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Monday, November 12, 2012

Implications of Health Care Reforms on U.S. Trauma System

Up close and personal with the U.S. Health Care Trauma System
October 16, 5:17 P.M. I received the call, “Your son has been hit by a car. “At this point everything slowed down inside my head and all noise from the outside world was muffled. First, I breathe and then ask, is he conscious? Thankfully, he was alert according to the paramedic on the scene. He was being transferred to the local hospital emergency room for further treatment. By this time it is too late to make it down to the 5:30 ferry, so I was relegated to the 6:45, which means I wasn’t on the beach to see my son until 7:45P.M. I gave the paramedic my information and called the hospital giving them my E.T.A.
Traumatic Brain Injury
8:00 P.M. I arrive at the local hospital, a 262 bed facility with a Level III Trauma Center, and immediately found my teenager in the E.R. The treating physician informed me that he had multiple fractures, on his head and leg, the most worrisome of which was the skull fracture. (My son had just bought his new skateboard and did not have his helmet at the time of the accident.) The first thing Nathan says when he sees me is “I’m sorry Mom,” and then he starts asking for pain medication, yet he was calm, and composed. The doctor informs me the head trauma has caused a brain bleed, and Nathan needs to be transferred to a pediatric trauma center. At this point, I requested Seattle Children’s Hospital for the transfer, but it turned out that Harborview Medical Center had the pediatric –neuro-rotation for that night.  So off we went in the ambulance to the Level I Trauma Center, which is funded by the State through the University of Washington.
If you haven’t experienced the controlled chaos of an urban trauma center, it is reminiscent of a mental health ward, serves as a repository for the homeless in varying degrees of inebriated battle-weary skirmishes, and of course, is the collecting point for trauma victims. Some patients were on gurneys in the hallway while more urgent cases were treated in the E.R. suites, which were divided only by a curtain which runs two feet above the ground, and circles the bed like a shower curtain. Consequently you can hear everything in the ward, which can be somewhat disturbing.
Patient Safety Observations
Nathan was admitted to Harborview at 11:10P.M. October 16th. Throughout the night teams of specialists came in to examine him and he was not allowed to sleep until he could be fully evaluated, after the C.T. scan(s). Teams included pediatric neurological surgeons, general care pediatricians, orthopedic surgeons, and ortho/maxillofacial  surgeons.  Procedures which he endured included putting a cast on his leg and a second cast on his arm, which was later removed after it was discovered there was no arm fracture, and lots of tests. Unfortunately whoever installed the I.V. line did not removed the tourniquet after finding a vein and it was allowed to linger on his arm until the next day. This included some nurse actually attempting to put a blood pressure cuff over the tourniquet, which was high up on his arm and slipped under the cap sleeved gown. The tension of the tourniquet left a circular barbed-wire-tattoo on his arm. If he had circulatory problems this safety lapse may have caused severe problems. During his hospital stay, the phlebotomist came in to draw blood and asked if he was the patient in Bed A or Bed B, and I said I don’t know what bed this is, but he is my son and his name is Nathan. Again, isn’t it a better verification to use a patient’s name rather than the bed insignia?
Shortage of Beds for Patients
October 17, 5:30A.M. Nathan was transferred to the Intensive Care Unit where he spent two days for observation of his brain bleed, which had doubled in size but was stabilized. Yes, we spent the night in the E.R., with him on the gurney and me in a straight-backed chair, because we were waiting for a bed to become available anywhere in the hospital. This is not an unusual phenomenon for urban trauma centers, as they received referrals from all regional hospitals, for Traumatic Brain Injury (TBI) cases, burns, and other traumas. Children of course get top priority, so a bed was found. Literally, this trauma center does not have enough beds for its patients.  The Intensive Care Unit (I.C.U.) floor featured a shared ward with the burn victims and as it turns out, one mental health patient in the midst of an episode. Though the room was private and it actually had views of the harbor, the hallway between all of the other “rooms” in the ward was an open design, separated from the patient’s area only by a curtain. This meant that sound carried throughout the ward. Thankfully Nathan was loaded up on some pain medication and I crashed out on one of those folding bed/chairs.
