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In South Florida And The Nation, Healthcare Costs Often Are Shrouded In Secrecy

Kaiser Health News - Mon, 09/15/2014 - 1:38pm

At a hearing to discuss the rising costs of healthcare benefits for Miami-Dade County employees this year, a labor union consultant raised his hand to ask what seemed like a basic question.

Could the committee charged with reducing Miami-Dade labor’s healthcare expenses look at the spreadsheet showing the rates that the county pays local hospitals and doctors for medical services to employees?

Healthcare Prices: Many Moving Parts Veiled By Confidentiality Agreements

“We really need to understand where the money is being spent in order to be insightful about benefit design changes,’’ said Duane Fitch, a healthcare consultant for SEIU Local 1991, which represents physicians and nurses at the county-owned Jackson Health System.

But the answer to Fitch’s question at that inaugural meeting of the Miami-Dade Labor Healthcare Committee last March was the same response he would receive every time he repeated the question during the panel’s next six meetings through July.

Essentially, no.

“Contracts are proprietary,” said Patricia Nelson, regional head of strategic accounts for AvMed Health Plans, the county’s health benefits administrator that negotiated the payment rates for medical services for county employees. She noted that both the insurance company and the healthcare providers agree to keep such payment rates confidential.

Fitch and others who asked for the information never got to see precisely how Miami-Dade spends more than $400 million a year to pay healthcare claims for nearly 60,000 employees, retirees and dependents in the health plan.

That’s because Miami-Dade — like many employers across the country — isn’t allowed to know the prices their own insurance plan administrators negotiate with healthcare providers, even when they’re self-insured, like Miami-Dade County, and the claims are paid with taxpayer dollars.

And that means that the mayor’s healthcare committee has no more insight than the average Florida consumer on how to lower costs for their employees or themselves — frustrating everyone from union leaders to county commissioners who are trying to push down prices.

Because when county officials claim they are doing everything they can to reduce employee healthcare costs, they actually don’t know how and where the public’s money is being spent.

“You need the data in order to do the proper plan design that drives your outcomes,’’ said Miami-Dade Commissioner Juan C. Zapata, whose requests for AvMed’s contracted rates also have been rejected. “Without that, you’re just shooting in the dark, basically.’’

No Disclosure

The lack of disclosure of a most basic fact — how much does it cost? — has prompted a movement around the country toward greater price transparency, even as insurance companies and hospitals say revealing those rates will put them at a financial disadvantage with competitors.

A local hospital CEO, Steve Sonenreich of Mount Sinai Medical Center on Miami Beach, even made a public pledge on WLRN-91.3 FM radio last year that he would reveal the contractual rates the hospital charges private insurers — only to learn that he was barred under the non-disclosure agreement in the contract.

Sonenreich said in a written statement this week that he believes one of the problems with pricing secrecy is that it allows large hospital systems to leverage their “geographic dominance” to run up rates on insurers, who pass on the increases to employers and consumers through higher premiums, deductibles and other costs.

“If we make healthcare pricing information available to consumers, particularly employers,’’ he said, “they will be able to make better decisions.’’

But the push for price transparency has had an uneven impact across the country.

Some states, such as Colorado, New Hampshire and Massachusetts, have adopted legislation that requires insurance companies and healthcare providers to report reimbursement rates and payments for use in what they call an “all-payer claims database” — a repository of comprehensive information on healthcare use and payments for all medical services by Medicaid, Medicare and commercial insurers, among others.

Florida has enacted or amended statutes and regulations more than a dozen times since 1985 requiring some level of transparency and disclosure from hospitals and physicians, but not insurers.

A state-mandated website managed by the Agency for Healthcare Administration at floridahealthfinder.gov gives consumers average and total charges for a variety of medical services by hospitals — but not specific reimbursement rates.

In the bewildering world of healthcare pricing, charges are not the same as prices — because almost every payer gets a discount on hospital charges, and usually by double-digit percentages.

While Florida’s price transparency efforts are not as robust as other states, AHCA officials did request about $5 million in annual funding this year to build and maintain an all-payer claims database. The request was ignored by state lawmakers.

By keeping prices secret, healthcare providers and insurers leave employers with little choice for managing their benefits costs as they go up. Most choose to shift more financial burden onto employees, said Francois de Brantes, executive director of Health Care Incentives Improvement Institute, a Connecticut nonprofit that advocates for payment reform.

“If you’re an employer,’’ de Brantes said, “and you don’t have access to your underlying claims data, even though you’re self-insured, there’s absolutely no way for you to make decisions on benefit design — other than using the brute force of across-the-board premium increases.’’

And that’s what the county’s healthcare committee recommended in its final report: Require a biweekly premium for employees who currently pay none for single coverage in the county’s HMO plan, and increase existing premiums for those in the POS plan. Employees also will be offered a new plan with no premiums for individual coverage, but a limited choice of hospitals and doctors.

Need For Transparency

For most people with employer-provided health insurance, rising premiums are not unusual. Insured consumers across the country are shouldering more financial responsibility for their medical care through high deductibles, co-insurance rates and health savings accounts — fueling momentum for price transparency.

“The consumer is going to basically have to take responsibility for their own healthcare,’’ said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network in South Broward County, “and look not only at costs but quality outcomes, the safety metrics. All of that has to be transparent, and then they’ll have to make informed decisions.”

But translating healthcare pricing to into useful information for consumers is complicated because every patient’s experience can be different, even for similar procedures, said Linda Quick, president of the South Florida Hospital and Healthcare Association, a trade group for regional providers.

Then there’s the variety of payers, from government programs such as Medicaid and Medicare, to private commercial insurers — all paying a different rate.

Adding to the complexity: a procedure such as a knee replacement may require that an insurer pay a number of different providers, from the lab and physician to the hospital and home health agency.

“So if the hospital told you that their cost is $27,000,’’ Quick said, “it’s still not a true representation of the cost of knee surgery, because the surgeon’s bill is going to be separate, and the anesthesiologist is going to bill separately.

“It’s very hard,’’ she said, “to make it totally transparent.”

AvMed, the county’s health insurance administrator, declined to discuss healthcare pricing with the Herald and WLRN, canceling two interviews with Jim Repp, vice president of marketing. The company also declined to discuss its management of Miami-Dade’s employee health plan while the county’s labor unions and administrators negotiate new collective bargaining agreements in the coming months.

But when Repp addressed the mayor’s healthcare committee in June, he said AvMed had secured average discounts of 65 percent with South Florida hospitals and physicians, helping to save the county what he estimated was about $56 million on expected claims from 2010 through 2013.

Private Sector

For employers, having access to data on actual payments would be much more useful than knowing the average discount negotiated by a plan administrator, de Brantes said.

When he worked as a program leader for General Electric Corporate Health Care Programs in the mid-1990s, de Brantes said, GE required its health plan administrator to deliver the data — or lose the company’s business.

“We would use those data constantly to figure out: What do we need to do as an employer to improve cost and quality? Where are there problems? And even to do accurate modeling of what would be the impact of, say, increasing our co-pay on ER visits,’’ de Brantes said. “How many people would that impact? And who’s going there more often? Is it people who have chronic illness, or those seeking routine service?

“You wouldn’t even know that,’’ he said, “if you didn’t have the claims data.’’

Miami-Dade could also take a cue from other large private employers, such as aerospace giant Boeing, and negotiate contracts directly with hospitals and other healthcare providers, said Joe Smith, a physician and engineer who chairs the board of West Health Policy Center, a Washington, D.C.-based nonprofit that studies healthcare reform.

“Healthcare has enough middlemen,’’ Smith said of plan administrators. “The employers are not ignorant at this. They’re good at negotiating contracts, and can also use market power to gain information.’’

De Brantes questioned AvMed’s incentive to reduce Miami-Dade’s annual healthcare costs since the insurance company pays claims with the county’s money, and receives an administrative fee of $31 per employee per month — regardless of the rates it negotiates with providers.

“They don’t care because it’s not their money,’’ de Brantes said. “That’s the bottom line.’’

For 2014, AvMed’s fee is estimated to be $16 million, about 4 percent of annual claims, according to county reports.

In The Dark

Without price transparency — and a review of AvMed’s negotiated rates — there’s no way for Miami-Dade to evaluate AvMed’s job performance, said Fitch, the healthcare consultant to SEIU 1991.

Fitch expressed concern that AvMed could be giving preferable treatment to Baptist Health South Florida, the largest hospital system in the region and the top-paid provider in the county’s employee health plan.

AvMed is the administrator for both Baptist Health’s employee health plan and Miami-Dade’s, Fitch pointed out, creating “a perception that there is unfair dealing.’’

At a meeting of the county healthcare committee, Fitch asked Repp how AvMed manages to negotiate rates on behalf of Miami-Dade with a hospital system that is also AvMed’s client.

“Very delicately,’’ Repp said. “We do have clients who are also providers. We keep those two divisions of the organization separate from each other.’’

Christine Kotler, a Baptist Health spokeswoman, declined to address price variances between the system’s hospitals and others in Miami-Dade’s plan. She said Baptist Health hospitals score high marks in clinical safety and consumer satisfaction surveys.

“In discussions about cost and price,’’ she said in a written statement, “it’s important to also talk about quality.’’

