to both allocate hundreds of millions of dollars in additional funds and allow waivers for many of those who remained uninsured.

"Any of these national proposals are going to have to offer substantial subsidies, because the cost of health insurance is so high that minor subsidies are just not going to draw in many people," concludes Wicks. "And if you make it mandatory that you provide coverage, you've got to provide subsidies sizable enough to make it affordable."

Health care: The hidden business killer

Soaring health insurance costs hurt small companies more than their big rivals. Here's how smart entrepreneurs are coping with the crisis.

Patricia B. Gray

CNNMoney.com

January 28, 2009

Fortune Small Business -- Rich Gallo says he can't afford to provide health insurance for his nine employees. For a long time he put off buying insurance for himself, figuring he needed time to shop carefully. Gallo's desk was piled high with policy proposals when he suffered a heart attack. Lacking insurance, he delayed going to the hospital for several hours.

"I could have died," says the 50-year-old owner of Office Outlet, an office-products supplier in Indiana, Pa. Medical care related to Gallo's heart attack cost $200,000, which was paid by the state welfare department, a foundation affiliated with the hospital, and donations from Gallo's church.

Gallo isn't the only small business owner struggling to cover the cost of health care. The long-simmering crisis has reached a flash point in the past few months. Premiums on group policies have soared by as much as 30%, on top of double-digit increases in each of the past five years. Coverage is shrinking. Thanks to insurer consolidation, policy choices are more limited than ever. And in a seller's market for insurance, small business owners have little room to negotiate prices or terms.

The escalation of the health-care crisis couldn't come at a more difficult time. Sales and profit margins are dwindling amid a weakening economy and a credit crunch. As a result, companies can no longer pass higher health-care costs on to their customers.

"Many of our members are wrestling with very tough issues," says Karen Kerrigan, CEO of the Small Business and Entrepreneurship Council, an advocacy group based in Oakton, Va. "Do they lay off some workers in order to provide coverage for the rest?"

President Barack Obama has promised reform, but health care is only one item on an urgent to-do list that is also crowded with two wars, a ballooning budget deficit and a faltering economy. Health care may indeed get a sweeping overhaul under the new administration, but policymakers will probably exercise caution in changing a system that accounts for 16% of the U.S. economy. Many powerful interests will have their say in crafting legislation, including (but not limited to) insurers, state regulators, doctors and the drug industry. Proposals range from eliminating employer-based health insurance and requiring all Americans to buy plans through state-run agencies, to lowering the cost of insurance by allowing employers to join insurance associations that pool risk across state lines. (For more on the policy debate, see "Fixing Health Care.")

Relief could take years. That's cold comfort to Donna Partin, who owns two Merry Maids franchises that employ a total of 40 workers in Camp Hill and York, Pa. Only about a third of her employees opt for coverage, and Partin pays a total of $5,000 a month to insure them. (Partin owns another Merry Maids franchise in St. Augustine, Fla., where she cannot afford coverage for her 10 employees.) Her premium has tripled since 2000.

"I'm paying more and more for less and less every year," Partin complains. Like many owners, she says health insurance is vital because it helps her retain trusted workers, which is particularly important for a housecleaning business. To maintain coverage, she has pared other benefits, such as vacations and bonuses.

The health-care crisis has hit entrepreneurs like Partin particularly hard. Small businesses typically pay 18% more for health insurance than big companies, which can use their purchasing power to drive down the cost of coverage, according to a study by the Commonwealth Fund, a health policy research foundation. And the number of small firms that provide health insurance to their employees has been shrinking every year: 59% in 2007, down from 68% in 2000, according to the Kaiser Family Foundation. Of the 46 million uninsured in the U.S., 27 million are small business owners, their employees or their dependents.

The good news? Many U.S. entrepreneurs are finding innovative ways to cover themselves and their employees.

Take Steve Cole, 59, who runs an auto body shop in Villa Park, Ill. For more than a decade, providing health insurance for himself and his five employees was a "headache." Now it's a migraine. In 1997 an employee's wife had a bout with breast cancer. Cole's monthly premiums promptly soared from about $300 to about $1,800 per employee. Every year since then, Cole and his broker have engaged in a complicated dance they call the shuffle. It involves switching insurers almost annually to qualify for low introductory premiums. Cole does get lower premiums - he's had eight insurers in the last 10 years - but at a price: He spends six to eight hours each fall filling out new insurance forms.

This year Cole's monthly premium climbed 30%. He then switched to a policy that primarily covers medical catastrophes - but there's a catch. His bad back and sinus problem are considered pre-existing conditions and aren't covered under the policy. Soon, Cole frets, he may be uninsurable. "This is an ugly situation," he says. "I just hope I can hang in there until I qualify for Medicare."

In some states small firms have banded together to qualify for lower group rates on insurance. In Cleveland, for example, companies with 500 employees or fewer can buy health insurance through the Council of Smaller Enterprises (COSE), the partner of the regional chamber of commerce. Rates are about 8% lower than on the open market. Some 14,000 companies participate in the pool, which dates back to the 1980s. But Cleveland's experiment has not been widely imitated. Pools are difficult to organize and costly to administer. And insurers are less motivated to participate now that there's less competition in the industry. (For more on pools, see "Why pools haven't worked.")

Insurance woes are forcing many entrepreneurs to rethink their business plans. In 2007, Debbie and Ned Wicker launched Mission Enabled, a Web publishing business based in Oconomowoc, Wis. The Wickers knew that one of their biggest challenges would be finding affordable health insurance for themselves. Debbie's former employer had been paying an annual insurance premium of $18,000 for the Wickers. (Ned, 58, had tested positive for high blood sugar several years before. That triggered the high premium, even though he hadn't developed diabetes.)

