Straight Talk on Health Care

Stopping the Over Charging in the U.S. Health Care System

2011-12-28T09:29:00.000-08:00

How Profit-taking Distorts Health Care Delivery in America
Recently, a Public Broadcasting Station (Channel 9) featured a story on a for-profit hospital group which was using obscure diagnostic codes to achieve higher Medicare payments. The level of unethical and fraudulent activity was so egregious that more than one of their billing coders quit their jobs and testified against their former employer. The Wall Street Journal has also reported on fraudulent Medicare billing, including requisitioning public records from CMS(Medicare) and identifying abusive billing practices by multiple clinicians. For example, the New York City osteopath who billed Medicare 2 million for family medicine, when this was not the nature of her medical practice. WSJ staffers examined the Medicare database and uncovered 25 billing codes for an array of expensive medical tests which were regularly performed by 20 other clinicians in the country. Of that group, 33% have already been convicted of fraud, have undergone professional ethics investigations, or worked in the same firm as the convicted physicians. It is safe to say that this high correlation of billing blips is no accident. Unfortunately, because the American Medical Association prohibits the government from disclosing clinician compensation, even if billing practices are fraudulent, those physicians are not publicly named. Basically, this means a lot of people are still getting away with fraud. This article reviews how profit-taking motives distort the U.S. health care system and does not contribute to health care improvement.

First of all, it is legal to deliver health care services and make a profit in the United States, but it is not legal to defraud the government or private sector insurance companies by making false claims to incur higher reimbursements. In plain language, this is known as stealing and this article will show how the incentives to steal are so high in the current U.S. health care system that despite penalties, including jail sentences, the phenomena continues to rob money from all U.S. health care payers. The payers are the individuals who must obtain health care services at inflated prices to subsidize excessive profiteering and fraudulent activities in many sectors of the national health care milieu.

By focusing on changing the alignment of reimbursements for many health care providers from a volume-based principle to outcome-linked measures we will be able to identify the outliers in the shell game of medical monopoly. Several aspects of the 2010 health care reforms seek to address the abuses of health care reimbursement in the country, including more stringent requirements for health insurance company financial reporting of premium payment utilization. Additionally, there are financial incentives for clinicians who achieve better outcomes for targeted medical conditions under the Shared Savings Rules. And finally, the systemic review of medical supplier over-charging is also included in the reform provisions.

Accountable Care & Incentives for Health Care Outcomes
Accountable Care rules for hospitals and integrated health care organizations include Shared Savings methodology or a bonus if you will, for those medical groups which produce desirable clinical outcomes. This realignment in Medicare & Medicaid reimbursements will ultimately save U.S. taxpayers money for federally funded health care programs. In other words this changes the equation from paying for volume to actually paying for clinical performance, and the best performers will receive more money than those who have poorer clinical quality. For example, if your facility has more hospital re-admissions for a specific procedure than the evidence shows is desirable, that will impact your reimbursement. This is a good thing for the country, although I am sure some health care providers are concerned about the ramifications for their practices. Clinics and hospitals are not required to become designated as Accountable Care Organizations at this time, but the pay-for-performance methodology will ultimately be spread throughout the country as organizations respond to this trend.

Creating Efficiencies System-wide
As previously reported in 2010, the establishment of the Comparative Research Institute seeks to review system-wide data on medical equipment suppliers and clinician practices, in order to optimize value for U.S. taxpayers who fund federal health care programs like Medicare. Though this has been criticized as just another government agency, the purpose is to look across the health care system of disparate providers including; medical equipment suppliers, purveyors of high-tech devices, and clinics to find ways to save money for the entire system. Certainly not everyone will be happy with this process, but one wonders how many of them are in fact the excessive profiteers.

Like it or not, several components of the 2010 landmark health care legislation are here to stay because they profoundly impact Medicare and Medicaid programs, which consumes 32% of the 2011 federal budget. We do need to spend taxpayer money more wisely and part of that process includes scrutinizing all of the components of health care delivery. The government oversight is necessary to curtail cheating and other criminal activities.

A Clinical Case: How America’s Private Health Care System Is Not Producing Best Practice Results for Kidney Dialysis
A basic tenant of a capitalist economic system creates a disproportionate incentive towards money making activities which often fall short of optimal patient care. A good example of this capitalist infusion is the kidney dialysis system in the United States, which sprang up because of the congressional ruling to cover end-stage-renal-disease under the Medicare umbrella in the 1960’s. The entities that seized this “new market” were largely for-profit corporations. For those of you who do not know, kidney dialysis is a mechanical cleansing process which is lifesaving for those whose kidneys have ceased to support their renal systems. International data on dialysis treatment shows that Americans on dialysis do not survive as long as patients in other industrialized countries and also experience more clinical complications. This should come as no surprise when the corresponding American health care incentives are based only on providing the dialysis procedure, not optimizing patient health.
For the profitable dialysis centers, like DaVita, business has been brisk as the American population undergoing dialysis has grown from 11,000 people at inception to over 300,000 people today. Each patient on dialysis brings in about $72,000 just for that procedure, so the industry is worth billions. Examples of how the maximization of profit has impaired clinical processes include the dialysis center protocols which discourage the use of fresh kidney processing devices for each patient and thereby greatly increase the chance of infection. So some MBA figured out they could save their organization money by reusing artificial kidneys on a critically ill population and this has become a standard of practice.
Another example of a U.S. renal failure outcome which differs from other global practices is the limited number of dialysis patients who use the peritoneal process, which can improve the individual’s the quality of life. Clinicians have suggested that American patients are often too ill to be eligible for the home-based peritoneal process. As a society which is paying for this treatment, we need to be asking what we can do to treat these people earlier in their disease progress, so they may become eligible for less taxing treatments(and less expensive). Too often the U.S. health care system steps in literally at the “end-stage-of-treatment” because our system of economic reinforcements only assures payment at that time. This dichotomy is what needs to change.