Miami-Dade employees do express a preference for Baptist Health centers when using a hospital, according to analyses by Gallagher Benefits Services, a county consultant. Consequently, most of Miami-Dade’s healthcare dollars go to Baptist Health hospitals — more than $61 million in claims for 2013, Gallagher reported, well above the second-highest paid provider, the University of Miami Health System, which received $24.3 million in payments.

But county officials have lacked the specific payment rate data they need to properly evaluate plan changes that could save Miami-Dade taxpayers money, according to a Gallagher analysis of all medical claims for the year ending June 30, 2012.

For example, the report noted that county employees have “unusually high” rates of emergency room use, likely because their copays for the service are low. But county administrators didn’t have the payment data to determine whether raising the copays to steer employees toward cheaper “urgent care” centers would save enough money to be worthwhile.

Instead of payment rates and claims data, county officials were given average costs per member, showing that Baptist Health facilities cost an average of $12,988 per overnight admission.

Baptist wasn’t the most expensive by that metric. Aventura Hospital and Medical Center, owned by Hospital Corporation of America, cost the county plan $14,975 per admission.

But Gallagher’s analysis showed that visits to Baptist ERs that year cost Miami-Dade more per encounter, an average $2,427, higher than any of the top 14 providers in the plan network.

Gallagher noted another interesting figure during recent meetings of the county healthcare committee.

In 2013, Miami-Dade’s plan paid Jackson Health hospitals an average of $9,380 per overnight admission. The average paid to all other hospital systems: $15,513 per patient — a difference of $6,133.

Gallagher projected that if all hospitals in the county employees’ network were paid at the same level as Jackson, Miami-Dade could have saved nearly $77 million in claims.

“We think there’s a lot of room for savings because of this price variation,” said Martha Baker, president of Jackson’s labor union for physicians and nurses.

Repp and others, including Jackson Health’s chief financial officer, Mark Knight, disputed that number.

“We don’t know the mix of the patients,” Knight said. “That $15,000 average could have been based on a bunch of really bad, train wreck patients who were in a bad motor vehicle accident and intensive care for a month. You can’t tell.”

Drawbacks

But Knight did illustrate one potential drawback for the consumer when it comes to price transparency: When Jackson officials read the Gallagher report showing the health system was being paid the lower rate in 2012, they went back to AvMed and renegotiated prices — higher.

The result? It now costs Miami-Dade more for its employees to use Jackson Health, though the plan still saves money when its members choose Jackson over a higher-priced competitor.

Unless consumers and employers know beforehand how much a medical service costs, they’ll never be able to make informed — and cost-saving — choices.

“Just like the individual needs choice,’’ said Smith, of the West Health Policy Center, “Miami-Dade County needs choice as it thinks about who it’s going to contract with. Otherwise, there’s just too much risk of hiding the ball.’’

Categories: Health Care

Healthcare Prices: Many Moving Parts Veiled By Confidentiality Agreements

Kaiser Health News - Mon, 09/15/2014 - 1:37pm

The average Medicare payment for a knee replacement at a South Florida medical center in 2012 ranged from a low of $9,700 at Holy Cross Hospital in Fort Lauderdale to a high of $24,000 at Jackson Memorial Hospital in Miami — even though Holy Cross’s average charge of $63,000 was about $2,000 higher than Jackson’s.

Private commercial insurers do not publish their payments like Medicare does, but healthcare experts say the prices they pay hospitals for the same procedure can vary just as much — and the reason often depends on more than just the hospital where the knee replacement was performed.

For most insured Americans, the reasons for such variance in healthcare prices also can include the medical condition of the patient, complications that may arise, physicians’ fees, market competition, and even who’s paying for the procedure and how.

That’s a lot of moving parts for anyone to nail down a firm price, said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network for South Broward County.

“Healthcare pricing,’’ he said, “is probably the most complex, convoluted pricing of anything that I’ve ever seen in my life.’’

One way to begin unraveling the twisted threads of healthcare pricing is to understand the difference between charge and price. Every hospital establishes a list of charges or so-called “charge masters’’ for medical services, but almost no one pays those rates.

Charges include a hospital’s costs for all services provided to a patient plus a variety of factors unique to each hospital, said Karen Godfrey, corporate vice president of revenue management for Baptist Health South Florida, the largest hospital system in the region.

Some hospitals may have higher costs due to high-intensity services, such as organ transplants, trauma centers and neonatal intensive care units. Or they may have higher mission-related expenses, such as teaching, medical research or caring for the uninsured.

“That may sound simple and straightforward,’’ Godfrey said. “It’s not. If you come in for emergency services, since we don’t know what’s wrong with you, we don’t ultimately know what the charges are going to be.’’

What the hospital collects in payment is the price, and that can range depending on the payer.

For government payers, such as Medicare and Medicaid, prices are publicly available and the rates are set, with provisions made for so-called “outlier” patients whose conditions are especially complex or severe. Typically, Medicare and Medicaid pay less than a hospital’s actual cost to provide care.

So hospitals recoup their operating losses, plus a small margin, in their contracted prices with commercial insurers, Sacco said.

When insurers and hospitals meet behind closed doors to negotiate payment rates, insurers are trading market reach and patient volumes for discounts on hospitals’ rates. Hospitals are leveraging their range of services, quality ratings — and size.

Pat Geraghty, president of Florida Blue, the state’s oldest and largest health insurance company, agreed that a hospital system’s geographic reach can be “critical” in negotiations, but said quality and customer satisfaction may matter more.

“It really matters will the service be redone because it wasn’t done as well in one setting versus another setting,’’ he said. “It really does matter that if it could be done outpatient as opposed to inpatient that we use that setting, or if someone’s disease state could be managed from home as opposed to in any setting.’’

Geraghty said healthcare payments are moving in the direction of packaged prices for episodes of care, and arrangements that hold providers more accountable for healthy patient outcomes if they want to earn higher rates.

“If the patient’s condition worsens and requires more care,’’ Geraghty said, “then the provider takes the loss financially. But if the provider manages the patient’s care efficiently, then he gets to keep the savings.’’

Right now, most hospitals are paid a daily rate or a fee per service or diagnosis group.

Advocates for payment reform argue that under the fee-for-service system, hospitals and other providers have an incentive to over-treat because they're reimbursed by procedure.

But when consumers know the prices for some services across all providers, they’re more likely to comparison shop — according to a recent study published in the journal Health Affairs that found publishing MRI prices led to lower patient costs and reduced price variation.

Categories: Health Care

Study: Subsidy Quirk Means Young People Pay More For Bronze Plans

Kaiser Health News - Mon, 09/15/2014 - 9:32am

How the government calculates insurance subsidies makes the cheapest bronze plans more costly for young people relative to those aged 54 to 64, reports The Philadelphia Inquirer. Meanwhile, Oregon budgets $2 million for a lawsuit fight with Oracle over its health insurance marketplace.

The Philadelphia Inquirer: Subsidy Formula Makes Some Policies Costlier For The Young
Young adults are paying as much or more in premiums for the cheapest bronze plans purchased on the Affordable Care Act marketplace as people ages 54 to 64, according to a University of Tennessee Health Science Center study. The study, published online last week in the Annals of Internal Medicine, found that the reverse premium age curve -- premiums should be cheaper for younger people, who use less health care -- is the result of how tax credit subsidies are calculated under the law. It could mean that paying the penalty for not buying insurance as required by the individual mandate would be less than the monthly premiums for those low-premium policies (Calandra, 9/14). 

The Associated Press:  State Budgets $2M For Cover Oregon Lawsuit
Oregon has budgeted $2 million for its legal fight with software giant Oracle over the state's failed health care exchange website. The state sued the Redwood City, California, company in Marion County Circuit Court last month, claiming that Oracle officials lied, breached contracts and engaged in "a pattern of racketeering activity." Meanwhile, the company has sued the state in federal court alleging breach of contract. Oracle was the largest technology contractor working on Oregon's health insurance enrollment website, known as Cover Oregon. The public website was never launched, forcing the state to hire hundreds of workers to process paper applications by hand. The issue became a political liability for Democratic Gov. John Kitzhaber (9/14).

The New York Times: A Rebound Takes Root In Michigan, But Voters’ Gloom Is Hard To Shake
Yet the economic recovery taking root in Michigan -- among the states hit hardest by the 2008 recession -- has not translated into an improved political environment for officials in either party. ... On the lower end, the worst of the desperation has subsided, helped in part by government action. Barbara Grinwis, 63, executive director of Oasis of Hope, a free health clinic on Leonard Street, spends much of her time signing up patients for Michigan’s insurance exchange or expanded Medicaid under the president’s health care law (Weisman, 9/12). 

Also, developments in the Medicaid expansion debates in Texas and Florida are tracked -- 

Texas Tribune: In Health Care, Organizers Find Issue To Spur Hispanics
When Armando Rodriguez opened the front door of his home here on the city’s west side, Chris Ornelas of the Texas Organizing Project met him with one question. “What are some of the biggest concerns you have in your life right now?” Ornelas asked in Spanish. Health care, Rodriguez replied, and whether his family could afford it. The conversation was familiar for Ornelas, who goes door to door to talk to residents as part of efforts by the Texas Organizing Project to increase voter participation among minorities. The group’s field organizing team often meets minority voters who list health care as a top concern, and it is looking to leverage that issue to get more Hispanic voters to the polls in November (Ura, 9/14).