Debbie, 51, discovered an ingenious solution when she took a class at the University of Wisconsin. By enrolling in one course each semester, she qualified for low-cost student health insurance with an annual premium of $4,000 and a deductible of $250. (Her annual tuition bill is $2,200.) "I'm lucky I found a loophole," Debbie says. "Without it we're basically uninsurable."

What a difference a decade makes. Back in the 1990s, the Wickers owned a sports magazine with a circulation of 45,000. They offered health insurance to all 20 of their employees. But they sold the magazine in the late 1990s, and their new Web venture relies entirely on freelance contractors.

"I liked having workers on the payroll and offering benefits," Debbie says. "I think it's patriotic - jobs for America and all that. Will I do it again? Probably not. Insurance costs are a big disincentive to an entrepreneur."

Whittling down coverage

Small businesses that do provide health benefits are trying to cut costs any way they can. Many firms impose long waiting periods before new hires become eligible for health coverage.

"Thirty days used to be common," says Alex Miller, an insurance broker in Armonk, N.Y. "Then they pushed it to six months. Now some workers are waiting a year for their coverage to kick in."

Once they qualify for health benefits, employees are likely to receive bare-bones coverage that doesn't include dependents. Such policies also tend to exclude alternative treatments such as acupuncture as well as conditions such as infertility. They often trim mental-health benefits by limiting therapy sessions.

And many employers reduce insurance costs by choosing plans with high deductibles. At Northridge Holdings, a 15-employee real estate investment company in Addison, Ill., single workers pay a deductible of $2,600; the family deductible is $5,200. That's not unusual: More than a third of covered employees of small businesses - those with a workforce of fewer than 200 - pay deductibles of at least $1,000 before coverage kicks in, according to a survey by the Kaiser Family Foundation and the Health Research & Educational Trust. That's up from 21% in 2007.

Another option for business owners is bypassing the health-insurance market and covering employee medical costs directly. Fifteen years ago, Thomas Johnson left Ghana in search of the American dream. A skilled woodworker who had studied classical joinery in Italy, he arrived in the U.S. with $20 and a young man's zeal for hard work. Today, Johnson owns Thomas A. Johnson Furniture, a successful furniture-making business in Lynchburg, Va. Eight employees - apprentices, in his view - work side by side with him to learn how to craft fine furniture.

Unable to afford group health insurance, Johnson pays out-of-pocket for his employees' medical expenses. So far the bills have been minimal and mostly for antibiotics. Skilled woodworkers are hard to find, and Johnson can't afford to lose those in whom he has invested so much time.

"My workers are part of my business and part of my family," he says. "They are exceedingly valuable to me." To him, paying their medical bills is a matter of honor - and pragmatism.

It's also risky. By picking up the tab for medical bills, according to some legal experts, Johnson has set a precedent that could obligate him to pay for all his workers' medical expenses - even for a catastrophic illness such as cancer, which typically costs hundreds of thousands of dollars to treat. Johnson acknowledges that a big medical bill would devastate his business, which posted 2008 revenues of $400,000. But he can't afford to buy insurance in the current economic downturn.

"What I am doing is very dangerous, I know," he says. "But I don't have a choice."

Employers who buy health insurance can pare costs in several ways. Some pressure employees to switch to generic drugs, take preventive measures during flu season, and limit doctor visits for colds and other minor maladies. Others have tried to lower insurance costs by putting a price on vice - penalizing unhealthy behavior such as smoking and overeating. Sixteen percent of the nation's largest employers make workers who smoke contribute more than nonsmokers to cover health-insurance premiums, according to Mercer, a global human resources consulting firm.

Small business is following suit, adding thousands of dollars to the deductibles of workers who suffer from obesity or high cholesterol. (To comply with federal law, employers must offer programs such as smoking-cessation classes or Weight Watchers (WTW) to help workers get fit.)

At Independent Alliance Banks, a bank holding company in Fort Wayne, employees can undergo an optional annual screening that measures body mass index, blood pressure, cholesterol and tobacco use. Test results determine employee deductibles; merely taking the test leads to a reduction. Independent Alliance's family plan sets a deductible of $1,400 for workers who score in the healthy range on all four tests. For those who won't take the test, that number jumps to $5,400. Independent Alliance hasn't exactly set the bar too high to start - employees can be substantially overweight, but not obese - but promises stricter standards in 2010.

Such penalties represent a new twist on a decadelong effort by employers to reverse the nation's slide into sloth - and save money on insurance. In the 1990s companies of all sizes started wellness programs to push workers to shape up and lose weight. Some even offered rewards such as movie tickets and cash. Results were mixed.

"People put pedometers on their dogs to log mileage and did all sorts of crazy things to win the prizes - anything but exercise or lose the weight," says Doug Short, CEO of BeniComp, which crafted the cost-reducing plan for Independent Alliance. "Now people have to take responsibility for their health."

Anecdotal evidence aside, it's unclear that wellness programs make a major dent in health-care costs. And despite the increasing popularity of this approach, it has another downside: TMI. That's "too much information" - about workers and their private lives. Some business owners confess they are uncomfortable discussing personal health issues with workers or sponsoring contests that require embarrassing weigh-ins reminiscent of The Biggest Loser.

"I have one employee - kind of a big guy - and we've got to keep him under a certain weight," says Cole, the body-shop owner. "I hate telling someone to lay off the doughnuts. And I don't like nagging folks not to go to the doctor for a sniffle, but I do it now."

California's high court bans balance billing

Doctors say the decision will burden an already strained emergency care system.

Amy Lynn Sorrel

American Medical News

January 26, 2009

A recent California Supreme Court ruling may have quelled an ongoing feud over whether out-of-network emergency physicians can balance bill patients. But doctors say the decision left unresolved the root cause of the issue -- HMOs' routine underpayments to physicians.