Who Pays the Bill?
At both the local hospital and the regional trauma center, I was queried on where I worked, if I had full-time or part-time employment, and other insurance payment questions. Incidentally, evidence of employment in the United States does not mean that medical insurance is available to the employee or her family, as only about half of all businesses offer any type of group medical insurance. This payment interrogation is part of the follow-the-money-trail of all health care providers in the United States. Even though my son had insurance and I presented his insurance card, there is still the secondary payer inquiry, to allocate fault or payment somewhere else. Speaking of fault, the ambulance company billed me immediately and assumed that because my son was hit by a car that it was an auto insurance claim and asked for that information.  Of course these questions are routine and did not drive my son’s health care, but they serve as a constant reminder that our health care system is always about the money trail. Because the United States lacks a national health care program, we must concern ourselves with the ugly word, subrogation, which is an insurance industry term for assigning blame in order to obtain payment or reimbursement. In fact, at 12:04P.M., on October 18th, I received a call from the man who drove the car which hit my child, asking for money to fix his truck. Aside from the ghoulishness and timing of the request, it too reflects on a predominant driver in the U.S. health care system, which is getting paid.
Follow-up Care
Fortunately our follow-up care at Children’s Hospital was a marvel, with concierge-type service from department to department, making fast work of the registration and verifying patient identity quickly, and with humor. Another marvel was the complete lack of any measurable wait time at Children’s Hospital as compared to the follow-up  care we also completed at the trauma center. While at the latter a hospital volunteer retrieved an unconscious man who was unable to speak from the “drive-up” and wheeled him to the X-ray and imaging department. Though I have difficulty imagining what family member would leave someone this vulnerable without an advocate, I was reassured when I saw him alert later in the day when he was waiting for his ride home. In conclusion, a patient advocate is always a good idea during a traumatic event as the family member and the patient may be too upset to make good decisions.
Implications for the Hospital Safety Net
With the implementation of the Affordable Care Act in 2014, more employees will have access to affordable health insurance through federal subsidies and insurance exchanges, regardless of what their employers are doing, so the full-time or part-time work question will become less important. But what remains is an acute shortage of hospital beds, especially in urban trauma centers and this will require an infusion of cash to overcome. Though Disproportionate Share or DSH hospitals like Harborview do receive additional funding from the federal government, it is not enough to finance a building expansion. The resourcing of health care falls to the local hospital district which will have to raise the money through a bond issue or some other means. We cannot afford to staff every hospital with the neurological and other specialty personnel required for Level I Trauma Centers, so surely we must do everything we can to preserve the ones we have. Since 2013 will focus on the budget crisis I hope lawmakers will consider the hospital safety net when they make their cuts.
And this is the healthpolicymaven signing off in real time.
This article was written by Roberta E. Winter, MHA, MPA, a health care journalist, consultant, and mother.