Orlando Sentinel: Crist Team Explores Medicaid Expansion
Democratic gubernatorial candidate Charlie Crist said his team is researching the prospect that he could sign an executive order on his first day in office to immediately and unilaterally expand the state's Medicaid program to cover uninsured Floridians. In a day of dueling politics in Orlando – with both Crist and Gov. Rick Scott appearing – Crist started by announcing his interest in an executive order while speaking to the Florida Nurses Association on Saturday at the Florida Hotel and Conference Center (Powers, 9/13).

Categories: Health Care

Can Cancer Early Detection Be A 'Double-Edged Sword'?

Kaiser Health News - Mon, 09/15/2014 - 9:27am

The Wall Street Journal: Some Cancer Experts See 'Overdiagnosis,' Question Emphasis On Early Detection
Early detection has long been seen as a powerful weapon in the battle against cancer. But some experts now see it as double-edged sword. While it's clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm (Beck, 9/14). 

Categories: Health Care

Gilead To Boost Price Of New Hepatitis C Drug

Kaiser Health News - Mon, 09/15/2014 - 9:27am

Gilead Sciences says its next generation drug to combat hepatitis C, slated to launch next month, will be more expensive than $1,000-a-pill Sovaldi, in part because the new treatment will be shorter and simpler. Gilead also struck a deal with Indian generic drugmakers to sell lower-cost versions of Sovaldi in poor countries.

Reuters:  Gilead To Raise Price For New Hepatitis C Drug
The next generation version of Gilead Sciences Inc's $84,000 hepatitis C drug, already under fire for its record-breaking costs, is going to be even more expensive. Gregg Alton, Gilead's executive vice president of corporate and medical affairs, declined to give an exact price for the new medicine, the first all-oral treatment for the virus which is expected to launch next month. The total cost of the current treatment is $95,000, which includes Sovaldi and two older medicines, ribavirin and interferon, according to Gilead. The price of the new drug would be based on that cost, Alton said in an interview (Beasley, 9/12).

The New York Times: Maker Of Hepatitis C Drug Strikes Deal On Generics For Poor Countries
The maker of one of the costliest drugs in the world announced on Monday that it had struck agreements with seven Indian generic drug makers to sell lower-cost versions of its $1,000-a-pill Hepatitis C drug in poorer countries (Harris, 9/15). 

Also, a report about scant supplies of an increasingly popular alternative to hospital dialysis -

Los Angeles Times: Shortage Of In-Home Dialysis Solution Has Patients Worried
Joanna Galeas relies on an increasingly popular at-home alternative to treat her kidney failure. Galeas, a 30-year-old Los Angeles resident, is among tens of thousands of U.S. residents who use peritoneal dialysis at home. She fills her abdomen with a sterile solution that helps remove toxins from her blood, a function ordinarily performed by healthy kidneys. Now, Baxter International Inc., the nation's leading supplier of the home dialysis solution, says it can't keep up with demand and has started rationing the product, directing physicians to limit the number of new patients to whom they prescribe the treatment and reducing the size of shipments sent to existing customers (Pfeifer and Terhune, 9/12). 

Categories: Health Care

GOP Senate May Not Be Able To Repeal Health Law, But It Could Cripple Key Provisions

Kaiser Health News - Mon, 09/15/2014 - 9:26am

News outlets examine what the future could hold for the health law especially as the Senate increasingly appears to be within GOP reach.   

Politico: A GOP Senate Could Take On Obamacare — But Not Repeal It
A Republican-controlled Senate cannot repeal Obamacare, no matter how fervently GOP candidates pledge to do so on the campaign trail this fall. But if they do win the majority, Senate Republicans could inflict deep and lasting damage to the president’s signature law. Republicans are quick to say they are not yet measuring the proverbial drapes. But they are taking the political measurements of repealing large parts of the health law, considering which pieces could be repealed with Democratic support, and how to leverage the annual appropriations and budget process to eliminate funding or large pieces of the law (Haberkorn, 9/15). 

Politico: Would a GOP Senate Be King Of The World?
If the Republicans win the Senate in November, the first thing they’ll say is: Finally, we can pass all of our bills and force President Barack Obama to deal with them. The second thing they’ll say is: Oh, wait a second. This is the Senate. That tension — between their desire to bring Obama to his knees and their ability to actually do it — is the political reality that will determine the Republicans’ legislative strategy if they win the Senate majority (Nather, 9/14).

Politico: Senate Showdown: GOP Frets Over Harkin Seat 
Few states are more important than Iowa in the battle for the Senate this fall. But anxiety is rising within Republican ranks that deep-pocketed conservative donors and outside groups are not doing enough, as Democrats outspend them by millions of dollars to retain the seat of retiring liberal Sen. Tom Harkin. Since GOP nominee Joni Ernst won the June primary, Democratic Rep. Bruce Braley and his allies have outspent Ernst and her supporters by more than $2.1 million .... Meanwhile, interest groups from the left are piling on. ... Braley's allies stress that he has also been getting hammered with attack ads — many over absences from House Veterans Affairs Committee hearings in the House and support for Obamacare. (Hohmann, 9/14).

The Washington Post: In Just A Year Obamacare Goes From Top Congress Issue To Barely Mentioned
It was last September when Republicans sparred with Democrats over the future of the health-care law, a disagreement that prompted a 17-day federal government shutdown and overall chaos. It was pretty much [all] anyone on Capitol Hill talked about. Republicans wanted you to know how terrible it was for America, and Democrats wanted you to remember to sign up on Oct. 1. In that month, a mere 12 months ago, the word Obamacare was uttered on the House and Senate floor 2,753 times, ... With just one full week of work left this month, members of Congress have brought up Obamacare in floor speeches just 27 times (Itkowitz, 9/13).

The Hill: Elections Poised To Expand ObamaCare
Democrats running in five highly competitive governors races this year have vowed to expand Medicaid coverage through ObamaCare if they are elected, something that could result in 1.7 million new people getting covered. The dramatic stakes in the governors’ races come even as Democrats are fearful they could lose the Senate .... If federal Medicaid programs are expanded in the five states — Florida, Maine, Kansas, Wisconsin and Georgia — it would also have a dramatic effect on the federal budget. ... Republicans are favored to gain seats in the House and Senate, but the party is playing defense in the race for state houses (Ferris, 9/12).

In other related news -

The New York Times: Building Legacy, Obama Reshapes Appellate Bench
Democrats have reversed the partisan imbalance on the federal appeals courts that long favored conservatives, a little-noticed shift with far-reaching consequences for the law and President Obama's legacy. ... The shift, one of the most significant but unheralded accomplishments of the Obama era, is likely to have ramifications for how the courts decide the legality of some of the president's most controversial actions on health care, immigration and clean air (Peters, 9/13).

And, here's news regarding how issues like Medicare and over-the-counter birth control are playing on the campaign trail -

The Wall Street Journal's Washington Wire: OTC Birth-Control Fight Hits Airwaves In Colorado, North Carolina
Planned Parenthood’s political arm is ratcheting up its fight with some Republican Senate candidates over the issue of possible over-the-counter contraceptives, calling the candidates' support of [over-the-counter] pills "empty gestures." Planned Parenthood Votes jumped into the middle of hotly-contested Senate races in Colorado and North Carolina with television ads denouncing GOP candidates there, Rep. Cory Gardner (R., Colo.) and Thom Tillis (Burton, 9/12).

Tampa Bay Times: PolitiFact: Medicare, That Favorite Campaign Attack Line
When it comes to claims about Medicare, some political talking points just never die. In Iowa and Virginia, Republicans have accused Democrats of cutting Medicare to pay for Obamacare. In Florida, a Republican was slammed for ending the Medicare "guarantee." Other Medicare-related attacks have been deployed in Arkansas and Kentucky Senate races. The point of all the attacks is to convince midterm voters that one side or the other won't protect the program (Jacobson and Holan, 9/12).

Categories: Health Care

Medicaid: 25 Ways States Game The System

Kaiser Health News - Mon, 09/15/2014 - 9:26am

The Department of Health and Human Services has identified the key problems the Centers for Medicare & Medicaid Services needs to address to ensure that states pay their fair share of the state-federal low income insurance program.

The Washington Post: How States Have Gamed Medicaid For Hundreds Of Millions Of Dollars
States have developed various ways to avoid paying their fair share of Medicaid expenses over the years, in some cases costing the federal government hundreds of millions of dollars in extra funding for the program. The Department of Health and Human Services, which runs Medicaid through its Centers for Medicare and Medicaid Services (CMS), has known about the issue for more than a decade, but states still find ways to game the system. The agency’s inspector general this year listed the issue among 25 key problems the agency needs to address (Hicks, 9/15).

Also in the news, a report details how the American wealth gap is putting the squeeze on state revenue and spending for Medicaid -

The Associated Press: US Wealth Gap Putting The Squeeze On State Revenue
As the growth of tax revenue has slowed, states have faced tensions over whether to raise taxes or cut spending to balance their budgets as required by law. “Rising income inequality is not just a social issue,” said Gabriel Petek, the S&P credit analyst who wrote the report. “It presents a very significant set of challenges for the policymakers.” Stagnant pay for most people has compounded the pressure on states to preserve funding for education, highways and social programs such as Medicaid. Their investments in education and infrastructure have also fueled economic growth. Yet they’re at risk without a strong flow of tax revenue (9/15).