The high court concluded unanimously that state laws clearly prohibit doctors from turning to patients for outstanding bills that health plans refuse to cover. Such reimbursement squabbles "must be resolved solely between the emergency room doctors, who are entitled to a reasonable payment for their services, and the HMO, which is obligated to make that payment," Justice Ming W. Chin wrote in a Jan. 8 opinion. Patients "may not be interjected into the dispute."

In a disappointment to doctors, however, the court declined to address the larger problem of determining what constitutes reasonable compensation for emergency care.

While state officials and health plans hailed the decision as an important protection for patients, physicians fear the court's failure to remedy reimbursement discrepancies will deal yet another blow to an already strained emergency care system.

Doctors sympathize with patients, "but you can't just give a blank check to HMOs," California Medical Assn. President Dev GnanaDev, MD, said. The CMA, along with the Litigation Center of the American Medical Association and State Medical Societies, filed a friend-of-the-court brief in the case.

Rather than forcing HMOs to appropriately pay doctors -- as required by law -- the ruling shifts the burden to physicians to recoup any reimbursements due, Dr. GnanaDev said. "There's no way a little trauma surgeon like me can go after any HMO. My resources are minimal. It's like David versus Goliath."

According to CMA data, emergency departments in the state were underpaid more than $1 billion in 2007, while financial struggles have forced the closure of more than 70 emergency departments in recent years.

Dept. of Managed Health Care Director Cindy Ehnes reassured physicians the agency "will not retreat from efforts to make sure that doctors are paid fairly." At the same time, the decision removes "a crushing economic burden" on patients "caught in the middle of billing disputes," she said in a statement.

The ruling also reaffirms recent department regulations defining balance billing for out-of-network emergency care as an unfair billing pattern, Ehnes said. A trial court in December 2008 upheld the DMHC's authority to create the regulation, instituted last October. The CMA initiated the legal challenge, but officials said they do not plan to appeal, in light of the recent Supreme Court ruling.

Gov. Arnold Schwarzenegger, who urged the new rules, said the high court's decision "will protect Californians who have done the right thing by obtaining insurance, but then later receive burdensome medical bills that they do not owe."

Health plans, meanwhile, say the decision will help keep health care affordable.

"We see a wide variety of out-of-network charges" for emergency care, California Assn. of Health Plans spokeswoman Nicole K. Evans said, and eliminating balance billing will help eliminate the threat of potentially excessive bills.

Holding HMOs accountable

Justices agreed with doctors that an HMO does not have "unfettered discretion to determine unilaterally the amount it will reimburse a noncontracting provider." But the court noted the Legislature did not intend to involve patients in the payment process.

State laws and regulations already ban balance billing for contracted care and provide other measures to protect the interests of out-of-network emergency doctors by:

Requiring HMOs to pay for emergency services policyholders incur.

Prohibiting HMOs from engaging in unfair payment practices.

Mandating that HMOs adopt internal dispute resolution mechanisms that can be used.

Allowing emergency physicians to sue HMOs over reimbursement issues they encounter.

But doctors said those avenues have done little to hold HMOs accountable, and they are pursuing other options.

The CMA continues to advocate for legislation similar to that in New Jersey and Colorado requiring insurers to first pay a bill in full before resolving disputes over the amount, whether through arbitration or court.

Meanwhile, the DMHC has touted an independent dispute resolution process to help address disagreements over reasonable and customary rates for health care services. The California Assn. of Health Plans has supported the effort.

But doctors are not too keen on the program, which costs $25 to $50 to participate. With average underpayments to doctors of $30, such alternatives -- especially more expensive court options -- give doctors little recourse, Dr. GnanaDev said.

"A lot more needs to be done."

Texas Medical Association Warns Patients About Getting their Health Insurance Cancelled

Medical Quack

January 27, 2998

If we remember the movie Sicko, we saw quite a few of these examples played out on the screen and there was the case of the woman in California that had breast cancer last year that was cancelled and all over the media.

As the article states, most people do not omit information on purpose, but rather may forget something that happened years ago that one would consider minor, maybe a sinus infection, reaction to a medication, etc. in other words something that didn’t get included in your history when filling out the application, and these things do happen; however, if found later, as the article states, it could be grounds for denial of coverage.

Some of the insurance companies now connect to a PHR, personal health record whereby you can import what your insurer has on file. I mention this too as it is a good idea to see what is on file, and you may even find errors with information in file too as in the case of identity theft.

At any rate, it is a good way to perhaps double check and see if your file is accurate. Also, keep in mind too that everybody is mining information today from the web, so all information let’s say on a social network can be read as well, in other words, make sure everything jives if you are perhaps discussing a condition on the web with using your real identity and it could be an potential accidental omissions on your file. If you are one who visits the doctor frequently and have an extensive health history file, anyone could possibly forget small items.

In some cases, the article states that payments have been rescinded that have already been paid, again the movie Sicko reminded us of some of those cases that came to light. The Texas Medical Association is pushing for laws to be enacted to prohibit the practice in Texas.

Government Payer

Relief Seen for Jobless and States in Health Care Plan

ROBERT PEAR

New York Times

January 28, 2009

WASHINGTON — The stimulus bill working its way through Congress is not just a package of spending increases and tax cuts intended to jolt the nation out of recession. For Democrats, it is also a tool for rewriting the social contract with the poor, the uninsured and the unemployed, in ways they have long yearned to do.

With little notice and no public hearings, House Democrats would create a temporary new entitlement allowing workers getting unemployment checks to qualify for Medicaid, the health program for low-income people. Spouses and children could also receive benefits, no matter how much money the family had.