Thursday, October 4, 2012

Presidential Debate Uno-What Did they really say about health care?

A few months ago I wrote an article entitled Why We Don’t Want to Get Rid of Medicare, Our Best Tool For Health Care Reform which alluded to Republican attempts to “block grant” both Medicare and Medicaid programs and Mitt Romney, Republican Presidential Candidate stated as much in his debate with Presidential Obama last night. To the one person who questioned the validity of my previous article, please feel free to eat crow now. This piece reviews the 2010 health care reforms that Mr. Romney would eradicate, based on his debate comments.

Romney indicated there is broad based support to have the federal government just give state governments money to administer their own Medicaid programs for low income residents, without government mandates. Sure, who wouldn’t want more money to meet a social need, without strings attached? The problem with this is the federal government is funded by all states and all residents and not merely a few, though as Mr. Romney has suggested 47% of us are just free loaders, enjoying life on the dole. To be fair, funding Medicaid benefits is a challenge for all states because the federal government does not pay anywhere near the cost of the program. Some states, like Oregon have used this challenge to come up with a creative health care plan which assigns values to health services and targets public dollars to those which do the most good for its Medicaid population. Actually the Oregon approach is also used in Scandinavia and Europe, where programs funded by the government must meet certain criteria for health effectiveness.  This is incidentally, what the Accountable Care Act and the Center for Medicare and Medicaid (CMS) programs seek to accomplish.
 Having completed many fifty-state analysis of Medicaid and other health programs, there is currently sufficient variety in state Medicaid programs. Some of the variables include; at which level of poverty must one bear in order to become eligible for state medical assistance, variations in plan benefits, and levels of cost sharing. As a tax payer we have to ask ourselves if it is prudent to merely give money to another agency without some performance expectations and program measurement criteria. States who wish to modify their Medicaid plans may currently do so under Section 1115 Waver Plans, which has been around for over a decade. Nearly half of the states already have 1115 Waivers.

Mr. Romney indicated he wouldn’t change Medicare for those who are retired or near retirement, whatever that means (needs their votes), but his plan is to have eligible residents under age 55 subject to block granting for a health care budget. What this means is a fixed allowance would be given to each eligible person to purchase insurance and then get rid of the most popular social program today, Medicare. I wonder what would happen to the “hold harmless” clause that prevents health care providers from charging patients more than what they receive in reimbursement without Medicare setting the standard.  Block granting is a means to affix a budget for a health care spend, similar to what many employers do for their health care programs. This is a way to increase cost sharing among program recipients and to fix costs for the plan sponsor. The problem with this approach is two-fold; you are ultimately passing on a greater burden of health care expenses to those who are least able to pay for it. Let’s face it many seniors have to choose between dinner and their medications, especially since the U.S. government chooses not to bargain with the pharmaceutical companies. Secondly, eliminating the largest stakeholder would remove much of the systemic power for change in health care processes. The arc of Medicare is sufficiently large that as a nation we are able to conduct low-cost demonstration projects to find out which is the best way to align physician compensation with improved clinical results for patients. And changes made by Medicare or CMS do impact the entire health care delivery system in the United States. No other element of the health care system has this much influence.
In order for the country to effectively lower the cost of health care proportionally, we must create a better model of delivery and block granting Medicare by allowing private sector insurance companies to do this is not the answer. What you may ask is wrong with this, well for one thing, private sector insurance companies charge three times as much as Medicare for plan administration and this does not include the margin for profits. As an expert in the health insurance industry and someone who used to negotiate employer plans, I understand all too well the various loads and expense factors which the private sector includes in administration. So, the smart health care consumer will want to spend less for the administrative load, just as the smart investor does for mutual funds. But the Romney health care answer would simply foist the health care purchaser into the already more expensive private sector marketplace. Additionally, the private sector has long had the reputation for “cherry picking” risks and avoiding those folks who are more likely to need health care services. In fact, this is the main reason we have Medicare today, because the private sector insurance companies did not want to serve the elderly, much less the low-income elderly. In conclusion, if you want to have less of your insurance premium dollars paying for your actual health care, have difficulty finding an insurance company that will accept you, and be responsible for a much greater portion of your health care expenses, then by all means, the Romney Plan is for you.

Health Care Expenditure Oversight by A Panel of Experts-Yeah or Ney
Another one of the health care reforms Mr. Romney would obliterate is the Independent Payment Advisory Board which is an appointed commission of health care experts, which would have the authority to rein in Medicare spending. Romney used the scare tactic harking back to the anti-Clinton-health-plan era, which is that this panel would tell you what medical treatments you could have. This is not true, as the advisory panel would examine treatments for targeted diseases and view the most effective outcomes and recommend practices which would save the nation money in the Medicare program without harming the patient. By the way, this is also a process I was involved in while working as an internal consultant for a large hospital group.  The government wouldn’t be telling you what procedure you can have but rather what it is willing to pay for. This is exactly what we need a speed checking device on the gas pedal, as Medicare spending is a huge concern and our elected officials have conflicts of interest from drug company, medical supplier, and big hospital corporations who contribute to their election campaigns.  Do you want someone who is beholden to a private company with a financial interest in the outcome deciding what your health benefits will cost? Why wouldn’t you want an informed unbiased group of experts who use data driven consensus based process making this national policy decision?  Mr. Romney said that private sector always has better solutions than government and solutions to health care spending should be left to the private sector. Well, if that is the case, then why is health care so expensive when we already have private sector individual and employer-based insurance? The answer is none of those stakeholders can change the health care delivery system on their own and we need to work together as a nation to accomplish this gargantuan task.

