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Top Doc Says Ebola Shows Skewed Priorities

Top Doc Says Ebola Shows Skewed Priorities

By Amitabh Pal
The Progressive, Oct. 17, 2014

The Ebola crisis has revealed severe deficiencies in how the American health care system works, experts say.

Dr. Walter Tsou, past president of the American Public Health Association and the former health commissioner for Philadelphia, says that the Ebola crisis shows the skewed priorities of the U.S. health care system.

“Our chronic disease-oriented health care system is ill-equipped to address an acute infectious disease outbreak,” Dr. Tsou, a board adviser to Physicians for a National Health Program, tells The Progressive. “We don’t have enough biocontainment units, sufficiently trained experts on how to control for highly infectious disease agents, trained sanitation crews who can clean up and properly handle waste disposal.”

Tsou says that the Ebola epidemic has uncovered big flaws in the global health system, too.

“We have known about Ebola since 1976 and yet we still have no vaccine or treatment,” he points out. “The fact that we are now scrambling to find some type of vaccine and  treatment only speaks to the paucity of research that we have invested in the developing world. In the cruel economics of the pharmaceutical industry, unless the drugs promise a significant return on investment, they are unwilling to invest in it essentially condemning most of the developing world.”

The Ebola crisis has also made apparent the impact of drastic health budget cuts. Bloomberg News reports that there’s been a nearly one-fifth reduction in public health employees at the state and local levels in just the last six years, with 60,000 fewer people employed than in 2008. This manifests itself in many ways.

“There are fewer people to deploy to take care of education, training, public service messages, and other information,” Johns Hopkins Professor Albert Wu tells Bloomberg. “Ebola is not the first and is not the last challenge to our public health system.”

Dr. Tsou says that the lack of sufficient resources is not confined to the United States.

“The World Health Organization is a shadow of what it should be and is unable to mount a ‘boots on the ground surveillance, mitigation and quarantine program,” he says. “The United Nations has called for the world to donate $1 billion to confront the Ebola crisis, but we only have $100,000 in the bank so far.”

National Nurses United Executive Director RoseAnn DeMoro has commended the recent appointment of an Ebola czar, but has asked the Obama Administration to go further.

“What we need is a real czar to assure public safety, not a communicator, and the power to cut the hospitals’ Medicare and Medicaid funding if they still refuse to adhere to those standards and leave their patients, nurses and other caregivers at extreme risk,” she states in a press release.

For Dr. Tsou, one key public policy measure is necessary to combat such public health emergencies.

“All residents, including immigrants regardless of legal or financial status, should be able to access the health care system to be diagnosed and treated,” he says. “Our health care system already excludes over 42 million who are uninsured and erroneously denies insurance to millions of immigrants, many who are the most likely to bring Ebola into the country. A single payer system, open to all, offers the best mechanism to ensure early detection of illnesses.”

– See more at: http://www.progressive.org/news/2014/10/187889/top-doc-says-ebola-shows-skewed-priorities#sthash.HWi8BPmb.dpuf

Ebola didn’t have to kill Thomas Eric Duncan, nephew says

By Josephus Weeks
The Dallas Morning News, Oct. 14, 2014

On Friday, Sept. 25, 2014, my uncle Thomas Eric Duncan went to Texas Health Presbyterian Hospital Dallas. He had a high fever and stomach pains. He told the nurse he had recently been in Liberia. But he was a man of color with no health insurance and no means to pay for treatment, so within hours he was released with some antibiotics and Tylenol.

Two days later, he returned to the hospital in an ambulance. Two days after that, he was finally diagnosed with Ebola. Eight days later, he died alone in a hospital room.

Now, Dallas suffers. Our country is concerned. Greatly. About the lack of answers and transparency coming from a hospital whose ignorance, incompetence and indecency has yet to be explained. I write this on behalf of my family because we want to set the record straight about what happened and ensure that Thomas Eric did not die in vain. So, here’s the truth about my uncle and his battle with Ebola.

Thomas Eric Duncan was cautious. Among the most offensive errors in the media during my uncle’s illness are the accusations that he knew he was exposed to Ebola — that is just not true. Eric lived in a careful manner, as he understood the dangers of living in Liberia amid this outbreak. He limited guests in his home, he did not share drinking cups or eating utensils.

And while the stories of my uncle helping a pregnant woman with Ebola are courageous, Thomas Eric personally told me that never happened. Like hundreds of thousands of West Africans, carefully avoiding Ebola was part of my uncle’s daily life.

And I can tell you with 100 percent certainty: Thomas Eric would have never knowingly exposed anyone to this illness.

Thomas Eric Duncan was a victim of a broken system. The biggest unanswered question about my uncle’s death is why the hospital would send home a patient with a 103-degree fever and stomach pains who had recently been in Liberia — and he told them he had just returned from Liberia explicitly due to the Ebola threat.

Some speculate that this was a failure of the internal communications systems. Others have speculated that antibiotics and Tylenol are the standard protocol for a patient without insurance.

The hospital is not talking. Until then, we are all left to wonder. What we do know is that their error affects all of society. Their bad judgment or misjudgment sent my uncle back into the community for days with a highly contagious case of Ebola. And now, officials suspect that a breach of protocol by the hospital is responsible for a new Ebola case, and that all health care workers who care for my uncle could potentially be exposed.

Their error set the wheels in motion for my uncle’s death and additional Ebola cases, and their ignorance, incompetence or indecency has created a national security threat for our country.

Thomas Eric Duncan could have been saved. Finally, what is most difficult for us — Thomas Eric’s mother, children and those closest to him — to accept is the fact that our loved one could have been saved. From his botched release from the emergency room to his delayed testing and delayed treatment and the denial of experimental drugs that have been available to every other case of Ebola treated in the U.S., the hospital invited death every step of the way.

When my uncle was first admitted, the hospital told us that an Ebola test would take three to seven days. Miraculously, the deputy who was feared to have Ebola just last week was tested and had results within 24 hours.

The fact is, nine days passed between my uncle’s first ER visit and the day the hospital asked our consent to give him an experimental drug — but despite the hospital’s request they were never able to access these drugs for my uncle. (Editor’s note: Hospital officials have said they started giving Duncan the drug Brincidofovir on October 4.) He died alone. His only medication was a saline drip.