Categories: Health Care

Health Clinics Getting New $295 Million For Primary Care Through Health Law

Kaiser Health News - Mon, 09/15/2014 - 9:25am

The money will go to expand primary care services, stay open longer and provide expanded services not always available at the clinics across the United States.

Kansas Health Institute News Service: Kansas, Missouri Health Clinics Get $9.6M For Primary Care
Twenty-five health centers in Missouri and 16 in Kansas have been awarded $9.6 million in federal funds to expand primary care services. The funding is part of $295 million awarded to 1,195 health centers nationwide under the Affordable Care Act, or Obamacare. The money is to be used to hire new staff, help the clinics stay open longer and provide oral health, mental and behavioral health, pharmacy and vision services (Margolies, 9/12).

Seattle Times: $7.5M To Boost Care At Low-income, Minority Health Clinics In Washington
Health clinics in Washington that largely serve low-income and minority residents will receive nearly $7.5 million in federal grants to increase access to primary care. The U.S. Department of Health and Human Services is awarding more than $295 million to community clinics nationwide, according to an announcement made Friday. In Washington, the money will go to 25 community health centers that treat medically underserved communities. The grants will help pay for an estimated 104 full-time health-care providers and benefit roughly 40,000 new patients. The Affordable Care Act and its expansion of health-care coverage has increased the number of people seeking medical care, putting added strain on a primary care system that was already stretched thin in places (Stiffler, 9/12).

Georgia Health News: Georgia Health Centers Get Funding To Expand Care
A federal agency has awarded $6.9 million in Affordable Care Act funding to 30 community health centers in Georgia that will help expand their primary care services. That funding was part of $295 million awarded nationally to 1,195 health centers by the Department of Human and Human Services (HHS) (Miller, 9/14).

But in Charlotte, a health center reduces hours after financial troubles --

Charlotte Observer: Financially Troubled Health Center Reduces Hours, Patients
C.W. Williams Community Health Center, a federally funded clinic that’s provided medical care for low-income patients in Mecklenburg County for more than 30 years, has temporarily reduced hours at its Wilkinson Boulevard clinic after closing its satellite clinic on East Boulevard. A notice posted on the door at the Wilkinson location says it remains open three days a week – Monday, Wednesday and Thursday – instead of the usual five, that it has one staff physician instead of three in the past and that only 25 adult patients with appointments can be seen in a day. ... C.W. Williams is the only federally qualified health center in Mecklenburg and one of 32 in the state. Based on the latest federal data, the health center got an 18 percent increase in federal funding from 2011 to 2013, but treated 22 percent fewer patients in the same period. C.W. Williams’ federal funding increased from $955,000 in 2011 to $1.1 million in 2013, according to the U.S. Health Resources and Services Administration. In the same period, the number of patients served dropped from 10,169 to 7,908 (Garloch, 9/14).

Categories: Health Care

Appeals Court Considers Texas Abortion Clinic LAw

Kaiser Health News - Mon, 09/15/2014 - 9:25am

The law, which was ruled unconstitutional last month, would allow Texas to close more than half the state's abortion facilities.

Kaiser Health News: Appeals Court Weighs Texas Abortion Law
A federal appeals court in New Orleans is reviewing whether 11 clinics that provide abortion in Texas must immediately close their doors because they don’t comply with a state law requiring that they meet all the standards of an outpatient surgical center (Feibel, 9/12). 

The Associated Press: Texas Asks Court To Allow Closure Of Most Clinics 
Texas asked a federal appeals court Friday to allow the state to immediately enforce a law requiring all abortion clinics to adhere to costly standards required for walk-in surgical clinics, which would close more than half of the state's abortion facilities. Texas Solicitor General Jonathan Mitchell asked the 5th U.S. Circuit Court of Appeals to temporarily reinstate the requirement, which was ruled unconstitutional by a lower court last month. The New Orleans-based appeals court has already upheld another new abortion restriction that has shuttered several abortion clinics in Texas (McConnaughey, 9/12).

Categories: Health Care

State Highlights: Calif. Prop 45 Ad Truth Check; S.D. ER Doctors Give Care In Kansas; Medi-Cal Autism Coverage

Kaiser Health News - Mon, 09/15/2014 - 9:24am

A selection of health policy stories from Florida, California, Kansas, Illinois, Washington state and Minnesota.

San Jose Mercury News: New Anti-Prop. 45 Ad Is Partiallly Misleading
Proposition 45 would give California's elected insurance commissioner the authority to reject excessive health insurance rate hikes, a power the commissioner already wields for auto and homeowners insurance rates. The campaign against it -- for which the insurance industry has so far put up $37.3 million -- is now airing a 60-second radio ad narrated by a nurse named Candy Campbell. What does the ad say? Campbell says voters have a choice between letting the state's "new independent commission" negotiate rates and reject expensive plans, or handing that power over to "one politician" who can "take millions in campaign contributions from special interests." Is it true? The "commission" Campbell is referring to is the board of Covered California, the state's new health insurance exchange created by the Affordable Care Act, commonly called "Obamacare." Covered California is indeed an independent part of state government. But it's somewhat misleading to describe the board as "independent." The board members are appointed by politicians -- the governor and the Legislature (Richman, 9/13).

Kansas Health Institute News Service:  Specialists In South Dakota Use Telehealth System To Give ER Care In Kansas
A new nurse was on duty a few weeks ago in the emergency room at the Phillips County Hospital when paramedics arrived with a critically injured patient. She immediately pushed the red button on some newly installed equipment. Seconds later, a seasoned ER nurse and board-certified doctor sitting at a bank of monitors 380 miles away in Sioux Falls, S.D., were using a high-definition camera and other diagnostic equipment to monitor the patient, give advice and document everything the on-site nurse was doing to save the patient’s life. The Phillipsburg hospital is the first in the state to sign up for a 24/7 telemedicine program operated by Avera Health, a Catholic health care system based in Sioux Falls. For a flat fee of about $65,000 a year, it and the other hospitals in the network can make unlimited use of the eEmergency system (McLean, 9/15).

Kaiser Health News: California To Broaden Autism Coverage For Kids Through Medicaid
A new initiative seeks to help level the playing field. Starting Monday, September 15, thousands of children from low-income families who are on the autism spectrum will be eligible for behavioral therapy under Medi-Cal, the state’s health plan for the poor. California is among the first states to respond to a recent rule by the U.S. Centers for Medicare & Medicaid Services that requires the therapy to be covered, when deemed medically necessary, as part of a “comprehensive array of preventive, diagnostic and treatment services” for low-income people 21 and under (Hernandez, 9/15).

Miami Herald: Health Care Prices: Many Moving Parts Veiled By Confidentiality Agreements
Private commercial insurers do not publish their payments like Medicare does, but health care experts say the prices they pay hospitals for the same procedure can vary just as much -- and the reason often depends on more than just the hospital where the knee replacement was performed. For most insured Americans, the reasons for such variance in health care prices also can include the medical condition of the patient, complications that may arise, physicians’ fees, market competition, and even who’s paying for the procedure and how. That’s a lot of moving parts for anyone to nail down a firm price, said Frank Sacco, chief executive of Memorial Healthcare System, the public hospital network for South Broward County (Chang, 9/14).

Chicago Sun Times: Emanuel Socks City Retirees With 40 Percent Health Insurance Hike
Mayor Rahm Emanuel on Friday dropped another financial bombshell on Chicago’s 25,000 retired city workers and their dependents: their monthly health insurance premiums will  be going up by a whopping 40 percent -- in spite of a pending lawsuit and a precedent-setting Illinois Supreme Court ruling. Last year, Emanuel announced plans to save $108.7 million a year by phasing out the city’s 55 percent subsidy for retiree health care and forcing retirees to make the switch to Obamacare. For the city, the Year One savings was $25 million. For retirees, that translated into an increase in monthly health insurance premiums in the 20 percent and 30 percent-range. On Friday, city retirees and their dependents got hit again -- only this time, even harder. The city notified them of a 30-percent to 40-percent increase that will cost most of the retirees between another $300 to $400 a month (Spielman, 9/12).

Los Angeles Times: Medi-Cal Official To Leave Health Care Post In January
The official who led California's giant public health care services department through a tumultuous implementation of Obamacare reforms -- including a months-long period during which hundreds of thousands of Medicaid applications have languished, waiting to be processed -- will depart his position in January, state officials have announced. Toby Douglas directed the state's $91-billion Department of Health Care Services for four years (Brown, 9/12).

California Healthline: Douglas Resigns as DHCS Director
Toby Douglas announced his resignation Friday as director of California's embattled Department of Health Care Services. Appointed director by Gov. Jerry Brown (D) in 2011, Douglas oversaw tumultuous change in the growing department as the state expanded its Medicaid program and launched several initiatives as part of California's response to the Affordable Care Act (Lauer, 9/12).

