Texas Medical Association News Clips
Thursday, February 28, 2013
By Paula Span
February 28, 2013
The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports, kicked off last spring. It is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.
It took an elegantly simple approach: By working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”
The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest.
Among the 18 new lists released last week are recommendations from geriatricians and palliative care specialists, which may be of particular interest to New Old Age readers. I’ve previously written about a number of these warnings, but it’s helpful to have them in single, strongly worded documents.
The winners — or perhaps, losers?
Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for people with advanced dementia.
“This is not news; the data’s been out for at least 15 years,” said Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five. Feeding tubes don’t prevent aspiration pneumonia or prolong dementia patients’ lives, the research shows, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.
The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.
The other questionable tests and treatments:
No. 3: Prescribing medications to achieve “tight glycemic control” (defined as below 7.5 on the A1c test) in elderly diabetics, who need to control their blood sugar, but not as strictly as younger patients.
No. 4: Turning to sleeping pills as the first choice for older people who suffer from agitation, delirium or insomnia. Xanax, Ativan, Valium, Ambien, Lunesta — “they don’t magically disappear from your body when you wake up in the morning,” Dr. Lee said. They continue to slow reaction times, resulting in falls and auto accidents. Other sleep therapies are preferable.
No. 5: Prescribing antibiotics when tests indicate a urinary tract infection, but the patient has no discomfort or other symptoms. Many older people have bacteria in their bladders but don’t suffer ill effects; repeated use of antibiotics just causes drug resistance, leaving them vulnerable to more dangerous infections. “Treat the patient, not the lab test,” Dr. Lee said.
The palliative care doctors’ Five Things list cautions against delaying palliative care, which can relieve pain and control symptoms even as patients pursue treatments for their diseases.
It also urges discussion about deactivating implantable cardioverter-defibrillators, or ICDs, in patients with irreversible diseases. “Being shocked is like being kicked in the chest by a mule,” said Eric Widera, a palliative care specialist at the San Francisco V.A. Medical Center who served on the American Academy of Hospice and Palliative Medicine working group. “As someone gets close to the end of life, these ICDs can’t prolong life and they cause a lot of pain.”
Turning the devices off — an option many patients don’t realize they have — requires simple computer reprogramming or a magnet, not the surgery that installed them in the first place.
The palliative care doctors also pointed out that patients suffering pain as cancer spreads to their bones get as much relief, the evidence shows, from a single dose of radiation than from 10 daily doses that require travel to hospitals or treatment centers.
Finally, their list warned that topical gels widely used by hospice staffs to control nausea do not work because they aren’t absorbed through the skin. “We have lots of other ways to give anti-nausea drugs,” Dr. Widera said.
You can read all the Five Things lists (more are coming later this year), and the Consumer Reports publications that do a good job of translating them, on the Choosing Wisely Web site.
By Julie Appleby
Feb 28, 2013
This fall, health insurers in a few states will be seeing stars.
Not the celestial kind, but stars that reflect their scores on quality measures designed to help consumers make better-informed decisions about what coverage to buy.
In Oregon, for instance, insurers will get one to four stars depending on their screening rates for breast cancer, flu shot delivery and complaint resolution, among other measures. Maryland is considering ranking insurers on how they deal with chronic illnesses and interact with minority groups. Colorado will rate them based on a federal consumer satisfaction survey.
Those states and a handful of others, among them Minnesota and California, are opting to do the ratings early, before the federal health law requires them to do so in 2016. They’re scrambling now to decide what to measure and how to translate that into something useful to the millions of individuals and small businesses expected to shop for coverage in the new marketplaces beginning in October.
Those plans will take effect next January, when most Americans must carry health insurance. And while all plans offered in the new online markets must be accredited, consumers may have little information about an insurer's track record. The idea behind the ratings is to help them compare plans on more than price tag or benefits.
"The more information, the better," said Laura Etherton, health care policy analyst for US PIRG, an advocacy group. "If you've got a history of breast cancer in your family, you may want to know how well that insurance company did to make sure women between 40 and 69 got a mammogram. If you have a history of heart disease, how is that plan doing at making sure that patients with a heart condition get a cholesterol test?"
In many states, however, consumers will not see much data this fall. That's because the federal health law does not require states to post quality information about participating plans for two years. Federal officials say they intend to provide shoppers in the 26 markets they’re overseeing this year with data from a long-running government survey that tracks patient satisfaction with customer service and access to care.
Proponents say quality ratings were included in the health law not only to help consumers, but also to improve the health system. The idea is that measuring how well insurers, hospitals or physicians follow appropriate treatment guidelines, screen for cancer, save heart attack victims or treat diabetes is the first step toward improving care. The notion is not new: Medicare, for example, rates private insurance plans that offer coverage to seniors, and also uses quality data to rate nursing home, home health agencies and dialysis providers.
Still, skeptics say that progress remains debatable after more than two decades of public reporting of quality measures by private firms and government agencies.
Another problem is that people shopping for insurance say they want quality information, but "people pretty much focus on cost" and whether their doctor is in an insurers’ network, said Betsy Imholz, director of special projects for Consumers Union, which publishes Consumer Reports Magazine. "Many quality rankings show everyone is in the middle, or everyone is above average … so people don’t pay much attention to it."
For the states moving to meet the law’s requirement for quality comparisons ahead of the 2016 deadline, one of the first challenges is deciding what to measure. Hundreds of measures exist and they must be adjusted to account for differences among plans' enrollees. Additionally, many quality measures reflect how well hospitals or physician groups -- not insurers -- perform.
"You can measure customer service … but what that doesn't get down to is the true quality of care that is delivered," said Maribeth Shannon, a policy director at the California HealthCare Foundation, a nonprofit think tank.
Another issue is that little or none of the existing data reflects what consumers will experience in plans sold in the marketplaces because those policies will be new. Many will be offered by existing insurers, however, so states are rating other policies marketed by those insurers. Some insurers who are new to the market may have no track record, raising questions about fairness and how it will affect consumer choices if some plans receive scores and others are unrated.
Finally, the ratings have to be done without overwhelming shoppers with too much information. Consumers "don’t want to have to dig through 400 measures to pick a plan," said Nora Leibowitz, chief of policy, research and evaluation for Cover Oregon, one of the state marketplaces that will launch quality ratings this year.
Oregon Goes For Simplicity
Oregon officials considered more than 2,000 quality measures, paring them down to 13 with the help of a consulting firm. Among other things, the measures consider how an insurer performs on screening for breast cancer and diabetes, vaccinating adults for the flu, providing well-child visits from birth to 15 months and providing needed care "without delay."
Stars will be awarded for how well each insurer scores in three categories: preventive care, complex care and patient experience. Each will also receive an overall score.
"We wanted it to be relatively simple and understandable," said Leibowitz.
In Maryland, officials are still working on their plans, but expect to rate insurers on a five-star scale based on dozens of quality measures already tracked by state regulators. The information will include measures similar to those used by Oregon, as well as a component to track how well insurers improve members’ health with wellness and disease prevention efforts.
The state also plans to make a more detailed report for each plan available for consumers who want to know more, said Tequila Terry, the state marketplace’s director of plan and partner management.
Better Measures Expected In Future
For a variety of reasons, the first-year data provided by the marketplaces will be limited.
"The approach most are taking is to start with the basics," said Dan Mendelson, president of Washington D.C. consulting firm Avalere Health. "So quality will be, 'does the plan answer the telephones and is there a strong procedure for appeals and grievances?' More information can and should come later."
In the future, though, consumer advocates hope to see measures such as how often patients have to seek costly out-of-network care because they cannot find a specialist or treatment in the insurer's network, as well as information about how well they fare medically.
"For consumers, the most important things are outcomes, mortality rates and infection rates," said Bill Kramer, executive director for national health policy with the Pacific Business Group on Health, an employer coalition. "Those are the kinds of things that we need to see more of."
Some of that data is tracked, but isn’t currently in one place.
"The savvy consumer will still have to [go elsewhere to] find information not only about the health plan, but also its contracted networks of doctors and hospitals," said Dr. Bruce Spurlock, executive director of Cynosure Health, a nonprofit consulting firm in California.
It would be better, he said, to have all that information incorporated in the quality ratings offered through the marketplaces. "The marketplaces could drive that agenda, if they get enough size," he said.
The insurer uses its public filings to mark the health plan’s movement toward an integrated care delivery model that relies less on fee for service.
By Pamela Lewis Dolan
Feb. 27, 2013.
As part of what Humana CEO Michael McCallister described as his company’s plans to push an integrated care delivery model “as far and as fast as we can take it,” the insurer said it wanted to satisfy investors by showing its progress in some way.
Starting with its fourth-quarter 2012 earnings report delivered Feb. 4, Humana listed for investors the breakdown of how it pays its 180,000 contracted and employed “primary care providers,” including physicians. In its report, the Louisville, Ky.-based health insurer broke down its primary care population by the number of doctors paid by capitation, those who are paid by capitation but have no downside risk, and those paid by traditional forms of payment, such as fee for service (phx.corporate-ir.net/phoenix.zhtml?c=92913&p=irol-newsArticle&ID=1780772&highlight=).
Regina Nethery, Humana’s vice president of investor relations, said the decision was made to share the data with investors because the company is still fairly new in its efforts to implement an integrated care delivery model that includes putting more members into HMOs.
More employed physicians
The company’s earnings report showed an increase from 900 to 1,600 employed primary care health care professionals, who will be paid by capitation, assuming both upside and downside risks. The increase partially was due to the acquisition of some large-name health professional networks in late 2011 and 2012, including a $500 million deal to acquire Boca Raton, Fla.-based Metropolitan Health Networks in November 2012. Nethery said she expects the buying to continue in 2013.
The number of contracted primary care physicians and other health care professionals in full-risk payment arrangements remained unchanged at 2,900 from 2011 to 2012, according to the report. The number of those “on path to risk,” meaning they are paid by capitation and assume no downside risk but can qualify for bonus payments, rose from 12,000 to 18,200. The remainder were paid through fee for service.
Nethery said the goal is to move more physicians to the highest category of risk.
“What we have talked to investors about is that with the integrated care delivery model, we get the most effective care for the member at the least cost when the provider is in a full-risk arrangement. The provider is fully engaged, given lots of data to help them to ensure the member gets a high-quality experience. And the member satisfaction rates are the highest in those type of arrangements,” she said.
February 28, 2013
Major insurer, Genworth Financial, just announced that it will be raising rates for single female purchasers of long term care insurance by as much as 40% for women, not for men. Their attempt to justify this by the fact that women live longer than men makes my blood boil.
Yes, women do tend to live longer than men. Women also provide the lion’s share of caregiving to those men, their husbands, fathers and grandfathers. Oh, and let’s not forget the long term care they provide free to their mothers and grandmothers too. They give up jobs to stay home and give care to just about everyone in the family if needed. They sacrifice benefit packages and retirement contributions by doing so, cutting careers short.
Fewer than half of workers manage to hang onto their jobs throughout caregiving, according to a Workplace Options/Alzheimer’s Association report. They are quitting their jobs to take care of their parents or other aging loved ones. They are pitching in with their own savings to help loved ones financially. Their loved ones need less paid care. Perhaps they do not have to access any long term care insurance benefits as soon or as much because of this help, mostly provided by women.
Sandwich generation women struggle to finish raising their own kids while keeping their parents safe. They don’t discriminate on the basis of gender. They provide millions of hours every year in unpaid care for loved ones at home and they supplement care provided to their relatives in assisted living facilities.
Their reward? Line the pockets of insurance company executives who can’t imagine making premiums equal for both men and women applicants for long term care insurance because women will live longer. Single women may indeed need care themselves in the future. After age 75, most women are widowed or do not have a partner to care for them. That would be the point of buying the long term care insurance product in the first place. Only two states, Colorado and Montana are equal minded enough to forbid gender discriminatory pricing by insurers. I applaud them. Genworth can’t get away with gender discrimination pricing there. Take heed.
Here is what we need to do about this, folks. Rise up, protest, let your legislator know that you will not accept being punished for helping the men in your life when they need it, only to be overcharged when you need long term care insurance benefits yourself. This is an outrage of the worst kind, committed by one of the largest and formerly respected providers of such insurance. If they get away with this, other insurance carriers are sure to follow.
Under the Affordable Care Act, gender discrimination pricing in health insurance products is banned. Genworth managed to weasel out of inclusion in the ban with its long term care insurance product. It is blatantly unfair to every woman who will be forced to pay more than a man for the same coverage. Please speak up about this.
Any person who cares about equality for women, whether male or female, needs to write a letter, vote appropriately and make sure your representatives in Congress know that whatever loophole let Genworth get away with this needs to be closed now. The same rules that apply to health insurance should apply to long term care insurance in every state.
Now, I’m going to go jogging or jump on my bike to dissipate some of my fury. Then, I’ll write to my own Congressional representatives. Normally progressive CA is not as smart about this as Colorado or Montana. We all need to follow the lead they are showing us to thwart discrimination.
Until next time,
February 27, 2013
Two key Republicans legislators — both of them doctors — say they're sticking with Gov. Rick Perry’s position that Texas will reject the Medicaid expansion provision of federal health reform, despite a rising tide of Republican governors who are embracing it.
During a Texas Tribune TribLive conversation on Wednesday, Rep. John Zerwas, R-Simonton, and Sen. Charles Schwertner, R-Georgetown, both spoke against expanding Medicaid, which they called a “broken system.” But they left the door open to working with the Obama administration if it provides more flexibility to let Texas operate the program as it sees fit.
“We send our money up to Washington and it comes back to us with rules, regulations and golden handcuffs,” Schwertner said. “If we had flexibility, I think we could design a program that’s right for the citizens and right for the providers.”
Eight GOP governors have signed on to the Medicaid expansion, including the governors of New Jersey, Florida and Michigan. Overall, 24 states and the District of Columbia plan to participate.
Zerwas also said that while the governor holds the keys, the Legislature could play a key role in negotiating with the federal government on the feasibility of a Medicaid expansion in Texas.
“It’s the governor’s call, but I think the Legislature should certainly have a voice in this,” Zerwas said. “The Legislature could say, because of the magnitude of this, we should be weighing in on what the budgetary impact of this might be.”
Asked whether the Legislature would consider raising Medicaid reimbursement rates for Texas doctors, so as to avoid more providers leaving the safety net program, neither lawmaker would make a commitment. But they spoke of other ways to improve the state's physician base, including adding new graduate medical education slots for the state's medical students.
"We are looking at increasing GME slots in the state of Texas, graduate medical education slots, residency slots, to address some of the workforce shortages," Schwertner said. "It's important to make sure that we are educating in Texas ... rather than sending them out of state, where they are more likely to stay out of state."
Regarding the budget cuts in the last legislative session to family planning and women’s health care, both lawmakers said they support an initiative this session to restore funding by way of primary care programs.
"We're going to recommend a funding level for [women's health] ... at about 50 percent higher than what they had originally asked for," Zerwas said.