Evidence-based planning which I have previously written about (and continues to be one of the most popular articles for this readership) is all about reviewing appropriate scientific data to discern the optimal blend of clinical intervention and patient outcomes to benefit a population. This process is what we need to be doing as a nation in order to optimize health care services for the entire population.

Election Implications
Since 2012 is an election year, when you start to hear the rhetoric of “getting the government off our backs” remember that doesn’t mean you will pay less for your health care premiums or services. In our blended system of public and private health care services, we must have an external audit and enforcement arm and the government does this for us all. Like it or not, our government does perform essential services which benefit the average American. The 2012 election mantra should be focused on creating government oversight linked to performance outcomes, not merely less government.

Basic Economics
Anyone who has taken basic economics coursework knows that government intervention occurs when there is a failure-to-perform in the private sector. Certainly, the executives at Premera Blue Cross understand this principle, which also explains that entity’s rush to embraces some changes in their health insurance model. The old insurance company model was a paternalistic one where insurers dictated what they would cover, but the new model requires further explanation and reporting of clinical results, because of government requirements. Reporting results is a good thing for the health care consumer and the edict to explain them in an understandable transparent manner is a victory for health care consumers. This transparency also includes the disclosure of the commissions your insurance agent makes and there is nothing to be ashamed of there, if your agent or broker is working on your behalf and is not over charging (group insurance commissions are negotiated for experience-rated groups). In the truest sense of an open market, price information is available to the consumer who is then empowered to choose an agent or service provider for both the price and the value. Hopefully the disclosure will extend to voluntary health and accident programs as well, as some of the greatest abuses of value occur in that area.

The healthpolicymaven will be speaking at the Northwest Women’s Show March 2nd, 3rd, and 4th on the U.S. Health Care System and How to Optimize Your Health Care Outcomes in the Face of Reforms.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Why Diabetes Prevention and Management and the U.S. Health Care System Are At Odds

2011-12-04T06:41:00.000-08:00

Diabetes Current-State and Changes to Come

Unless you are Cro-Magnon-man and just emerged from a glacial field you are probably aware of some of the 2010 health care reforms. This article reviews how the United States got to be in such poor shape, health-wise and how some provisions of the 2010 reforms will create incremental changes.
Since I am nearly finished with my second book, the Russell Guide for Diabetes: Type I or Type II This Could Happen To You, let me share some mind boggling information about this scourge. The American statistics on this disease have a huge impact on government funded health plans, including Medicare and these metrics from the CDC explain why :
• The proportion of diagnosed diabetics in the United States has increased by more than 50% since 2007; 17.7 million in 2007 and 25.5 million in 2010
• Fully one third of the U.S. population is expected to be diabetic by 2025; 115 million
• In 2010 18.7% of the 25,564,000 U.S. residents diagnosed as diabetic were African Americans and 10.2% of that number were non Hispanic ( White)
• More than 90% of all diabetics are Type II, which is controllable by diet and exercise
• The CDC estimates that 33% of the country is in pre-diabetic mode in 2011

Obesity
Type II Diabetes is caused from obesity and a diet high in simple sugars and carbohydrates (think fast food, doughnuts, etc,) Being over-weight significantly increases your chances of becoming diabetic. I think it is time we Americans call a-spade-a-spade, so if one of these criteria fit you are fat:
1. 20 lbs. over weight-Yes, you are fat
2. 50 lbs. overweight-This qualifies you as obese
3. 100 or more lbs. overweight-Then you are exogenously obese
4. Body Mass Index or BMI exceeds 30 you are fat
5. If you have to replace the shocks on the driver’s side of your car more frequently than the passenger side, this is a clue that your girth has impacted vehicular performance.
6. If you have broken chairs in your house or someone else’s by sitting in them, yes my friend you are fat.
7. If you need to buy your clothes at Tacoma Tent and Awning, need I say more?
It is time we as Americans put down the doughnuts and look in the mirror. The country needs to go on a 12-Step Program for Over Eaters Anonymous. No more excuses, just bust a hump and get out there. Like everyone else I have had to battle-the-bulge as I’ve aged, but so far I do not qualify in any of the categories above.