In addition, the stimulus package would offer a hefty subsidy to help laid-off workers retain the same health plans they had from their former employers.

Altogether, the economic recovery bill would speed $127 billion over the next two and a half years to individuals and states for health care alone, a fact that has Republicans fuming that the stimulus package is a back door to universal health coverage.

“It’s raining money,” said Representative Michael C. Burgess, Republican of Texas.

The House plans to vote Wednesday on the $825 billion bill, and the Senate is expected to vote on a similar measure next week.

As Congress rushes to inject cash into a listless economy, it is setting aside many of the restraints that have checked new domestic spending for more than a decade. The White House said the changes contemplated by Congress would provide coverage for nearly 8.5 million newly uninsured people who had lost their jobs and would protect Medicaid for many more whose eligibility would otherwise be at risk.

Of the $127 billion cost, the Congressional Budget Office said, $87 billion would be used to increase the federal share of Medicaid, $29 billion would subsidize private insurance and $11 billion would finance Medicaid for unemployed workers who could not otherwise qualify.

Most of the aid is billed as temporary. But Republicans fear that states would get hooked on it, just as they might grow accustomed to a big increase in federal aid to education, also included in the bill.

Democrats said the current economic crisis did not allow time for public hearings on the legislation.

“This is as urgent as it gets,” said Representative Anna G. Eshoo, Democrat of California.

After the House Ways and Means Committee approved its piece of the economic recovery legislation last Thursday, Representative Pete Stark, Democrat of California, said, “We accomplished more today than in the last eight years.”

Congressional Democrats developed the package in close consultation with President Obama. Health care provisions of the bill taking shape in the Senate are broadly similar to those in the House bill, though they may prove less expensive. Obama aides and advisers said the president would insist on health insurance assistance for the unemployed as part of a final bill, which he wants to sign by mid-February.

The legislation would allow states to provide Medicaid to an entirely new group: those who are receiving unemployment insurance benefits, their spouses and children under 19.

Medicaid is normally for low-income people, and for decades it has been financed jointly by the federal government and the states, with the federal share averaging 57 percent of costs.

The economic stimulus bill prevents states from enforcing a means test, saying, “No income or resources test shall be applied with respect to any category of individuals” who become eligible for Medicaid because they are receiving unemployment benefits. The federal government would pay 100 percent of the costs for people enrolled under this option through December 2010.

Republicans said this proposal would take a big step toward federalizing Medicaid. For their part, Democrats said the changes took a major step toward their goal of coverage for all Americans.

At the same time, the legislation would provide a huge measure of fiscal relief to state Medicaid programs, at a time when state revenues are declining and the number of Medicaid recipients is rising because of the recession.

The federal share of Medicaid spending now ranges from 50 percent in higher-income states like New York and Connecticut to more than 73 percent in poor states like Mississippi and West Virginia. Under the House bill, the federal share would be increased by at least 4.9 percentage points in every state, and by much more in states with large increases in unemployment.

The bill would also offer a lifeline to workers who have lost health insurance along with their jobs. In theory, such workers and their families can keep their group health benefits for 18 months under a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1986, known as Cobra. But laid-off workers are often required to pay 102 percent of the full premium, including the employer’s share, so the cost now can be prohibitive.

Under the bill, the federal government would pay 65 percent of the premiums for a year. That subsidy would almost surely increase the number of laid-off workers choosing to continue coverage.

Republicans wanted to deny the premium subsidies to people who had annual incomes of more than $100,000 or assets of more than $1 million. They also wanted to prevent people with more than $1 million of family income from taking advantage of the Medicaid option for the unemployed.

Democrats voted down those proposals in the House Committee on Energy and Commerce.

Representative Nathan Deal, Republican of Georgia, said “the poorest of the poor” had long been subject to income and asset tests when applying for Medicaid. But, Mr. Deal argued, under the new option, a millionaire could get Medicaid benefits, financed entirely by the federal government, without being asked about such matters.

The committee chairman, Representative Henry A. Waxman, Democrat of California, said, “It’s highly unlikely that you are going to find millionaires who would like to go on Medicaid.”

Moreover, Mr. Waxman said, the purpose of the new options is to “streamline the enrollment process” and speed assistance to people who are unemployed.

“It’s going to set up an unnecessary barrier if we have any income test,” Mr. Waxman said, adding that the enforcement of a means test could require “a whole new bureaucracy.”

The bill would also create a new option for people 55 or older and for those who have worked for the same employer for 10 years or more. They could retain health benefits under Cobra, at their own expense, until they became eligible for Medicare at 65 or obtained coverage through another job. Under this option, employers said, younger workers could conceivably hold onto their coverage for decades.

In a joint letter to Congress, the United States Chamber of Commerce, the National Association of Manufacturers and the National Retail Federation opposed this proposal, saying it would drive up costs for workers already covered by employer health plans.

“The people who sign up for unsubsidized coverage under the new option are more likely to have serious medical conditions and therefore to increase the cost of employee health care disproportionately,” said E. Neil Trautwein, a vice president of the National Retail Federation.

If states wanted the federal government to pay a larger share of Medicaid, they would have to maintain current eligibility levels and could not adopt more restrictive criteria. But states could reduce benefits or payments to health care providers.

Representative Christopher S. Murphy, Democrat of Connecticut, said he feared that such cuts would make it more difficult for Medicaid recipients to find doctors in some parts of the country.

Senate poised to approve children's health bill

Donna Smith

Reuters

January 28, 2009

WASHINGTON (Reuters) - The Democratic-led U.S. Senate on Wednesday moved closer to approving an expansion of a popular children's health care program after rejecting Republican efforts to pare down eligibility requirements.

Democrats want to give President Barack Obama an early victory on a campaign promise to provide health care coverage to more children and send to him legislation that mirrors bills twice vetoed by former President George W. Bush.