For our family, the most humiliating part of this ordeal was the treatment we received from the hospital. For the 10 days he was in the hospital, they not only refused to help us communicate with Thomas Eric, but they also acted as an impediment. The day Thomas Eric died, we learned about it from the news media, not his doctors.

Our nation will never mourn the loss of my uncle, who was in this country for the first time to visit his son, as my family has. But our nation and our family can agree that what happened at Texas Health Presbyterian Hospital Dallas must never happen to another family.

In time, we may learn why my uncle’s initial visit to the hospital was met with such incompetence and insensitivity. Until that day comes, our family will fight for transparency, accountability and answers, for my uncle and for the safety of the country we love.

Josephus Weeks, a U.S. Army and Iraq War veteran who lives in North Carolina, wrote this piece exclusively for The Dallas Morning News. Reach him at josephusweeks@yahoo.com.

http://www.dallasnews.com/opinion/latest-columns/20141014-josephus-weeks-ebola-didnt-have-to-kill-my-uncle.ece

Complexity of the 90 day grace period for paying exchange plan premiums

The Ninety-Day Grace Period

Health Affairs, Health Policy Briefs, October 16, 2014

To help enrollees new to the system keep their insurance, the ACA provides a ninety-day grace period before an insurer can discontinue someone’s coverage for failure to pay a monthly premium. This applies only to those who have received an advance premium tax credit to purchase health insurance through the Marketplaces and have previously paid at least one month’s full premium in that benefit year.

The grace period allows for continuity of care for patients by preventing people from shifting or “churning” in and out of coverage when they fail to make a monthly premium payment.

In final regulations, CMS said issuers must pay all appropriate claims for medical services rendered to the enrollee during the first month of the grace period, and the insurer may put on hold claims for services rendered to the enrollee in the second and third months. Issuers must also notify HHS of such nonpayment and notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period.

During these second and third months of the grace period, because the patient is still insured, he or she cannot be billed by the provider for any remainder that is owed for medical services that the enrollee received. But if an enrollee fails to pay his or her premiums and the entire grace period elapses, providers are allowed to seek payment for the medical services they gave to that patient and for which the insurance company did not reimburse claims.

Patient assistance programs: Some providers have expressed interest in providing premium and cost-sharing assistance for their patients enrolled in coverage through the Marketplaces. By helping their patients maintain coverage and avoid the grace period in the first place, providers hope to reduce the risk that medical claims for care they provide will go unpaid.

However, questions continue to swirl about the legality of such an approach. Although federal anti-kickback regulations might seem to prohibit this type of practice, HHS has stated that such regulations do not apply to the Marketplaces, their plans, and premium tax credits because they are not considered “federal health care programs.”

The ACA’s uniform grace period could prove to play an important role in keeping people enrolled in their plans. But big questions remain unanswered about the financial risks to which physician practices or hospitals could be exposed, as well as how much risk insurers face for claims in the grace period and how that might affect premium growth for all enrollees over time.

http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=128

Comment:

By Don McCanne, M.D.

The Affordable Care Act provides a 90 day grace period during which health care coverage through exchange plans is continued before insurers can cancel the plans for non-payment of premiums. However, the insurers must pay claims for only the first 30 days, whereas providers are not allow to collect from the patient during the remaining 60 days. After 90 days of nonpayment of premiums, the patient can be retroactively billed, though collection can be difficult since most of these patients do not have enough funds to pay their premiums, much less their health care bills.

If you read the full Health Policy Brief, you will see that the issues are even more complex. The 90 day rule is yet one more unnecessary administrative burden that ACA added to our already highly complex system of financing health care. Under a single payer system there would be no such thing as a 90 day grace period. Financing of the health care system would be as automatic as it is now with Medicare.

US Hospitals Lead Global Pack on Costly Paperwork

By Steffie Woolhandler and David Himmelstein
Common Dreams, Oct. 16, 2014

In some countries, bereaved families get condolence cards and flowers. In ours, the survivors are also deluged with hospital bills and insurance paperwork.

That paperwork isn’t merely an insult. It costs our society a fortune. Take hospitals, for instance. According to research we recently published in Health Affairs, U.S. hospitals spent $215 billion in 2011 on billing and administration, a striking 1.43 percent of GDP.

Put another way, about $1 of every $4 of U.S. hospital spending goes to bureaucracy rather than patient care.

Other countries manage modern, first-rate hospital systems for far less. While administration devoured $667 per capita annually in the U.S., we found that Canada spent only $158, Scotland $164, England $225 and the Netherlands $325.

If U.S. hospitals ran as efficiently as Canada’s, the average U.S. family of four would save $2,000 annually on health care.

Moreover, our hospital paperwork costs have risen sharply since 2000, even after adjusting for inflation. In contrast, administration’s share of hospital budgets in Canada has actually fallen since 1999.

A generation ago, it took just one or two managers to run a U.S. hospital. Now, the CEO has been joined by “chief officers” for operations, finance, compliance, information, quality management, and more.

Each chief commands his/her own legions – hundreds of billing and registration clerks, referral managers, upcoding specialists (to translate doctors’ diagnoses into the most profitable billing codes), and massive IT departments whose first commandment is “get the bill right.”

Why are U.S. hospitals so inefficient? Our multiple-payer insurance system forces every hospital to negotiate rates with dozens of insurance plans, each with its own coverage rules, billing procedures and documentation requirements. And each hospital must collect deductibles, co-payments and co-insurance from tens of thousands of patients.

In contrast, Canada and Scotland – where bureaucratic costs are lowest – have single-payer systems that reject this kind of red tape and the need to bill for every Band-Aid. They pay hospitals simple lump-sum budgets, the way we fund local fire stations. And like fire departments, their hospitals don’t need to collect from each victim of misfortune.

But the complexity of hospital billing isn’t the only thing driving bureaucracy. Hospitals have been forced to add layers of business expertise in order to survive in our market-driven system.

A hospital that doesn’t show an operating profit can’t fund essential new investments in new equipment and cutting-edge services, or modern buildings. That means administrators have to devote resources to financial gaming like marketing lucrative services (e.g. sports medicine); billing units to squeeze every penny from insurers and patients; and strategies to recruit profitable (well-insured) patients, and avoid unprofitable (e.g. uninsured) ones.