Diet
Food is fuel and it really does matter what you consume. If you are going to persist in a diet that is high in simple sugars, lacking in fiber, and complex carbohydrates, it is similar to starving your body of essential food, so it craves more food. Diets which are high in “the whites” meaning white rice, white pasta, white bread, and sugar cause spiking in glycogen which is what the body creates when it breaks down food. Foods that convert to simple sugars cause the glycogen rush and over time damage the pancreas which ultimately ceases to work properly. At that point, listlessness, fatigue, and a sudden weight loss may be symptoms of diabetes. The United States has at least 5 million more people who are undiagnosed diabetics. The later diabetes is diagnosed the worse the damage is to the body systems. Here are some tips on wise food choices:
1. The large pizza is not intended for one person
2. 32 ounces of a soda-you may as well drink three beers calorically speaking; put down that big gulp unless you want the catheter that goes with it when you are on kidney dialysis later

What Happens If America Doesn’t Slim Down
Diabetes was the 7th leading cause of death in the United States as reported by the CDC for 2006 and it is advancing all of the time. And death from diabetes is not a quick process, but a torturous route of injections, circulatory problems (including amputations), hyper tension, and kidney failure. In the United States, 40% of diabetics end up on kidney dialysis. These metrics contrast sharply with other industrialized countries that have much lower renal failure rates, such as Austria at 30% or 34% in Germany. Life expectancy for someone on kidney dialysis in the United States is only a few years.

The link between heart failure and kidney dialysis is pronounced and a 2011 study showed that 36.1% of dialysis patient had high blood pressure, 38.2% had a history of heart infection, and 25% had excessive weight gain between dialysis sessions. All of these symptoms are exacerbated by the dialysis treatment process in the United States, which pushes patients to conform to business practice hours and not optimal clinical outcomes.

What are the Costs
The U.S. Medicare program has financed the cost for kidney dialysis for all persons who have Social Security numbers and are legal residents since 1973. President Nixon signed the legislation and at that time renal dialysis cost $12,273 per patient and 11,000 people needed it in the country. Fast forward to current time and dialysis now costs $77,000 per patient and there are over 350,000 people on it. The vast majority of people on dialysis are diabetic, with age being correlated with an increased incidence of renal failure. In 2010, Medicare spent 20 billion dollars on the renal dialysis program.

What Can Be Done
The vast majority of renal dialysis centers in the United States are operated by for-profit companies, like DaVita, fueled by Medicare’s reimbursement policy which rewards the process not clinical outcomes for dialysis centers. This may all be changing with President Obama’s endorsement of the Comparative Effectiveness Research Institute in 2010. This institute will look at clinical processes and outcomes across systems and compare them to global data to find ways for improvements. For example, the mortality or death rate for patients on kidney dialysis is much worse in the U.S.A. than in other industrialized countries, so this needs to be reviewed. And of course, a much greater percentage of American diabetics end up on dialysis than in other countries.

Another aspect of the 2010 Health care reforms was to require insurance companies to offer wellness or preventive care benefits. In my former career in the insurance business there was always a lot of teeth gnashing over offering preventive benefits because the industry promoted the idea the employees should pay for this service themselves. The industry also discouraged low co-payments or cost sharing as a means to lower the insurance premiums for the employer group. The problem with this mentality is it is inherently short term and the health of a person is a long term process. This is just one example of how the insurance industry has been at odds with promoting health for our country. Though it should be obvious, let me state that by mandating a base level national health surveillance system, such as an annual physical, offered gratis, we can find the people that are hypertensive or pre-diabetic and prevent more serious health damage. By reaching out and treating people earlier we will save money in government funded health programs. In order to accomplish this goal as a nation the country needs to continue to look at aligning provider incentives and reimbursements to promote national health not just a medical service. The goal of the country should be to work towards optimizing the health of its citizens not just treating their illnesses and injuries . If private sector insurance is to be a part of that equation, disease prevention services that are measureable and effective need to be included. Perhaps another model could include national clinics where physicals are administered by public health officials, which would provide privacy for the employee who may not wish to share his personal health metrics with the employer. Despite all of the HIPAA privacy hype, I can assure you there are a myriad of ways for an employer to discover employee health data, especially for a group which is self-insured.

On that note the healthpolicymaven is going to sign off and log my eight miles, which I have averaged per day this year. I recommend that you also slam down that pizza and put on your shoes.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Rolling Back The Clock On Women's Health Care

2011-10-31T09:10:00.000-07:00

Impact of the Vatican's Universal Translation of Faith, Catholic Owned Health Care Facilities and State Legislation on Health Care for Women
The triad of the new stricter Vatican rules for interpretation of Catholic protocols, the trend toward Catholic organizations purchasing non-Catholic hospitals, and the furor over the proposed women's health standards for the 2014 health insurance exchanges have made this a topic which must be revisited. In order of appearance here are the players:the Vatican, Swedish Health Services, and the State of Mississippi.

Vatican Rules on a Universal Translation for Catholics
Beginning November 27, 2011, the Vatican has issued another edict which attempts to tighten the interpretation of the Catholic faith, by mandating a single universal translation of the faith. The church hopes to reign in the more liberal interpretation which is prevalent in the United States and other western countries. Though one might think this only affects Catholics, not-so-fast, it affects all Catholic Church owned enterprises, including hospitals and schools, which serve an interfaith community and that brings us to our next player.