The $31.5 billion bill would provide 4 million more children with health insurance. Currently, 7.4 million are covered by the program, for which funding expires March 31.

The Senate rejected several amendments offered by Republicans who complained the latest version of the State Children's Health Insurance Program or SCHIP fails to target coverage to low-income families.

"Republicans are committed to making sure every child has access to affordable health insurance, but there are important differences between Republicans and Democrats in how you get there," said Senate Minority Leader Mitch McConnell of Kentucky.

One important dispute regards immigrants. Under current law, legal immigrants must wait for five years before they become eligible for either Medicaid, the state-federal health insurance plan for the poor, or SCHIP. Democrats want to drop the restriction.

The Senate could vote on the legislation as early as Thursday. The House of Representatives earlier this month approved its version and the two sides will have to work out their differences before sending a final version of the bill to Obama, who has promised to sign it.

McConnell and other Republicans said the legislation, which raises the federal tax on cigarettes to $1 from 39 cents a pack, would allow families earning as much a $88,000 to qualify for SCHIP.

SCHIP is designed to help those families who make too much money to qualify for the Medicaid health program for the poor, but who cannot afford private insurance.

The Senate rejected by 65-32 an alternative offered by McConnell that would have limited states from extending coverage to higher income families. Other Republican efforts to reshape the legislation met similar fates.

"Either you are for kids or not for kids," said Senate Finance Committee Chairman Max Baucus, a Montana Democrat.

He said the Senate bill was very similar to legislation overwhelmingly passed by Congress and rejected by Bush, who opposed the tobacco tax increase and argued the program would encourage families to drop private health plans.

Baucus said the issue would be addressed in a broader health reform sought by Obama and which lawmakers expect to undertake later this year.

"Our goal in national health insurance reform is to make sure everybody gets health insurance and that is going to include ways to shore up private coverage," Baucus told reporters.

States Take Aim At Medicaid

JANE ZHANG

Wall Street Journal

January 28, 2009

At least 25 states have enacted or proposed cuts in health-insurance programs for the poor, potentially leaving millions of patients with reduced levels of care or no coverage at all.

The cuts come as states are making painful moves to close record budget deficits while facing increased demand for services. Across the country, states have pared services under Medicaid, the federal-state health program for the poor, and 12 states have also targeted the State Children's Health Insurance Program, a federal-state program designed to provide health care for children from low-income families that earn too much to qualify for Medicaid, said a report to be released Wednesday by Families USA, an advocacy group in Washington.

The group estimates that more than 250,000 people will lose care because of cuts already enacted and proposed cuts could affect millions more.

States hope federal help will restore some of the funding. The House is expected to vote on a stimulus package as early as Wednesday that would provide about $87 billion over 27 months to boost state Medicaid programs. Senate committees are considering it, and President Barack Obama is pushing lawmakers to send him the bill to sign by mid-February.

The extra money would provide much-needed relief to states, but it's unclear if it would be enough to stave off cuts as job losses swell the Medicaid rolls. States In the meantime, public hospital administrators worry that they could end up paying down the road if patients postpone seeking treatment until they are acutely ill.

Some states have capped enrollment, cut benefits and slashed services that aren't specifically required by the federal government, such as home care for the disabled and vision and dental care. Others such as Nevada, with already-lean Medicaid programs, have resorted to across-the-board cuts in payments to hospitals and doctors. As it stands now, the stimulus legislation would require states to retain or restore Medicaid eligibility levels to those of July 1, 2008, but it wouldn't prevent states from making benefit or provider cuts.

Even before the financial crisis, Nevada's Medicaid spending was the lowest in the country per beneficiary -- $472 compared with a national average of $1,015, according to a 2006 survey. In September, Nevada cut Medicaid payments to hospitals by 5% across the board, and some physicians, especially pediatricians specializing in orthopedics, urology and cancer, saw their payments reduced by 41%. Still, the state faces a revenue shortfall of more than $2.3 billion in the next two fiscal years as gambling and sales-tax revenues have plummeted.

Nevada Gov. Jim Gibbons in his State of the State speech this month proposed increasing Medicaid spending by $206.6 million to $2.8 billion. But he also proposed eliminating Medicaid coverage for low-income pregnant mothers.

The state has already reduced personal-care assistance to the elderly and disabled, which led to complaints and some 200 hearings, said Charles Duarte, the state's Medicaid administrator. The state also capped dental benefits for its State Children's Health Insurance Program, or Schip, at $600 a year, and eliminated orthodontics and vision coverage. Gov. Gibbons plans to cap enrollment at 25,000 for the state's Schip program, which already has 23,000 enrollees and pending applications for 7,000 children. "We don't have money," Mr. Duarte said. "We try to look at things that will have the least impact."

The cuts meant $21 million less in Medicaid funding for the area's only public hospital, the University Medical Center of Southern Nevada in Las Vegas, said Chief Executive Kathy Silver. That came at a bad time for the hospital: Even before the cuts, it was expected to lose $51 million, about 10% of the hospital's net revenue, to uncompensated care.

The hospital, which treats most of the Medicaid and uninsured patients in the area, eliminated some services. By early November, it stopped accepting new patients at the outpatient oncology clinic, and then canceled a contract for outpatient dialysis, saving $2.5 million a year. It also ended routine prenatal care, leaving 600 women to find other providers, and it discouraged women with high-risk pregnancies from using the hospital by closing a unit that was losing more than $2 million a year, Ms. Silver said.

The transition hasn't been without risks, especially for the uninsured who can't afford costly oncology drugs. For undocumented immigrants, she said the hospital is working with the Mexican consulate in Las Vegas to "try to get them treatment or send them to Mexico, if they want."