The dismal record of for-profit hospitals illustrates the problem with running hospitals as businesses. The for-profits have higher death rates and employ fewer clinical personnel like nurses than their non-profit counterparts. But care at for-profits actually costs more, and they spend much more on the bureaucracy, a reflection of the high cost of implementing shrewd financial strategies.

Canadian and Scottish hospital administrators don’t have to play financial games to assure their survival. Government grants – rather than operating profits – pay for new buildings and equipment. Even in France and Germany, where hospitals bill multiple payers, bureaucratic costs are modest because government directly funds most hospital investments.

England and the Netherlands provide unfortunate counter-examples. Pro-market reforms initiated during the Thatcher era have driven English hospital administrative costs sharply higher. And only U.S. hospitals have higher administrative costs than those in the Netherlands, where radical market-oriented reforms now pressure hospitals to show a profit.

Economics textbooks hold that subjecting medicine to market forces will stimulate efficiency and root out waste. But reality stubbornly refuses to obey. In health care, market-oriented policies encourage hospitals to shift resources to business strategies that boost the bottom line, and contribute nothing to care.

The management takeover of health care is redolent of Charles Dickens’ tale of a hostel bequeathed as a lodging for six homeless travelers. Eventually, the charitable administrators fully occupied the hostel, and relegated the travelers to outbuildings:

“I found, too, that about a thirtieth part of the annual revenue was now expended on the purposes commemorated in the inscription over the door – the rest being handsomely laid out in chancery, law expenses, collectorship, receivership, poundage, and other appendages of management, highly complimentary to the importance of the six Poor Travelers.”

Dickens’ message was clear. Will we act accordingly today?

Dr. Steffie Woolhandler is a co-founder of Physicians for a National Health Program. She is professor of public health at the City University of New York and visiting professor of medicine at Harvard Medical School. She is also a primary care physician at Cambridge Hospital in Cambridge, Mass.

Dr. David Himmelstein is a co-founder of Physicians for a National Health Program. He is professor of public health at the City University of New York and visiting professor of medicine at Harvard Medical School. He has served as the chief of the division of social and community medicine at Cambridge Hospital where he practices primary care internal medicine, and co-founded the Center for a National Health Program Studies at Harvard.

This work is licensed under a Creative Commons Attribution-Share Alike 3.0 License

http://www.commondreams.org/views/2014/10/16/us-hospitals-lead-global-pack-costly-paperwork

Think about your health when you vote in November

By Philip Caper, M.D.
Bangor (Maine) Daily News, Oct. 16, 2014

Elections matter. And when it comes to health care, the upcoming election on Nov. 4 will matter a lot. This seems an appropriate time to take stock of where we stand.

I strongly believe in health care with dignity for everybody. When I took the Hippocratic Oath, I swore to put the patient first. That means treating people according to their medical needs, not their employment status, net worth, place of employment, age, gender, lifestyle or where they happen to live.

The United States spends more on health care — about 50 percent more — than any other wealthy country. Despite continuing to pour more and more money into health care, we still rank behind those countries on infant mortality, life expectancy, health care quality and access to needed care. The fact that we continue to do so every year tells us we need new thinking.

Where is all that money going? According to the Institute of Medicine, we in the U.S. waste $750 billion a year on our broken health care system.

The Affordable Care Act is a first step in trying to repair it. Offering federal subsidies for private insurance, expanding Medicaid and neighborhood health centers and regulating insurance industry abuses are important advances. We shouldn’t toss them aside. Repealing the ACA, as many conservatives propose, would be a disaster for Maine and for the country — unless we replace it with something better.

The ACA is in some ways a step forward, but it is not enough. Even with greatly expanded coverage, too many Americans will not see the benefits they would with a universal health care system.

Maine is the only state in New England that has failed to expand Medicaid and is one of just two states in the country where the number of people without health insurance increased in 2013. Expanding MaineCare would cover an additional 70,000 Mainers at almost no cost to the state and would inject nearly $1 million a day of federal revenue into our economy. Failure to do that — because of Gov. Paul LePage’s vetoes, sustained by Republicans in the Legislature — has cost the people of Maine more than $300 million so far.

We can do much better than that. We need a simpler, less expensive system that includes everybody. We already have such system for seniors — it’s called “Medicare.” When Medicare was implemented by the federal government in 1965, 19 million people were enrolled within nine months, using index cards. There were no software glitches, no crashing websites and little confusion. There was no need to re-enroll every year. Once people are enrolled in Medicare, they stay in it for life.

We need to extend the benefits of Medicare to every Mainer and to every American. There are two ways we can accomplish this.

Congress could pass a new law expanding Medicare. There are bills in the House and the Senate that would do that. But we don’t need to wait for new national legislation. There is another way.

Starting in 2017, existing federal law allows individual states to design their own health care reform if it provides at least as many benefits at no greater cost. No more exchanges, mandates on businesses and individuals to buy private insurance, or hard-to-enforce tax penalties.

That opportunity shouldn’t be missed. Our neighbors in Vermont already have passed a law setting the goal of a single publicly financed health care system to include every Vermonter. They are now moving forward to implement that law. Rather than cutting more people from the rolls, Maine should retake its position as a national leader in health care.

The popular and successful Canadian health care system, which was once almost identical to ours, got started in one province: Saskatchewan. It was so successful that within 10 years it spread across the country.

According to William Hsiao, an internationally respected Harvard health care economist, we could save $1 billion a year in unnecessary administrative costs in Maine alone by making fundamental changes in the ways we finance health care. The money we save could then be invested in roads and bridges, improved public safety and educating our children. It would result in higher wages for our workers and would stimulate the creation of new businesses. It would free our people up to pursue their dreams, instead of being stuck in dead end jobs just to get health care benefits.

But those changes can’t and won’t be made without the full and energetic support of our people, our governor, our legislature and our entire congressional delegation.

That’s worth thinking about when you go to the polls Nov. 4.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com or through his website at philcaper.net.

http://bangordailynews.com/2014/10/16/health/blogs-and-columns/think-about-your-health-when-you-vote-in-november/?ref=search

Will malpractice reform prevent “defensive medicine”?