Swedish Health Services Acquiescence to the Catholic Entity Providence Health
Counter-intuitive to the trend of Catholic hospitals purchasing non-Catholic facilities throughout the United States, the secular hospital group, Swedish Health Services has acquired Providence Health Services hospital and clinics. However, what is most interesting about this transaction is the Pope still got his way, as the deal is subject to his approval, and he has mandated a line-item-veto on the secular facility’s ability to provide abortions. One could understand a Catholic hospital which did not wish to provide abortions, but Swedish is a secular institution and it is acquiring Providence. Though Swedish has indicated this wouldn’t have a huge impact on the service for women in the Puget Sound area of Washington State, they did not have any public hearings about this reduction in service. Clinically, there are cases where women may require a hospital facility for an abortion, but that doesn’t seem to matter here. At least in the Seattle area there are other secular facilities which will provide the service. It is important to note that the Vatican has specifically addressed the elective abortions, which can include victims of rape or incest. I am sure these women consider their legal health concerns to be paramount and hardly “elective.” Apparently there is no due process required if it concerns female reproductive rights, even in the highly secular community of Seattle, where Swedish is based. The fact that we have allowed our health care practice to be determined by a celibate male from another country offends not only me, but also the majority of residents.

According to a 2005 report by Catholics for a Free Choice , there are 60 Catholic health care systems located in all 50 states in the United States. One of the concerns about Catholic hospitals is do they restrict health services? This question applies not only for reproductive rights, but also for advanced medical directives for patients who wish to die without certain medical interventions. According to a 2006 survey by Pew Research Council, 70% of Americans felt that patients should sometimes be allowed to die, 70% also indicated they would rather die at home, than in a prolonged artificially extended manner in the hospital. Only 22% of those polled said that life should be prolonged using extraordinary measures. The majority of Americans shun the loss of dignity while being kept alive mechanically, but would a Catholic hospital respect their wishes? The nonprofit group Catholics for a Free Choice, states that Catholic hospitals do restrict health care services based on the edicts of the Vatican via the Ethical and Religious Directives for Catholic Health Care. It should be obvious that non Catholic patients as well as Catholics may disagree with these practices, so it behooves the patient to verify any service restrictions in policy and in practice in advance of treatment in a Catholic facility. Unfortunately, for many people in America this is not an option, as the only hospital in their area may be a Catholic institution, which has an impact on end-stage-of-life-care and other health services decisions.

Mississippi is Close to Defining Life as at the Point of Conception
Previously I have written about my 50-state analysis of the 2010 health care mandates for the regional insurance purchasing cooperatives, including the incendiary furor over women’s reproductive autonomy. Not to be outdone in its leap to the dark ages, the State of Mississippi is close to passing a law which defines human life as beginning at the moment of conception. Needless to say, this will be a sticky wicket when it comes to actually, catching-someone-in-the-act. The personhood law, if it passes will make it a crime for a woman to obtain an abortion at all, as the life of the fetus will supersede that of the woman who is already alive and kicking. Additionally, this “chastity belt” would also outlaw the use of certain birth control devices, including IUD’s which are intrauterine devices that allow fertilization but prevent embryo attachment to the uterine wall. Of course, the morning after pill would not be allowed either. Going a step further than just the birth canal, the destruction of any in vitro fertilized eggs would also be a crime.
The proposed law certainly cuts a wide swath across those who are fertile and those who may have fertility challenges. This state could potentially institutionalize pregnant women to enforce delivery and likewise for rape victims or incest victims. More to the point, for those fertile lasses who have already had several children while using various birth control measures, and decide they cannot afford more children, they would become criminals. It will be interesting to see how this one winds its way through the courts, if it passes the legislature.
Lest you want to write off Mississippi as an rogue state, Colorado attempted to pass similar legislation in 2008, which thankfully failed. In fact, Personhood USA is based in Colorado and is the backer for the Mississippi bill. Additional states who are considering personhood laws to circumvent the 1973 Roe versus Wade ruling that confirmed constitutionality for a woman to have an abortion prior to the fetus’s ability to live outside the womb include; Arkansas, Montana, Nevada, and Oklahoma.
From this vantage point there is no end-in-sight for the pitch back to the dark ages for women in the United States. I can almost see the black hole from here.
On a more personal note, I expect my book, Unraveling U.S. Health Care to be available within the first quarter of 2012 and yes, it is OK to say FINALLY. Anyway, thanks for reading and I hope you continue to review and comment on my musings.

Reducing Health Care Costs By Improving Primary Health Care

2011-09-19T17:44:00.000-07:00

How Primary Care Reduces Health Care Costs in the Long Run
Now that the teeth gnashing over health care reforms has been ongoing for two years, before the lifelines are cut on financing health care for the forty-nine million uninsured population, let’s examine the health care continuum for the impact of a failure-to-fund the health insurance subsidies. One of the things that is missing from many discussions and assertions about the 2010 U.S. health care reforms are which systems need to be changed in order to reduce the long term cost of American health care. And when I say reduce, I mean reduce the cost increases in providing health care to an aging population. It is essential the U.S.A. get the per-capita cost of its health care in-line with other nations, as it gobbles funds that could be used for education, capital investments for industry, and other economy building activities. The country will need to make substantial investments in k-12 education as well as building a more energy efficient infrastructure to have a chance at competing with global leaders for competitive contracts, as Germany and other countries have done. This article addresses the components of American health care that are impacted by the 2010 mandates and what it means for managing patient care over a lifetime.
Perspective
Rather than thinking of health care as a commodity that deserving people get, for those who have worked where it is provided by an employer or who qualify for Medicare by virtue of accumulating enough quarters of eligible earnings, or military personnel, please consider it a part of the national infrastructure for a moment. A healthy population is necessary to obtain optimal output from workers, students, and for the care of our families. The provision of health care may be considered a utility. Utilities are measured by their output, the efficiency of their output, and the cost of producing the service. Measuring quality across the United States health care system, which is disparate and complex, is a major challenge in building higher efficiency into American health care.
Measuring Health
From the moment we are born until we die, we are introduced to various aspects of health care in the U.S. system. Even from birth, we do not provide the same level of care to all pregnant women, nor do all babies have the same chance of surviving their first year in America. In my book, Unraveling U.S. Health Care, I researched all fifty states for health metrics, including infant mortality statistics and in one area of the country, infant mortality was as poor as it is in developing countries (12.6 deaths per 100,000 babies for the District of Columbia) Only in a hand full of states was the infant mortality rate equal to European standards, of 5 or fewer deaths per 100,000 infants. Health care workers do understand and are alarmed about this dramatic difference in a basic health care outcome in the country; however, it seems much of the population is uninformed. A basic measurement for health is infant care and reducing the chance of infant death.