Hopefully this will clear the fog on the fifteen minutes of the debate which was devoted to health care.

This article was written by Roberta E. Winter, MHA, MPA, and may be reprinted with her permission or better yet, just share it on the paperless wings of the world.

Wednesday, September 19, 2012

Supreme Court Ruling and Medicaid Changes-Impact on the "47%"

Supreme Court Ruling on Health Care Reform-Impact on the 47%

Presidential Candidate,  Mitt Romney has identified the 47% of the country’s population which he doesn’t care about and this article addresses how the Supreme Court rulings on the Patient Protection and Affordable Care Act will impact “their” access to Medicaid and subsidized health care through the insurance exchanges in 2012. This article will also inform health care administrators in various government and nonprofit agencies who will be implementing the law. Additionally, business owners should have an understanding of the eligibility rules for the subsidized insurance plans, as, unbeknownst to Mr. Romney; people in the “47%” can actually have jobs and not have any health insurance. So, to all of you people out there who are working either part-time or full-time or unemployed, read on to learn what your options will be in 2014, assuming the health care reforms are not dismantled.

Supreme Court Ruling on Health Care Reform
Though the Supreme Court indicated the federal government could not use its bully pulpit and reduce federal government Medicaid payments to states which chose not to comply with the health care reforms for Medicaid, the government is allowed to implement the sweeping health care reforms. This means the requirement to purchase insurance stands, along with the scheduled subsidies for individuals to be able to purchase medical insurance and so does the government’s ability to tax individuals (and corporations) who opt not comply. So for those of you who think the health care changes are not going to happen, you better get busy on the implementation.

Affordable Care Act Impact on Medicaid Programs
Under the Patient Protection and Affordable Care Act, there are a number of changes to Medicaid, the jointly run federal and state program for the significant population of poor people living in the United States. Presently under the Medicaid program, low-income single people are not eligible for the program unless they are disabled. Under the rules change, low-income people, earning 133% of the federal poverty level, which is $11,170 for a single individual[1], could have an income of $14,856 and still qualify for Medicaid Insurance.  Also, people who are working full-time and only earning minimum wage, in states which do not have minimum-working-wages may only earn $11,000 a year, working at $5.50 an hour.

Impact on the Working Poor
Under the health care reforms, states can choose how far they want to go to participate in the revised Medicaid eligibility standards, in other words, to fully offer the program to all of their eligible poor residents (who must be citizens by the way). A quick way to gauge the impact of the Medicaid expansion for each state is to look at Department of Labor information for states lacking any minimum wage criteria and thus are likely to have a higher degree of individuals who are classified as the working poor.[2]  In this category are: Alabama, Louisiana, Mississippi, South Carolina, and Tennessee. To further underscore that point, these states actually have a minimum wage standard which is lower than the federal benchmark of $7.25 per hour are: Arkansas, Georgia, Minnesota, and Wyoming. A high five to all of the states who at least meet the federal wage standard and a special mention for the following states who have minimum wage guidelines higher than the federal mandate: Alaska, Arizona, California, Colorado, District of Columbia, Connecticut, Florida, Illinois, Maine, Massachusetts, Michigan, Ohio, Oregon, Nebraska, New Mexico, Rhode Island, Vermont, and Washington. The latter states perform their own economic analysis and arrive at a wage that theoretically is a “living wage” for a full-time employee.
Though there are federal inducements to cover the newly eligible Medicaid population, it remains to be seen which of these states will agree to implement the program, because after all they will have to contribute to the cost of it. For example, someone working full-time at the federal minimum wage and living in Texas would make $14,500 a year, which would qualify that individual for state Medicaid insurance based on the threshold of 133% of Federal Poverty Limits for 2012. I am betting there are quite a few individuals in that category in the Lone Star State.