The Effect of Malpractice Reform on Emergency Department Care

By Daniel A. Waxman, M.D., Ph.D., Michael D. Greenberg, J.D., Ph.D., M. Susan Ridgely, J.D., Arthur L. Kellermann, M.D., M.P.H., and Paul Heaton, Ph.D.
The New England Journal of Medicine, October 16, 2014

Emergency department care has been a particular focus of a new generation of malpractice reform laws. Approximately a decade ago, the states of Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005) changed their malpractice standard for emergency care to “willful and wanton negligence” (in Texas) and “gross negligence” (in Georgia and South Carolina). From a legal standpoint, these two standards are considered to be synonymous and are widely considered to be a very high bar for plaintiffs. Under typical interpretations of this standard, a plaintiff must show that a physician had “actual, subjective awareness” of “the likelihood of serious injury” but nevertheless proceeded with “conscious indifference.”

The Texas, Georgia, and South Carolina laws are intended to protect physicians who are practicing with incomplete information in high-intensity care settings. The enactment of these laws offers an unusual circumstantial experiment with which to evaluate a type of reform that is qualitatively different from what has been studied previously.

Study Design

We used a quasi-experimental analytic approach that was designed to evaluate the effect of legal reform on the treatment of Medicare patients in the emergency department; we attempted to isolate the effect of the law from temporal trends and from characteristics of patients and hospitals (i.e., to evaluate changes that could be attributable to the new policy).

Results

Malpractice reform was not associated with a significant decrease in CT or MRI utilization in any of the three states. There was no significant reduction in per-visit emergency department charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval [CI], 0.9 to 6.2; P=0.01) in charges. There was no reduction in the rate of hospital admissions in any of the three states.

Discussion

Malpractice reforms in Texas, Georgia, and South Carolina, which changed the liability standard for emergency care from ordinary negligence to gross negligence, provide unusually broad protection for emergency physicians. We did not find evidence that these reforms decreased practice intensity, as measured by the rate of the use of advanced imaging, by the rate of hospital admission, or in two of three cases, by average charges. Although there was a small reduction in charges in one of the three states (Georgia), our results in aggregate suggest that these strongly protective laws caused little (if any) change in practice intensity among physicians caring for Medicare patients in emergency departments.

In the context of the existing literature, our findings suggest that physicians are less motivated by legal risk than they believe themselves to be. Although a practice culture of abundant caution clearly exists, it seems likely that an aversion to legal risk exists in parallel with a more general risk aversion and with other behavioral, cultural, and economic motivations that might affect decision making. When legal risk decreases, the “path of least resistance” may still favor resource-intensive care. Our results suggest that malpractice reform may have less effect on costs than has been projected.

http://www.nejm.org/doi/full/10.1056/NEJMsa1313308

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Comment:

By Don McCanne, MD

When the topic of controlling health care costs comes up, those opposed to single payer reform, and, for that matter, opposed to the Affordable Care Act, frequently cite the need for malpractice reform, often claiming that defensive medicine (ordering unnecessary tests and medical interventions merely to prevent lawsuits) is a major cause of excess health care spending. This article casts doubt that malpractice reform would reduce supposed defensive medicine.

The three states studied – Texas, Georgia and South Carolina – passed laws requiring a much more rigid standard of “gross negligence” for emergency department physicians to be found liable for malpractice. Data available from Texas demonstrates that their reforms did reduce malpractice claim filings by 60 percent, and reduced malpractice payments by 70 percent. Physicians were reassured that they were protected as long as they did not proceed with “conscious indifference” with care that had a “likelihood of serious injury.”

Now that there was no longer a need for CT and MRI scans and hospital admissions that  were done only to prevent lawsuits, the level of these presumed defensive medicine measures should have decreased. They did not.

This suggests that these measures were taken for reasons other than simply to prevent lawsuits. A low yield test or procedure is not necessarily a no yield intervention. These are done because there is a real chance, even if at low odds, that the intervention may benefit the patient.

This study leads us to conclude that the concept that there is excessive resource-intensive care provided strictly as defensive medicine should be abandoned and replaced with patient-centered outcomes research to better determine what is of value in health care (PCORI in ACA is such an attempt).

We should no longer allow ourselves to be distracted by false promises of health care savings through flawed concepts such as defensive medicine. We know what will greatly reduce wasteful spending, and that is a single payer national health program. We must not be distracted from trying to achieve that goal.

States largely ignoring network inadequacies

Implementation of the Affordable Care Act: Cross-Cutting Issues: Six-State Case Study on Network Adequacy

By Sabrina Corlette, Kevin Lucia, and Sandy Ahn
Urban Institute, September 2014

During the transition to new health plans and new marketplaces under the Affordable Care Act (ACA), many insurers revamped their approach to network design, and many now offer narrower provider networks than they have in the past. In this study for the Robert Wood Johnson Foundation’s project to monitor ACA implementation, researchers assessed network changes and efforts at regulatory oversight in six states: Colorado, Maryland, New York, Oregon, Rhode Island, and Virginia. Researchers found that insurers made significant

changes to the provider networks of their individual market plans, both inside and outside the marketplaces, and that insurers took varying approaches to network design. Across all six states, insurers and state officials alike reported consumer and provider confusion about which plan networks included which providers, but most have received few consumer complaints about their ability to obtain in-network services. While three of the six states have taken action to improve provider directories, it appears unlikely that state legislatures, officials and regulators will dramatically change network adequacy standards, at least in the short-term.