Another health care measure is degree of healthy living, as measured by the DALE or Disability Adjusted Life Expectancy, which measures the number of years an American can expect to live healthily, able to move around, and do their activities of daily living. In other words, how many years you can expect to be reasonably free of impairment from chronic disease. The World Health Organization, developer of this index ranked Japan as the number one country for living longest in good health to an average age of 74.5 in the year 2,000. Though the earthquake and tsunami disaster may have some impact on this in the future, the Japanese have a national health care system designed to provide primary care for their population. The United States ranked below all other developed nations in these criteria, with a Dale index of 70 years. Women are expected to be healthy to age 72.6 (true in my Mom’s case), and American men are only healthy to age 67.5. Wake-up call for boomers born in 1957 or later, you are not eligible for full Social Security benefits (under current standards) until age 67, so guys, just about the time you are expected to lose your quality of life.
The ability to live free of chronic disease is an indication of the effectiveness of a health care system and how it identifies population needs and deploys successful interventions. The U.S. health care system has been less focused on primary care, largely because clinician reimbursements and the high cost of medical school have driven more practitioners into specialty care, which treats disease, but is not geared for prevention of chronic disease. One of the provisions of the 2010 health care reforms is the Medical Home provision in Medicare, which attempts to correct the primary care problem by paying clinicians more to be the primary care provider. This concept is a start in the right direction, but as a nation we need to have more health care incentives for primary care, which prevents chronic diseases from birth through life expectancy. Only through this process can we hope to reduce the incidence and associated costs, both social and economic of chronic disease like Type II Diabetes, hyper tension, and heart disease.
Cost of Delaying Treatment
As cited above, the United States had the poorest score for healthy life expectancy of any industrialized country, literally at the bottom, yet we spend 25% more than any other country in the world. The only way we are going to be able to change this result is to build efficiency into health care delivery and improve basic preventive and primary care.
Arguments about a person’s right to health care miss the Titanic-size glacier that pummels U.S. hospital systems, which is EMTALA, the Emergency Medical Treatment Act which requires all hospitals to treat patients, regardless of their ability to pay for services. States with huge uninsured populations, like Texas, with over 25% lacking any insurance , and half of those people are working for employers who do not provide any medical insurance . Not only do those people lack access to primary care, they appear at the hospital emergency department in advanced stages of chronic disease, which must be treated. This is not an effective way to deliver health care as a nation. Hospitals are designed to treat the acutely ill, not to provide primary care. Much discussion has occurred around the health care safety net for the nation, which directly addresses the ability of these hospital systems to continue to provide free care and pass those un-reimbursed charges on to full paying customers, enrolled in private sector health care plans.
Pass-Through Costs in the Health Care System
To those who complain about providing health insurance for the uninsured, a significant portion of the insurance premium these individuals already pay is based on reimbursing hospitals for under payment serving the uninsured and to a lesser extent, Medicare and Medicaid patients. By deferring treatment in the form of primary care, the nation has elected to force these folks to develop worse chronic disease conditions, which are more expensive to treat, and result in premature death from preventable conditions. In health care, treating a patient earlier in the care continuum is best clinically and economically and this is the direction the nation needs to go. For all of the caterwauling about health insurance rate increases, if there is any hope of stabilizing these impacts, it must be driven by increasing patient access to early and consistent primary care. Further, to those who object to paying a portion of their taxes for the provisions of health care, you are already doing so, by paying more than any other country for your health insurance and the administration of your health care. A better question would be how can we reduce the cost of health care overall? Should be continue to have employers contributing to health care financing or go the European route of having the individual be responsible? And finally, health insurance is a financing tool and not a delivery system for health care. We need to improve how we provide basic health care, including disease surveillance, continuity of care for those with chronic disease, and assurance of quality care throughout the country, not just for the lucky few who live close to centers of excellence.
Moving Forward
The 2010 health care mandates attempt to address these concerns in a number of ways, including improving access to primary care by subsidizing health insurance purchasing for small businesses and individuals and thus increasing the number of people who have health insurance and thereby the ability to obtain care. The Medical Home provisions are a start to addressing the access problem that seniors have with Medicare, which pays so little to doctors providing the care. And the Accountable Care Organization standards will pay health care systems more money for high quality patient outcomes in targeted areas for Medicare. FYI, changes in Medicare become a part of the private sector as well, so health care reporting of patient outcomes for Medicare, will also be reflected in the rest of the nonmilitary (Veterans Administration has its own health care system)population. None of these components of the 2010 reforms will go away, but further wrangling will continue on standardization of care for the health insurance purchasing cooperatives and the insurance purchasing subsidies. In a worst case scenario congress may choose not to fund the subsidies to help people buy medical insurance, which would of course result in tax penalties on all of the private sector who decide they cannot afford to buy the insurance. But then again the United States is famous for its unfair tax policies which tax the poor and middle-class much more than the wealthy. Just remember any deferment of health care access and treatment now will result in more serious chronic diseases later, which we will pay for, by increased hospital charges apportioned across the private sector insurance payers and higher costs for government health care programs.

