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AUDIE CORNISH, HOST: For the last 18 years, lawmakers have gone around and around and around trying to fix part of a Medicare law. Ironically, what they were trying to solve was originally supposed to be a fix. That issue – a law from the late 1990s that would cut Medicare payments to doctors to keep the program’s budget in check.
ROBERT SIEGEL, HOST: Lawmakers worried that the pay decreases might drive doctors away. So year after year, Congress scrambled to prevent these cuts from kicking in, and they called it the doc fix. This week – an end to the saga.
CORNISH: Congress finally repealed the controversial formula, and President Obama signed the new legislation this afternoon. Joining us now to say goodbye to the doc fix is Julie Rovner of Kaiser Health News. Hey there, Julie, welcome back.
JULIE ROVNER: Thanks, Audie.
CORNISH: Remind us the history here, I mean, this fix was supposed to be a good thing – right? – prevent overspending.This copyrighted story comes from NPR’s Shots blog. All rights reserved.
ROVNER: Well, the history is that they changed the way they paid doctors in the late 1980s, but they wanted to make sure that doctors who were going to lose money didn’t make it up by just doing more services. So they put in what were called volume controls, so that doctors would take a hit if they did too much. And that didn’t quite work, so they reconfigured it in 1997. And as you mentioned, it was supposed to make cuts to the overall budget if they went over the budget. And the problem was they kept going over the budget, and Congress would really postpone the cut rather than cancel it.
So what happened is that over time, the cuts kept getting bigger and bigger and more draconian until they were over 20 percent. And Congress knew that it couldn’t cut payments to doctors by more than 20 percent ’cause they’d stop seeing Medicare patients. So it became this consistent headache for Congress doing what we all call kicking the can down the road. So finally, you know, Republicans and Democrats were really sick of this and they got together actually two years ago and came up with this compromise. It’s taken really almost two years to get it through and to the president’s desk.
CORNISH: So how did it become such a political problem? And what was the kind of big idea that this fight ended up being about?
ROVNER: The political problem was whether or not it should be paid for. Is if you’re going to cancel this cut, do you actually have to find offsetting cuts to do it? And I remember back in 2007, Sen. Max Baucus, who was the brand-new chairman of the Finance Committee, suggested at a hearing that they would have to take a mulligan on it, meaning not pay for it. Nobody ever did that until just now when they finally decided that they weren’t going to pay for it – at least they weren’t going to pay for all of it. And I think that was sort of the key because last year, they had the bill finished, but they couldn’t – Republicans and Democrats couldn’t agree on a way to pay for it. And in the end, they decided not to pay for all of it.
CORNISH: So politically, who are the victors here? I mean, did lawmakers just kind of give up?
ROVNER: (Laughter) I think politically the victors are lawmakers themselves, particularly on the health committees who are so tired of doing this every year or every six months or every month. And also, you know, the nation’s doctors and other health professionals who are paid according to what Medicare pays doctors, who are going to get a new payment system and not have this Sword of Damocles of cuts hanging over their heads, and, of course, then the Medicare patients themselves. I should add that this bill also extended for two years. The Children’s Health Insurance Program – that was setting up as a potential fight. Democrats wanted to extend it for four years, but the two years was a compromise. This was a real serious Democratic-Republican compromise of the type we don’t often see.
CORNISH: Julie, what does this mean for Medicare going forward? I mean, as we mentioned at the outset here, this was supposed to prevent overspending.
ROVNER: That’s right. And what it means is that Medicare is going to change on the doctor side. They’re going to try and encourage doctors to have alternate payment system that pay them according to outcomes, to how well they do to how healthy they keep their patient. It’s not a done deal. There will be a lot of, as usual, Medicare problems with the technicalities of how to do this, but I think everybody agrees it was a step forward that Medicare needed to take.
CORNISH: Julie, is there – I don’t know – something on the epitaph of the doc fix grave?
ROVNER: (Laughter) Good riddance.
CORNISH: That’s Julie Rovner of Kaiser Health News. She covered the doc fix for many, many years.
Fifteen states are betting they can convince more doctors to accept the growing number of patients covered by Medicaid with a simple incentive: more money.
The Affordable Care Act gave states federal dollars to raise Medicaid reimbursement rates for primary care services—but only temporarily. The federal spigot ran dry on Jan. 1. Fearing that lowering the rates would exacerbate the shortage of primary care doctors willing to accept patients on Medicaid, the 15 states are dipping into their own coffers to continue to pay the doctors more.
It seems to be working.In Indiana, which is spending about $40 million a year in state dollars to keep the higher reimbursement rate, an additional 335 doctors have started accepting Medicaid patients since the beginning of this year. So have more than 600 other medical providers, such as nurse practitioners and physician assistants.