Changes to the Qualifying Criteria for Medicaid
The income calculation to determine whether or not someone qualifies for state Medicaid will be vetted using electronic income verification via your social security number and also include a personal declaration for those who lack regular employment, such as those who perform any-odd- job they can find in this economy. To Mr. Romney these are your bottom 47% but to the rest of us working stiffs, these are the people who mow your lawns, take care of your children, serve you lunch, and answer the phones in a myriad of locations. You would be surprised who is working for minimum wage or barely more than that. There is such a stigma in this country for earning a low wage people are reluctant to speak up, but if you are extremely wealthy by accident of your birth you can bellow all you want.

Under the Modified Adjusted Gross Income (MAGI) Medicaid criteria there is no longer an asset limit to qualify for Medicaid, so for example, one could own a home and qualify. Increasingly in my fundraising work I speak with senior citizens who qualify for federal poverty status, because all of their investments have dried up and they get minimal interest on any cash reserves that have left. Though they may have a dwelling, this does not make them wealthy and typically they even convey that back to the ever handy bankers with a reverse mortgage. Additionally, the income criteria may be reviewed for re-certification annually.  And finally, the members of the household who are included in the income qualification standards are the same as those for federal income tax filings.[3]

Children within 200% of the federal poverty level are eligible for Medicaid, which is the same standard as the CHIP or Children’s Health Insurance Plan, which has been around for years and is highly successful.

Pregnant women are eligible for Medicaid if their income is within 185% of the federal poverty rate and this is also the standard most states already use.

There are some new eligibility inclusions for families who are taking care of parents and caretakers of other relatives as well.

Categorically Eligible Medicaid Patients Unaffected by the Reforms
If you are unfortunate enough to be blind or disabled the health care reforms for Medicaid do not change your status, because you are already eligible regardless of being single and lacking children. Foster children will experience no change in their Medicaid eligibility either. And finally, those covered on Social Security (dual eligible patients for both Medicare and Medicaid) are also unchanged by the Medicaid updates.

Unintended Consequences
Though it is a good idea to find a way to expand the social safety net through improving health care access by increasing some level of payment to hospitals and clinics, this legislation doesn’t address the unreasonably low reimbursement for physicians who are expected to treat all of these new patients. The Medical Home legislation and some of the Centers for Medicare and Medicaid demonstration projects are investigating methods to improve the primary care treatment dichotomy, but the results are not available yet. Conclusion, many states will be reluctant to increase their Medicaid budget, which must be funded by sales or income taxes from state residents.

As one of the part-time workers who is in the bottom 47% by virtue of the fact I have not earned more than $20,000 a year since the 2007 regulatory failure which resulted in the economic meltdown, I guess this makes me less important to Mr. Romney and his cronies, but I can tell you this, the only magic underwear I believe in are those you buy at the department store.
And this is the healthpolicymaven signing off.
This article may be reprinted with the permission of Roberta E. Winter, MHA, MPA or preferably, share it virally without her permission.


Wednesday, August 22, 2012

Akins Assault on Women's Health & Dignity

Assault on Women’s Health Revisited with Senator Akin, leaving the Republican Party Belly-aching

Though the memory of the 2011 Republican attempts to redefine the rape of an unconscious woman as a noncriminal activity and thus not rape, are still etched in my memory, the party continues to horrify the nation with its Neanderthal postulations. The latest assertion came from Senator Akin from Missouri, who stated that women are unlikely to get pregnant in a true rape situation, because the woman’s Zen warrior vagina is able to battle the offending sperm from penetrating her nubile eggs.  OK, Akin didn’t say that part, but I thought I would add some humor to the situation.  Once again we seem to have a Republican senatorial candidate who still wants to redefine rape, so this ugly issue has not been vanquished.   In the interest of refining the conversation by adding some facts, this article will address actual data on rape, biology, and national data on abortion services for women.