Conclusion

Insurers have used—and are likely to continue to use— network design to curb costs and offer customers a more affordable premium. This was a clear trend in the individual market as insurers approached the 2014 plan year, and some of our informants believe it will soon extend to the group market as employers look for ways to reduce premiums. However, despite concerns among some regulators, consumer advocates, and providers that overly narrow networks could harm quality of care and place consumers at significant financial risk, most of our study states are not planning to significantly change their oversight of plan networks. Though consumers reported problems with inaccurate provider directories and a lack of consumer-friendly, comparable information about the scope of plan networks, only half of our study states report requiring insurers to improve the information made available to consumers. At the same time, state officials and insurers also reported that consumers were generally not complaining about difficulty obtaining needed care from providers. Consequently, most state legislatures, officials and regulators are unlikely to change network adequacy standards, at least in the short-term.

http://www.urban.org/UploadedPDF/413240-Six-State-Case-Study-on-Network-Adequacy.pdf

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Comment:

By Don McCanne, MD

Private insurers use narrow networks of physicians and hospitals so that they can negotiate more favorable provider rates which then supposedly allows them to keep their insurance premiums more competitive. The trade-off is that patients lose their choice of providers and increase the risk that they will suffer severe financial penalties because of unavoidable circumstances wherein care is obtained out of network, or worse, care is not received at all because of impaired access.

The use of narrow networks will cause harm to many patients. Yet, according to this report, for the present, “most state legislatures, officials and regulators are unlikely to change network adequacy standards.” Also, although provider directories are notoriously inaccurate, “only half of our study states report requiring insurers to improve the information made available to consumers.”

How much do the insurers really save by using narrow networks? The savings is not the difference between the prices specified by the providers and the amount contracted with the narrow network providers. Insurers already receive sharp discounts from the providers in their broad networks. So the savings is only the very modest additional amount squeezed out of those who contract for the more exclusive narrower networks. That savings is surely not worth the impaired access, loss of choice, and potential financial hardship brought by narrow networks.

With a single payer system, fair payments apply to all physicians and hospitals, therefore there is no need to establish separate networks. The one network is the entire health care delivery system (except for those who choose integrated delivery systems such as Kaiser Permanente). Government administered pricing is far more patient friendly than market-based manipulations, and isn’t the patient what it is all about?

Psychiatrist appointments hard to get, even for insured: Psychiatric Services study

Harvard researchers find poor access to outpatient psychiatric care in Boston, Chicago and Houston metro areas, with unreturned telephone calls, wrong numbers, and full practices

FOR IMMEDIATE RELEASE
Oct. 15, 2014

Contact:
Mark Almberg, communications director PNHP, mark@pnhp.org, (312) 782-6006

Obtaining access to private outpatient psychiatric care in the Boston, Chicago and Houston metropolitan areas is difficult, even for those with private insurance or those willing to pay out of pocket, a new study by Harvard researchers shows.

The researchers, who posed on the phone as patients seeking appointments with individual psychiatrists, encountered numerous obstacles, including unreturned calls, wrong numbers and providers who were no longer taking new patients. They met with success in only one-quarter of their attempts, even after two tries.

These and related findings were published online today [Wednesday, Oct. 15] by Psychiatric Services, a peer-reviewed journal of the American Psychiatric Association.

The researchers made telephone calls to 360 psychiatrists – 120 in each metro area – who were listed in the Blue Cross and Blue Shield (BCBS) online database of in-network providers. The callers posed as patients with BCBS PPO insurance or Medicare, or as willing to pay out of pocket.

They utilized the BCBS database because the BCBS system is the largest provider of health insurance in Massachusetts, Illinois and Texas. The psychiatrists were located within a 10-mile radius of suburban ZIP codes in Boston, Chicago and Houston.

Of 360 psychiatrists called, the “simulated patients” were able to obtain appointments with only 93 of them, or 26 percent. Although the callers were able to obtain appointments more frequently using BCBS or as self-pay compared to Medicare, this difference was not significant. There was a significant difference in success rate between cities, however, with psychiatrists in Boston least likely to offer an appointment and those in Houston most likely to do so.

In most cases, psychiatrists simply did not return calls (23 percent). There were also a large number of incorrect phone numbers (16 percent). The wrong numbers listed included a jewelry store, a boutique, and a McDonald’s restaurant. Additionally, 15 percent of practices were full and not accepting new patients. Another 10 percent of the psychiatrists identified through the BCBS directory did not see general adult outpatients.

These findings add to the growing evidence that the mental health system is difficult for consumers to access. They are in line with national data demonstrating that two-thirds of primary care physicians cannot obtain outpatient mental health services for patients who need them.

The findings also show that having insurance is not enough to guarantee access to outpatient psychiatric care. The authors conclude that increasing the number of psychiatrists would increase access. As such, they call for measures to make psychiatry a more appealing field for medical students to enter, including through measures such as integrating psychiatric care with primary care, along with better reimbursements for psychiatric care by insurers and others.

Lead author Monica Malowney, M.P.H., formerly at the Harvard-affiliated Cambridge Health Alliance and now with the Department of Population Health at the Maimonides Medical Center in Brooklyn, N.Y., said: “This study poignantly illustrates how difficult it can be for patients to obtain needed mental health care. Insurance companies need to ensure that the lists of providers they offer patients contain accurate phone numbers as well as practices that are actually accepting new patients. How likely is it that a severely depressed person would persevere through so many obstacles?”

Senior author Dr. J. Wesley Boyd, an attending psychiatrist at Cambridge Health Alliance and Harvard Medical School faculty member, said: “Insurers provide lists of providers, but they are filled with names of individuals whose practices are full or who don’t bother to return phone calls or with phone numbers that are simply wrong. Calling for a psychiatric appointment and reaching a McDonald’s? That is totally unacceptable.”

He continued: “Insurance companies care more about turning a profit than actually providing care. Everyone, even individuals with supposedly excellent insurance, has a hard time accessing psychiatric care, so what is needed is a comprehensive overhaul of psychiatric care in the context of a thoughtful single-payer system that allocates resources according to our nation’s medical needs.”

“Availability of Outpatient Care from Psychiatrists: A Simulated-Patient Study in Three Cities,” by Monica Malowney, M.P.H., Sarah Keltz, Daniel Fischer, M.D., J. Wesley Boyd, M.D., Ph.D. Psychiatric Services, November 2014, Vol. 65, No. 11, published online in advance on Oct. 15, 2014.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 19,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

U.S. hospitals not prepared for Ebola threat

By RoseAnn DeMoro
The Washington Post, Oct. 13, 2014

With reports that a nurse who treated Ebola patient Thomas Eric Duncan in Dallas has been infected, one thing urgently needs to be made clear: Our hospitals are not prepared to confront the deadly virus.