By Matthew Yglesias
Wednesday, Feb. 27, 2013
Arkansas governor Mike Beebe, a Democrat in a state that's become extremely conservative in national politics, struck a deal with the Department of Health and Human Services yesterday that could pave the way for future further Medicaid expansions in red states.
The basic arrangement is that Arkansas will take the federal money on offer to drastically expand its Medicaid program, and use it not to expand Medicaid but instead to offer coverage to low-income Arkansas via the Obamacare exchange process. As David Ramsey writes, this arrangement "would potentially be a windfall for insurance companies, as well as hospitals, who would likely see higher reimbursements from private insurance on the exchange." It also might even be a good deal for low-income Arkansans! Medicaid is helpful to the people who get it, but it's a pretty low-quality program in terms of the benefits. The Arkansas arrangement will likely lead to higher out-of-pocket costs via copays, but a higher standard of care than you'd get under a traditional Medicaid arrangement.
But whether or not this is better policy on the merits than straightforward Medicaid expansion, the political dynamics seem clear enough. The fact that Republicans in deep red states don't want to accept free money to expand Medicaid will naturally leave health care providers in those states looking to Democrats. That coalition dynamic naturally leads Democrats to want to twist the proposal in a more provider-friendly direction. The fact that this entails getting HHS to "concede" something to the state further helps the red state Democrat position himself as in the middle between the local GOP and the Sharia Socialist in the White House.
By Mary Ann Roser
Wednesday, February 27, 2013
UPDATED: New comments from two Republican lawmakers on Wednesday
With more than $200 million a year at stake, the Travis County Commissioners Court is urging the Legislature to expand Medicaid coverage to more needy people in Texas, the state with the highest rate of uninsured residents.
The court spent time Tuesday tweaking the resolution that it passed last week to satisfy its lone Republican member, Gerald Daugherty. It was approved unanimously, 5-0. Austin Interfaith leader Oralia Garza Cortes called the bipartisan support “absolutely critical” and said that sister organizations of the advocacy group in Dallas and Bexar counties helped pass similar resolutions this month.
Austin Interfaith and its allies hope those efforts put pressure on the Legislature to expand Medicaid, a central but now optional part of the federal health care law.
Even so, it could be for nothing. Gov. Rick Perry remains opposed and is expected to veto a bill, should one make it through the Legislature.
“The governor’s position has not changed,” deputy press secretary Lucy Nashed wrote in an email Tuesday afternoon. “It would be irresponsible to add more Texans and dump more taxpayer dollars into an unsustainable system that is broken and already consumes a quarter of our budget.”
Two GOP Texas legislators who are physicians, Rep. John Zerwas of Richmond and Sen. Charles Schwertner of Georgetown, said Wednesday morning they agree with the governor.
“Expanding a broken system is no way to fix it,” said Schwertner, who joined Zerwas at a Texas Tribune-hosted conversation over coffee at the Austin Club.
Schwertner said Texas needs the flexibility to change Medicaid by focusing more on individual responsibility and possibly offering different kinds of coverage to patients in the system. “Some recipients may not need a full package” of benefits, Schwertner said.
Zerwas added that he is concerned about having enough doctors to care for Medicaid patients because of low reimbursements.
Some other lawmakers, however, are pushing for a discussion on the issue because of the federal dollars Texas would pass up, in addition to the ability to cover more of the 23.8 percent of Texas residents who lack health insurance.
“It’s a life and death situation for our families,” Garza Cortes said in an interview. “We know so many people who hold off on medical care because they don’t have insurance, they don’t have the money. … It’s so cost-effective to do this.”
A report last month by consultant Billy Hamilton , former deputy comptroller for Texas, says that over the next 10 years, Texas stands to gain $100 billion in federal Medicaid dollars for making a $15 billion investment to expand. The report estimates how much counties would gain in 2016, the first full year of implementation.
In addition, the report says, the expansion would enable the state to gain 231,000 new jobs by 2016 and boost the state’s economic output by $67.9 billion over the next three years.
Doctors and other medical providers in Travis County alone would gain $275.8 million in 2016 under a “moderate scenario” in which 85 percent of the Medicaid-eligible adults are covered, says the report commissioned by Texas Impact and Methodist Healthcare Ministries of South Texas Inc. The corresponding gains for the surrounding counties are $101.6 million for Williamson, $39.5 million for Hays and $29.7 million for Bastrop, the report says.
“It’s important for our state elected officials to know Medicaid expansion matters at the local level, as evidenced by the action today of the commissioners court,” said Regina Rogoff, CEO of People’s Community Clinic, which provides care to uninsured and underinsured Central Texans.
The federal health care law instructs states to expand Medicaid coverage to adults earning 138 percent of the federal poverty level, or $15,401 for a single person and $31,809 for a family of four. The federal government will pay 100 percent of the expansion costs during the first three years and 90 percent by 2020 and beyond.
Schwertner said he was concerned about binding future legislatures to a vast expansion and questioned whether the federal match of 90 percent would hold up over time.
Hamilton’s report addressed some of the opponents’ concerns.
“Criticism that Texas cannot afford an expansion ignores the fact that Texas state and local governments and hospitals already spend enough on adult health care to more than cover the $15 billion in state match necessary for the ten-year period,” Hamilton’s report says. “In addition, the expansion would generate new state revenue that the state could use for match. Other states have had similar findings that have caused governors who initially opposed the expansion, such as Arizona’s governor, Jan Brewer, to change their minds.”
New Jersey Gov. Chris Christie, a Republican, announced Tuesday he was expanding Medicaid.
The resolution the commissioners approved Tuesday notes that 209,348 Travis County residents were uninsured in 2011 and that the expansion “would hopefully add $224.1 million in annual Medicaid funds to Travis County.” That estimate is based on an analysis by the Center for Public Policy Priorities , an Austin-based policy and research group.
Thursday, February 28, 2013
SAN FRANCISCO — Medicare paid billions in taxpayer dollars to nursing homes nationwide that were not meeting basic requirements to look after their residents, government investigators have found.
The report, released Thursday by the Department of Health and Human Services’ inspector general, said Medicare paid about $5.1 billion for patients to stay in skilled nursing facilities that failed to meet federal quality of care rules in 2009, in some cases resulting in dangerous and neglectful conditions.
One out of every three times patients wound up in nursing homes that year, they landed in facilities that failed to follow basic care requirements laid out by the federal agency that administers Medicare, investigators estimated.
By law, nursing homes need to write up care plans specially tailored for each resident, so doctors, nurses, therapists and all other caregivers are on the same page about how to help residents reach the highest possible levels of physical, mental and psychological well-being.
Not only are residents often going without the crucial help they need, but the government could be spending taxpayer money on facilities that could endanger people’s health, the report concluded. The findings come as concerns about health care quality and cost are garnering heightened attention as the Obama administration implements the nation’s sweeping health care overhaul.
“These findings raise concerns about what Medicare is paying for,” the report said.
Investigators estimate that in one out of five stays, patients’ health problems weren’t addressed in the care plans, falling far short of government directives. For example, one home made no plans to monitor a patient’s use of two anti-psychotic drugs and one depression medication, even though the drugs could have serious side effects.
In other cases, residents got therapy they didn’t need, which the report said was in the nursing homes’ financial interest because they would be reimbursed at a higher rate by Medicare.
In one example, a patient kept getting physical and occupational therapy even though the care plan said all the health goals had been met, the report said.
The Office of Inspector General’s report was based on medical records from 190 patient visits to nursing homes in 42 states that lasted at least three weeks, which investigators said gave them a statistically valid sample of Medicare beneficiaries’ experiences in skilled nursing facilities.
That sample represents about 1.1 million patient visits to nursing homes nationwide in 2009, the most recent year for which data was available, according to the review.
Overall, the review raises questions about whether the system is allowing homes to get paid for poor quality services that may be harming residents, investigators said, and recommended that the Centers for Medicare & Medicaid Services tie payments to homes’ abilities to meet basic care requirements. The report also recommended that the agency strengthen its regulations and ramp up its oversight. The review did not name individual homes, nor did it estimate the number of patients who had been mistreated, but instead looked at the overall number of stays in which problems arose.
In response, the agency agreed that it should consider tying Medicare reimbursements to homes’ provision of good care. CMS also said in written comments that it is reviewing its own regulations to improve enforcement at the homes.
“Medicare has made significant changes to the way we pay providers thanks to the health care law, to reward better quality care,” Medicare spokesman Brian Cook said in a statement to AP. “We are taking steps to make sure these facilities have the resources to improve the quality of their care, and make sure Medicare is paying for the quality of care that beneficiaries are entitled to.”
CMS hires state-level agencies to survey the homes and make sure they are complying with federal law, and can require correction plans, deny payment or end a contract with a home if major deficiencies come to light. The agency also said it would follow up on potential enforcement at the homes featured in the report.
Greg Crist, a Washington-based spokeswoman for the American Health Care Association, which represents the largest share of skilled nursing facilities nationwide, said overall nursing home operators are well regulated and follow federal guidelines but added that he could not fully comment on the report’s conclusions without having had the chance to read it.
“Our members begin every treatment with the individual’s personal health needs at the forefront. This is a hands-on process, involving doctors and even family members in an effort to enhance the health outcome of the patient,” Crist said.
Virginia Fichera, who has relatives in two nursing homes in New York, said she would welcome a greater push for accountability at skilled nursing facilities.
“Once you’re in a nursing home, if things don’t go right, you’re really a prisoner,” said Fichera, a retired professor in Sterling, NY. “As a concerned relative, you just want to know the care is good, and if there are problems, why they are happening and when they’ll be fixed.”
Once residents are ready to go back home or transfer to another facility, federal law also requires that the homes write special plans to make sure patients are safely discharged.
Investigators found the homes didn’t always do what was needed to ensure a smooth transition.
In nearly one-third of cases, facilities also did not provide enough information when the patient moved to another setting, the report found.
By N.C. Aizenman
February 27, 2013
Over the past several months, America’s hospitals have achieved a feat that long seemed beyond reach: substantially reducing the share of patients who must return for treatment almost as soon as they are discharged.
According to statistics compiled by the Obama administration, the nationwide rate of hospital readmissions of Medicare patients within 30 days of discharge declined to about 17.8 percent by last November after remaining stuck near 19 percent over the five years that the data has been collected, and likely for decades prior to that.
Jonathan Blum, a top official at the Centers for Medicare and Medicaid Services, is scheduled to release the figures Thursday at a Senate Finance Committee hearing. In an interview, he argued that the drop — which has already kept tens of thousands of people out of the hospital — is largely the result of provisions in President Obama’s health-care law.
These provisions include new financial penalties that Medicare, the federal health program for the elderly and disabled, has begun imposing on hospitals with high readmission rates. They also include extra funding and incentives for hospitals and outpatient providers to do a better job of coordinating care for patients after they head home.
“What I think is exciting is that a couple years ago the general reaction to these policies was that it was impossible to reduce hospital readmissions,” Blum said. “And what this data shows me is that it is possible. . . . I believe that what we are seeing is a fundamental, structural change.”
The news comes as the growth of health-care spending is slowing at a record pace.
For a variety of reasons, national spending on health care in 2011 grew by less than 4 percent for the third consecutive year. And in 2012, Medicare’s spending per beneficiary rose by only 0.4 percent, compared to an average of 1.9 percent in the preceding three years.
Yet many analysts say that Medicare continues to threaten the country’s long-term fiscal health, primarily because of the aging of the baby boomers. Administration officials hope that reducing unnecessary hospital readmissions will be a powerful, and politically palatable, tool for further curbing Medicare spending.
The data does not pinpoint the reasons for the reduction in the Medicare readmissions rate. But officials stressed that the decline occurred as hospitals began focusing more on readmissions, in part because of a combination of carrots and sticks in the health-care law.
The law, for example, includes a stream of funding for organizations promoting better coordination of patient care, such as 26 “hospital engagement networks” across the country that are working with 3,700 hospitals to identify ways to reduce unnecessary readmissions.
One of the largest such groups, Premier Healthcare Alliance, which has a $24 million two-year contract to serve 450 hospitals, has used the money to hire an army of advisers to come up with specific strategies tailored to each location. So far, the effort has reduced the average readmissions rate from 11.2 percent in 2010 to 10.2 percent by this past September.
Perhaps more significantly, Medicare in October began penalizing 2,217 hospitals under the law for having too many readmissions. More than 300 hospitals were hit with the maximum fine: a 1 percent reduction in their Medicare payments for every patient over the coming year.
Medicare also now links a portion of a hospital’s payments to its performance on quality measures, including some that could affect the readmission rate, such as whether a patient received an antibiotic before surgery.
These payment changes proved a powerful motivator for officials at Ridgeview Medical Center, a 109-bed hospital system in Waconia, Minn.
The hospital created a team dedicated to pushing down its readmission rates almost as soon as the health-care law was adopted in 2010.
“We knew we were at risk [for penalties] and we were trying to stay ahead of the curve,” said Michael Phelps, the hospital’s chief administrative officer.
Among other initiatives, the team created a template that physicians must use to detail patients’ conditions just before discharging them.
This ensures that the outpatient provider who next sees a patient has a clear record on which to base follow-up care.
Ridgeview also now sends paramedics to visit patients at home within 72 hours of their discharges. The paramedics check that the patients are following their medication plans, and look out for health hazards, even ones as minor as carpeting that could cause the patients to trip and fall.
The results have mostly been encouraging. From 2010 to the second quarter of 2012, Ridgeview improved markedly on a measure that considers only readmissions that were “preventable.” Nonetheless, the hospital’s overall rate of readmission for all patients actually went up, to 8.4 percent from 7.6 percent.
And in October, Ridgeview was informed that it will be subject to the readmissions penalty, which is calculated based on the rates over three years from July 2008 through June 2011.
The fine amounts to about $1 per Medicare patient.
Still, hospital officials say they think the fines could have been far more severe had the hospital not launched its program to reduce readmissions.
And they expect to improve their figures.
“I don’t think there’s one golden nugget to really reduce your readmissions rate,” said Sarah Urtel, the executive leading the effort at Ridgeview. “It’s the culmination of a lot of different strategies.”
February 27, 2013
WASHINGTON — Hospitals, doctors and other Medicare providers are on the hook for a 2 percent cut under looming government spending reductions. But they’re not raising a ruckus. Why?
The pain could be a lot worse if President Barack Obama and congressional Republicans actually did reach a sweeping agreement to reduce federal deficits.
Automatic cuts taking effect Friday — the “sequester” in Washington-speak — would reduce Medicare spending by about $100 billion over a decade. But Obama had put on the table $400 billion in health care cuts, mainly from Medicare. And Republicans wanted more.
“What people were really worried about was the prospect of a huge deficit bill that could target Medicare for $400 billion or $500 billion,” said John Rother, president of the National Coalition on Health Care, an umbrella group that includes service providers.