Officials at the local Mexican consulate declined to comment.

Meanwhile, some doctors -- especially specialty pediatricians -- have stopped seeing Medicaid patients. Mark Barry, an orthopedic pediatrician at Desert Orthopaedic Center in Las Vegas, said he stopped accepting patients after Medicaid slashed reimbursement rates 41%. "It's extremely troubling," Dr. Barry said. "There's nothing more I want to do than provide care."

Health clinics and doctors' offices that still accept Medicaid are overcrowded, and some patients are looking for care out of state. "We are almost creating medical refugees out of the Las Vegas area," said Stacey Gross, community-programs manager in southern Nevada for Susan G. Komen for the Cure, a nonprofit dedicated to fighting breast cancer. "Only a small fraction of people are actually securing any amount of charity care."

As the economy worsens and job losses mount at casinos and elsewhere, some fear patients will eventually flood emergency rooms when their conditions worsen. "I feel like this is a tsunami coming," said University Medical Center's Ms. Silver.

If Nevada's state legislature approves the governor's budget, Mr. Duarte said hospitals will get another 5% payment cut on July 1 this year.

Some fear window is narrow for healthcare overhaul

Economy dominates on Capitol Hill

Lisa Wangsness

Boston Globe

January 28, 2009

WASHINGTON - Mindful of how delays sapped the political will to overhaul healthcare during the Clinton administration, health advocates hoped to get a major bill during the new administration's first 100 days. Now, it looks like it will take longer, and some observers fear that a historic opportunity could be missed.

"The waters are very perilous, and whether the healthcare boat can traverse them given everything else that is going on, is, I think, very much an open question," said Robert Reischauer, president of the Urban Institute and the head of the Congressional Budget Office during the Clinton administration.

The economic downturn - which some say highlighted the burden of rising healthcare costs on businesses - has worsened to the point where deficit projections are already beyond $1 trillion. The stimulus bill and financial bailout are devouring the fledgling administration's political energy and kicking up considerable partisanship in Congress.

Meanwhile, President Obama conceded earlier this month that his campaign proposal to pay for healthcare by repealing the Bush tax cuts for the rich would not work. Senator Edward M. Kennedy, the Senate's most driven leader on healthcare, is in Florida following a seizure related to his brain cancer, and it is unclear when he will return. A major healthcare bill his aides had hoped to have ready early this year is still in progress.

The House, meanwhile, has contributed little to the discussion of a major reconception of the health system. In an interview last weekend, House majority whip James Clyburn said he did not expect to pass a major health-reform bill this year, prompting House Speaker Nancy Pelosi to tell a Capitol Hill newspaper that she expected "a major step" forward.

Those developments are alarming to some advocates of universal healthcare, even though key senators and the administration insist that healthcare remains a priority.

If Congress does not act between the expected approval of a stimulus package in mid-February and the start of campaigning for the midterm elections a year from now, "a rare window of opportunity" will be lost, warned Drew Altman, president of the Kaiser Family Foundation, a leading health policy organization, on the group's website this month.

In that brief span, Congress must consider a vast array of interest groups, and devise a way to fund a plan that could cost more than $100 billion a year.

"Maintaining support through a lengthy national debate may be even more difficult in the modern era where public opinion can be influenced by interest groups waging ad wars on TV, or now on YouTube, much like in political campaigns," Altman wrote.

Senate Finance Committee chairman Max Baucus dismissed such worries yesterday. Baucus, who put out a detailed policy road map in November, and whose aides are working closely with Kennedy staff on a health bill, chuckled at the suggestion that the stimulus bill - which he is also overseeing - might crowd out healthcare.

"It's just so important," he said. "The cost of not doing something on health reform is much greater than the cost of taking on health reform."

Kennedy, in an e-mailed statement, said: "Naysayers always find reasons not to take action. But the American people and American business know that we cannot afford inaction. The president and the Congress know it too. We are moving swiftly and deliberately to pass much needed healthcare reform. The president is committed to it and so am I."

Many healthcare advocates say the outlook for a significant change is still better than it has been in a generation. Business groups are demanding change, and insurers have indicated some willingness to make concessions. Unions and liberal advocacy groups have set aside millions to wage a ground campaign for a bill.

In the Senate, aides to Baucus and Kennedy have been working intensively on laying the groundwork. Obama appointed Tom Daschle, a former Senate majority leader who recently wrote a book on healthcare, as his point man. Obama in his inaugural address dismissed those "who suggest that our system cannot tolerate too many big plans. Their memories are short."

Many healthcare advocates also see the economic stimulus package as a first installment on a healthcare overhaul, since it will spend billions of dollars on technological infrastructure that could support the health system of the future.

Health Care for America Now, a liberal coalition, is urging a quick passage of the stimulus in hopes of creating momentum. Richard Kirsch, the group's director, said he was confident that the president "would [tend to] the short-term economic crisis and then move on to the larger issues affecting our economy."

John Rother, a lobbyist for AARP, said that as long as a bill gets through both houses of Congress by early fall, the effort will be on track.

Still, he said, timing is critical: "The farther away we get from that presidential honeymoon, the more difficult this is going to be politically."

Professional Liability

Local doctors defend care of gun shot victim who blames them for leg amputation

David Yates

Southeast Texas Record

January 28, 2009

Doctors don't have complete control over the body's process of healing, said a local physician during a medical malpractice trial that began this week in Jefferson County.

Dr. Charles Domingues [TMA member], his colleague Dr. Daniel Thompson [TMA member] and the Beaumont Bone & Joint Institute are defendants in a case filed by a man who survived a gun shot wound but blames the doctors' negligence for the subsequent amputation of his leg.