It is long past time to stop relying on a business-as-usual approach to a virus that has killed thousands in West Africa and has such a frighteningly high mortality rate. There is no margin for error. That means there can be no standard short of optimal in the protective equipment, such as hazmat suits, given to nurses and others who are the first to engage patients with Ebola-like symptoms. All nurses must have access to the same state-of-the-art equipment used by Emory University Hospital staff when they transported Ebola patients from Africa, but too many hospitals are trying to get by on the cheap.

In addition, hospitals and other frontline providers should immediately conduct hands-on training and drills so that personnel can practice, in teams, vital safety procedures such as the proper way to put on and remove protective equipment. Hospitals must also maintain properly equipped isolation rooms to ensure the safety of patients, visitors and staff and harden their procedures for disposal of medical waste and linens.

We all count on nurses to be there for us when we’re at our sickest and most vulnerable, and it’s everyone’s problem if nurses are not protected. But according to an overwhelming majority of nurses surveyed by National Nurses United at facilities across the United States, many hospitals remain unprepared.

And Ebola is exposing a broader problem: the sober reality of our fragmented, uncoordinated private health-care system. We have enormous health-care resources in the United States. What we lack is a national, integrated system needed to respond effectively to a severe national threat such as Ebola.

The Centers for Disease Control and Prevention issues guidelines but has no authority to enforce them. Hospitals have wide latitude to pick and choose what protocols they will follow; too often in a corporate medical system those decisions are based on budget priorities, not what is best for the health and safety of patients and caregivers. Congress and state lawmakers put few mandates on what hospitals must do in the face of pandemics or other emergencies, and local health officials do not have the authority to direct procedures and protocols at hospitals.

Where other countries — notably Canada, which took action after its vulnerabilities were exposed by the 2003 SARS epidemic — have empowered their public health agencies to coordinate local, state and federal detection and response efforts for pandemics, the United States cut funding for its already-weak system. Federal funding for public health preparedness and response activities was $1 billion less in fiscal 2013 than 2002.

As one CDC official recently admitted to The Post: “We let our guard down a little bit. . . . Now that we’ve seen this happen, we know now that we need to do more to make people feel prepared.”

We should have seen this coming. As recently as August, an inspector general’s report evaluating the Department of Homeland Security’s pandemic preparedness concluded that “the Department has no assurance it has sufficient personal protective equipment and antiviral medical countermeasures for a pandemic response.”

We know what works: a federal agency with the authority to ensure local, state and national coordination in response to outbreaks. In such an empowered public health system, local health officials are assured of having the resources to identify the source of an outbreak, isolate and treat the sick, and follow up with those who have had close contact with the sick. Only greater integration and the authority of a public health system with national, uniform standards can protect Americans.

It’s time to listen to our nurses. Let’s stop Ebola now and be better prepared for the next pandemic.

RoseAnn DeMoro is executive director of National Nurses United.

http://www.washingtonpost.com/opinions/roseann-demoro-us-hospitals-not-prepared-for-ebola-threat/2014/10/13/4351ffc2-52cf-11e4-892e-602188e70e9c_story.html

Status of higher payment for primary care under Medicaid

Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015

By Vernon K. Smith, Kathleen Gifford, Eileen Ellis, Robin Rudowitz and Laura Snyder
Kaiser Family Foundation, October 14, 2014

Primary Care Payments

The ACA included a provision to increase Medicaid payment rates for primary care services to Medicare rates from January 1, 2013 through December 31, 2014. The federal government funded 100 percent of the difference between Medicaid rates that were in effect as of July 1, 2009 and the full Medicare rates for these two years. States were asked about their plans to extend this provision beyond December 31, 2014 (at regular FMAP rates). For states that have Medicaid rates for physician services that were already at or close to 100 percent of Medicare rates, this issue was not significant.

  • Twenty-two states indicated that they would not be continuing the primary care rate increase.
  • Fifteen states (Alaska, Alabama, Colorado, Connecticut, Delaware, Hawaii, Iowa, Maryland, Maine, Michigan, Mississippi, Nebraska, Nevada, New Mexico, and South Carolina) indicated that they will continue the higher rates at least partially if not fully. For example one state will provide a proportionate increase for all primary care physicians (half of the ACA rate increase); others plan to continue temporarily or target it to certain types of primary care.
  • Fourteen states indicated they had not yet made a decision on this policy and were still evaluating whether the enhanced rates had any impact on provider participation. Given the delayed implementation of the rate enhancement and the difficulty of attributing changes in provider enrollment and access to the enhanced payments, the impact of the increased rates is difficult to determine.

Medicaid in an Era of Health & Delivery System Reform: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2014 and 2015 – Provider Rates and Taxes or Fees

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Primary Care Services under Managed Care Delivery Systems

Medicaid.gov

Qs &As on the Increased Medicaid Payment for Primary Care CMS 2370-F – MANAGED CARE

The requirements under 42 CFR 438.804 specify that the states submit two methodologies to the Centers for Medicare & Medicaid Services (CMS) for review and approval to implement this rule. How does approval of these methodologies impact the approval process for managed care contracts and rate packages for 2013?

Implementing regulations at 42 CFR 438.804 require states to submit to CMS a methodology for calculating the July 1, 2009, baseline rate for eligible primary care services and a methodology for calculating the rate differential eligible for 100 percent of Federal Financial Participation (FFP) by March 31, 2013. Further, 42 CFR 438.6 (c)(5)(vi) establishes Managed Care Organization (MCO), Prepaid Inpatient Health Plan (PHIP) or Prepaid Ambulatory Health Plan (PAHP) contract requirements to comply with this provision. It is CMS’s expectation that as soon as practicable after the State submits the required methodologies in 42 CFR 438.804 and receives CMS approval, the State will:

  1. submit revised actuarial certification documents reflecting the Medicare rate for eligible primary care services in their MCO, PIHP or PAHP capitation rates; and
  2. submit amendment(s) to this contract to ensure compliance with 42 CFR 438.6 (c)(5)(vi).