This article was written by Roberta E. Winter, MHA, MPA an independent health care consultant and journalist and may be reprinted with her permission.

Improving Health Care at Hospitals

2011-08-06T18:44:00.000-07:00

Methods for Improving Health Care in the Hospital
The Centers for Medicare and Medicaid have required hospitals to start reporting on quality criteria for reimbursement consideration as early as 2012, based on 2010 health care reforms. Major changes that clinicians and hospitals must conform to include:
Value-based Purchasing-This provides greater reimbursement with an emphasis on better clinical outcomes, starting in 2013.
Risk-Adjusted Reimbursement-This accounts for higher risk patients with multiple conditions and gives the doctor a higher fee to manage their care than previously, effective in 2014.
Reduced Payments for Hospitals with Excessive Re-admission Rates-This is a penalty for poorer performance and is effective in 2013 for hospitals who do not perform within certain guidelines for specific diagnoses.
This article reviews a report commissioned by The Commonwealth Fund to analyze some of the things the top performing hospitals, who submitted to quality surveys by the independent quality watch dog nonprofit, Leapfrog Group, are doing to improve clinical care and efficiency at their facilities.
Case Study Criteria
This information was drawn from case study analysis of 4 hospitals out of the top 13 hospitals in Leapfrog's Highest Value Hospital criteria using their 2008 survey data. Standards reviewed included short lengths of stay and low readmission rates for the following cardiac procedures; CABG, PCI, and AMI, in addition to pneunomia. The case study review was conducted by Jennifer Edwards, Sharon Silow-Carroll, and Aimee Lashbrook in a report entitled, Achieving Efficiency: Lessons from Four Top Performing Hospitals and was published as a Synthesis Report for the Commonwealth Fund in July 2011.Hospitals included in the report are Fairview Southdale Hospital in Edina, Minnesota,Park-Nicollet Methodist Hospital in Minneapolis, Minnesota, North Mississippi Medical center in Tupelo, Mississippi, and Providence St. Vincent's Medical center in Portland, Oregon. These hospitals scored high in at least three of the four criteria and were recognized as high value hospitals. The Commonwealth Fund commissioned the study in order to assess what hospitals were doing to create high quality outcomes with low resource investments, in other words, producing good results for less money. Here are the top factors influencing high patient quality outcomes at hospitals, listed in order of precedence:
Full-time Quality Assessment Departments
All four hospitals have full-time quality development, measurement, and compliance departments, but the difference between the best scoring facilities and the medium hospitals was how they trained their staff to solve quality problems as a part of their job. This includes clinical and nonclinical staff that assess performance improvement processes. At Fairview Southdale, every department director is required to sponsor at least two initiatives to improve clinical quality and produce a minimum of $60,000 in savings yearly.
Matrix Management Models Enhance Fluid Organizational Changes
In the top hospitals, executives with more fluid organizational roles rather than hierarchical, were able to make systemic adjustments more readily. Matrix operational models support management changes based on organizational links impacting outcomes rather than chain-of-command methods.
Increased Use of Hospitalists as Patient Care Coordinators
All four of these hospitals used hospitalists to coordinate inpatient care rather than "on-call" physicians. These full-time clinicians make patient assessments and provide greater continuity of patient care, making it easier to measure and track patient health. It is easier to implement standards of practice changes with full-time employees than independent contractors. Notably, the Accountable Care Organization criteria looks at reduced hospital re-admissions when rewarding hospitals with higher payments.
Engaging Staff: Quality Improvement is the Responsibility of Everyone
North Mississippi Medical Center, a recipient of the Malcolm Baldridge Award for Quality, solicits all its employees for ideas on process improvement and in 2008, 37% of those were implemented. This process is reinforced through recognition and incentives. Staff empowerment is also one of the measures for the Baldridge Award. St, Vincent's Hospital in Portland, Oregon created a new model to increase staff engagement, called self-governance or one-team-many-hands approach, which gives all staffers representation in hospital decision making.
Information Systems Supporting Patient Care
St. Vincent's and Fairview Southdale are part of integrated systems where patients can request medications on-line, facilitate non emergency health assessments, and schedule appointments. It is much harder for nonintegrated health systems to offer these tools, but here are some of the creative things these facilities have done with technology to improve patient care:
1. An electronic bed board for optimizing facility space and accommodating patients.
2. Patient discharge systems for streamlining patient processes when leaving the facility.
3. An internal alert process when a unit is close to capacity so other departments can handle the back fill.
4. Fairview Southdale uses wireless technology to allow ambulances to send electrocardiograms to the hospital when a patient is enroute, which reduces patient care time by twenty minutes.
Standardization and Simplification
All four hospitals had processes to eliminate unnecessary redundancies, reduce patient slow downs, and stop errors. Something as simple as a defined protocol for assigning a bed for a patient eliminated slowdowns. And in health care, minimizing delays means patients obtain care quicker and financially the facility is able to optimize its resources for all patients. St. Vincent's uses a staggered staffing system to avoid shift change down time.
Centers for Medicare and Medicaid Demonstration Projects
Here is a brief list of health care demonstration projects through CMS:
Global Capitation Payments-This is a project which is in five states and attempts to address the hospital safety net, which is the extent hospitals serve the poor and uninsured, and it runs from 2010 to 2012.
Medicare Shared Savings-This is part of the Accountable Care initiative, which rewards clinicians for performing within certain evidence-based standards for targeted diagnoses beginning in 2013.
Medicaid Children's Health Insurance Shared Savings Program-Like the adult shared savings program.
Bundled Medicaid Demonstration Projects-This reviews episodes of care in a hospital and other settings, is deployed in eight states, and runs from 2012 to 2016.
Bundled Medicare Payments-This is a method of enhancing primary or Medical Home provisions to increase clinician reimbursement for patient care.
In closing, all of the selected hospitals were part of health systems, where benchmarking and resourcing services are readily available, which could be problematic for community hospitals lacking these resources. Still, these four stellar hospitals provide creative solutions for managing patient care on a budget, in urban and suburban settings.
It was excruciating to sequester myself to write this article when it is the peak of the Pacific Northwest nirvana weather, so I thank those of you who are going to read it tomorrow morning when it posts. My service to you is reducing the 25 page report down to less than 2 pages. This is the healthpolicymaven signing off in 78 degree air with 56% humidity.