“We’ve seen good results,” said Joe Moser, the state’s Medicaid director. “We are interested in seeing if the results continue, and we have every reason to think that it will.”
Colorado has had a similar experience. There the number of new providers participating in Medicaid is increasing by about 100 each month, according to Marc Williams, spokesman for the Department of Health Care Policy and Financing.This copyrighted story comes from Stateline, the daily news service of the Pew Charitable Trusts. (Learn more about republishing Stateline content)
In addition to Indiana and Colorado, Alabama, Iowa, Maryland, Mississippi and New Mexico are keeping reimbursement rates where they were before the federal bump ended. Connecticut, Delaware, Hawaii and Maine, Michigan, Nebraska, Nevada, and South Carolina also are continuing to pay higher rates, though they aren’t as high as they were before the federal money disappeared, according to a March report to Congress from the Medicaid and CHIP Payment and Access Commission (MACPAC).
In the 23 states that have indicated they won’t continue to make the higher payments, payments for primary care will fall 47 percent on average this year, an Urban Institute analysisestimates.
David Schultz, a family physician who runs a clinic with a high percentage of Medicaid enrollees in southwestern Indiana, said low Medicaid reimbursement rates had made it increasingly difficult to maintain the practice.
“Frankly, we were losing money and losing personnel,” he said. “We had to increase the numbers of people we saw every day, stayed open much longer, worked through lunches, not taking half-days off.”
The higher rates haven’t changed his life enormously, he said, but the office has at least been able to cut back on the heavy scheduling.Rejecting Medicaid
In 2012, a third of primary care doctors didn’t accept new patients with Medicaid coverage, according to a previous MACPAC report to Congress. Only 25 percent of patients covered by Medicare, the government health program for seniors, were turned away. And only 15 percent with private insurance were.
Before the federally subsidized higher reimbursements were paid, Medicaid paid only 59 percent of what Medicare did for primary care services, according to the Henry J. Kaiser Family Foundation.
When the federal subsidy ended, states had to decide whether to continue to pay higher rates with little hard data on whether doing so would persuade more doctors to accept Medicaid patients. Other factors, such as the relatively long time it takes doctors to receive their Medicaid payments, also may contribute to their reluctance to take on Medicaid patients.
A multistate study on the impact of the reimbursement increase published in the New England Journal of Medicine in February found that the availability of primary care appointments for Medicaid patients had increased 7.7 percent with the higher payments. But the study did not examine how many more doctors were accepting Medicaid patients.
There was, however, anecdotal evidence from individual states. Alaska, for example, has long paid Medicaid reimbursement rates that are higher than those for Medicare. Margaret Brodie, director of the Division of Health Care Services, said she believes that’s why the state hasn’t had a shortage of Medicaid providers.
And in Connecticut, the number of primary care doctors participating in Medicaid was 3,589 at the start of this year, up from 1,622 on Jan. 1, 2012, the year before the fee bump, according to David Dearborn, a spokesman for the Department of Social Services.Paying for the Bump
The states that are continuing the higher payments are turning to a variety of sources to finance them.
Indiana will do it with an increase in the cigarette tax and an eventual increase in taxes on hospitals.
Nebraska is using state general funds for the $8.9 million it needs to pay the higher rate. Maine is redirecting $7.4 million in state tobacco settlement money to help pay the higher rates. To get the $18 million it will cost to fund the increase for six months, Colorado is relying on an advantageous recalibration of its federal-state Medicaid match.
Maia Crawford, a program officer at the Center for Health Care Strategies, a nonprofit that focuses on improvements in publicly financed health care, argues that maintaining the higher rates isn’t a heavy price for states to pay in return for “garnering good will among Medicaid providers and working to ensure that Medicaid stays well stocked with providers.”
The highest court in Massachusetts has upheld a $63 million judgment against the manufacturer of Children’s Motrin awarded to a family whose daughter developed a life-threatening disease after taking the over-the-counter medicine.
A Superior Court jury ruled in 2013 that Johnson & Johnson failed to provide sufficient warnings about the potential side effects of Motrin.
Samantha Reckis was 7 in 2003 when she was given the ibuprofen product to reduce a fever. She suffered a rare skin disease known as toxic epidermal necrolysis and was blinded.
Johnson & Johnson appealed on several grounds, including that the family failed to prove the medicine caused the disease and that damages were excessive.
The Supreme Judicial Court rejected those arguments in Friday’s decision.
A company spokeswoman woman did not immediately respond to an email seeking comment.
It’s not surprising that this week’s On Point hour on the “stark realities of autistic adulthood” drew a raft of calls from parents: Rates of diagnosed autism in America have risen dramatically in recent years, and now, a whole generation of autistic children are entering young adulthood.