The Associated Press: WSU Regents Approve Plan For New Medical School 
Washington State University's board of regents on Friday unanimously approved the administration's controversial effort to start a new medical school in Spokane, citing the "dire need" for more doctors in the state. ... WSU's plan is opposed by the University of Washington, which operates the state's only publicly funded medical school. While approving WSU President Elson S. Floyd's pursuit of the independent medical school, the regents said the university should continue its partnership with the University of Washington's WWAMI program, which trains doctors for the states of Washington, Wyoming, Alaska, Montana and Idaho (Geranios, 9/12). 

The Associated Press: Kids Go To Adult Trauma Centers, Treatment Delayed
Florida state guidelines require children with traumatic injuries to be taken to a trauma center specializing in pediatric care. Yet, in recent years, dozens of Florida kids have instead gone to adult centers that weren't able to treat them, according to an investigation by the Tampa Bay Times. The Times reported Sunday that in years past, children went to adult centers only when those facilities were significantly closer than ones designated for pediatric care, or because paramedics believed the child wouldn't survive a longer journey. Experts say 50 miles is considered a reasonable distance to fly an injured patient for proper care. Since 2009, though, the state has approved six new Hospital Corporation of America trauma centers. And at least 100 children have been taken to those facilities instead of pediatric centers even though in most cases they were not more than 50 miles away. Of that group, than 60 children then had to be transferred to pediatric trauma centers (9/14).

Minneapolis Star Tribune: New Minnesota Law Pushes Mental Health System To A Crisis Point
Hundreds of people with severe mental illnesses are languishing for weeks or even months without proper medical treatment, in part because of a law that requires state psychiatric facilities to admit some jail inmates ahead of hospital patients, regardless of clinical need or cost. The longer waits for mental health beds are an unintended consequence of 2013 legislation that was designed to shrink the swelling population of mentally ill people housed in county jails. The law, known as the “48-hour rule,” required inmates to be transferred to a state psychiatric facility within 48 hours after being committed by a state judge. Though the rule was hailed by law enforcement officials, it has raised safety concerns in hospitals (Serres, 9/14).

Sacramento Bee: Think Sacramento Is All About State Workers? Health Care Sector Is Surging
Sacramento has long been known as a state worker town. These days, it’s just as accurate to call it a health worker town. The health care sector in the four-county Sacramento region has grown steadily and significantly for more than a decade, according to the California Employment Development Department. While most other sectors shed jobs during the recession, hospitals, doctor’s offices and nursing homes held strong, adding 10,000 workers between 2008 and 2014 (Reese, 9/15).

Categories: Health Care

Obamacare Boosts Bottom Lines Of Washington Hospitals

Kaiser Health News - Mon, 09/15/2014 - 9:23am

Hospitals attribute the 30 percent reduction in uncompensated care to the expansion of Medicaid and private coverage under the federal health law. Meanwhile, insurers are pushing back against a wave of hospital mergers nationwide.

Seattle Times: Obamacare Helps Slash Hospital Charity Care Costs In State
Washington hospitals provided nearly $154 million less in charity care in the first half of this year than in the first half of 2013, in many cases boosting the hospitals’ bottom lines. Hospitals attributed the plunge in charity care -- about 30 percent -- to the Affordable Care Act’s focus on reducing the number of uninsured patients. This year, for the first time, low-income and uninsured patients whose care was previously covered under hospitals’ charity-care programs were able under the ACA to qualify for Medicaid coverage or subsidized private insurance. About 600,000 Washington residents signed up for health insurance through Medicaid under expanded eligibility guidelines or through private plans (Ostrom, 9/14).

Forbes: Insurers Fight Hospital Mergers As ACA Snubs Fee For Service Medicine
A wave of hospital mergers and acquisitions spreading across the U.S. has the health insurance industry attempting to stand in the way with legalese, Congressional lobbying and in the court of public opinion. America’s Health Insurance Plans, the powerful lobby and trade group representing the biggest names in commercial insurance appears to be leading the charge battling deals in New York, Chicago and beyond. In Chicago, Advocate Health Care and NorthShore University HealthSystem want to merge to form the 11th largest tax-exempt health system in the nation. The stakes are high for health insurance companies as they manage millions and millions more newly insured subscribers thanks to the Affordable Care Act, the signature legislative achievement of President Obama (Jaspen, 9/14).

Categories: Health Care

Advocates To Refine Health Enrollment Message

Kaiser Health News - Mon, 09/15/2014 - 9:23am

When sign-ups begin in November, advocates and those giving enrollment assistance will use lessons from last fall to help attract new customers and help those re-enrolling. Also, several news outlets look at the challenges for consumers.

The Wall Street Journal: Health-Law Advocates To Tweak ACA Marketing Campaign For The Fall
The sales pitch for the health law is getting an overhaul for the fall. Supporters and advocates of the Affordable Care Act say they learned lessons from last year's sign-up effort, when they persuaded a few million uninsured people to buy coverage. ... In for this fall: testimonials from real people, more emphasis on deadlines, and an increased focus on in-person help. Out: No longer will ACA advocates steer clear of talking about the law's requirement that people either get health coverage or pay a penalty when they file their taxes (Radnofsky, 9/14). 

The New York Times: Renewing Health Coverage May Not Be As Automatic As Government Says 
Millions of consumers will soon receive notices from health insurance companies stating that their coverage is being automatically renewed for 2015, along with the financial assistance they received this year from the federal government. But consumer advocates and insurers say they see a significant potential for confusion because some of the information will be out of date and misleading on costs and other aspects of coverage. Some people who have been receiving monthly subsidy payments this year could get much less if they stay in their current health plans (Pear, 9/14). 

The Associated Press: Hurdles For Obama Health Law In 2nd Sign-Up Season
Potential complications await consumers as President Barack Obama's health care law approaches its second open enrollment season, just two months away. Don't expect a repeat of last year's website meltdown, but the new sign-up period could expose underlying problems with the law itself that are less easily fixed than a computer system. Getting those who signed up this year enrolled again for 2015 won't be as easy as it might seem. And the law's interaction between insurance and taxes looks like a sure-fire formula for confusion (Alonso-Zaldivar, 9/14).

The Associated Press: Melding Health Overhaul And Taxes Gets Complicated 
President Barack Obama's health care law uses the tax system to subsidize coverage for the uninsured. Promoting social policy goals through the tax code is a time-honored strategy for both political parties. ... But melding insurance and taxes -- two of the most complicated topics for consumers -- won't be easy (9/14).

Categories: Health Care

Viewpoints: Crediting The Health Law For Modest Premium Increases; Hollywood Misses The Mark On Sick Teens

Kaiser Health News - Mon, 09/15/2014 - 9:22am

The New York Times: Better News On Insurance Premiums
The rate of growth on premiums for employer-based health coverage in the first five months of this year was one of the lowest in 16 years. Despite longstanding concerns that employer-sponsored coverage might become too costly to sustain, that market seems to have stabilized for now .... Thanks to the Affordable Care Act, federal tax credit subsidies — available for people earning up to 400 percent of the federal poverty level ($95,400 for a family of four) — are helping to make these policies affordable and cushioning the impact of premium increases in some cities (9/14).

The Wall Street Journal: In Employer Health Insurance Costs, Stability Is the New Normal
[O]ver the past decade ... premium increases for employer health insurance have moderated sharply and stabilized. Premiums for family policies in the group market grew 72% between 1999 and 2004; 34% between 2004 and 2009; and 26% between 2009 and 2014. Even as premium growth moderated, health insurance costs still outpaced inflation and wage growth. But this year premiums grew 3%, about the same rate as wages and inflation. Despite fears that premiums would rise in the group market because of the Affordable Care Act, they have remained stable (Drew Altman, 9/12).

Forbes: Obamacare Has Failed To Collapse -- But Its Premiums Continue To Climb
Democrats are trumpeting preliminary estimates indicating that premiums on Obamacare's insurance exchanges will rise modestly, on average, in 2015. ... it's true: Obamacare isn't collapsing. But in the real world, we don't measure the success of the "Affordable Care Act" by its failure to collapse. We measure it by looking at the underlying affordability of American health care. And there can be no doubt that health care today is more costly than it would have been without Obamacare (Avik Roy, 9/14). 

USA Today: Be Wary Of Doctor-Rating Sites
The public can rate almost everything on the Internet today: books, hotels, restaurants — and even doctors. But while your chances of getting a great meal at a 5-star restaurant are pretty high, receiving excellent care from a 5-star doctor is less certain. Doctor ratings generally focus on more subjective issues, such as patient wait times, time spent with the doctor, and physician courtesy. Those are obviously important issues, but they paint an incomplete picture. Doctors with stellar interpersonal skills may not be the best at controlling patients' blood pressures or managing their diabetes  (Dr. Kevin Pho, 9/14). 

The Washington Post: Hollywood Has It Wrong: I'm A Teenager With An Illness And It's Not Glamorous At All
In 2008, it was all about vampires. In 2011, it was dystopian societies with corrupt governments. And now, 2014 seems to be the year of teenagers with fatal diseases. ... When I was 14, I was diagnosed with an autonomic nervous system disorder called postural orthostatic tachycardia syndrome (POTS) that causes extreme dizziness, fatigue and other debilitating symptoms. ... In the past five years I’ve spent quite a bit of time in emergency rooms and hospitals across the country, and none of the patients I’ve seen were anything like the characters in the hospital portrayed in the pilot episode of "Red Band Society," a new Fox show premiering Wednesday (Lillie Lainoff, 9/12). 