“The health care industry fears the alternative more than they fear a predictable reduction in rates,” said Dan Mendelson, president of Avalere Health, a market analysis firm. “They just do not want to roll the dice. That is why you do not hear as much of an outcry on Medicare.”
The budget machinations come at a time when the threat that the government will be overwhelmed by surging health costs seems less immediate. Taking care of aging baby boomers is still a huge challenge, but health care inflation has slowed dramatically in the last few years, leading government number crunchers to scale back their estimates of future costs.
The nonpartisan Congressional Budget Office has reduced its 10-year projections of Medicare spending by $137 billion, a liability wiped off the ledger without the need to cut reimbursements to hospitals and doctors, or to raise premiums for Medicare’s 50 million beneficiaries.
The health care portion of the automatic spending cuts was designed to try to avoid pain for individuals and families. Medicaid, the health care program for the poor, was exempted, as were the biggest subsidies under Obama’s health care law, which starting next year will help uninsured people pay premiums.
The Medicare cut was intended to fall on providers: hospitals, doctors, health plans, drug companies and others. Once the sequester takes effect, Medicare will reimburse them at 98 cents on the dollar.
Seniors’ benefits and premiums weren’t touched. However, if the cuts go into effect and remain in place, beneficiaries enrolled in Medicare Advantage plans could see higher premiums over time, if private insurers decide to pass on the 2 percent cut.
Hospitals account for the lion’s share of Medicare spending and will have to absorb most of the automatic cuts — about 40 percent of the total. They’re followed by Medicare Advantage plans and doctors.
The American Hospital Association and other industry groups say some jobs will be lost if the automatic cuts are allowed to go through.
The Henry Ford Health System in Detroit started planning last year for a $20-million hit from the sequester. CEO Nancy Schlichting says they were able to minimize layoffs by leaving vacant positions unfilled and streamlining operations to reduce costs. The system, a network of hospitals and clinics that employs 24,000 people, also runs a health insurance plan.
It could have been worse, says Schlichting. Cuts considered during the last federal budget showdown late last year were definitely bigger than the sequester.
Those included changes to billing codes, reductions in special payments to teaching hospitals, and cuts in aid to hospitals that treat many uninsured and low-income patients. When they didn’t happen, the Henry Ford system was left facing the more predictable 2-percent reduction.
“We don’t take any of the cuts lightly,” said Schlichting. “I don’t think we’re protected at this point, even with the sequester.”
Expected Medicare payment cuts have hospitals and doctors worried. Public health and medical research programs may suffer disproportionately more.
By Noam N. Levey
February 27, 2013
WASHINGTON — As the Obama administration begins to implement $85 billion in cuts to federal spending this year, no part of the budget other than defense will take a bigger hit than healthcare.
And the so-called sequester appears likely to have a disproportionate effect on areas of the health system already hobbled by years of retrenchment or underfunding, including public health and medical research.
Although the Medicare program will account for the largest chunk of dollars cut from healthcare simply because of its great size, the scheduled 2% reduction in its payments to doctors and hospitals is significantly smaller than what many public health and research programs face.
Laboratories at major universities and medical centers are already laying off scientists, even before the latest round of cuts is scheduled to take effect. And local public health officials, hit by years of cutbacks, are scaling back immunization campaigns and other efforts to track and control infectious diseases.
"They are doing cuts on top of cuts on top of cuts," said Eric Hoffman, director of the Center for Genetic Medicine Research at Children's National Medical Center in Washington. Hoffman's labs have had to delay several major projects, including new research into muscular dystrophy in children.
Also threatened are new initiatives sparked by public health crises such as mass shootings — which have generated calls for strengthening the nation's mental health system — and outbreaks of food-borne illness.
Compounding the challenges is a lack of direction from Washington. Obama administration health officials have provided little guidance about how they plan to implement many of the cutbacks and when precisely they will hit.
A Health and Human Services Department spokesman said only that the agency would be sending general notifications Friday to those who rely on federal money. More specific instructions will follow. The agency is expected to cut about $15.5 billion from its overall spending, with about two-thirds of that coming from Medicare, which covers the elderly and disabled.
Major medical groups, including the American Medical Assn., the American Hospital Assn. and the American Nurses Assn., have warned that the Medicare cuts will lead to lost jobs. The reimbursement cuts may be particularly difficult for providers with fewer privately insured patients.
"Doctors are very nervous about this," said Gene Ransom, executive director of the Maryland State Medical Society. "It's not like the cost of business has gone down."
But many hospitals and other providers, such as Adventist Health System's Florida Hospital in Orlando, had already planned for these cuts. "We assumed at the beginning of the budget cycle that this would occur," Adventist Vice President Rich Morrison said.
Ironically, what worries some medical leaders more is the possibility that Congress and the White House could reach a larger deal to avert the sequester. Any such deal might involve steeper cuts in Medicare or reductions in Medicaid, which was exempted from the sequester.
For now, the budget ax will fall most heavily on programs that already have been battered by years of government cutbacks.
Nationwide, as many as 46,000 public health jobs have been eliminated in the last five years, the Assn. of State and Territorial Health Officials and the National Assn. of County and City Health Officials estimate.
Now, the federal Centers for Disease Control and Prevention plans to cut more. Health and Human Services Secretary Kathleen Sebelius told Congress this month that the CDC cuts could result in 424,000 fewer HIV tests by state and local health programs the agency funds. Of the agency's $6-billion budget, 70% goes as grants to state and local health efforts.
"These cuts are going to have a real impact," said Washington state Health Secretary Mary C. Selecky, whose department has seen a 38% cut in state funding over the last six years. "In the next six to eight weeks, we're going to have to say we're closed on Fridays or we can't provide this or that service anymore."
Anxieties also run high among researchers who rely on grants from the National Institutes of Health. NIH Director Francis Collins told reporters this week that his agency was looking at losing $1.6 billion by the end of the year. That comes after a decade of flat budgets.
"It is so frustrating," said Heidi Hamm, chair of pharmacology at Vanderbilt University in Nashville. NIH cuts will probably force her to lay off one of the eight researchers in her lab working to develop drugs to prevent the blood clots responsible for heart attacks, she said.
"There has never been a time when scientific breakthroughs are more possible," Hamm said. "But there has been a steady erosion in what we can do."
By Jay Hancock
February 28th, 2013
How much will hospitals reduce prices in an effort to win what are expected to be millions of newly insured patients under the Affordable Care Act? A little, not a lot, if deals disclosed this week by Tenet Healthcare are any indication.
The Dallas-based hospital chain told analysts that its first contracts to treat patients buying policies in the ACA’s online marketplaces next year include total discounts of less than 10 percent compared with existing business. The agreements were made with three Blues plans in undisclosed locations.
“At an investor conference in January, there was some talk about the possibility of deeper discounts in pricing — at [low] Medicare and Medicaid levels,” Tenet CEO Trevor Fetter told stock analysts on a Tuesday conference call. ”Our recent negotiations should reassure you that this is not the case and that this market is turning out as expected.”
What insurers pay for hospital care will be a key factor in the affordability of plans for people seeking coverage in the ACA marketplaces, also known as exchanges. With the health act’s requirement that everyone obtain insurance, exchanges are projected to furnish coverage for 24 million by 2016. But even with generous subsidies for those on lower incomes, questions loom about whether those lacking coverage will feel they can afford the plans on the exchanges or will choose to pay relatively low penalties for remaining uninsured.
Insurer-hospital contracts are rarely made public. Tenet disclosed only outlines of the Blues contracts, and only for three deals. Still, those details suggest that insurers can’t cut that deep a bargain even by promising patient volume in return for discounts at select hospitals. Many have expected insurers to fight hospital consolidation and pricing power by steering patients into “narrow” provider networks with attractive prices, including in the exchanges. One of the Blues/Tenet deals involves a narrow network; the others are tiered networks, a variation on the same theme.
For Tenet shareholders and hospitals generally, Tenet’s ability to land what’s likely to be substantial Blues exchange business with moderate price concessions seems like good news, even for an industry accustomed to raising prices for private payers, not lowering them.
“We believe the movement to exchanges will eventually lead to a more price-competitive environment” for hospitals, Leerink Swann analyst Jason Gurda and colleagues wrote in a report to clients. ”However, we expect the pace of change to be slow and we see little risk to aggregate commercial [hospital] rates over the next few years.”
Consumers who will pay hospitals’ prices via their exchange plans, on the other hand, might be wishing that the Blues had had a sharper pencil.
By Mary Agnes Carey
Feb 27, 2013
While physicians have sidestepped drastic Medicare payment cuts for 2013, doctors’ groups and lawmakers are gearing up for yet another battle to scrap the formula that forces Congress to consider the “doc fix” on a yearly basis.
For doctors, the nail-biter has become a familiar but frustrating rite. Lawmakers invariably defer the cuts prescribed by a 1997 reimbursement formula, which everyone agrees is broken beyond repair. But the deferrals are always temporary due to the difficulty of finding offsetting cuts to pay for a permanent fix. In 2010, Congress delayed scheduled cuts five times, with the longest patch lasting one year.
While Democratic and Republican leaders say they do not want Medicare physicians' payments to be cut, there is often disagreement about how to offset the costs of a fix. But proponents of a change were buoyed by the recent report from the Congressional Budget Office showing the price tag is now lower than past estimates due to slower growth in Medicare costs over recent years. “Cutting scores in half is certainly helpful,” House Ways and Means Chairman Dave Camp told reporters in late February, noting, “that’s still a very large number.”
Two House initiatives to get rid of the payment formula have been announced already in this Congress: a plan unveiled by key GOP committee leaders and, separately, a bill offered by a Democrat and a Republican. “For far too long, the only thing certain about the Medicare physician payment system has been uncertainty about the future,” House Energy and Commerce Chairman Fred Upton and Ways and Health Subcommittee Chairman Joe Pitts wrote in a statement about the Republicans’ efforts. “As a result, the complexity of the problem and financial burden on taxpayers has snowballed.”
Here are some answers to frequently-asked questions about the doc fix.
Q: How did this become an issue?
Today's problem is a result of yesterday's efforts to control federal spending – a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula based on economic growth and known as the "sustainable growth rate" (SGR). For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases. But in 2002, doctors reacted with fury when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size – and price tag – of the fix needed the next time.
The formula also reinforces what many experts say are some of the worst aspects of the current fee-for-service system – rewarding doctors for providing more tests, more procedures and more visits, rather than for better, more effective care. In an Oct. 14, 2011, letter to lawmakers, the Medicare Payment Advisory Commission (MedPAC), which advises lawmakers on Medicare payments, called the formula "fundamentally flawed" and said it "has failed to restrain volume growth and, in fact, may have exacerbated it."
Q. Why don't lawmakers simply eliminate the formula?
Money is the biggest problem. While a Feb. 5 Congressional Budget Office estimate lowered the cost of the doc fix over the next decade to $138 billion due to lower Medicare spending on physician services over the last three years, that’s still a lot of money, and so far Congress can’t agree on where to find that kind of cash. Last January CBO estimated the cost of the doc fix at $316 billion, which it reduced to $245 billion last August.
For physicians, the prospect of facing big payment cuts is a source of mounting frustration. Some say the uncertainty has led them to quit the program, while others are threatening to do so. Still, defections have not been significant to date, according to MedPAC. In a March 2012 report the panel stated that while beneficiaries’ access to care was good, for some “finding a new primary care physician continues to be more difficult than finding a new specialist.”
Physician groups continue to lobby Congress to repeal the SGR and to enact a permanent payment fix. The deal Congress passed Jan. 1 to avoid the fiscal cliff by raising some taxes and putting off automatic budget cuts also stopped a 26.5 percent doctor pay cut but did not raise the level of Medicare reimbursement to physicians.
Q: What do experts recommend?
In October, 2011, MedPAC recommended eliminating the formula without increasing the deficit by cutting fees for specialists and imposing a 10-year freeze on rates for primary care physicians. That proposal was strongly opposed by health industry groups, as well as the American Medical Association (AMA).
The AMA has recommended a five-year transition fee scale that allows time to test new payment approaches, including several being tested as part of the 2010 health care law.
Other options to fix the reimbursement formula include a bill introduced Feb. 5 by Rep. Allyson Schwartz, D-Pa., and Rep. Joe Heck, R-Nev., an osteopathic physician. Among its provisions, the measure would repeal the SGR, increase payments to physicians for four years and test new payment and delivery models.
Some key House Republicans also have a plan as well. The chairmen of the Energy and Commerce and the Ways and Means committees, as well as subcommittee leaders, unveiled an SGR repeal plan that would freeze physician payment rates at their current levels for the next 10 years with future increased based individual physicians’ quality of care and efficiency. The have promised any fix “will not add a dime to the deficit.” They are seeking comments on the proposal.
Q: What happens next?
The current fix expires on Dec. 31, but a permanent fix would likely have to be melded into larger financial reforms.
Meanwhile, doctors could still face a more moderate Medicare pay cut this year. A series of automatic cuts in federal spending, called sequestration, was put off for two months by the Congress with the Jan. 1 vote. Those cuts include a 2 percent reduction to physicians and other Medicare providers – including hospitals.
Carol Eisenberg and Lexie Verdon contributed to this report.
This article was produced by Kaiser Health News with support from The SCAN Foundation.
By Mary Agnes Carey
February 27th, 2013
The chairman of the House Ways and Means Committee made clear Tuesday that finding a solution to the vexing issue of setting Medicare physician payment rates is on his to-do list this year, and he got some tepid support from a key Democrat.
Rep. Dave Camp, R-Mich., said that the effort could be helped by a recent reassessment of how much it would cost. Earlier this month, the Congressional Budget Office lowered its cost estimate for fixing Medicare’s physician payment formula over the next decade to $138 billion due to lower Medicare spending on physician services during the past three years. In January 2012, the CBO estimated the cost of the fix at $316 billion, which it reduced to $245 billion last August.
“Cutting scores in half is certainly helpful,” the committee chairman told reporters Tuesday, adding later, “that’s still a very large number.” It may be even harder to find funding amid the ongoing fight over “sequestration,” a package of automatic spending cuts set to kick in March 1. President Barack Obama and lawmakers are also battling over how to fund the government after the current continuing resolution expires on March 27.
Camp did not say where he would find the money to pay for the SGR overhaul, but he has promised it “will not add a dime to the deficit.” He said he is working on the proposal with a fellow Michigan Republican — House Energy and Commerce Committee Chairman Fred Upton. It might be part of a larger piece of legislation or it might move on its own.
“It’s hard to know right now,” he said. “I wouldn’t close off any avenue on that.” Camp said the SGR legislation is part of a broader committee agenda to examine safety net programs. The yearly “doc fix” dilemma stems from a 1997 deficit reduction law that called for setting Medicare physician payment rates through a formula known as the “sustainable growth rate” (SGR), based on economic growth. For the first few years, Medicare expenditures did not exceed the target and doctors received modest pay increases.