As WBUR’s Martha Bebinger recently reported in a powerful piece titled “Troubled Future For Young Adults On Autism Spectrum,” this is a “pioneer generation” that often lacks supports in place.
Our colleagues at On Point have posted a write-up of the many calls from parents that their segment prompted, including these:
“This is the first time I’ve broken up about this,” caller Lisa from Nashville said. “I have a 21-year old daughter here in Nashville. She has moderately severe autism, severe speech impairment, intellectual disabilities.”
A backlog of applicants waiting for state support in Nashville has led Lisa to leave her state once her daughter ages out of the school-age care currently provided her.
“My plan is to relocate and to leave the state of Tennessee,” Lisa told us. “We’ll be able to provide housing for her, but how can a family that’s not making 300,000 and up provide that 24/7 care that she needs? There is no safety net for these people.”
Other callers, like Maisel in New Orleans, found school-age care for children with autism no better than the nonexistent care for adults.
“My son has autism, he’s 15 years old,” Maisel told us. “For the past two years, I have been homeschooling him. The school system didn’t work for my son.”
And caller Jane, from Hartford, CT, told us what life can sometimes look like when further complications arise in adult autistic care.
“My son is 23 years old, and we fell off the cliff that everybody talks about two years ago,” Jane said. “Graduation is so happy for people, but it was a very different feeling for my son. We took what we had saved for my son’s college fund to buy a house and hire staff.”
But Jane’s husband was diagnosed with cancer a year ago, and the work she’s been doing to work with her young son has been entirely on her shoulders.
To share your own story of a child entering adulthood with autism, please go to the On Point post here: Parents Speak Out On Autism Care Cliff.
The following is a guest post by Kimberly Allen, our planning officer for the Law Library of Congress and editor for In Custodia Legis.
Spring may well be my favorite time of year, and I believe there is nowhere more gorgeous than D.C. in the springtime. It comes upon us quickly after the cold weather breaks, and the various trees, bushes and flowers seem to erupt in waves of beauty.
Like any good baseball fan I took annual leave recently to attend Opening Day and on my way to Nationals Park was delighted to see that the cherry blossoms near the Library of Congress had popped! Since I was a passenger I was able to snap a picture, which I would like to share with you.
These are a few of the cherry blossoms on the southeast corner of the Jefferson Building grounds. The building in the background is the Madison Building.Sakura: Cherry Blossoms as Living Symbols of Friendship. Kelly also posted on the history and legal connection of the trees.
In 1989, Randy Pierce was fresh out of college, living in southern New Hampshire and working happily as a computer hardware designer. One day in fencing class, his instructor noticed that his blind spot was oddly enlarged. You need to go to the doctor, the instructor said. Today.
A neurological disease was attacking Pierce’s optic nerve. Within two weeks he had lost all the sight in his right eye, and half the sight in his left. In the following years, he lost the last remnants of his sight, and damage to his cerebellum destroyed his balance, landing him in a wheelchair.
On Monday, he will be running the Boston Marathon.
Pierce, 48, will be running on Team With A Vision, which supports the Massachusetts Association for the Blind and Visually Impaired. He’s running to raise money — and to make a point, about what he calls “ability awareness.”
“I have a disability — I can’t see,” he says. “We all have disabilities, things that we can’t do. I think it’s so much more important to put the focus of our lives on things we can do. And if something is important enough to you, I say anything is possible, you’re just going to have to problem-solve and persevere to get there.”
An example of problem-solving: Last year, Pierce became the first blind American to complete a Tough Mudder obstacle course, and last month he repeated the feat. (See the video below.)[Watch on YouTube]
From a platform 25 feet high, he had to leap out about 8 feet, grab a T-shaped, trapeze-like bar, swing farther out and release his grip at just the right moment to hit a remote hanging bell before plunging down into the muddy water below. He used his cane to feel for where the T-bar was, to form a mental image of it, and friends’ descriptions of where the bell was hanging.
The crowd went wild.
“You know, those are just moments — every one of those people out there would have told you this is impossible. Now they won’t,” Pierce says. “They’ll believe me when I say everything’s possible — or they’ll believe in themselves, which is the more important part.”
As for the perseverance Pierce talks about, he used it to fight his way out of the wheelchair that he occupied “for one year, eight months and 21 days — which tells you how I feel about it. Pretty challenging.”
Pierce’s wife, Tracy, says that somehow, his struggles and losses led him to adopt the supremely positive attitude that uplifts him now.
“From what he’s told me, that time period of losing his sight and losing the ability to walk, those were really difficult times,” she says, “and when he first lost his sight he was unhappy and bitter and not somebody that most people would want to hang around with.
“But he’s always been jovial and charismatic, and I think he was lucky to have a few people to say, ‘Hey, don’t lose who you are.’ And I think that experience added on to the joviality and just made him appreciate things more.”