Consumer Tips for Surgery

2011-07-02T10:07:00.000-07:00

One of the chapters in my book, Unraveling U.S. Health Care, which is a guide to the health care system, addresses surgery and tips on how to vet your surgeon and find the optimal facility.
Finding a Surgeon
The best web site for researching surgical specialties is the American College of Surgeons, which allows consumers to look up surgeons by specialty and location. The web site for this is: www.facs.org. For instance if you need a neurosurgeon, you can enter that and voila, the universe of neurosurgeons is revealed. These specialists are typically associated with university medical centers and large trauma centers. However, it is amazing that some health care consumers still think that neurosurgeons are available at rural 25 bed hospitals. Even if they were, why would you want to have this type of surgery done at that kind of facility?
Hospital Safety Rankings
Secondarily, it is worth your while to review hospital patient safety ratings before deciding on the facility. Methods to discern patient safety ratings of hospitals include reviewing the published information on www.leapfroggroup.org, by going to the 2010 hospital survey and looking up your state and the targeted hospital. Another method is to go to the federal Health & Human Services Agency web site for comparing hospital performance. It allows you to look at multiple hospitals at once. The web address for this is http://www.hospitalcompare.hhs.gov. and the site was recently updated to make it easier for consumers to use.
Reporting of Hospital Medical Errors
Another important aspect of doing your due diligence before undergoing surgery is reviewing patient medical errors and whether or not your state shares this information with the general public. Let me save you the time on this one, as I have reviewed all fifty states and the District of Columbia and the only states which required public reporting of hospital medical errors impacting patient safety were: Minnesota,Connecticut, and Indiana, The following states collect the data but do not necessarily make it readily available to the public or the data is not facility specific: Colorado, Illinois, Maryland, Massachusetts, Michigan, Missouri, New Jersey, Oklahoma, Oregon, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Washington, and Wyoming. I will also mention California, but they have been criticized for not complying with a state law on the reporting of hospital patient safety data. Scarier still is the 2005 Montana Law that has been dubbed the "I'm Sorry Law" giving health care providers additional protections for adverse patient safety events. Though Montana is rural and retention of some clinicians may be an issue, it is still of concern when in 2003, they repealed the requirement for a statewide health database and now clinicians are given more protections than patients.
In terms of preparing for any surgical procedure, it is most important to select the surgeon and the facility, but also to verify the accuracy of the diagnosis, so getting second opinions are a good method if you have any doubt. However, given today's digital imaging, it is much easier to see clear images of tumors and other issues than in 1993 when I had my first big surgical event. So verification of the diagnosis is key.
Once the diagnosis is determined,the treatment plan needs to be discussed and planned. Adverse events, post surgical recovery, and rehabilitation need to be considered in any plan. I suggest using a healthy level of detachment and planning your surgery like a project.
Presently an agent is reviewing my consumer opus: Unraveling U.S. Health Care: A Guidebook to the Complex and Confounding U.S. Health System. I hope to have the publishing path decided soon and of course, I will keep you posted.
Ending with my usual penache the healthpolicymaven suggests that having surgery done at a local facility, one where it is easier for friends to visit, or with a clinician you like are not enough evidence to support a decision potentially involving your health and well being. Take the time to look up the data, as reviewed by independent third party nonprofit organizations or a government agency under the Health & Human Services arm.
And finally, to the douchebag patients who criticize surgeons for not giving them a back rub and serving as their psychologist, that is not his or her job. They are skilled at cutting you up and putting you back together quickly and with low margin for error, so forgive them if they took the cram course in bedside manner. For oncologists, whose relationship with patients is typically long-term the consultative manner of the M.D. is more important. Having had a few surgeries myself, I do not go into the operating theater thinking I am special, but I realize I am one of many in the sea of humanity and many whiny consumers would do well to consider this perspective. It doesn't mean you take less care in your research, preparation, or recovery from your surgery, it just means, have a little consideration for the brilliant hard working medical staff, especially the surgeons.
For an advanced peek at my guide to the health care system, you can read part of it on:http://www.authonomy.com/books/24823/unraveling-u-s-health-care-everything-you-always-wanted-to-know-about-health-care-but-were-afraid-to-ask/
And this is your healthpolicymaven signing off.