Categories: Health Care

Political Cartoon: 'Documented Case?'

Kaiser Health News - Mon, 09/15/2014 - 9:22am

Kaiser Health News provides a fresh take on health policy developments with "Documented Case?" by Dan Danglo.

And here's today's health policy haiku:

MEDI-CAL EVENS THE PLAYING FIELD FOR CHILDREN ON THE SPECTRUM 

Low-income children
with autism will now have
more treatment options.
-Anonymous

If you have a health policy haiku to share, please send it to us at http://www.kaiserhealthnews.org/ContactUs.aspx and let us know if you want to include your name. Keep in mind that we give extra points if you link back to a KHN original story.

Categories: Health Care

First Edition: September 15, 2014

Kaiser Health News - Mon, 09/15/2014 - 7:12am

Today's headlines include reports about how the health law sales pitch is getting an overhaul in advance of the upcoming sign-up period as well as reports about complications that may occur during the open enrollment season.

Kaiser Health News: California To Broaden Autism Coverage For Kids Through Medicaid
Kaiser Health News staff writer Daniela Hernandez reports: “A new initiative seeks to help level the playing field. Starting Monday, September 15,thousands of children from low-income families who are on the autism spectrum will be eligible for behavioral therapy under Medi-Cal, the state’s health plan for the poor. California is among the first states to respond to a recent rule by the U.S. Centers for Medicare & Medicaid Services that requires the therapy to be covered, when deemed medically necessary, as part of a “comprehensive array of preventive, diagnostic and treatment services” for low-income people 21 and under” (Hernandez, 9/15). Read the story, which also ran in the Los Angeles Daily News.

Kaiser Health News: Appeals Court Weighs Texas Abortion Law
KUHF’s Carrie Feibel, working in partnership with Kaiser Health News and NPR, reports: “A federal appeals court in New Orleans is reviewing whether 11 clinics that provide abortion in Texas must immediately close their doors because they don’t comply with a state law requiring that they meet all the standards of an outpatient surgical center” (Feibel, 9/12). Read the story

The Wall Street Journal: Health-Law Advocates To Tweak ACA Marketing Campaign For The Fall
The sales pitch for the health law is getting an overhaul for the fall. Supporters and advocates of the Affordable Care Act say they learned lessons from last year's sign-up effort, when they persuaded a few million uninsured people to buy coverage. They plan to incorporate those lessons into the marketing campaign for the next enrollment period, which begins in mid-November (Radnofsky, 9/14). 

The New York Times: Renewing Health Coverage May Not Be As Automatic As Government Says 
Millions of consumers will soon receive notices from health insurance companies stating that their coverage is being automatically renewed for 2015, along with the financial assistance they received this year from the federal government. But consumer advocates and insurers say they see a significant potential for confusion because some of the information will be out of date and misleading on costs and other aspects of coverage. Some people who have been receiving monthly subsidy payments this year could get much less if they stay in their current health plans (Pear, 9/14). 

The Associated Press: Hurdles For Obama Health Law In 2nd Sign-Up Season
Potential complications await consumers as President Barack Obama's health care law approaches its second open enrollment season, just two months away. Don't expect a repeat of last year's website meltdown, but the new sign-up period could expose underlying problems with the law itself that are less easily fixed than a computer system. Getting those who signed up this year enrolled again for 2015 won't be as easy as it might seem. And the law's interaction between insurance and taxes looks like a sure-fire formula for confusion (Alonso-Zaldivar, 9/14).

The Associated Press: Melding Health Overhaul And Taxes Gets Complicated 
President Barack Obama's health care law uses the tax system to subsidize coverage for the uninsured. Promoting social policy goals through the tax code is a time-honored strategy for both political parties. ... But melding insurance and taxes — two of the most complicated topics for consumers — won't be easy (9/14). 

The Washington Post: How States Have Gamed Medicaid For Hundreds Of Millions Of Dollars
States have developed various ways to avoid paying their fair share of Medicaid expenses over the years, in some cases costing the federal government hundreds of millions of dollars in extra funding for the program. The Department of Health and Human Services, which runs Medicaid through its Centers for Medicare and Medicaid Services (CMS), has known about the issue for more than a decade, but states still find ways to game the system. The agency’s inspector general this year listed the issue among 25 key problems the agency needs to address (Hicks, 9/15).

The Associated Press: US Wealth Gap Putting The Squeeze On State Revenue
As the growth of tax revenue has slowed, states have faced tensions over whether to raise taxes or cut spending to balance their budgets as required by law. “Rising income inequality is not just a social issue,” said Gabriel Petek, the S&P credit analyst who wrote the report. “It presents a very significant set of challenges for the policymakers.” Stagnant pay for most people has compounded the pressure on states to preserve funding for education, highways and social programs such as Medicaid. Their investments in education and infrastructure have also fueled economic growth. Yet they’re at risk without a strong flow of tax revenue (9/15).

Politico: A GOP Senate Could Take On Obamacare — But Not Repeal It
A Republican-controlled Senate cannot repeal Obamacare, no matter how fervently GOP candidates pledge to do so on the campaign trail this fall. But if they do win the majority, Senate Republicans could inflict deep and lasting damage to the president’s signature law. Republicans are quick to say they are not yet measuring the proverbial drapes. But they are taking the political measurements of repealing large parts of the health law, considering which pieces could be repealed with Democratic support, and how to leverage the annual appropriations and budget process to eliminate funding or large pieces of the law (Haberkorn, 9/15). 

The New York Times: A Rebound Takes Root In Michigan, But Voters’ Gloom Is Hard To Shake
Another blustery Midwestern winter approaches, but along a blue-collar stretch of Leonard Street in this conservative, famously button-down city, an economic springtime has arrived. ... Yet the economic recovery taking root in Michigan — among the states hit hardest by the 2008 recession — has not translated into an improved political environment for officials in either party. ... On the lower end, the worst of the desperation has subsided, helped in part by government action. Barbara Grinwis, 63, executive director of Oasis of Hope, a free health clinic on Leonard Street, spends much of her time signing up patients for Michigan’s insurance exchange or expanded Medicaid under the president’s health care law (Weisman, 9/12). 

The New York Times: Building Legacy, Obama Reshapes Appellate Bench
Democrats have reversed the partisan imbalance on the federal appeals courts that long favored conservatives, a little-noticed shift with far-reaching consequences for the law and President Obama’s legacy. ... The shift, one of the most significant but unheralded accomplishments of the Obama era, is likely to have ramifications for how the courts decide the legality of some of the president’s most controversial actions on health care, immigration and clean air (Peters, 9/13). 

The Washington Post: In Just A Year Obamacare Goes From Top Congress Issue To Barely Mentioned
It was last September when Republicans sparred with Democrats over the future of the health-care law, a disagreement that prompted a 17-day federal government shutdown and overall chaos. It was pretty much anyone on Capitol Hill talked about. Republicans wanted you to know how terrible it was for America, and Democrats wanted you to remember to sign up on Oct. 1. In that month, a mere 12 months ago, the word Obamacare was uttered on the House and Senate floor 2,753 times, ... With just one full week of work left this month, members of Congress have brought up Obamacare in floor speeches just 27 times (Itkowitz, 9/13). 

The Texas Tribune/The New York Times: Texas Group Uses Health Care Issue To Get Hispanics To The Polls 
When Armando Rodriguez opened the front door of his home here on the city’s west side, Chris Ornelas of the Texas Organizing Project met him with one question. “What are some of the biggest concerns you have in your life right now?” Mr. Ornelas asked in Spanish. Health care, Mr. Rodriguez replied, and whether his family could afford it. ... The issue of Medicaid expansion resonates strongly with Hispanics, who make up a large portion of the state’s uninsured population. In Harris, Dallas and Bexar Counties — three of the state’s most populous counties — the Texas Organizing Project is working to use Hispanic support of affordable health care to spur a movement that could change the state’s electoral tide (Ura, 9/13). 

Politico: Senate Showdown: GOP Frets Over Harkin Seat 
Few states are more important than Iowa in the battle for the Senate this fall. But anxiety is rising within Republican ranks that deep-pocketed conservative donors and outside groups are not doing enough, as Democrats outspend them by millions of dollars to retain the seat of retiring liberal Sen. Tom Harkin. Since GOP nominee Joni Ernst won the June primary, Democratic Rep. Bruce Braley and his allies have outspent Ernst and her supporters by more than $2.1 million, ... Meanwhile, interest groups from the left are piling on. ... Braley’s allies stress that he has also been getting hammered with attack ads — many over absences from House Veterans Affairs Committee hearings in the House and support for Obamacare. (Hohmann, 9/14). 

The Wall Street Journal’s Washington Wire: OTC Birth-Control Fight Hits Airwaves In Colorado, North Carolina
Planned Parenthood’s political arm is ratcheting up its fight with some Republican Senate candidates over the issue of possible over-the-counter contraceptives, calling the candidates’ support of OTC pills “empty gestures.” Planned Parenthood Votes jumped into the middle of hotly-contested Senate races in Colorado and North Carolina with television ads denouncing GOP candidates there, Rep. Cory Gardner (R., Colo.) and Thom Tillis (Burton, 9/12).