Pierce got treatment to help restore his balance, and he did hours upon hours of exercises and physical therapy to walk again.
Then he decided to hike. He had always loved the mountains as a child, but hike blind? He explains:
“First, when you can’t walk, like my time in the wheelchair, you learn to celebrate and appreciate what a gift walking is in this world. Second, my dog guide and I would walk as many places as possible, and what I learned he loved the most is when we took our walks in the woods.”
That dog guide was The Mighty Quinn, a noble yellow lab who led Pierce to the epic goal he set for himself: to climb all 48 New Hampshire mountains over 4,000 feet in a single winter season. Through snow and ice and wind, they succeeded in 2012. Then Pierce decided to do it again — but in warmer weather this time.
People often ask Pierce: What can a blind man, who can’t enjoy the views, get out of climbing a mountain? Many things, he answers. Sometimes it’s picturing the beautiful views that companions describe in his mind’s eye — like, on one demanding winter hike that included Mount Washington, a massive cliff ridge that was glowing neon pink in the sunset, lighting up the fist-sized diamonds of rime ice growing out of the ground, “spreading color like a prismatic spray.”
Sometimes it’s just listening to the wind in the trees.
“I hear these swirls of wind at one speed in this group of leaves — maybe up to my right — and then down at the ravine there’s another wind going through the trees at a different pitch and a different velocity,” he says. “And all these different sounds kind of make this little symphony of the wind there. Even the type of tree will change the sound the wind makes blowing through it. When you learn to appreciate all those little things, you’re given a whole bunch of rewards.”
Soon after leading Pierce to his 48th summit for the second time, The Mighty Quinn fell ill with terminal bone cancer.
As Quinn lay dying in late 2013, Pierce reflected that losing his 24/7 companion of seven years would be the hardest day of his life. “But what do you do? It’s the same thing I talk about when I went blind or went into a wheelchair. Yup, it’s hard, but, where do I go? That’s up to me.
“I didn’t choose to go blind. But the choice I made after going blind, that’s what defined my life. I’m not ‘a blind person.’ I’m a person who does all the things he wants to — and that’s all because of the choice I made. Really, the choice you make in how to respond to any adversity will have a bigger impact on your life than any adversity ever could. And the same thing’s going to be true when I lose Quinn. I will mourn, a lot — but I’ll also set myself going forward.”
Quinn died on Jan. 20 last year, and Pierce is still mourning; he still can’t talk about Quinn without a catch in his voice. But he also did move forward with a new guide dog, a playful black and tan labrador retriever named Autumn. And he pursued his next goal: the Boston Marathon.
He will be running with bib No. 25485 on Monday, and he’ll navigate by holding one end of a white cane whose other end is held by a sighted guide — a husband-and-wife tag team will each guide him for half the marathon. See more details of his marathon plan at 2020visionquest.org, the site of Pierce’s nonprofit; he funnels fundraising and speaking fees to the guide-dog school Guiding Eyes for the Blind and the New Hampshire Association for the Blind.
Overall, among the 30,000 runners expected at the Boston Marathon on Monday, only about 40 are listed in race’s Visually Impaired Division, says Joshua Warren, director of marketing and development for the Massachusetts Association for the Blind and Visually Impaired.
Most visually impaired runners on the association’s team, he says, will be running, like Pierce, with some sort of “tether” — “so they’ll be running side by side with their sighted guide, each of them holding a different end of a bungee cord or a rope or a small strip of webbing.”
The association has just created a website — UnitedInStride — to help blind runners and sighted guides find and partner with each other.
Of Pierce, Warren says, “Randy is the embodiment” of the idea that “with the right support, someone who is blind or visually impaired can do anything.”
Even as Pierce takes on one athletic challenge after another, his medical outlook remains unclear.
He has just a tentative diagnosis — that he seems to have a mitochondrial disease — and along with the blindness and balance problems, he’s lost some sensation in his limbs. He doesn’t know which nerves the disease will attack next.
“As positive as I am,” he says, “do I have a fear? You bet. The wrong part of my brain dying could change who I am.”
He recently had his genes sequenced and is hoping genetic analysis might yield a better understanding of what’s wrong with him — and what his future holds.
For now, Pierce has his next big goal lined up: In late September, he and his wife are aiming to climb the world’s tallest freestanding mountain — Kilimanjaro.
The inevitable question: Are you just driven?
His answer: “Ha! I do have a passion for life and I rediscovered that I didn’t have to let that go, once I learned that I could believe in possibility. Henry Ford really did say it best: Whether you think you can or think you can’t, you’re probably right. I’m driven to savor life and every step along the way.”
Special thanks to WBUR’s Tim Skoog, who produced the audio version of this piece (to be posted later) and who has completed many an epic mountain hike of his own.