But in 2002, doctors reacted with fury when they came in for a 4.8 percent pay cut. Every year since, Congress has staved off scheduled cuts. But each deferral just increased the size – and price tag – of the fix needed the next time.
Camp and Upton, along with their panels’ respective health subcommittee chairs, have unveiled an SGR repeal plan that would freeze physician payment rates at their current levels for the next 10 years, with future increases based on individual physicians’ quality of care and efficiency.
Camp said Tuesday he has not discussed the draft with either the White House or the Centers for Medicare and Medicaid Services.
Rep. Jim McDermott of Washington, the ranking Democrat on the Ways and Means health subcommittee, said the GOP outline “leaves plenty of room for agreement if people want to find it.” But he warned that making beneficiaries finance the fix wouldn’t fly.
“If done smartly, this issue could reshape our entire health economy for the better, but costs just can’t be hoisted onto the backs of beneficiaries,” he said. “There are better options, with strong policy justifications, to pay for the needed SGR policy changes.”
Bipartisan groups of lawmakers have proposed fixing the SGR formula in the past, but have been unable to agree on how to pay for it.
February 27, 2013
After vocal GOP opposition to President Barack Obama's health care overhaul, three prominent Republican governors recently signed-on to one key element of the law. NPR Political Junkie Ken Rudin and NPR health policy correspondent Julie Rovner explain on the shifting politics of health care.
NEAL CONAN, HOST:
And now it's a supersize edition of the Political Junkie. Ken Rudin, of course, is staying with us. John Kasich, Rick Scott, now, Chris Christie - three high-profile Republican governors and outspoken critics of Obamacare - have all decided to accept federal money to expand Medicaid coverage. The governor of New Jersey explained his reasoning yesterday.
(SOUNDBITE OF SPEECH)
GOVERNOR CHRIS CHRISTIE: I am no fan of the Affordable Care Act. I think it's wrong for New Jersey and I think it's wrong for America. I fought against it and believe, in the long run, it will not achieve what it promises. However, it is now the law of the land. And I will make all my judgments as governor based on what I believe is best for New Jersey.
CONAN: Joining us now to talk about the changing politics of health care is NPR health policy correspondent, Julie Rovner. She's with us here in Studio 3A. Always delighted to have you with us.
JULIE ROVNER, BYLINE: Always a delight to be here.
CONAN: And as heard from Governor Christie there, this was hardly a conversion on the road to Damascus.
ROVNER: Exactly. We seem to be hearing the same theme from a lot of these governors that are doing this. We still hate this law. We still think it won't work. But we think we're going to take the money, anyway.
CONAN: And how big a deal is it? These are three pretty high-profile anti-Obamacare campaigners.
ROVNER: That's right. They are. But you know what? There was a prediction last year when the Supreme Court made the expansion of Medicaid optional, that eventually, most of the Republicans would do this. And the reasoning is fairly simple - and actually, Chris Christie said this yesterday in his speech to the legislature - which is that if he didn't take this money, it's going to be New Jersey taxpayer money that's going to go to people in other states. And that's pretty much what Rick Scott said. That's what Governor Snyder said in Michigan.
The way it works, the way that this Medicaid money works is that, right now, hospitals get money - hospitals who serve a large number of uninsured people, and there, obviously, are a large number of uninsured people - get payments that are called disproportionate share payments. That means they serve a disproportionate share of people who don't have insurance. Those payments are going away under the law, because the law assumed that there wouldn't be that many more uninsured people, because there was going to be this big expansion of Medicaid.
So if your state doesn't expand Medicaid, there's this double-whammy. Your hospitals don't get this extra money anymore, and that...
CONAN: The disproportionate share money.
ROVNER: The disproportionate share money. And if your state doesn't expand Medicaid, you don't get this extra money from the federal government to cover them. Therefore, your hospitals are now in deep financial trouble. So in all of these states, the hospitals have been coming to the Republican governors, saying, hey. It's money coming from Washington.
CONAN: It's free money.
ROVNER: It's free money. At least for the first three years, it's free money. It's 100 percent for the first three years. It phases down, but it only phases down to 90 percent. You really should take it. And I think that's what's driving a lot of these governors to take it.
KEN RUDIN, BYLINE: Julie, a lot of the political commentaries have been about the fact that they switched positions and they're flip-floppers. But we also heard - we heard Chris - Governor Christie saying that we don't want the other states to get the money that we'd ordinarily would get. But also, Chris Christie is up for re-election this year. John Kasich, Rick Scott, Rick Snyder of Michigan, John Kasich, they're all up next year. These are not unpopular decisions to take regarding the voters back home, right?
ROVNER: That's right. And in not every case was this a flip-flop. Certainly, in Rick Scott's case, this was a flip-flop. He, of course, ran for governor in the first place in 2010 saying that, you know, Obamacare is an abomination. He was - you know, his state led the charge against it. But Chris Christie had actually never said whether or not he was going to take the Medicaid money. And as he - as we heard in the clip, he's still no fan of the law. So some of these governors, they had just sort of bided their time. Some of them did say, initially, right after the Supreme Court decision last summer, that they weren't going to do it. And now they're changing their tune. But some of them have just been sort of holding out, waiting to see what would happen.
RUDIN: But aside from not being invited to CPAC, I mean, what risk is it for these Republican governors?
ROVNER: Well, it is a risk. I mean, already, Rick Scott is getting sort of hit from the right. Pam Bondi, who's the attorney general who had taken on the case against the health law, is now, you know, sort of saying that Scott has, you know, gone over to the other side. But again...
CONAN: A traitor to the cause.
ROVNER: Yes, a traitor to the cause, I believe, was the phrase that was used. So there are those on the right who were going to say that, you know, how dare they do this? On the other hand, remember, they have to run for office. The health care lobby, if you will, is a place where Republicans do tend to get a fair bit of money, so it's not insignificant. They're being pressed from both sides. One would expect that they would tend to go with a lot of these major hospitals in their states who are, you know, who will be filling their campaign coffers at some point.
CONAN: And the law was designed that way to attract people who might not otherwise have gone for this. But are there going to be governors who will hold out and say no, we're not going to take the money?
ROVNER: I expect there will be. I mean, one of them is Rick Perry in Texas who, you know, who has said over and over again that, you know, he does not want any part of this, and there will not be any part of this law, you know, enforced in his state. Texas, obviously, has the largest number of - largest number and largest percentage - it's not just because it's a big state - of uninsured people in the country. And Rick Perry has been one of those people who said, you know, I will have no part of it.
Now, what's interesting to watch about that is Texas, particularly down in Houston, has an enormous hospital research complex that will, you know, certainly come to bear some significant pressure on the state government, and we will see how that goes. But I will be very surprised to see Governor Perry sign on to this. I imagine he'll be the last one.
But in a lot of other states, we're still watching. It is budget season, so this is when one would expect to see these governors make these decisions. There's no particular deadline, so they don't have to decide, you know, right away. But it's not a surprise that we're seeing these in these couple of weeks.
CONAN: And there seems to be some flexibility. I wanted to ask you about the governor of another deep red state, and that's Mike Beebe of Arkansas, who proposed an interesting swap.
ROVNER: That's right. There is some flexibility. The Health and Human Services secretary - the U.S. Health and Human Services Secretary, Kathleen Sebelius, has been meeting with the governors. In fact, she was at the governors' meeting over the weekend here in Washington. She did not appear publicly, but she was apparently ensconced up in a conference room, meeting individually with governors to see what it would take to get them to sign on.
And, you know, what these Republican governors say is that Medicaid is a flawed program. It doesn't work very well. They would like to change the way it works. Now, they - a lot of the way they would like to change it is perhaps to have people pay a little bit more for their coverage, which is difficult when you're talking about the poorest of the poor, who don't have a lot of money. But these governors would at least like to change some incentives, bring the private sector into it more. There are things that can be worked out. In fact, Rick Scott in Florida announced he would be doing this just hours after he got a waiver from the federal government to put more people who get Medicaid into managed care. This is apparently what's going also in Arkansas.
So there are deals that can and are being worked out with the federal government. It is kind of you give us this, we'll give us that, you know, we'll take that. And I am hearing that, I heard that over the weekend from several Republican governors I was talking to. You know, they're holding out. Maybe we'll sign on if you let us have a little more flexibility.
CONAN: And it's interesting - after that Supreme Court decision last year, there were grave concerns - states given the choices, a lot of governors, as you said, said we're not going to take it - that a lot of people who were designed to be covered under this were not going to be covered. It's now looking like most of them probably will.
ROVNER: Well, I don't know whether I would say most of them yet. Yet there are 30 Republican governors, and so far eight have signed on. Certainly we're getting some of the big states now: Michigan, New Jersey, Florida. So some of the concern about, you know, many people not having coverage have gone away.
Now, the administration did say, and this was significant because a lot of governors were saying maybe we could just cover some people, perhaps up to 100 percent of poverty, and let the rest of the people, those low income people, go into these health care marketplaces, the exchanges. And those people would then be covered under the federal - it was going to be quite confusing. And the HHS came out in December and said no, that's not going to work. It's going to be all or nothing. You either take everybody or you take nobody. And that sort of made some of these governors unhappy.
But as you mentioned and as I mentioned, they're still coming back and trying to find ways to negotiate. Maybe they could, you know, redo their Medicaid programs just a little bit. Maybe that would be okay with the federal government. But the bottom line is these are still people with very low incomes, so there's a limit to how much they can be expected to kick in for their health care coverage.
CONAN: You mentioned those exchanges. States also got to choose. Under the law - this wasn't the Supreme Court, but under the law, whether to set up an exchange of their own or let the federal government do it for them, and a lot of people thought initially Republican governors would want to set up those exchanges themselves, keep it local.
ROVNER: That's right. And a vast majority of them didn't. In the end, most of the governors decided, hey, we're going to let the federal government go ahead and do this. Now, what's turned out is that the federal government has said if we come in and build your exchange and run it, you can take it over whenever you want. And that turned out to be kind of attractive to a lot of the governors. It's like, great. You build it. You set it up, and if we like it, then we can pick it up later.
There is a lingering concern that perhaps there won't be enough money for the federal government to go out and promote it and, you know, get people to sign up. And then perhaps some of those people may end up not with private insurance but a lot of those people will end up on Medicaid and that could end up costing the state some more money. So there are - this is not perfect, and there's still a lot of things to be worried about. And the federal government's going to end up running, you know, 30-some exchanges rather than the, you know, perhaps eight or nine that was anticipated when the law passed.
CONAN: And it's interesting as we go through this, next year, just next year, the vast bulk of this law takes effect.
ROVNER: Yes. It's not really even just next year. October 1 is when enrollment starts, so we're really months away from this really beginning.
CONAN: And let me switch to a related but different topic. A fascinating piece today in the New York Times that said we're all talking about the sequester and the - well, maybe we can make a grand bargain where the Republicans might agree to just some tax loopholes, and Democrats, under the president's old plan, from, what, 11 months ago, would've been willing to make some cuts on entitlement programs like Medicare, maybe raise the age of eligibility. It turns out that Medicare is costing less than people projected it to cost. And now the seams of this deal are unraveling.
ROVNER: That's right. This is one of the - who ever would have thought that Medicare - that health care costs, if not going down, at least health care inflation slowing, would mess things up in terms of making a deal on entitlements? But that is exactly what's happening. Nobody is quite sure why health care spending is slowing, and I will not say going down. And be careful when you read these things. Health care costs are definitely not going down. But health care inflation is definitely slowing. It has been for the past several years, both public and private. So we were seeing it in Medicare. We're seeing it in the private sector.
Some people - the administration would like to say it's thanks for the Affordable Care Act.
CONAN: Take the credit.
ROVNER: That's right. It seems to be more than that. It seems to be - a good deal of it is certainly due to the recession. People lost their jobs, they lost their insurance, they stopped getting care. But even as the economy rebounds, we're still seeing this persistent slowdown. And it's - we're not quite sure why.
CONAN: And significant.
ROVNER: It is significant. We did see it a little bit during back after the Clinton health plan died. We saw sort of a temporary lull in health care spending and then health care inflation came back with a vengeance. So it does tend to ebb and flow and you can see it over the years. But this is a rather significant slowdown and it's kind of a good time while we, you know, sort of try to get our act together as a nation, as a society figuring out what to do. But yeah, it is kind of making a mess, trying to get this grand bargain.
CONAN: We're talking with NPR health policy correspondent Julie Rovner. Of course Political Junkie Ken Rudin is with us as he is every Wednesday. You're listening to TALK OF THE NATION from NPR News.
And just explain to me how this logic works. So the increase in health care spending is going down a little bit. Democrats start saying wait a minute, we don't have to give money back on this. We've already saved that money, so we don't have to - we're not going to go along with further cuts in Medicare.
ROVNER: That's right. And also when you make a cut, it's worthless because it's going up - if the trajectory is smaller when you do something, you get less bang for you buck because the baseline is now smaller. So if you take - it used to be if you would make this policy change, you would get X amount of dollars for it.
CONAN: You'll reap X amount of dollars.
ROVNER: Right. If you would reap $1,000 for making this policy change, well, now that things are going up slower, you'd only reap half of that. And so it's not nearly as, you know, worth doing as far- if it's going to be something painful, if the policy is going to be something painful, why should you do it if you only get half as much money?
CONAN: Let's see if we can get a caller around the conversation. Let's go to Jerry, and Jerry is with us from O'Fallon, Missouri.
JERRY: Yes. Good afternoon.
JERRY: I live in a state where we have Democratic governor, Jay Nixon. But we also now have a veto-approved majority in both the statehouse and in the Senate. And they are going forward with implementing, so far as setting the budget, et cetera, without taking the - expanding Medicaid. And what's really sad to me is the fact that really it will lower health costs in the long run or probably in a not-very-long run because there are people - a lot of people here, especially in rural areas, that will not have access to diagnostic care that could prevent a much more serious illness that we, the public, will wind up paying for.
And of course there will probably be people that will, you know, die unnecessarily because of this. And what I find interesting is, I had a friend recently deceased who was a doctor in a rural area. And he did not - probably 80 percent of his patients were on Medicaid or Medicare. And he said there is not a single one of them, if the conversation veered into politics, was going to vote for any Democratic office holder or candidate. So it seems just a little - it's also kind of sad.
CONAN: An insight into politics, and again, another deeply red state now, Arkansas, even though they have a Democratic governor, as he mentioned, that veto-approved majority in both houses of the legislature.
ROVNER: Yeah. You know, it's important to remember when we talked about these governors saying they're going to do this or that, that most of these decisions also have to go through state legislatures. Obviously Missouri, an example where there is a Democratic governor, but Republican legislature in a lot of cases. You know, yesterday with Chris Christie, when he announced that he was going to expand Medicaid, he got a standing ovation because it's a largely Democratic legislature. So in a lot of these states, you've got a governor of one party, legislature of the other. So these things are not necessarily done deals when the governor says, you know, he or she wants to do something. They do have to go through the full legislative process in most cases.