The medical malpractice trial of Jerry Sylvester vs. Christus St. Elizabeth Hospital et al began Wednesday, Jan. 21, in Judge Milton Shuffield's 136th District Court.

The plaintiff and his attorney, Brian Sutton, maintain that Sylvester's treating physicians did not properly clean and treat his gunshot wound, which resulted in the infection that claimed his leg.

Sylvester was shot in the leg on April 14, 2004, and after receiving emergency care at Christus Hospital St. Elizabeth and continued treatment with Drs. Domingues and Thompson at Beaumont Bone & Joint.

He sued the medical facilities and physicians in 2006 for failing to save his leg from amputation. Christus, one of the original defendants, settled out of court in December.

According to his court testimony, Dr. Domingues was the orthopedist on call the night Sylvester was shot. Dr. Domingues was paged to come to Christus, and when he arrived around 2 a.m. he found that Sylvester's wound already been cleaned and bandaged.

Dr. Domingues testified that he inspected the wound and after evaluation, decided blood was still flowing to the leg - making surgery unnecessary.

Although Dr. Domingues testified that he re-cleaned the wound and prescribed antibiotics for Sylvester, the plaintiff's counsel argued that had the doctor properly cleaned the wound, Sylvester would still have his leg.

"There are forces beyond our control," Dr. Domingues testified. "We can facilitate healing, but we cannot command it."

Dr. Domingues also said that even though the bullet shattered a bone in Sylvester's leg, the wound "was stable" and that he "wasn't expecting him to lose his leg, but it was certainly a possibility."

The physicians are defending themselves against 20 acts of alleged general negligence listed in Sylvester's original lawsuit, such as failing to detect his condition and failing to run the appropriate tests.

In court papers, the defendants maintain that the loss of Sylvester's leg "was solely caused by the occurrence in question (the shooting)."

"Defendant(s) possessed no right of control and had no responsibilities … for factors which solely caused the occurrence in question," the defendants' original answer states.

During the next few weeks, defendants Beaumont Bone & Joint, Dr. Domingues and Dr. Thompson will have to convince a Jefferson County jury they did everything in their power to save Sylvester's leg.

The defendants are represented by Marion Kruse Jr. of the Kruse Law Firm in Houston.

Sutton is a partner in the Sutton & Jacobs law firm in Beaumont.

Sylvester is asking jurors to award him money for his mental anguish, impairment and medical expenses.

According to a news report in the Beaumont Enterprise, Sylvester's assailant, Rico Holland, was 19 years old when he shot Sylvester and was also up on chargers for shooting Curtis Everett in the ankle on May 22, 2004, when the two met after a confrontation earlier in the day.

"Holland already had been sentenced … to 20 years for shooting Jerry Sylvester of Beaumont in the leg," the article states. "Sylvester later lost his leg from the knee down."

Neither the suit nor news report state why Holland shot Sylvester.

According to court documents, Holland appealed after he was handed the 20 year sentence, and on Oct. 10, 2006, justices seated on the Texas Ninth District Court of Appeals denied his request for a mistrial.

Public Health

Tarrant County flu pandemic would affect as many as 844,000 people, health official says

ANTHONY SPANGLER

Fort Worth Star-Telegram

January 28, 2009

FORT WORTH — A flu pandemic in Tarrant County would affect as many as 844,000 people, hospitalize nearly 9,000 and cause about 1,800 deaths, according to a worst-case scenario by Tarrant County Public Health.

Dr. Sandra Parker [TMA member], the agency’s medical director, said Tarrant County needs to continue preparing because current antiviral drugs and vaccinations will not stop a flu pandemic.

"You answered your own question unequivocally that we know a pandemic is coming. How do we know this?" Commissioner Roy C. Brooks said.

He and other commissioners asked questions about the $1.5 million spent this year to prepare for a pandemic.

"Because it has happened in the past, and we know it will likely repeat itself," Parker said.

"That’s not evidence," Brooks said.

"No, it isn’t evidence," Parker said. "But we’ve had an outbreak in 1918, 1957 and 1962. To say that we’ve had things in the past and it’s not going to happen again isn’t evidence, either. There is nothing to support that it is not going to happen."

The danger, she said, is that the flu virus continues to change, making it the most likely source of a pandemic outbreak. Since 2003, 107 people worldwide have died of avian flu — considered a possible source of a pandemic — according to health officials.

Responding to a question from Tarrant County Judge Glen Whitley, Parker said technology not available in previous pandemics would help health officials respond faster.

"That’s why it is important that we spend the money now to prepare ourselves for the future," she said.

New Prez, New Studies: New Era for Stem Cells?

Obama Presidency: Some Declare Victory for Embryonic Stem Cell Research; Others Say Battle Has Just Begun

DAN CHILDS/JAY BHATT, DO

ABC News

January 26, 2009

As the dust settles from the U.S. Food and Drug Administration's approval of the first-ever study of a treatment based on human embryonic stem cells, researchers are now assessing what this trial may mean for the years to come in stem cell research -- and how the politics of the past decade may have damaged their progress.

The study, for which California based Geron Corp. won FDA approval on Friday, will examine the potential of an embryonic stem cell treatment in fixing severe spinal cord injuries in humans.

For proponents of stem cell research, the double impact of the first-of-its-kind trial and an administration that appears open to exploiting the potential of embryonic stem cells is a promising sign that progress is finally on its way.

"I am in favor of anything that will bring us closer to a cure for diseases like Alzheimer's and diabetes," said former first lady Nancy Reagan in a statement issued Friday in response to news of the study. Reagan emerged as a prominent supporter of stem cell research after her husband, President Ronald Reagan, passed away in 2004 after a 10-year battle with Alzheimer's disease.

"I am very pleased to hear that human trials of embryonic stem cell therapy will begin soon and am very hopeful that it will be successful so that further trials can move forward," the statement reads.