The Wall Street Journal: Some Cancer Experts See 'Overdiagnosis,' Question Emphasis On Early Detection
Early detection has long been seen as a powerful weapon in the battle against cancer. But some experts now see it as double-edged sword. While it's clear that early-stage cancers are more treatable than late-stage ones, some leading cancer experts say that zealous screening and advanced diagnostic tools are finding ever-smaller abnormalities in prostate, breast, thyroid and other tissues. Many are being labeled cancer or precancer and treated aggressively, even though they may never have caused harm (Beck, 9/14). 

USA Today: Pre-Diabetes, Diabetes Rates Fuel National Health Crisis
Americans are getting fatter, and older. These converging trends are putting the USA on the path to an alarming health crisis: Nearly half of adults have either pre-diabetes or diabetes, raising their risk of heart attacks, blindness, amputations and cancer. Federal health statistics show that 12.3% of Americans 20 and older have diabetes, either diagnosed or undiagnosed. Another 37% have pre-diabetes, a condition marked by higher-than-normal blood sugar. That's up from 27% a decade ago. An analysis of 16 studies involving almost 900,000 people worldwide, published in the current issue of the journal Diabetologia, shows pre-diabetes not only sets the stage for diabetes but also increases the risk of cancer by 15% (Unger, 9/15). 

USA Today: Schizophrenia Is Eight Different Diseases, Not One
New research shows that schizophrenia is not a single disease, but a group of eight distinct disorders, each caused by changes in clusters of genes that lead to different sets of symptoms. The finding sets the stage for scientists to develop better ways to diagnose and treat schizophrenia, a mental illness that can be devastating when not adequately managed, says C. Robert Cloninger, co-author of the study published today in the American Journal of Psychiatry (Szabo, 9/15). 

The New York Times: Maker Of Hepatitis C Drug Strikes Deal On Generics For Poor Countries
The maker of one of the costliest drugs in the world announced on Monday that it had struck agreements with seven Indian generic drug makers to sell lower-cost versions of its $1,000-a-pill Hepatitis C drug in poorer countries (Harris, 9/15). 

Los Angeles Times: Shortage Of In-Home Dialysis Solution Has Patients Worried
Unlike the hundreds of thousands of Americans who drive several times a week to a dialysis center, Joanna Galeas relies on an increasingly popular at-home alternative to treat her kidney failure. Galeas, a 30-year-old Los Angeles resident, is among tens of thousands of U.S. residents who use peritoneal dialysis at home. She fills her abdomen with a sterile solution that helps remove toxins from her blood, a function ordinarily performed by healthy kidneys (Pfeifer and Terhune, 9/12). 

USA Today: There Is An Epidemic Of Medical Identity Theft
Despite government assurances that the recent hacking of HealthCare.gov did not compromise the security of the personal information of enrollees and the hack was confined to a server that was not supposed to be connected to the Internet, many security experts continue to have doubts about the security of the HealthCare.gov website. And why wouldn't they? (Weisman, 9/14). 

The Associated Press: Texas Asks Court To Allow Closure Of Most Clinics 
Texas asked a federal appeals court Friday to allow the state to immediately enforce a law requiring all abortion clinics to adhere to costly standards required for walk-in surgical clinics, which would close more than half of the state's abortion facilities. Texas Solicitor General Jonathan Mitchell asked the 5th U.S. Circuit Court of Appeals to temporarily reinstate the requirement, which was ruled unconstitutional by a lower court last month. The New Orleans-based appeals court has already upheld another new abortion restriction that has shuttered several abortion clinics in Texas (McConnaughey, 9/12). 

Los Angeles Times: Medi-Cal Official To Leave Healthcare Post In January
The official who led California's giant public healthcare services department through a tumultuous implementation of Obamacare reforms -- including a months-long period during which hundreds of thousands of Medicaid applications have languished, waiting to be processed -- will depart his position in January, state officials have announced (Brown, 9/12).

The Associated Press: WSU Regents Approve Plan For New Medical School 
Washington State University's board of regents on Friday unanimously approved the administration's controversial effort to start a new medical school in Spokane, citing the "dire need" for more doctors in the state. ... WSU's plan is opposed by the University of Washington, which operates the state's only publicly funded medical school. While approving WSU President Elson S. Floyd's pursuit of the independent medical school, the regents said the university should continue its partnership with the University of Washington's WWAMI program, which trains doctors for the states of Washington, Wyoming, Alaska, Montana and Idaho (Geranios, 9/12). 

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Categories: Health Care

Boston-Based Partners In Health Leaps Into Ebola Crisis

CommonHealth (WBUR) - Mon, 09/15/2014 - 7:06am

Members of Partners in Health work with representatives from Liberia and Sierra Leone via conference call to help combat the Ebola outbreak. (Jesse Costa/WBUR)

An advance team from Boston-based Partners In Health heads for Ebola-stricken Liberia Monday. Four doctors, including co-founder Paul Farmer, and two operations staff will lay the groundwork for an ambitious two- to three-year project that will require well over 100 volunteer doctors, nurses, lab techs and public health workers. The budget for just the first year is $35 million.

“We are at a dangerous moment with Ebola,” said Farmer as he prepared for the trip. “Even though this is a huge jump for PIH, I am confident we will succeed.”

PIH will work with two established groups, Last Mile Health in Liberia and Wellbody Alliance in Sierra Leone, to strengthen existing public health clinics and train several hundred new community health workers. In addition, PIH will open two 50-bed Ebola treatment centers in rural areas of each country.

The plan began to take shape last week, as the World Health Organization reported a near doubling of Ebola cases in Liberia and an estimate from Columbia University projects 30,000 cases by mid-October if conditions in the country deteriorate.

In the colorful offices of PIH, decorated with art from countries where the group works, some staffers are flashing back to 2010 and the weeks following Haiti’s earthquake. Ebola is creating another humanitarian crisis, one that is unfolding right before their eyes.

The call for volunteers went up on PIH’s website five days ago. More than 100 people responded within 24 hours, but it will take some time to determine if the skills of applicants fit the needs of these rural Ebola treatment and isolation units. PIH is trying to screen potential recruits quickly. It plans to send a first round to a training run by the Centers for Disease Control next week and open the centers by mid-October or early November.

“To do this right, we will depend on people who are willing to fight against this terrible crisis,” said Joia Mukherjee, chief medical officer at PIH. “The reason we will need a lot of non-Liberians, non-Sierra Leoneans — these countries simply do not have enough doctors and nurses.”

“There’s more doctors on a single floor of the Brigham than in the entire country of Liberia,” added Farmer, who is also chief of the Division of Global Health Equity at Brigham and Women’s Hospital.

He hopes to tap the medical wealth of Boston for the Ebola project, but the PIH board has demanded that a plan to treat and evacuate sick volunteers is in place before the operation begins. Farmer and Mukherjee are talking to the U.S. Department of Defense and other possible partners about transportation and care options.

A fourth doctor in Sierra Leone died Saturday, bringing the total number of health care worker deaths in Liberia, Sierra Leone and Guinea from Ebola to 150.

Groups that have adequate supplies and follow strict protocols, including Doctors Without Borders, have largely avoided the infections that trigger high fever, headaches, muscle and joint pain, nausea and diarrhea. But “we are overwhelmed,” said Dr. Deane Marchbein, president of Doctors Without Borders USA. “We are at the point of having to close the doors and leave otherwise sick patients dying outside our doors.”

Marchbein says she’s delighted to hear that PIH will be working in Liberia and Sierra Leone. A spokesman for WHO Director General Margaret Chan says the PIH plan fits the plea Chan made last Friday.

“Our response is running short on nearly everything from PPE (Personal Protective Equipment), body bags, to mobile laboratories to isolation wards. But the thing we need most of all is people, health care workers,” Chan said.

No one is minimizing the difficulty of the PIH plan or stress it will place on recruits. PIH is asking for a minimum of 10 weeks, which would include training, six weeks treating patients and three weeks in quarantine.

Dr. Corrado Cancedda buys first aid supplies for an urgent trip to assess the outbreak of Ebola in Liberia. (Martha Bebinger/WBUR)

Dr. Corrado Cancedda, an infectious disease doctor at the Brigham who has traveled with PIH before, will head for Liberia with Farmer, just one week after hearing that PIH might get involved in the effort to stop Ebola.

“It was crazy,” he recalled, laughing. “It was literally [a week ago] Sunday night. I was looking at emails and said, ‘Oh boy, Elizabeth, I think this Ebola thing — we may have to do something about it.’ ”

Cancedda looked at his wife, Elizabeth Barrera-Cancedda.

“It was almost like a catastrophe had hit us,” he said.

Cancedda spent the next few days rearranging his work schedule, reassuring his parents who are in Italy, enlisting help with the couple’s new puppy and drafting a will with his wife, just in case. He’ll be gone one week on this trip and is not sure what happens after that. But Cancedda said he’ll do what he can to help control Ebola.

“It is really a moral call; we just need to do it,” Cancedda said. “There’s this sense of urgency.”

Ebola is eroding access to care for all kinds of patients in Liberia, Sierra Leone and Guinea, even those with common illnesses. Many hospitals are full or have closed because health care workers are on strike.