CONAN: Jerry, thanks very much for the call.
JERRY: Thank you.
CONAN: And if that situation pertains, what happens to Missouri's share of this Medicaid money if they refuse to accept it?
ROVNER: It will — as Governor Christie pointed out, what would've happened...
CONAN: Some small portion of it will go to New Jersey.
ROVNER: Some small portion of it will go to New Jersey. That's, in fact, I believe Missouri is a state where the voters passed - I guess it was the legislature passed a law that forbade them from setting up their own exchange. The governor wanted to set up an exchange and there's now a law that says he can't.
CONAN: It's so interesting that - as we say, these are not fans of the Affordable Health Care Act. Yet there is grudging acceptance. This is the law. It's going to happen. We'd better get in line with it.
ROVNER: I was amazed this weekend talking to governors how many of them, and these were - these are very, very conservative governors who said, you know, I talked to Butch Otter from Idaho, and he said, you know, we tried to fight it in court. We tried to get a new president. We tried to get a new Senate. It failed. And you know what, at some point there is a rule of law. This is the law. We got to deal with it the way it is.
CONAN: Julie Rovner, thank you very much for your time today. Really interesting. The shifting politics of health care. Ken, nice to see you. I will not be here next week.
RUDIN: No. You're voting - you're going to be at the Vatican voting for the pope.
CONAN: Exactly. That conclave is in a couple of weeks. I'll be on vacation in Hawaii. So I'm looking forward to that.
RUDIN: Unfortunately by car.
CONAN: Yeah, exactly. Long drive. In the meantime, Ken Rudin will be back with another edition of the Political Junkie next week. I will return in two week's time. Tomorrow, as the civil trial continues over how much BP may have to pay for the 2010 Gulf oil blowout, we'll get an update on the recovery along the Gulf Coast. We hope you'll join us for that conversation. It's the TALK OF THE NATION from NPR News. I'm Neal Conan in Washington.
By Eduardo Porter
February 26, 2013
What’s the rush? For all the white-knuckled wrangling over spending cuts set to start on Friday, the fundamental partisan argument over how to fix the government’s finances is not about the immediate future. It is about the much longer term: how will the nation pay for the care of older Americans as the vast baby boom generation retires? Will the government keep Medicare spending in check by asking older Americans to shoulder more costs? Should we raise taxes instead?
It might not be a good idea to try to resolve these questions quite so urgently. Partisan bickering under the threat of automatic budget cuts is unlikely to produce a calm, thoughtful deal.
“We don’t have to solve this tomorrow; not even next year,” said Jonathan Gruber, an economist at the Massachusetts Institute of Technology who worked on the design of President Obama’s health care reform.
More significantly perhaps, some economists point out that the problem may already be on the way toward largely fixing itself. The budget-busting rise in health care costs, it seems, is finally losing speed. While it would be foolhardy to assume that this alone will stabilize government’s finances, the slowdown offers hope that the challenge may not be as daunting as the frenzied declarations from Washington make it seem.
The growth of the nation’s spending slowed sharply over the last four years. This year, it is expected to increase only 3.8 percent, according to the Centers for Medicare and Medicaid Services, the slowest pace in four decades and slower than the rate of nominal economic growth.
Medicare spending is growing faster — stretched by baby boomers stepping out of the work force and into retirement. But its pace has slowed markedly, too. Earlier this month, the Congressional Budget Office said that by 2020 Medicare spending would be $126 billion less than it predicted three years ago. Spending over the coming decade, it added, would be $143 billion less than it forecast just last August.
While economists acknowledge that the recession accounts for part of the decline, depressing incomes and consumption, something else also seems to be going on: insurers, doctors, hospitals and other providers are experimenting with new, cheaper and more efficient ways to deliver care.
Prodded by President Obama’s Affordable Care Act, which offers providers a share of savings reaped by Medicare from any efficiency gains, many doctors are dropping the costly practice of charging a fee for each service regardless of its contribution to patients’ health. Doctors are joining hundreds of so-called Accountable Care Organizations, which are paid to maintain patients in good health and are thus encouraged to seek the most effective treatments at the lowest possible cost.
This has kindled hope among some scholars that Medicare could achieve the needed savings just by cleaning out the health care system’s waste.
Elliott Fisher, who directs Dartmouth’s Atlas of Health Care, which tracks disparities in medical practices and outcomes across the country, pointed out that Medicare spending per person varies widely regardless of quality — from $7,734 a year in Minneapolis to $11,646 in Chicago — even after correcting for the different age, sex and race profiles of their populations.
He noted that if hospital stays by Medicare enrollees across the country fell to the length prevailing in Oregon and Washington, hospital use — one of the biggest drivers of costs — would fall by almost a third.
“Twenty to 30 percent of Medicare spending is pure waste,” Dr. Fisher argues. “The challenge of getting those savings is nontrivial. But those kinds of savings are not out of the question.”
We could be disappointed, of course. Similar breakthroughs before have quickly fizzled. Just think back to that brief spell in the mid-1990s when health maintenance organizations seemed to beat health care inflation — until patients rebelled against being denied services and doctors dropped out of their networks rather than accept lower fees.
The Centers for Medicare and Medicaid Services already expects spending to rebound in coming years. Without tougher cost control devices, be it vouchers to limit government spending or direct government rationing, counting on savings of the scale needed to overcome the expected increase in Medicare rolls may be hoping for pie in the sky.
“It makes no sense,” said Eugene Steuerle, an economist at the Urban Institute, to expect the government will reap vast Medicare savings without having an impact on the quality of care.
The Affordable Care Act already contemplates fairly big cuts to Medicare. In its latest long-term projections published last year, the Congressional Budget Office estimated that under current law, growth in spending per beneficiary over the coming decade would be about half a percentage point slower than the rate of economic growth per person.
To understand how ambitious this is, consider that Medicare spending per beneficiary since 1985 has exceeded the growth of gross domestic product per person by about 1.5 percentage points per year. Slowing down that spending would require deep cuts in doctor reimbursements that, though written into law, Congress has never allowed to happen — repeatedly voting to cancel or postpone them.
Under a more realistic situation, the Budget Office projected that the growth of Medicare spending per capita over the next 10 years would be in fact 0.6 percentage points higher than under current law and accelerate further after that.
Yet despite the ambition of these targets, they would not be enough to stabilize future Medicare spending as a share of the economy. A report by three health care policy experts, Michael Chernew and Richard Frank of Harvard Medical School, together with Stephen Parente of the University of Minnesota, concluded that to do that would require limiting the growth of spending per beneficiary at 1.25 percentage points less than the growth of our gross domestic product per person.
“The Affordable Care Act places Medicare spending on a trajectory that is historically low,” Mr. Chernew said, noting his opinion was not an official statement as vice chairman of Medicare’s Payment Advisory Commission, which advises Congress on Medicare. “Could we do better? Of course. Will we? That requires a little more skepticism.”
Yet even if it is unrealistic to expect that newfound efficiencies will stabilize Medicare’s finances, the slowdown in health care spending suggests that politicians in Washington calm down. It offers, at the very least, more breathing room to carefully consider reforms to the system to raise revenue or trim benefits in the least damaging way.
There are many ideas out there — from changing Medicare’s premiums, deductibles and coinsurance to introducing a tax on carbon emissions to raise revenue. Some of them are not as good as others. Until recently, President Obama favored increasing the eligibility age for Medicare. Then research by the Kaiser Family Foundation concluded that raising the age would increase insurance premiums and cost businesses, beneficiaries and states more than the federal government would save. The nation would lose money in the deal.
“As we do this, there are smarter and dumber ways to do it,” Mr. Gruber said. “It would be a problem if we were to do things in a panic mode that set us backward.”
By Elise Viebeck
February 27, 2013
Democratic support for President Obama's healthcare law has dropped 15 points since November, contributing to a rise in negative attitudes toward the reform, according to a new poll.
Opponents of the Affordable Care Act currently outnumber supporters (42 percent to 36), according to the Kaiser Family Foundation's latest tracking survey. Public opinion has switched back and forth since the law passed in 2010, and in November, support for the law was 4 percent higher than opposition (43 percent to 39).
Kaiser attributed the marked slide in support among Democrats to a "post-presidential election fade." In November, 72 percent of that group expressed support for the law, compared with 57 percent who feel favorably toward it now.
Unaffiliated voters saw a similar but less dramatic decline in support, with 32 percent approving of the healthcare law compared with 37 percent in November.
"It's difficult to say whether this downward drop will last," Kaiser analysts wrote of the decline in overall support for the law. "Support seems to have shifted to the no-opinion category, up to nearly a quarter, a new high in Kaiser polling."
Obama's win in November cements the future of the Affordable Care Act. Implementation has begun in earnest in anticipation of 2014, when several major provisions will take effect.
Wednesday's poll was Kaiser's first effort since November to survey opinions on healthcare reform.
By Sam Baker
February 27, 2013
House Republican doctors released a "healthcare state of the union" video Wednesday that criticizes President Obama's signature healthcare law but does not mention repealing it.
The video shows floor speeches from frequent critics of the healthcare law, including Reps. Phil Roe (R-Tenn.) and Phil Gingrey (R-Ga.). It shows lawmakers arguing that the Affordable Care Act will raise costs and criticizing its taxes on medical devices.
"There's a saying: If you want to discourage something, tax it … is that the same thinking we have about innovative medical devices?" Rep. Andy Harris (R-Md.) says in the video. "Are they all of a sudden not a good idea? Because that's exactly what this bill does, it taxes them."
Republicans have narrowed their focus since Obama won a second term, moving from calls for all-out repeal to a more targeted campaign against certain provisions — including the device tax and a new board tasked with slowing the growth in Medicare spending.
The GOP video also criticizes the healthcare law because it did not replace Medicare's payment formula for physicians. (House Democrats attempted to include a permanent fix in their version of healthcare reform, but did not pay for the provision and were blocked by Republicans.)
Gingrey pledged that the GOP-controlled House would advance a permanent fix, ending the expensive cycle of stopgap measures to temporarily avert enormous cuts in Medicare's payments to doctors.
By Elise Viebeck
February 27, 2013
Four in 10 people incorrectly believe that President Obama's healthcare law provides benefits to illegal immigrants, a new poll revealed Wednesday.
This figure comprises about one in three Democrats and more than half of Republicans, according to the Kaiser Family Foundation, which conducted the survey.
In all, 42 percent believe that the Affordable Care Act extends insurance subsidies or Medicaid eligibility to illegal aliens, which it does not. About one in four say they are not sure.
Surprisingly, the survey found that decisive majorities favor giving healthcare benefits to illegal immigrants who gain provisional legal status.
Sixty-three percent said provisionally legal immigrants should be able to enroll in Medicaid, while 59 percent said they should receive insurance subsidies under healthcare reform.
This question has been in headlines as debate continues on overhauling the U.S. immigration system.
Republicans have said that newly legal immigrants should not be permitted to access federal benefits, and the White House reform framework released in January would not permit assistance for this group under healthcare reform.
Support for giving healthcare benefits to provisionally legal immigrants was highest among Hispanics (83-86 percent support), blacks (77-78) and Democrats (75-77).
Half of whites backed insurance subsidies, meanwhile, and 56 percent agreed that people with legal status should be eligible for Medicaid.
Illegal immigrants are prohibited from enrolling in Medicaid and the Children's Health Insurance Program, though program funds may support their emergency and prenatal care, in some cases.
February 28, 2013
[Moving] 65-70 year olds from Medicare into private insurance populations will make those [private insurance] populations, in the aggregate, more expensive. Some of these people are bound to end up in the exchanges, and the ACA has a provision designed to limit age discrimination there; on the exchanges, insurance companies can only charge the old folk three times what they charge us young’ns (which I discussed a few weeks ago). This constraint was never meant to account for members of the 65+ crowd being pushed into the private insurance risk pool. When the insurance companies recalculate to account for the additional medical expenses these seniors would bring, it’d likely raise premiums across the board.
The new context is that McIntyre is responding to a clever proposal by Yuval Levin to raise the age of Medicare eligibility from 65 to 70, but only for wealthier individuals. It’s a reasonable way to address the problem that raising the Medicare age for everyone disproportionately hurts those of lower means. But before one takes this to the bank, one has to cost out all the implications. As McIntyre suggests, it is a near certainty that there will be cost offsets. Some will hit the government, like the exchange subsidy cost. Some will hit individuals, like increased premiums in all non-Medicare risk pools, whether exchange- or employer-based.
What’s crucial is that health and the spending it generates is not the same thing as wealth (duh!). So, moving wealthy people out of Medicare still shifts their spending. That spending is higher per person than that for the younger individuals in the pools to which the would-be Medicare beneficiaries are shifted.
What’s likely spared is Medicaid, I think. We’re talking about shifting wealthy individuals out of Medicare eligibility. If wealth is accumulated assets and not income, it is still possible some of these folks could be Medicaid eligible under the new rules, though only in states that adopt the expansion. Under the expansion, anyone — independent of assets — is eligible if their income is below 138% of the federal poverty level (133% net a 5% income disregard). However, I believe it is the case that if you’re in a population that would have qualified under the old Medicaid rules — and the elderly are — then the old asset tests still apply. Do I have that right? If so, Medicaid is spared any cost shift. If not, the shift is on!
In any case, the cost shift to the exchanges is a result of the modified community rating rules to which McIntyre refers. The obvious objection by Levin might be that we shouldn’t have community rating, modified or otherwise, in the first place. That’s another debate though, and for the moment, it’s settled. The law is on the books and I see no clear sign of it being altered in this regard.
Nevertheless, I suppose another option here is to carve out the 65+ population in the exchanges and permit insurers to charge them their actuarially fair premium, sparing the rest of the pool the expense. (This doesn’t apply to employer plans though.) It’ll be a steep price. Expect a lot of pushback from people of means. The history of sticking higher costs to wealthy Medicare beneficiaries is, well, interesting.
Bottom line, someone needs to nail down the specifics and run the numbers. We should withhold judgement until we see them.
UPDATE: Rearranged some paragraphs for more logical flow.
February 26, 2013
Updated, 5:20 p.m.:
During four hours of public testimony on Senate Bill 7 on Tuesday, disability rights stakeholders aired concerns on the bill's proposals to redesign Medicaid and acute care services to contain costs.
“Transition is hard for all of us, but it can be devastating for the intellectually disabled,” said Wayne Johnson, the father of an intellectually disabled 27-year old daughter who lives at the Mary Lee group home in Austin. He urged lawmakers to remember how sensitive disabled people can be when approving drastic changes to the system. “Remember their feelings, remember their routines, their community and their relationships so they can attain all that they can possibly be,” he said.
SB 7 aims to curb costs by expanding managed care services, establishing pilot programs to try capping costs and to monitor services more efficiently. It would also set up an "intellectual and developmental disability system redesign advisory committee" — made up of stakeholders from disability rights groups — to advise the Health and Human Services Commission on ways to efficiently redesign Medicaid acute care services.