After CMS approval of the revised contract and rates, the MCO, PIHP or PAHP must direct the full amount of the enhanced payment to the eligible provider to reflect the enhanced payment effective January 1, 2013. Federal financial participation (FFP) is available at a rate of 100 percent for the portion of capitation rates attributable to these enhanced payments; however, receipt of the enhanced FFP is contingent upon the state’s successful completion of this process.

http://www.medicaid.gov/AffordableCareAct/Provisions/Downloads/Q-and-A-on-Increased-Medicaid-Payments-for-PCPs-managed-care.pdf

CMS 2370-F – MANAGED CARE (Set II)

The final rule specified that states will need to recoup the enhanced payments made to non- eligible providers identified through the annual statistically valid sample. Must health plans follow the same procedure for non-eligible providers?

States must require health plans to recoup erroneous payments found through the sampled pools of providers, and in a number of states, this sample will include both FFS and managed care providers.

Are MCOs permitted to include amounts sufficient to account for the payment differential on expected utilization while still holding the sub-capitated primary care physicians at risk for some level of increase in utilization due to the higher rates? Or must MCOs remove the risk to primary care physicians for utilization to ensure that these physicians receive the increased amount for actual experience?

The purpose of section 1202 of the Affordable Care Act and the final rule is to ensure access to and utilization of beneficial primary care services. Towards that goal, eligible primary care physicians must receive the full benefit of the enhanced payment at the Medicare rate for eligible services rendered. If a Medicaid managed care health plan retains sub-capitation arrangements, the health plan would be obligated to provide additional payments to providers to ensure that every unit of primary care services provided is reimbursed at the Medicare rate.

http://www.medicaid.gov/AffordableCareAct/Provisions/Downloads/Qs-andAs-on-the-Increased-Medicaid-Payment-for-Primary-Care-MANAGED-CARE-Set-II.pdf

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Comment:

By Don McCanne, MD

As the Affordable Care Act (ACA) was being crafted, it was recognized that the expansion of coverage under Medicaid could result in greater access problems because of the low Medicaid payment rates and the lack of willing providers. In order to improve access, at least to primary care, it was decided to increase Medicaid primary care payment rates to the same level as Medicare for the years 2013 and 2014. As with so many of the ACA provisions, this seemingly simple solution has proven to be more complex.

Before and during this transition most states were moving many or all of their Medicaid patients into managed care programs. So the government had to issue guidelines on how to move enhanced Medicaid primary care payments into managed care organizations receiving capitation payments, and to be sure that these enhanced payments were directed to the eligible primary care providers (more administrative excesses). Although we are near the end of the two year period in which primary care payments are enhanced, news reports suggest that confusion and delays have not been entirely resolved.

Although these enhanced payments were considered to be crucial in ensuring adequate participation of primary care providers, twenty-two states have indicated that they would not be continuing the primary care rate increases. Fifteen states have decided to continue, though many at lower rates and perhaps only temporarily. Fourteen states are undecided. “Given the delayed implementation of the rate enhancement and the difficulty of attributing changes in provider enrollment and access to the enhanced payments, the impact of the increased rates is difficult to determine.”

Medicaid is a welfare program, and, as such, will continue to be chronically underfunded. Medicaid patients frequently have difficulties accessing primary care services, and the continued underfunding will perpetuate that problem. Access to specialized services is even more limited because of the very low participation rates of specialists.

Single payer would eliminate these injustices since we would all have the same high-quality program – an improved Medicare for all.

Dr. Martin Luther King on health care injustice

PNHP note: The Associated Press wire story below, dated March 26, 1966, contains the first known published reference to Dr. King’s famous quotation regarding injustice in health care, namely, “Of all the forms of inequality, injustice in health is the most shocking and inhuman.”

According to this AP account, Dr. King’s remarks were made at a Chicago press conference held on March 25, 1966, in connection with the annual meeting of Medical Committee for Human Rights. The AP story, which carries no byline, was published the next day in newspapers around the country.

PNHP’s Dr. Quentin Young, who was present at the press conference in his capacity as a leader of MCHR, has frequently attested to the accuracy of the quotation, but until recently he and other PNHP staff were unaware of any published accounts of the proceedings that corroborated his memory.

A slightly different version of Dr. King’s remarks was published in a Cleveland newspaper, the Call and Post, about three weeks later, on April 16, 1966. In that account, produced by the NPI news service, Dr. King is quoted as saying, “Of all forms of discrimination and inequalities, injustice in health is the most shocking and inhuman.” It’s reasonable to assume that the AP story, published the day after the press conference, is the more accurate of the two.

Both stories are reproduced below.

King Berates Medical Care Given Negroes

Oshkosh Daily Northwestern (Oshkosh, Wis.), March 26, 1966

CHICAGO (AP) – Massive direct-action is needed to “raise the conscience of the nation” to the segregated and inferior medical care received by Negroes, Dr. Martin Luther King Jr. said Friday night.

Calling for court suits to force doctors and hospitals to comply with the Civil Rights Act, King and officers of the Medical Committee for Human Rights accused the American Medical Association of a “conspiracy of inaction” in civil rights.

At a press conference before his speech to the committee’s annual meeting. King said: “We are concerned about the constant use of federal funds to support this most notorious expression of segregation. Of all the forms of inequality, injustice in health is the most shocking and the most inhuman because it often results in physical death.

“I see no alternative to direct action and creative nonviolence to raise the conscience of the nation.”

Dr. John L. S. Holloman, a New York City physician who heads the interracial committee, told reporters: “There is scarcely a hospital North or South that does not overtly or covertly discriminate against Negroes. County medical societies, especially in the South, have discriminated in admitting qualified Negro doctors.” he said. “We put the blame right on their (the AMA’s) doorstep.” The AMA had no immediate comment.

http://www.newspapers.com/newspage/21451804/

The same Associated Press wire story appeared in the Fresno Bee (Fresno, Calif.), the Ironwood Daily Globe (Ironwood, Mich.), and the Mt. Vernon Register News (Mt. Vernon, Ill.), among other outlets.

Three-Pronged Assault Planned for Hospitals

Call and Post (Cleveland), April 16, 1966

CHICAGO (NPI) – Hospitals that discriminate against Negroes face a triple assault – from both private and government sources.

An official of the U.S. Department of Health, Education, and Welfare said HEW plans to cut off federal aid to hospitals found guilty of practicing discrimination.