Once and For All Here Are the Definitions and Data on Rape
The New York Times reported that nearly 1 out of 5 women admitted to having been sexually assaulted in the United States. The National Intimate Partner and Sexual Violence Survey, which was funded by the Department of Defense reviewed the records of 16,507 adults and of those, 33% of the women indicated they had been raped, beaten, or stalked, or horrifically, in combination. Rape was defined as a completed forced penetration, forced penetration facilitated by drugs or alcohol, or attempted forced penetration. If you apply this relationship to the U.S. female population about  1.3 million American women are rape victims annually. In the same survey 1 out of 71 men also reported they had been raped. [1]

The ability of a sperm to penetrate an egg or ovum has little to do with the female vagina’s functioning, but rather with the sperms facileness and speed within the window of opportunity in terms of the female ovulation cycle. The vagina is the entry point for the sperm. Where the individual woman’s work really comes into play is in the ability to carry the fertilized egg through  the development cycle of the pregnancy term. The woman’s “welcoming vagina” does not clinically decide pregnancy, as-in- yea for the good guy and nea for the rapist.

Implications for Women’s Health Care
The assault on women’s health care has been ongoing for years, but the attempts to offer low income women the same health care options that wealthier women have for family planning has increased the temperature of this pot boiler. In my previous articles on statewide positions for reproductive autonomy I have revealed which states restrict oral birth control, even for private sector employees, those that restrict birth control options for any state worker, and of course, those seeking the personhood amendment for an unborn fetus. If these states are so concerned for the unborn child, let’s take a closer look at the welfare of children in Missouri, which spawned the odious Senator Akin.

Missouri  currently has a ban on abortion, which is not enforceable because of federal protection under Roe-V-Wade. Though Missouri has not criminalized abortion (yet), it is one of the more restrictive states for this medical procedure. For example, in the State of Missouri, all private insurance plans are restricted from providing abortion coverage in their health plans. This flies in the face of the national statistic which indicates that 46% of private employer plans offered abortion services in their group medical plans according to a 2003 Kaiser Foundation Survey.  So Missouri already makes it tough for women who are forcibly impregnated.  Missouri also denies access to abortion for Medicaid women.

According to the Kaiser Foundation 2010 National Insurance Survey, 82% of Missourian women had some type of insurance, with nearly 19% on Missouri Medicaid or other state subsidized plan for women living in poverty. Compared to the nation, Missouri is in the middle in terms of how much income a woman is allowed to have in order to qualify for its Medicaid program, at 185% of the federal poverty level.

Akin has created a lot of belly-aching though his views are shared by many in the Republican Party which has recently come out with its formal platform stating it is against abortion even in the event of rape or incest.  Though I pride myself on my objectivity and data-driven approach to policy making and of course my voting process, my ability to consider any Republican candidate as suitable material for elected office is waning when the party spends its time coming up with this type of proclamation during one of the worst economic depressions the United States has seen. To all women in this country, I remind you that we are at least 51% of the country’s population and I encourage you all to vote with your autonomous vaginas in-tact.

For more information on how your state ranks in terms of reproductive autonomy, contact the healthpolicymaven, who conducted a fifty-state survey in 2010 and recently updated it in 2012.
And this is the healthpolicymaven signing off still unpenetrated by the Republican attempts to control my privacy.

This article was written by Roberta E. Winter, MHA, MPA, and may be reprinted with her permission. I do encourage you all to share it virally for this issue deserves attention.

[1]Naomi Wolf,  Vagina, A New Biography, Published by Harper Collins, September 2012,  Chapter, The Traumatized Vagina, p. 97