Health care providers, intellectually and developmentally disabled Texans and their family members had a long list of concerns.
Some said the pilot programs could not adequately test proposed payment changes without including state-supported living centers, which aren’t in the current bill. Others had specific concerns about the introduction of managed care organizations into the delivery and reimbursements for care. For example, some advocates said, home and residential care providers’ Medicaid payment rates are already inadequate, and managed care organizations have a history of reducing provider reimbursement rates.
“I ask that Senate Bill 7 not be passed, because it would take away our health care that we really need,” testified a resident at Evergreen Life Services in Dallas, almost in tears. “With the help of the staff and all of Evergreen, I have actually been able to cook, wash my own clothes…I just have an everyday life.”
“This is a major bill and a major change, but I think that the concerns are misinformation-driven to a huge extent,” said Nelson. She asked the Department of Aging and Disability Services to hold additional stakeholder meetings to educate the disability rights community on the redesign proposed in SB 7. That meeting will be held March 4.
“We put too much attention on labels, we need to start serving people with the services they need,” said Jennifer McPhail with ADAPT of Texas, a disabilities rights group. Many members of ADAPT of Texas testified to the committee while wearing hats with the slogan, “Label Jars Not People.” They expressed support for the intent of SB 7 to reform Medicaid services, but hoped lawmakers would be more specific about how stakeholders’ input would be incorporated in the redesign process.
Chris Traylor, the state’s chief deputy health commissioner, held a question-and-answer session at the Capitol to address stakeholders’ apprehensions Tuesday afternoon. A handful of the people testifying, including Johnson, changed their position from against SB 7 to neutral, saying the meeting had assuaged many of their concerns.
“I think we got a much greater level of clarity with some of the parents, provider groups and some of the stakeholders,” said Traylor. When asked by the committee if he’d determined any additional amendments lawmakers should consider to SB 7, he said he would like “to cogitate on some of that for awhile and come up with the right language and work with stakeholders to make sure we get it right.”
Looking to save Texas millions of Medicaid dollars, the Senate Health and Human Services Committee laid out plans on Tuesday to redesign long-term care services for disabled Texans.
Hundreds of thousands of inpatients fall annually, with Medicare policy barring payment for injuries related to them.
By Kevin B. O'Reilly
Feb. 26, 2013.
Integrating fall-prevention protocols into scheduled rounds, grouping cognitively impaired patients into so-called safety zones and doing post-fall assessments are some new strategies to reduce the number of falls for hospital patients. The ideas are part of a recently released Agency for Healthcare Research and Quality toolkit aimed at cutting the estimated 700,000 patient falls that happen in hospitals each year.
Since 2008, the Centers for Medicare & Medicaid Services has denied hospitals payment for complications due to a fall or trauma in the hospital that results in fractures, burns or other serious injuries. Despite the financial incentive, progress in preventing falls has not been easy, experts say. Setting a goal of zero falls is probably unrealistic, they added, given that hospitalized patients often need treatments that may make them unstable on their feet, and yet they need to be mobile to prevent bed-rest complications such as deconditioning, pressure ulcers, aspiration and deep-vein thrombosis.
“The patient is not there typically because they are at risk for falling,” said William Spector, PhD, who helped develop the AHRQ toolkit. “They’re there for surgery or something else, but you’d like to make sure they don’t become deconditioned. This should not be seen as a reduce-falls-at-all-costs manual.”
Most hospitals, nursing homes and long-term-care facilities are familiar with and probably employ fall precautions that apply to all patients, said Spector, senior social scientist with AHRQ’s Center for Delivery, Organization and Markets. These precautions include showing the patient how to use the call light, keeping their possessions within reach and having sturdy handrails in bathrooms, patient rooms and hallways. Many hospitals also assess patients at risk of falling at admission, based on criteria such as age, medication regimen and a history of falling.
The toolkit covers how to implement these concepts but also suggests that physicians and hospital officials consider making fall prevention a part of scheduled rounds. That involves assessing the patient’s pain and rearranging room items so that objects such as the TV remote, tissue box and waste basket are within reach. The health professional rounding also would double-check to make sure that the bed is in a locked position and ask if the patient needs anything before leaving.
Another idea covered in the toolkit is grouping patients with cognitive impairments or other high-risk patients into so-called safety zones. In these areas of the floor, patients may be checked as often as every 15 minutes. Rooms may be equipped with lower beds, mats on each side of the bed, and a big stop sign reminding patients not to get up by themselves.
When falls do happen, hospital officials need a standardized way to interview patients and nurses about why the fall occurred to prevent future occasions. Such rigorous root-cause analyses could uncover contributors to falls, such as tangled medical equipment.
“Very few hospitals, from what I understand, do a root-cause analysis in a systematic way to link an event to the falls incidence rate to try to understand what’s causing these problems,” Spector said. “What’s collected is typically haphazard in terms of who gets interviewed. Here we have a standard protocol to help people.”
A post-fall assessment is included in the toolkit, which was produced by patient safety experts at the nonprofit RAND Corp., Boston University of Public Health and the ECRI Institute. The 202-page toolkit was released in January (www.ahrq.gov/research/ltc/fallpxtoolkit/).
Accountable care organization executives say doctors are skeptical about value-based payments and resistant to make the transition from fee for service.
By Sue Ter Maat
Feb. 25, 2013.
A major stumbling block to the full implementation of accountable care organizations involves the challenge of moving the health care culture away from fee for service and toward payments based on the value of care, according to ACO executives speaking Feb. 13 at a National Committee for Quality Assurance webinar.
During the event, which featured some of the first ACOs to receive NCQA accreditation, some executives said physician compensation under their ACO models hasn’t changed but will soon. Some of the organizations became ACOs almost a decade ago, making them some of the earliest adopters of the business model that seeks to share savings through more coordinated care.
Some ACO executives said a major obstacle to internal alignment is the reluctance of some health professionals and payers to embrace the ACO model fully. It has resulted in a slower transition from fee for service to value-based payments, and, in some cases, the transition hasn’t even begun to take place.
“We are certainly not new to this, and despite the fact we have been involved with this on the Medicare side for a number of years, it really hasn’t had an impact on our marketplace,” said Douglas Carr, MD, medical director of education and system initiatives at the Billings Clinic in Montana, which became an ACO in 2005. “We are entirely fee for service. The managed care tidal wave never hit Montana at the end of the last century, so it never had an impact on the commercial market. It’s a very difficult environment to create an ACO discussion.”
The wait for acceptance
Some have been dubious of the ACO payment model because they are so used to fee for service, making it harder to transition to value-based care when most of the health care world is still functioning based on volume, said Hal Teitelbaum, MD. He’s managing partner and chief executive officer of Crystal Run Healthcare in Middletown, N.Y.
“So every time we standardize around best practices, improve efficiencies and eliminate waste, that potentially results in decreased compensation to providers and others in the health care system, and that concept of functioning with one foot in two canoes is certainly a challenging one.” Dr. Teitelbaum said.
Crystal Run Healthcare ACO legally formed in 2011. Its first accountable care contract started in April 2012 with its participation in the Medicare Shared Savings Program, said Jonathan Nasser, MD, Crystal Run’s co-chief clinical transformation officer. Crystal Run’s only risk-based contract is with the Centers for Medicare & Medicaid Services, but it expects to announce value-based contracts with private payers later in 2013.
“The reasons that we have not made this shift are related to private-payer factors — a lack of interest from some, who are advantaged from our current work in a fee-for-service contract, and a lack of sophistication from others, who do not have the data analytic capabilities to engage in this type of contract,” Dr. Nasser wrote in a statement.
At Crystal Run, physician compensation will become more aligned with the ACO model in the coming months, Dr. Teitelbaum wrote in an email to American Medical News after the webinar. The senior leadership has told doctors that fee for service is unsustainable because of external pressures, including the recent economic downturn, federal deficits, pressure on Medicare and commercial provider payments, and problems with the sustainable growth rate that helps determine Medicare physician pay, he said.
“We believe the time to adopt value-based care transformation is now — most importantly, because it is the right thing to do, but additionally, because it is the smart thing to do financially,” Dr. Teitelbaum said.
Crystal Run has created a physician matrix that offers bonuses for doctors who meet quality, cost and patient experience benchmarks. It plans to change this model to reward based more on value than on volume.
It expects to pilot a different compensation plan in the first half of 2013 and roll out the model to all of its physicians in 18 months to two years, said Scott Hines, MD, Crystal Run’s co-chief clinical transformation officer, who also spoke with American Medical News after the webinar.
While going through the accreditation process, Crystal Run has learned that it must align physicians early on in the transition from volume to value, Dr. Teitelbaum said. Although ACOs are geared toward primary care physicians, specialists are important to their success, and getting them on board may involve more prodding, Dr. Teitelbaum said.
Specialists deal with patients on a more episodic basis than do primary care doctors, so they are more used to fee-for-service payments. Making a point to discuss the benefits of ACOs is key, but specialists must buy into the ACO concept, he said. “The question is: Do you want to get paid for procedures or paid for outcomes?”
At Essentia Health in Duluth, Minn., physicians’ pay has not been affected. Essentia will work on a physician compensation system to make sure that it aligns fully with ACO strategy, said John Smylie, Essentia’s chief operating officer, in an email to American Medical News after the webinar.
“We do see the need to have our internal compensation system fully aligned with external reimbursement,” Smylie said. “Aligning the internal compensation programs with the ACO program will be a key initiative this year that will include extensive involvement from our physicians.”
By Rich Daly and Jessica Zigmond
February 27, 2013
Tags: Hospitals, Insurers, Legislation, Medicare, Nursing, Physicians, Reimbursement
If sequestration kicks in Friday as planned, the 2% payment reduction to Medicare providers and insurers will be for services provided on or after April 1, an HHS spokesman confirmed Wednesday.
When asked if HHS has already alerted providers and insurers about the date of the payment cuts, the spokesman replied in an e-mail, “If sequestration occurs, official notifications will be made.”
The lack of any notice from HHS left provider groups to wonder when their members will see those reductions. An official for the American Health Care Association—which represents skilled-nursing facilities and assisted-living providers—said there has been confusion among the organization's staff and lawyers about when those cuts would take place, while the American Hospital Association, Federation of American Hospitals and National Association of Public Hospitals and Health Systems all anticipated the cuts would begin in April.
“That was an extrapolation from the January extension,” said Shawn Gremminger, an NAPH lobbyist, about the two-month delay to the start of the sequester approved in a Jan. 2 budget deal.
Legislation that created the sequester specified that it cut Medicare reimbursements for services provided the month after the sequester's start, which was originally scheduled for Jan. 2. Providers are expected to see the cuts show up in their Medicare reimbursements sometime around mid-April—depending on the time the CMS typically takes to process their payments.
Read more: Sequester's Medicare cuts would start with services provided in April | Modern Healthcare http://www.modernhealthcare.com/article/20130227/NEWS/302279950#ixzz2MCsiIJoY?trk=tynt
By Christy Hoppe
February 27, 2013
Update 2 pm: No vote on the bill yet. The committee met but has left the bill pending.
Original post: A bill that would place new restrictions and mandates on doctors who prescribed the RU-486 abortion pill is likely to come up for a vote today in the Health and Human Services Committee.
Chairwoman Sen. Jane Nelson, R-Flower Mound, had indicated that she will ask for a vote at a meeting of the committee today.
The proposal by Sen. Dan Patrick, R-Houston, who also authored the law to require sonograms before abortions two years ago, faced stiff opposition from OB-GYNs and the Texas Medical Association, who called it government intrusion into medical practices that would do more harm than good.
Under the bill, doctors who prescribe abortion drugs would be required to sign a contract with another physician who would be on call if complications developed. The patient would be given the phone number of the second doctor and the name of the hospital where that physician must have surgical privileges.
The bill also would require that Federal Drug Administration protocols for the abortion drugs be given to the patient and followed by the doctor. Records would have to be kept to track complications that might arise from use of the drugs.
Patrick said the bill will protect patients by ensuring they are aware of possible dangers and can receive emergency care if necessary.
Lisa M. Hollier, chairwoman of the American Congress of Obstetricians and Gynecologists’ Texas District, said that the FDA protocol ordered in the bill dates from 2000 and that improved dosages and regimens have since been developed.
She said in testimony to the committee that the bill actually would force doctors to mistreat their patients by using a regimen that has more side effects, higher costs and a slightly lower success rate than ones currently being practiced.
For instance, she pointed out that FDA-approved regimen of 600 mg dose of mifepristone is three times greater than what the OB-GYN group currently endorses. The FDA also calls for taking the pill orally, while new research shows that vaginal administration is superior.
In addition, Hollier pointed out that placing the FDA protocols into law would prohibit doctors from following future improvements.
“The bill will not enhance public safety. This bill will not improve the quality of care that women receive. This bill does not promote women’s health,” she said.
February 28, 2013
The Poteet Police Department is excited to announce its first Annual Bicycle Rodeo Fest taking place on March 2, 2013 at Poteet’s Canyon Park. The event will promptly start at 9:00 a.m. and will end when the final participant has completed the course.
This year The Poteet Police Department has partnered up with The South Texas Regional Urgent Care Center in Pleasanton, The South Texas Family Care Center in Poteet, and the Texas Medical Association’s Hard Hats for Little Heads Program to give away a bicycle helmet to all attending children.
March is Brain Injury Awareness Month and this year we want to do our part in reducing the 475,000 Child traumatic brain injuries that occur each year in the United States.
The Poteet Police Department extends Special thanks to The South Texas Regional Medical Center for its assistance and participation.
Wednesday, February 27, 2013
To kick off WATCH Week, March 4-8, Fort Bend ISD and the Fort Bend Medical Society Alliance will host the 7th Annual WATCH Your Wellness Health and Fitness Fair on Saturday, March 2, from 10:00 am to 1:00 pm, in the Sugar Land Town Square. The free event welcomes all families and community members and kicks off WATCH Week in FBISD schools.
WATCH (Weight, Activity, Tobacco, Cholesterol and Hypertension) is a heart health awareness program that highlights the five major risk factors contributing to heart attack and stroke. The program also promotes choices for healthy lifestyles and reducing obesity. The WATCH Your Wellness Health and Fitness Fair will provide families with information and activities to promote good health.
Among the many offerings will be: Radio Disney (sponsored by H-E-B), entertainment provided by FBISD student groups, health screenings (bone density, blood pressure and blood glucose), immunizations by Access Family Health*, cooking demonstrations by Recipe for Success, child ID cards and fire safety presentations by the Sugar Land Police and Fire Departments, a Teddy Bear Clinic provided by Kelsey-Seybold Clinic, giveaways and lots of other fun activities.
Representatives from the American Diabetes Association and American Heart Association, as well as family practice physicians and medical staff, will be available to answer questions regarding diabetes hypertension and heart health. Iron Man Sports Medicine Clinic staff will provide information pertaining to sports injuries. The Fort Bend Medical Society Alliance will sponsor free bike helmet giveaways as part of the Texas Medical Association’s Hard Hats for Little Heads program, created to help reduce brain injuries and encourage children to exercise.