Meanwhile, Dr. Martin Luther King, Jr., said that civil rights leaders are planning “direct action” against Chicago hospitals that fail to give Negroes equal treatment.

Also, Dr. John L.S. Holloman, Jr., chairman, Medical Committee for Human Rights, revealed that his organization will soon assist in federal suits against hospitals that practice discrimination.

The HEW action was announced by Philip R. Lee, the department’s secretary for health and scientific affairs. Lee said his department is fully prepared to stop funds to hospitals in order to bring about compliance with Title VI of the 1965 Civil Rights Act.

That section of the law forbids the federal government to aid any activity which discriminates on grounds of race or national origin.

Lee said 220 discrimination complaints are on file with HEW.

In announcing his “direct action campaign” against Chicago hospital discrimination, Dr. King noted that the Negro infant mortality rate in the city’s poverty-stricken Woodlawn area is as bad as Mississippi’s rate.

“Of all forms of discrimination and inequalities, injustice in health is the most shocking and inhuman,” Dr. King said.

The rights leader said federal officials have promised to look into hospital discrimination, but have done nothing.

“We must move beyond sending complaints to Washington and act directly,” he asserted.

He said he had not decided what form is “direct action” program will take.

Dr. King also charged that the American Medical Association has not taken needed steps to end racial discrimination in the treatment received by Negroes and within the AMA itself.

Meanwhile, Dr. John L.S. Holloman, Jr., national chairman of the Medical Committee for Human Rights, announced a program of lawsuits against discrimination-practicing Southern hospitals that will “cover every hospital that is guilty.”

He said his committee would gather data and advise and assist people in the South who would formal open the legal campaign.

The first cases, he said, would be brought in Mississippi, where almost every hospital, he pointed out, discriminates.

Dr. Holloman – like Dr. King – scathingly denounced hospital discrimination in Northern hospitals.

“There is scarcely a Northern hospital that does not discriminate against Negro patients either in commission or omission,” said Dr. Holloman, president-elect of the predominantly Negro National Medical Association.

The hospital discrimination found by the three leaders would not be hard to prove.

Only a week before, a government survey of health and welfare service desegregation in the South revealed widespread non-compliance with the law in federally supported programs, some of them run by state and local governments.

A survey sponsored by the U.S. Commission on Civil Rights found that almost all Southern state hospitals remained segregated, with the exception of mental hospitals.

Meanwhile, a nurse who has spent eight months in Holmes County, Miss., revealed that hospitals in the South continue to discriminate – “but these days they’re subtle about it.”

According to Helen Richardson, 31, who served as a nurse and health counselor at a clinic in the Mississippi city, the hospitals have taken down their “Negro Entrance” signs, but they try to avoid admitting Negro patients.

“They’re sneaky about it,” she said.

Private health plans no longer assure adequate protection

Privately Insured in America: Opinions on Health Care Costs and Coverage

The Associated Press-NORC Center for Public Affairs Research, October 2014

A significant minority of those with private health insurance, including those covered by high-deductible health plans (HDHPs), are greatly impacted by the out-of-pocket cost of health care—they are concerned with the uncertainty of major expenses, skip necessary medical treatment, and experience real financial burden when obtaining health care. All told, about 1 in 8 privately insured Americans—or more than 16 million people—face major financial hardships like going without food or using up all of their savings as a result of medical bills.

When asked about nine specific behaviors to reduce personal health care expenses, about half of privately insured adults age 18-64 experienced at least one of them.

  • As a result of health care costs, significant minorities of privately insured individuals don’t go to the doctor when they are sick (19 percent), go without preventive and recommended care (18 percent), use up all or most of their savings (18 percent), and go without basic needs (13 percent).
  • A quarter of privately insured adults age 18-64 lack confidence in their ability to pay for a major unexpected medical expense.
  • The privately insured who report having a HDHP are more likely than those who do not to decrease their contributions to savings (41 percent vs. 26 percent) and retirement plans (28 percent vs. 15 percent) as a result of health care costs.
  • Nearly 1 in 4 adults age 18-64 covered by a HDHP reports that paying for health care expenses caused them to use up their savings.
  • Thirty-five percent of those surveyed indicate that when enrolling in a health insurance plan, their current plan was the only option available.
  • With out-of-pocket costs emerging as a major source of uncertainty among the privately insured, more privately insured Americans choose a health care plan with a relatively high monthly premium but lower out-of-pocket costs (52 percent) over a plan with relatively low premiums and higher out-of-pocket costs (40 percent), when presented with the tradeoff.
  • But, there isn’t overwhelming support for plans with select networks5 designed to keep out-of-pocket costs low. Twenty percent say they are extremely or very willing to participate in this type of plan, 38 percent are somewhat willing, and 40 percent are not too or not at all willing.

Of those who indicate they have used health care services since enrolling in their current health insurance plan, 39 percent say the out-of-pocket costs being higher than expected has been a major (14 percent) or a minor (24 percent) problem.

As the health care marketplace is evolving with the advent of new exchanges, those who purchase their health insurance plans directly or through exchanges are more likely to express difficulty finding health care providers covered under their plans.

Those who have changed health insurance plans and say they have HDHPs are especially likely to cite increased costs without a corresponding increase in quality.

http://www.apnorc.org/PDFs/Coverage/AP-NORC-Opinions%20on%20Health%20Care%20Costs%20and%20Coverage_FINAL%20web%20(1).pdf

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Comment:

By Don McCanne, MD

This new survey conducted by the Associated Press-NORC Center for Public Affairs Research confirms, once again, that private health insurance in the United States often is not providing adequate financial protection for those with health care needs. More than 16 million people who have private insurance “face major financial hardships like going without food or using up all of their savings as a result of medical bills.” The one-half of Americans who use hardly any health care at all likely do not realize that they are one major illness away from similar financial hardship.

When something is not working, we should fix it. The inadequacies of private plans cannot be repaired without intolerable increases in health insurance premiums. Yet a well designed single payer national health program could remove the financial barriers to care – for everyone – without any increase in our current national health expenditures. Without action, 30 million will remain without any insurance at all, and many of the rest of us could remain vulnerable to high out-of-pocket medical costs in spite of our private insurance coverage.