“So that’s the crisis that is being faced,” Farmer said. “Health care that would be delivered in the absence of the Ebola epidemic is not coming to pass.”

Health care workers in Sierra Leone and Liberia say they’ve seen this pattern again and again.

“We have outbreaks, they are contained, then another outbreak comes again,” said Dr. Mohamed Bailor Barrie, a co-founder of Wellbody Alliance in Sierra Leone.

Barrie is optimistic that the PIH intervention will help end this cycle. They take a comprehensive approach, Barrie said. “Working with them is a dream come true for me.”

Categories: Health Care

California To Broaden Autism Coverage For Kids Through Medicaid

Kaiser Health News - Mon, 09/15/2014 - 5:02am

Maria Cruz had never heard the word autism until her daughter, Shirley, was diagnosed as a toddler.

“I felt a knot in my brain. I didn’t know where to turn,” recalled Cruz, a Mexican immigrant who speaks only Spanish. “I didn’t have any idea how to help her.”

Maria Cruz, 45, and her daughter Shirley Cruz, 9, both get frustrated during a homework session in their South Los Angeles apartment. Maria says Shirley’s autism makes it hard for her to concentrate (Photo by Heidi de Marco/KHN).

No one in her low-income South Los Angeles neighborhood seemed to know anything about autism spectrum disorder, a developmental condition that can impair language, learning and social interaction. Years passed as Shirley struggled through school, where she was bullied and beaten up. Now 9, Shirley aces math tests but can barely dress herself, brush her teeth or eat with utensils.

Shirley is like many autistic children from poor families: She hasn’t gotten much outside help. The parents often lack the know-how and means of middle-class families to advocate for their children at schools and state regional centers for the developmentally disabled.

A new initiative seeks to help level the playing field. Starting Monday, September 15,thousands of children from low-income families who are on the autism spectrum will be eligible for behavioral therapy under Medi-Cal, the state’s health plan for the poor.

California is among the first states to respond to a recent rule by the U.S. Centers for Medicare & Medicaid Services that requires the therapy to be covered, when deemed medically necessary, as part of a “comprehensive array of preventive, diagnostic and treatment services” for low-income people 21 and under. (Medi-Cal is California’s version of Medicaid.)

This type of treatment includes the sometimes costly “applied behavioral analysis,” which uses intensive drills and rewards to teach kids how to communicate and interact socially.

In California, a huge percentage of the population that stands to benefit is Latino. About a third of beneficiaries speak Spanish as their primary language, yet historically their communities have been underserved because of a shortage of Spanish-speaking providers and meager outreach and education efforts.

Taking the lead

California, however, is ahead of many states: It already has programs in place that cover a portion of autistic kids through public school districts and the California Department of Developmental Services.
Although several states, including Louisiana and Washington, have taken early steps to make behavioral therapy for autism, others offer little or no public coverage for it.

Roughly 1 in 68 kids in the country has been diagnosed with autism spectrum disorder, according to the federal Centers for Disease Control and Prevention.

“For as long as I can remember, when a family called me for help, I had to ask them what kind of insurance they had. If they had Medi-Cal, there wasn’t much I could do to help them,” said Kristin Jacobson of Autism Deserves Equal Coverage, a Burlingame, California-based advocacy group. “Now they’ll have access to this treatment that can help these children reach their potential.”

Shirley Cruz, 9, was diagnosed with autism as a toddler and needs help from her mother, Maria Cruz, 45, with simple things like washing her hands (Photo by Heidi de Marco/KHN).

At least, that’s the theory. In practice, many details remain to be worked out.

Among the unsettled questions is what rates will be paid to providers. “In every state, it’s going to be critical that rates be sufficient” to cover high-quality applied behavioral analysis, said Daniel Unumb, the executive director of the Autism Legal Resource Center at Autism Speaks, a national advocacy group.

“Otherwise, they will not attract sufficient providers and there will be huge problems with access.” On the other hand, some officials warned that Medicaid programs must be on the alert for providers who might misdiagnose or over-prescribe services in the interest of greater profits.

The challenge is that clinicians don’t yet fully understand autism or the amount and type of treatment from which different children will benefit most, said Matt Salo, the executive director of the National Association of Medicaid Directors. States are still “trying to get a handle on what is this all going to mean. Is this going to be an open ended entitlement to a very nebulous set of services that could continue forever or a more specific, targeted intervention?” he said.

Controlling Costs

California will seek to contain costs by setting fixed rates for care, under a managed care model, officials said. Even so, some observers remain concerned that the influx of thousands of kids newly eligible for autism treatment could overwhelm an already-strapped system.

Last year, the state Department of Developmental Services (DDS) spent roughly $88 million on behavioral treatment for about 7,500 children believed to be eligible for Medi-Cal. The state Department of Health Care Services, which runs Medi-Cal, won’t speculate on how many kids may sign up for the treatment for the first time as a result of the new rule on Medi-Cal coverage – but advocates say the state could be covering between 4,000 and 6,000 additional children.

Most of the kids expected to benefit have been eligible for Medi-Cal for some time – so, for them, the state can’t draw the blanket federal subsidies offered under the recent Medicaid expansion provided for in the nation’s health law. The federal government will cover just half the costs; California will have to absorb the rest.

The state will most likely cover any new expenses with money from the general fund, said Dylan Roby, a health care economist at the University of California, Los Angeles’ Fielding School of Public Health. If that runs dry, “they would need to pay for it by moving funds around, cutting existing programs, or getting additional appropriations from the state legislature and governor later in the year or as part of the next budget package,” Roby wrote in an email.

Still unclear is how the new system of Medi-Cal coverage will mesh with the bureaucracies and funding already in place for treatment of children in public schools and through DDS regional centers. Some advocates expect these systems to remain in place for the near term, but state officials said they could not yet discuss their plans.

Not A Panacea

For poor families, the coverage does not remove every obstacle. Some families can’t take the time off work to attend behavioral treatment regimens, which often require an adult to accompany a child. It can be a commitment of up to 40 hours a week-- the equivalent of a full-time job.

Perhaps one of the most challenging issues for state officials will be reaching out to poor families -- making sure they understand the disorder and don’t delay diagnosis or treatment out of any sense of denial or stigma.

Nine-year-old Shirley Cruz suffers from a mild case of autism. Her condition makes it hard, and sometimes dangerous, for her to use utensils. Her mother, Maria Cruz, has to monitor her while she eats (Photo by Heidi de Marco/KHN).

For many years, Cruz rationalized Shirley’s behavior: she was her youngest, the last of four. She had been babied; she was naturally quiet. When the DDS regional center that diagnosed Shirley inexplicably stopped calling about providing treatment, Cruz accepted it without pushing back.

A conversation with a friend from church about a year ago woke her up. They were talking about how Shirley’s schoolmates had spit on and hit her. Cruz confided that she loved her daughter, but she could not accept that she might have this condition. Her friend chided her, saying that what Shirley needed was her mom’s unconditional support; otherwise Cruz was no better than the bullies.

It was a harsh thing to say. But it also marked a turning point. Since then, Cruz has pored over legal and scientific texts and vigorously pressed her local DDS regional center to help her daughter. She’s dropped off letters spelling out the treatment she believes Shirley is entitled to, complete with the legal codes. She’s even taken a bus with other advocates to Sacramento to push for better access to treatment for all autistic children.

But until a reporter mentioned it this month, Cruz was unaware that Medi-Cal – her daughter’s insurance plan—would soon cover behavioral therapy. Cruz only wishes she could have gotten services for Shirley earlier—her daughter might be better off. Still, Cruz is hopeful the new rules will finally give Shirley a better chance at succeeding in school and making friends.

“It makes me happy ... It’s important for her life, for her future,” Cruz said. Right now, “our children are losing out a lot.”

DanielaH@Kff.org

Categories: Health Care

The Roosevelts: An Intimate History

Massachsuetts Trial Court Law Library - Sun, 09/14/2014 - 6:00am
Ken Burns' new film, The Roosevelts: An Intimate History, premiers tonight from 8 pm to 10 pm ET on PBS stations and will run for 7 consecutive nights.  The film chronicles the stories of Theodore, Franklin and Eleanor from the birth of Theodore in 1858 to Eleanor's death in 1962.

According to the overview on PBS, "Together, these three individuals not only redefined the relationship Americans had with their government and with each other, but also redefined the role of the United States withing the wider world.  The series encompasses the history the Roosevelts helped to shape: the creation of National Parks, the digging of the Panama Canal, the passage of innovative New Deal programs, the defeat of Hitler, and the postwar struggles for civil rights at home and human rights abroad.  It is also an intimate human story about love, betrayal, family loyalty, personal courage and the conquest of fear."

Tomorrow the entire 14 hours will be available to stream through PBS stations' video sites, pbs.org/theroosevelts, and PBS branded digital platforms including ROKU, Apple TV and Xbox for 2 weeks through September 29th.
The film can be previewed here.


Categories: Research & Litigation

Rashi Fein, Economist Who Urged Medicare, Dies at 88

Medicare -- New York Times - Sun, 09/14/2014 - 12:00am
Dr. Fein’s ethical and humanitarian perspectives on national health care were influential from the Truman administration to President Obama’s Affordable Care Act.
Categories: Elder, Medicare

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