The health and fitness fair will offer a fun time for all; so, don’t miss this free event.
*Note: Immunizations will be provided to students under age 18. If children are covered through CHIP or Medicaid, please bring the card. Parents must be present with a copy of the child’s immunization record for 7th grade immunizations and the Meningococcal vaccine for college students.
By Tim Eaton
In a legislative session that has lacked the bitter polarization seen in years past, an utterly contentious issue rose Wednesday to the top of the political barrel.
An eclectic coalition of Austin hippies, homeschooled children and subscribers to Ron Paul’s libertarian philosophy showed up en masse to tout the benefits of unpasteurized milk from cows and goats before the House Public Health committee.
The committee — headed by Rep. Lois Kolkorst, R-Brenham — also heard from critics of the velvety and thick product.
Energizing the unusual alliance of raw milk drinkers is a bill filed by Rep. Dan Flynn, R-Van, for the second consecutive session that will allow raw milk to be more widely sold. Now, consumers can only buy raw milk at farms producing it. Flynn’s House Bill 46 would add sales at farmers markets and county fairs to the mix.
It’s about free enterprise, Flynn said, but the Texas Association of Dairyman and other organizations beg to differ.
While raw milk sales are minuscule compared with those of big dairy operations, a disease outbreak from raw milk could have a devastating effect on mainstream dairies if consumers react by shunning all milk products, said Darren Turley, the executive director of the dairy farmers’ group.
Flynn moo-moos that argument.
“It’s about competition,” he said. “The big guys will go after the very small people who really don’t affect their market.”
Medical groups — including the Texas Medical Association, the Texas Pediatric Society and the Texas Academy of Family Physicians — also oppose Flynn’s measure.
Unpasteurized raw milk can contain bacteria that can cause serious sicknesses, Edward Sherwood [TMA member], a physician representing medical groups told the committee.
“If HB 46 is implemented, more people may become ill from raw milk consumption — resulting in greater costs to the state for investigation, inspection, and the care of those who will need to be hospitalized.” he said. “These illnesses and hospitalizations are preventable.”
Flynn said he hopes to minimize opposition from the milk titans by requiring safe transportation of raw milk and adding strongly worded health warning labels.
Most raw milk producers already have safe practices, said a raw milk producer from outside of Fort Worth. Eldon Hooley, 45, a Mennonite dairy farmer from Grandview, said he can more consistently transport milk at a safe temperature than his customers.
Fresh off a three-hour road trip with his wife and seven children, Hooley of Rosey Ridge Farm also said he would be open to the idea of warning labels.
“I wouldn’t have a problem with that,” Hooley said. “My customers would laugh at it.”
Ted Norris, a physician and holistic doctor, called pasteurized, homogenized milk a “foreign product,” and thanked former presidential hopeful Ron Paul for speaking on the campaign trail about overturning a federal ban on transporting raw milk across state lines.
Margaret Errickson, an 11-year-old homeschooled girl from Houston, also testified, saying raw milk helps manage her eczema and allergies.
The bill was left pending, but Kolkorst said she expects committee members to approve Flynn’s measure.
February 27, 2013
State Rep. Dan Flynn, R-Canton, said that legislation he authored to expand options for selling unpasteurized milk in Texas quickly received praise from across the state.
“When I filed this bill during early filing, I got over 500 emails that week in support from the Panhandle to the Rio Grande Valley,” Flynn said Wednesday. “It’s a product, there’s a public that wants it. If they can buy it at one place, they should be able to buy it elsewhere.”
Flynn's legislation, House Bill 46, would allow the sale of raw milk at farmers markets and other sites like fairs and flea markets.
And while many testified Wednesday in support of his measure at a House Public Health Committee hearing, a few raised concerns about regulation and health risks.
Currently, farmers who produce unpasteurized milk can only sell it at the site of the dairy. That means customers of the state’s 49 licensed farms that produce raw milk have to drive to the farms, which may be several hours away.
Robert Hutchins, whose family owns Rehoboth Ranch in Greenville, sell beef and other products at farmers markets every week but can only sell their raw goat milk at the Greenville property, he said.
“We haven’t been able to grow the dairy adequately to become as profitable as we need to be to continue our operation,” Hutchins said. “If we could sell our milk at farmer's markets to which we already travel every week, we could double or triple the amount we sell every week.”
There could be costs associated if an increased number of farms seek licenses to sell raw milk, said Dan McCreary, who manages the Milk Group for the Department of State Health Services. For example, the department might need to hire more inspectors to oversee farms and could face increased lab testing costs. He spoke to offer information and did not support or object to the measure.
Critics of the bill said Wednesday that only 1 percent to 3 percent of Americans consume raw milk and that unpasteurized milk can pose a health risk. They added that unclear language about regulation could raise confusion about where the milk can be sold and how it should be labeled.
The Centers for Disease Control and Prevention has tied raw milk consumption to bacterial illnesses like E. coli and listeria.
Edward Sherwood of the Texas Medical Association and the Texas Pediatric Society said any raw milk legislation would require clear labeling and a more educated public to make the product safe to sell, especially for consumption by children.
“We’re not worried about the people you’ve heard from today because they’ve gone to great lengths to educate themselves about health and health risks,” Sherwood said, noting that most Texans don’t know much about raw milk.
But San Antonio dietitian Anna Macnak said she frequently encourages people to try raw milk to solve physical ailments. The freshness and natural state of raw milk make it a great choice, and the benefits outweigh the health risks for many Texans, she said.
"If you put something in your mouth, there’s a risk you could be come ill," Macnak said. "But that’s not necessarily a reason to restrict access to fresh food."
Flynn said he expects state Sen. Bob Deuell, R-Greenville, to file a raw milk bill in the Senate. Deuell filed the bill in the 2011 session but it did not get a committee hearing.
The bill remains pending before the House Public Health Committee.
February 27, 2013
The victory of a pro-gun-control candidate in the Illinois Democratic primary race to replace Rep. Jesse Jackson Jr. was also a political win for New York City Mayor Michael Bloomberg, whose superPAC backed the winner over a candidate it linked to the NRA.
But Robin Kelly's victory Tuesday was, for Bloomberg, more than just another achievement on the gun control front. It was one more win in Bloomberg's unique assault on what he views as the public health problems of our time.
The billionaire mayor has had a long interest in public health. The millions of dollars he has donated over the years to Johns Hopkins University to advance work on public health issues is reflected in the school's name, the Bloomberg School of Public Health.
The Baltimore school took Bloomberg's name in 2001, the same year he was elected mayor of New York City. That coincidence symbolizes how Bloomberg has been able to use the various levers available to him as a public policymaker, a political power player and a philanthropist to fight threats to the well-being of Americans.
Thus you get the mayor who led the controversial ban on supersized sugary drinks being sold in many places in his city, who pushed to get packaged food makers to significantly reduce the amount of salt in their products, and who got New York restaurants to phase out the use of artificial transfats and post the calorie counts of the meals they serve.
You also get the Bloomberg public-health school housing the activities of the Center for Gun Policy and Research. And you get Bloomberg's Independence USA PAC supporting gun control candidate Kelly, a former state legislator, in the Illinois congressional race's Democratic primary over several candidates, including former Rep. Debbie Halvorson. Much of the more than $2 million in Bloomberg's superPAC money was used to criticize Halvorson's stances against gun control.
When it comes to public health, it's hard to think of another big-city mayor or other political figure of our time who has exerted so much influence in so many different ways.
"He rises very quickly to the top of the list, no question about it," said Dr. Georges Benjamin, executive director of the American Public Health Association. "I mean, there are obviously others who have [attacked public health problems] in their own way, but he's clearly the one that has been the broadest.
"If you're serious about improving health in the broadest sense, then you've got to do what the mayor is doing. You've got to put your money where your mouth is, into those things that address the social determinants that influence health."
Benjamin credits Bloomberg for being a tell-me-what-works kind of leader who is willing to take political flak. "I know he's asked his people, 'Tell me the science, I'll handle the politics.' He's obviously willing to do politically difficult things. And the sugary drinks issue he's just addressed is an excellent example of that." Or, for that matter, tangling with the NRA.
By Maggie Fox
February 28, 2013
Dr. William Begg wiped away tears as he pleaded with Congress on Wednesday to help rescind laws that limit medical research into gun deaths and that restrict doctors from asking patients about guns in their homes.
Begg’s testimony highlighted a growing battle between some doctors and some gun advocates over whether federal health dollars should be spent on research into gun violence, and on whether doctors should counsel their patients about gun safety.
Medical groups have been complaining for years about restrictions on the research. And now 101 doctors from Newtown, Conn., have started their own group to try to influence both legislation and, perhaps, the U.S. culture itself.
“We are being intimidated not to discuss gun violence as a public health issue,” Begg, emergency medical services director at Danbury Hospital, 10 miles from Newtown, said in testimony to a Senate Judiciary Committee hearing on gun violence.
Begg was working in his hospital’s emergency department on Dec. 14 when Adam Lanza shot and killed 20 small children at Sandy Hook Elementary School using his mother’s assault rifle and other weapons. He has begun speaking out, with other doctors, against what they see as efforts to keep them from doing their utmost to prevent gun violence.
“Allow me as a medical doctor, when I see a patient and I talk to them about the risks of excess alcohol, or tobacco use, or safe sex, morbid obesity, seat belts, texting and driving, can I talk to them about the risk of gun violence, please?” Begg asked.
Begg asked Congress to ban assault weapons, high capacity ammunition magazines and semi-automatic rifles. “People say the overall number of assault weapons deaths is small. Please don’t say that to the people of Tucson or Columbine or Aurora or Virginia Tech and don’t tell that to the people of Newtown,” he said to applause from the audience in the hearing room.
“This is a tipping point. And this is a public health issue.”
Begg referred to legislation in Florida – rescinded after a judge ruled against it — that would have pulled the medical licenses of doctors who tried to discuss gun safety with patients and then fined $10,000. The American Medical Association, the American Academy of Pediatrics and other medical groups all oppose such legislation – and they had been calling even before the Connecticut shootings for more research on gun violence.
In 1996, after a particularly critical report on gun deaths in the United States, Ark. Rep. Jay Dickey sponsored an amendment that removed $2.6 million from the Centers for Disease Control and Prevention’s budget, which was the precise amount the agency had spent on firearms studies. It hasn’t published a gun study since.
President Barack Obama earlier this year issued a memorandum directly ordering the CDC and other federal agencies to do gun research. But groups like the Union of Concerned Scientists say more needs to be done to ensure that medical professionals can have a hand in compiling statistics on gun deaths, can talk to patients about the dangers of firearms, and can speak out about their findings publicly.
Pediatrician Dr. Greg Dworkin agrees. He and about 100 other doctors from the Newtown area, Begg among them, have started a group called United Physicians for Newtown.
“We, the physicians, felt that we needed to do something and we needed to do it in a way that was consistent with our own profession,” Dworkin said in a telephone interview.
“We got together as physicians to see if there was something we could agree on, knowing the whole issue of how to prevent violence like this is not so simple.”
As in any community, the doctors in Newtown – who had begun calling one another and moving into place to help within minutes of learning about the shootings – have a range of political views.
“Newtown is a rural area,” Dworkin said. It’s full of hunters and sports shooting enthusiasts. Some people even have backyard gun ranges. The doctors were sensitive to fears that peoples’ guns might be taken away from them.
But there was plenty they did agree on.
“We felt that as a first principle, we want to speak up as physicians (and say) that research on violence, gun violence, violence against children should be done,” he said.
“We agreed mental health should be part of this. We agreed there is a culture of violence,” he added.
“We agreed we had to take a stand about gun safety.”
Universal background checks, assault weapons bans and bans on high capacity-ammunition magazines all won wide support from the doctors, he said.
And they wanted to keep party politics out of it. “But it is reasonable for physicians and professional health workers to be allowed to discuss this,” Dworkin said.
“We are talking about a registry of injuries,” he added. After the Sept. 11 attacks, public health officials started a registry of illnesses among people exposed to toxic dust as the World Trade Centers collapsed. There needs to be something similar for firearms injuries, the group agreed. “It’s a public health issue,” Dworkin says.
Dworkin, himself a blogger for the Daily Kos, says members of the group want to speak publicly – at hearings before the Senate Judiciary Committee, for instance.
Begg reeled off the statistics.”If you actually own a gun in your home because you think it is going to make you safer, let me give you some facts,” he told the committee hearing.
“Women are five times more likely be killed by a spouse if there’s a gun in the house. That’s a real study. If you have a gun in the house you are five times as likely to die of suicide, 20 times as likely to die of unintentional gun death.”
Research like this can only inform the argument, Begg, Dworkin and the other doctors of Newtown argue.
By Todd Ackerman
February 28, 2013
After successfully passing the law that requires women seeking an abortion to first undergo a sonogram, Sen. Dan Patrick now is taking aim at practices involving the "month-after" abortion pill.
Under a Patrick bill moving through the state Senate, Texas doctors who prescribe RU-486 to women who opt for medical rather than surgical abortion must schedule a follow-up visit within two weeks of the drug's administration and contract with another physician to treat any emergencies arising from it.
"This is a straightforward bill intended to protect women's safety," said Patrick, R-Houston, denying it's part of a strategy to restrict abortion. "If the abortion industry wants to take a shortcut with women's health, that shouldn't be acceptable."
Patrick said Tuesday at a Senate Health and Human Services Committee hearing that the bill follows FDA guidelines for use of the drug. On Wednesday, however, he acknowledged he is working on a substitute to the bill to reflect newer FDA guidelines of which he was unaware.
The bill was assailed by abortion-rights advocates and doctor groups, including the Texas Medical Association. They called it an intrusion into the doctor-patient relationship and said it mandates practicing in a manner not in the best interests of individual patients.
"Essentially, this is the Legislature practicing medicine without a license," said Dr. Albert Gros, representing the Texas district of the American Congress of Obstetricians and Gynecologists, at the hearing. "It's a badly drafted bill that would set a dangerous precedent for other medical procedures. I've never heard of a cardiologist, for example, being required to contract with a cardiovascular surgeon in case he ruptures an artery replacing a stent."
Of the roughly 85,000 abortions performed in Texas each year, 18,000 are achieved through the administration of RU-486, according to a doctor who testified at the hearing. The drug is different from the so-called "morning-after pill," which is taken in the 72 hours after unprotected intercourse and disrupts fertilization.
RU-486, which works by blocking progesterone receptors and preventing implantation, was approved by the Food and Drug Administration in 2000 as an alternative to surgical abortion. It actually consists of two drugs usually taken a couple days apart by women up to seven weeks pregnant. It is sometimes given as late as nine weeks.
Patrick said his bill is motivated by lax practices that have been reported to his office. Two women, invited by him to provide testimony, told of their horrible experiences with the drug and the lack of warnings provided by clinics before the experience and lack of responsiveness after.