And where proponents were hopeful, some stem cells researchers were ecstatic. One such researcher is Dr. Robert Lanza of the Institute for Regenerative Medicine at Wake Forest University School of Medicine. Lanza is also chief scientific officer for Advanced Cell Technology, which is planning its own FDA-approved study this summer which would test a technique using embryonic stem cells to prevent blindness.

"This is what we've all been waiting for," Lanza said. "It has been over a decade since embryonic stem cells were first discovered; this sends a message that we're ready at last to start helping people."

Still, others are more cautious in their appraisal. Dr. George Daley, immediate past president of the International Society for Stem Cell Research, paradoxically termed the approval "[a] huge first step, but only a tiny one."

And Lorraine Iacovitti, interim director of the Farber Institute for Neurosciences at Thomas Jefferson University Medical College, said much work remains in order to make up for lost time.

"It will of course require a significant infusion of new federal money into the field to attract back many researchers who were frightened away over the last eight years under President Bush," Iacovitti said. "Despite the difficulties during that period, much progress was made understanding which stem cells work, how they work and in what ways they can be modified to improve their therapeutic potential."

Did Obama Win Influence Approval?

Naomi Kleitman, director of the Extramural Research Program for the National Institutes of Health, told ABC News that Obama's presidential victory had nothing to do with the FDA approval of Geron's trial. But most researchers agree that the presence of the Obama administration is a welcome sign for a field of research that after a decade and a half of political roadblocks is finally beginning to hit its stride.

Embryonic stem cell research has been a field plagued by a dearth of federal funds since the mid-1990s, when President Bill Clinton made the first executive branch move to block federal funding for the creation of embryos for stem cell research. In August 2001, President George W. Bush strengthened the ban on federal funding dramatically by barring federal funds for research on all but a few existing embryonic stem cell lines.

What has traditionally made embryonic stem cells such a hot-button issue is the fact that, in order to obtain them, researchers must destroy human embryos -- a step that some say violates the sanctity of human life.

But Geron's research uses discarded embryos from in-vitro fertilization procedures, which in all likelihood would have been destroyed anyway.

Ruth Macklin, a professor of bioethics at the Albert Einstein College of Medicine, said that the influx of federal funds through the NIH will also come attached with rigorous ethical oversight, as it the case with other federally funded research.

"With a more favorable funding environment -- meaning, specifically, NIH funding -- stem cell research can proceed more expeditiously and more efficiently," Macklin said. "It will be more efficient since there will be no need to engage in elaborate ways to segregate stem cell research from federally funded research within research institutions, as has been the case under the Bush ban."

The Risks of First Steps

But with so much riding on the success of this first step, some wonder if the spinal cord trial puts the best foot forward. Even Lanza's optimism is tempered by the possibility that such a trial will go wrong, an outcome he said would be "a disaster." And Daley noted, "There is some controversy regarding whether spinal cord injury is the appropriate patient population to test the first embryonic stem cell products; some feel only patients with fatal diseases should be treated."

Thoru Pederson, professor of biochemistry and molecular pharmacology at the University of Massachusetts Medical School, countered that "[researchers] have to start clinical evaluation somehow, after all."

But all agree that a setback at this point -- the death of an experimental subject or an unexpected negative side effect -- could do more to hurt the beleaguered field of research than even the eight-year stranglehold on federal funds. Bryon Petersen, associate professor in the department of pathology at the University of Florida, terms the trial a "hail Mary pass" that he feels may be destined for disaster.

"Pushing the envelope of medicine is what we do, but we have to be very cautious," he warned. "There are new therapies waiting to be discovered, but if this trial fails in a big way it will push the field 10 years back."

Trusted Leader

OB/GYN physician joins medical staff

Blanco County News

January 28, 2009

Michael G. Campbell, M.D. [TMA member], has joined the medical staff of Hill Country Memorial Hospital.

Dr. Campbell is a part of Pedernales Medical Group where he is associated with Pamela Cantu, M.D. [TMA member]; Nancy Thompson, M.D. [TMA member]; James Partin, M.D. [TMA member]; and Felicia Howard, M.D. [TMA member]

Dr. Campbell’s specialty is OB/GYN, including post-menopausal management, hysteroscopy, larparoscopic procedures, surgical and non-surgical treatment for urinary incontinence, gynecological evaluation and surgery, and high-risk obstetrics.

Hospital CEO Michael Williams, D.O, M.D. [TMA member], said he is pleased to have Dr. Campbell on the medical staff. “We have a strong history of excellence in OB/GYN, and I’m glad to have someone with our great standards come aboard to expand our capacity for care in this area.”

Dr. Campbell received his medical doctorate from Texas Tech University Health Science Center School of Medicine in 1996, and he received the Special Excellence in Endoscopic Procedures award at the end of his residency in 2000. For the past eight years, Dr. Campbell has practiced obstetrics and gynecology in Decatur, TX. He was a member of the Wise Regional Health System medical staff, where he was chief of gynecologic surgery from 2003 to 2006. He also served on the quality assurance and peer review committees. He is a member of the Texas Medical Association, Texas Association of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists.

Dr. Campbell is married and has four children. He grew up in Floydada, TX, and said he moved to Fredericksburg to enjoy the Texas Hill Country. “We wanted to live somewhere where the people are friendly, hard working and down to earth,” he said. “This is the ideal place for my family to live.”

He is starting out with some long-distance patients. “Many of my patients in Decatur were disappointed I was leaving, and some said they would come all the way down here to see me,” he said.

“I focus on doing less invasive surgeries,” he said. “I also practice preventive care, with an emphasis on lifestyle and keeping people healthy. I offer a full spectrum approach.”