"I experienced the most excruciating pain I had ever felt in my life," said Sarah Michelle Chapa. "I curled up on the bathroom floor in tears with the clinic on the line, asking them how many pain killers I could take before I would overdose."
Patrick said Tuesday that all he's asking abortion providers to do is administer the two drugs in separate appointments and see the patient in a third two weeks later, what the FDA recommended in 2000.
Gros called the 13-year-old FDA regulations cited by Patrick "archaic." Clinical research since then, he said, has demonstrated newer, off-label regimens result in fewer complications and a 96 percent to 99 percent success rate. The success rate under the old regimen was 92 percent, he said.
A doctor invited by Patrick to testify cited a 2009 Finland study that found a 20 percent rate of complications with RU-486, such as hemorrhaging and incomplete abortions. He translated that into 10 adverse events a day in Texas.
Gros did not address the FDA recommendation of a follow-up visit.
Blake Rocap, legislative counsel for the Texas chapter of the National Abortion and Reproductive Rights Action League, said the additional trip to the doctor's office can be "a real issue" for women with children or transportation limitations in some areas of the state.
Patrick said Tuesday's testimony brought out information that FDA guidelines have changed, from three doctor visits to two - the initial one and the follow-up appointment. He said his substitute bill would reflect the current recommendation.
Wed February 27, 2013
From the Texas Tribune:
The Senate Health and Human Services Committee heard testimony Tuesday on legislation that would tighten abortion restrictions.
Senate Bill 97 requires physicians to personally administer the two-drug cocktail that induces a medical abortion, which must be taken 24 hours apart, and to see the patient for a follow-up appointment within 14 days. The bill also requires physicians performing abortions to put existing verbal agreements with back-up physicians into written contracts, so that the state can track the names of doctors with hospital privileges that are willing to treat abortion patients in emergency situations.
It is not my intention to debate the merits of this bill. My interest in it comes from a different direction. My question is this: Have the Republicans forgotten that there was an election last November? This bill is a dagger to the heart—of Patrick's own party. It is anathema to one of the constituencies that is a crucial part of the Democratic coalition that won the election: college-educated women. Has Senator Patrick forgotten the name of Todd Akin? Of Robert Mourdock? Of Sandra Fluke?
This bill is a case study of why Republicans are losing national elections. They do not have a clue about the nature of the coalition that defeated them. If one reflects on what the Legislature has done over the past four years, beginning with 2009, the main thrust of its efforts has not been to improve the lives of ordinary Texans. It has been to harm and harass the constituencies that threaten them. Hence the Legislature has passed Voter I.D. legislation, gerrymandered redistricting maps, restrictions on the conduct of elections, huge cuts in public education, a dismembered women's health program, the burden of all of which fall on the constituencies that make up the Democratic coalition. The irony is that Republicans are doing their part to turn Texas blue.
February 27, 2013
Texas teenagers had the third-highest pregnancy and birth rates in the U.S. in 2008, according to the Guttmacher Institute.
Texas teens had 85 pregnancies and 61 births for every 1,000 women aged 15-19. The state ranked 31st in abortion rate, with 16 for every 100 pregnancies ending in abortion or live birth.
In 2008, New Mexico had the highest teen pregnancy rate (93 per 1,000 women aged 15–19), followed by Mississippi, Texas, Nevada, Arkansas and Arizona. The lowest rates were in New Hampshire (33 per 1,000), Vermont, Minnesota, North Dakota and Massachusetts.
Teen pregnancy rates have declined steadily in all 50 states between 1988 and 2005.
February 27, 2013
The Texas Supreme Court has rejected a physician’s whistleblower suit against UT Southwestern Medical Center, according to Culture Map Dallas.
The court said tenured professor Larry Gentilello, MD, did not notify the right authority about his claims of fraud when he told his supervisor, Robert Rege, MD, chairman of the department of surgery, of allegedly improper billing practices in the hospital’s emergency room.
Gentilello later sued UT’s medical school for retaliation in 2007, claiming he was demoted and barred from the operating room after he notified Dr. Rege of the alleged fraud, according to the report. Under Texas’ whistleblower act, employees are protected from retaliation only if they report what they believe is a law violation to the appropriate law enforcement agency, the report said. The appropriate authority in this case, the court said, was the Centers for Medicare and Medicaid.
Wednesday, Feb. 27, 2013
DALLAS — The board of Parkland Memorial Hospital has approved design changes to add space for the planned new $1.3 billion Dallas County public hospital.
The Dallas Morning News reports the update approved Tuesday means adding two floors atop a planned loading dock. The extra space will help accommodate the hospital's 45,000-square-foot biochemistry lab amid greater patient demand.
The board also approved placing several outpatient clinics in a vacant warehouse on the new campus and reusing two older buildings as additional outpatient clinics. Improvement costs will be covered by the hospital's 2014 and 2015 capital budgets.
Voters in 2008 approved a new hospital to replace the structure built in 1954. Construction began two years ago.
President John F. Kennedy was transported to Parkland after being fatally shot on Nov. 22, 1963.
February 27, 2013
With the clock ticking on sequestration and its cuts to healthcare funding, it seems callous to pile onto rural providers with more gray news.
And yet, lost this week amid the lead-story brouhaha over the self-inflicted wounds administered by our federal elected officials were two items that illustrate the challenges of bringing physicians to rural America.
First, the New York Times reported that a 15-member commission created more than two years under the Patient Protection and Affordable Care Act and charged with assessing the needs of nation's healthcare workforce has never met because funding hasn't been allocated.
Of course, nobody expected the National Health Care Workforce Commission would solve the problems of recruiting and retaining physicians and other clinicians into underserved areas. And the federal government is doing other things to encourage physicians to settle in underserved areas with debt-relief programs such as the National Health Service Corps.
However, a high-profile commission could have raised public awareness about these chronic, widespread and growing clinician shortages in rural areas.
Also this week, the Association of American Medical Colleges issued its annual report, Physician Education Debt and the Cost to Attend Medical School, and found that while the average debt load for medical school graduates in 2012 was $170,000—up 5% over 2011—those new doctors did not prioritize debt as the driving force in their decisions to seek a particular specialty.
In fact, "education debt" placed 11th—dead last—on the list of "influence of various factors on the specialty choice of 2012 graduating medical students."
Upon review, the low priority of debt obligation in making a lifelong career decision makes sense. Yes, $170,000 in student loans is nothing to sneeze at, especially if you've just acquired a doctorate in phrenology.
However, we're talking about highly compensated professionals. Although you wouldn't know it by listening to them, physicians are among the highest paid classes of workers in the United States. Primary care docs fresh out of residency can earn about $170,000. That's a much better debt-to-salary ratio than the typical law school graduate or new veterinarians.
Atul Grover, MD, a general internist and AAMC's chief public policy officer, tells HealthLeaders Media that student loan debt concerns among medical school graduates have been overblown by policymakers and the media.
"That was the conventional wisdom, but I don't think it was informed by very good studies," Grover says. "As we have done better and better surveys over the years from our graduating classes and gotten better information about what is driving their specialty choices, we have noted for a couple of years now that there doesn't appear to be a clear relationship to debt."
The problem, however, is that many of the government programs that are designed to attract physicians to rural areas center on student debt deferment, reduction, or forgiveness, an incentive we now learn that these young docs don't prioritize.
"When it comes to the actual specialty choice, debt does not seem to be that much of a big driver. It has more to do with people's personality and how well that fits what they want to spend their day doing. What we don't know is whether it had an influence on people's willingness to serve underserved communities," Grover says.
"If you have a large amount of debt and you are worried about making your loan payments, while it may not affect your specialty choice it may affect your decision to serve an underserved population that has a high Medicaid population with lower reimbursements. We already have trouble getting physicians to see Medicaid patients now. And Medicare is always on the edge with the (Sustainable Growth Rate [formula])."
The results of the report also suggest that finding actionable and effective enticements to bring physicians into rural areas could be problematic. Many of the enticements the young doctors cited when they chose a particular specialty were based on personal opinions and preferences such as personality fit, lifestyle choices, work/life balance, and future family plans. It would be hard to develop a rural healthcare physician recruiting strategy around intangibles such as "role model influence."
The AAMC study is limited because it surveys medical school students who've already accepted the burden of amassing debts. The study cannot gauge the intimidating effect of these debts in chasing away would-be physicians from attending medical school in the first place—particularly students from minority groups or lower socio-economic backgrounds.
"Does it discourage them from going into medicine because they may not understand how it is possible to repay very large debts of $170,000 to $180,000?" Grover says. "From that standpoint, if you are scaring off potential physicians from rural and underserved areas because of that huge price tag and those are the very students more likely to go back and serve those communities, then debt is a much bigger issue."
Many observers, including Grover, believe that the best way to find physicians willing to serve in rural and underserved areas is to recruit medical school students from those same areas.
"If you look at a lot of public medical schools like the University of Mississippi and the University of Arkansas, where they specifically are taking students from the state, that is part of their mandate as a public university," Grover says. "They do a much better job of keeping those doctors in their states and also going back into their communities, because that is where families are."
That is not as easy as it sounds.
"The challenge there is we can't start that at medical school or even college. It's a K-12 issue," Grover says. "People have to understand that this is an opportunity to aspire to do this when they are going through middle school. When you get to college it is often too late."
"The other thing we find is if you want to get physicians in rural areas, it's not just helpful that they are from rural areas. Their spouse has to be from a rural area. So, we have to get rural physicians and then match make for them," Grover says with a laugh, although it's not clear if he's joking.
By Stephanie Kelly
Feb 27 2013
For people struggling to put food on the table and a roof over their heads, "voluntary" participation in clinical trials is a slippery slope. While disclosure of new data from pharmaceutical companies is a good first step, questions remain.
The purpose of clinical trials is to find out if the newest wonder drug is all that wonderful, and what kind of side effects we humans might expect. It worked on animals, but will this drug kill people, and/or turn them green? Every warning you see on a label is there because a test subject -- or 50 of them, or 500 of them -- have suffered that side effect.
These clinical trials for new medications take place all over the world, but developing countries often serve as cost effective locations.
In 2008, the Center for Research on Multinational Corporations released a document full of examples of the detrimental effects of unethical clinical testing that went on the 1990s and throughout the 2000s in the developing world. The report included the case of clinical trials in Uganda between 1997 and 2003, when women taking the anti-transmission drug Nevirapine experienced thousands of serious adverse effects (SAEs). These symptoms went unreported and testing was allowed to continue, resulting in the (also unreported) deaths of 14 women. In Hyperabad, India in 2003, eight test subjects died during the testing of the anti-clotting drug Streptokinase. The worst part, though, was that the subjects did not even know that they were part of a trial.
These two cases are just a couple out of numerous in the report, which is only one of numerous reports of unethical clinical testing on the world's least privileged people.
Until now, pharmaceutical companies themselves have acted under cloak and dagger, not telling us just how many test subjects have suffered ill effects, so that we can stop a headache, or have better sex, or sleep more soundly.
In that sense, we stand to gain huge knowledge from GlaxoSmithKline's recent commitment to publish clinical study reports from the last 20 years, a move the company is claiming will further transparency, aid future research, and protect patients from misinformation. But what do the numbers hide?
Clinical study reports describe every aspect of the clinical trial for a new drug, including the number of participants, methodology, analysis, and conclusions. While releasing this data is a huge step in the intensely competitive and all too secretive pharmaceutical industry, it is researchers, health care practitioners, and patients who stand to gain. What about the 1 or 50 or 500 test subjects in rural Uganda or the slums of India who the numbers are describing?
"But what about those participants whose health did improve? And either way, these test subjects volunteered for these programs, freedom over your own body etc, etc." I hear you shouting at your screen. True, there is a chance that test subjects stand to see their health improve. But when people sign up to participate in drug trials, they are signing up for a casual game of Russian roulette with their health; the stakes are high.
Not only that, but drug trials do not last forever. Once the period of allotted time for testing ends, the researchers can pack up and head back to headquarters. What if the illness being cured involves lifelong treatment, such as for HIV/AIDS patients? Indeed, what if the treatment being tested requires interrupting testing, just to see what happens?
This is what happened in the case of anti-retroviral methodology research in Uganda, Zimbabwe, and the Cote d'Ivoire cited in the SOMO document. The research, sponsored by a multitude of pharmaceutical research firms including GSK, caused uproar as patients were separated into two groups -- one group to get continuous anti-retroviral treatment, one to get interrupted treatment with the same drug. Needless to say, not taking necessary anti-retrovirals took a lethal toll on participants and some died in the process. While we now know that interrupting anti-retroviral therapy for 12 weeks at a time is a bad idea, participants had to die for this discovery to be made.
So this is where the argument about "free" will comes in. These same participants died because they volunteered to take part in the study, right? Choice is a tricky concept in developing countries where people and their families are struggling to put food on the table and a roof over their heads. To what extent do you have a choice about participating when you see an opportunity to feed your starving family, or assist your extended family, or get treatment for a terminal disease you could never hope to pay for by conventional means? This problem has been documented again and again, particularly in India, where women are under pressure from their families to participate in trials which carry a greater return than many other potential occupations for women. With these kinds of life or death pressures, the idea that it is a choice gets fuzzy. It gets even more complicated when you consider language barriers.
That is, assuming that the researchers go to the trouble of translating consent documents. One of the most commonly cited ethical qualms with clinical trials tends to be misinformation. While sometimes it is a case of "lost in translation," there are even more dubious cases of misrepresentation at work. In Kano, Nigeria Pfizer tested a new drug called trovafloxacin on children infected with meningitis without informing their parents; five died in treatment. While this case dates back to 1996, deceptive research practice is still alive and well.
Just last year, the BBC reported on patients from India's lowest caste being placed in drug trials without their informed consent. For a deeply divided country, being of the lowest caste and given medical treatment is an honor, one not to be questioned. The power of the white coat, the elevated role of the doctor throughout the world as a demi-God who has the power to save lives, is one that is being taken advantage of in India where doctors enroll their trusting and often uneducated patients in risky drug trials, at a profit of course. These trials led to 438 deaths in 2011 alone. This kind of misinformation will not show up in the data released by GSK.
Why Are So Many People Still Suffering From Leprosy?
While ethics boards exist to investigate and expose the ethical misconduct at play in clinical research in the developing world, accountability is difficult as many research endeavors involve pharmaceutical research firms teaming up to carry out trials. This makes it difficult to pin down the perpetrator for any kind of retribution. Even if the finger of blame could be pointed at one firm, whose finger would it be? For wronged research subjects in African villages or Indian slums, retribution seems unattainable. Reporting the wrongdoings of a multinational company to your local police station in the depths of Uganda doesn't achieve a whole lot. Even when it is possible, monetary compensation would be a pittance relative to the money being made by the world's largest pharmaceutical companies.
These things considered, the win-win of pharmaceutical firms targeting developing countries looks more like a zero-sum game.