Health Insurance Premiums and Government Oversight: Consumer Implications from the Affordable Care Act Implications

2011-06-11T10:06:00.000-07:00

Government Oversight of Private Insurance: What it Means for the Cost of Your Health Insurance
The plethora of health care laws passed in 2010 under the Affordable Care Act,include provisions for “rate setting” and monitoring of private sector insurance plans on a federal level. The ruling applies to all insurance plans which participate in any government funded health care program, including Medicare, Medicaid, and the soon-to-be-deployed regional insurance exchanges. This article explains how this differs from present rate monitoring and premium-setting and the ultimate impact on the consumer.
The Rules
Health & Human Services is charged with establishing a health insurance rate oversight committee, to assess the reasonableness of proposed health insurance rate increases starting in 2014. Since health insurance premiums have continued to grow at a rate in excess of inflation and increased 41% between 2003 and 2009, according to a Commonwealth Fund study , affordability is a concern. The federal PPACA law mandates health insurance as a means to providing national health care, so the viability of the national health care program depends on manageable health insurance premiums for the private sector.
Current State
Insurance premiums are determined based on each state’s rate authorization standards with the Insurance Commissioner, who is an elected official. Some states have a “use and file” policy which means the insurance company can decide to make plan changes, adjust the rates, and start implementing before the state approves them. Other states have a “file and preapproval” policy, which means you have to get the state office to approve of your math, the reasons for your plan increase first. The insurance company then has the opportunity to comment and either accept the commissioners regulations or withdraw the product. In the case of Principal Financial Group, when a previous Washington State Insurance Commissioner mandated that all individual medical plans provide maternity coverage and other provisions, they pulled their product from the state. In economic terms this is referred to as an unintended consequent of a regulatory action. The federal government does not have the authority to control state insurance premiums for the private sector. Medicare and Medicaid plans are of course, a different story as they are government plans.
Altered State
Through the process of gathering data, analyzing cost impacts, discerning patterns, and revealing information to health care purchasers, both individual and corporate, Health and Human Services, which oversees the Centers for Medicare and Medicaid, is charged with creating a more transparent process for what you actually end up paying for medical insurance. The intent is good, but there is no regulatory authority to enforce rate fairness by state and a regulation without enforcement can be problematic. Finally, the cost of the regulation will be borne by the private sector rate payers, which will add a nominal cost to individual premiums, spread over the entire population.
Economic Impact
I spoke briefly of unintended consequences above, but let me restate, if an additional regulation means more insurance companies will cease to offer insurance plans to the small group and individual markets, this may not be a good thing for consumers. Of course, the insurance industry is already seeing a reduction in the number of companies offering medical insurance and this trend has been going on since I was in the benefits business in the 80’s and 90’s. In short, private sector companies, both for-profit and not-for-profit will make market decisions based on where their strengths lie and act accordingly. And one could argue that as long as the companies which remain are of quality and offer good consumer products and services, this change is not untenable. The Netherlands and Switzerland both have private sector insurance programs financing their public health plans and only a hand full of companies provide the coverage, which seems to work fine. Also, they pay much less per-capita for health care than the United States does, but the healthpolicymaven has told you that before.
What it Means to the Health Insurance Premium Payer
OK, here is the “skinny” on this one, since the federal government Does Not have rate setting authority for insurance, which is controlled by each state’s elected insurance commissioner and those state administrators, this change will not have a direct impact on the rates you pay for medical insurance. What is more, since it is highly unlikely the government will be able to overturn ERISA or the McCarran Ferguson Act; don’t expect to see any rate relief. ERISA is the Employee Retirement Income Security Act which created the exemption for self-funded or self-insured plans, which most major employers have used to exempt themselves from many state and federal mandates. I do not see the government succeeding in overturning this act either. The McCarran Ferguson Act is a federal law which gives states the authority to regulate insurance. It should also be noted that insurance premiums taxes are a major source of funding for the states and they will never give up that revenue. Indirectly the fact the government is requiring the disclosure of the rate factors and will publish the information is a good thing for consumers. You will no longer have to be an insider in the insurance business, which you know I was for a couple of decades, to understand this process. In conclusion, will this make your insurance cheaper, no, because that depends on many complex factors that have to do with underfunding of government programs which the private sector has to support with cost transfers, market supply factors, and the degree to which primary health care is deployed in this country. Finally, people will still have to care enough to read about the provisions and many people don’t. The healthpolicymaven’s book, Unraveling U.S. Health Care should come out later this year and it is a guidebook to our health system, in lay person’s terms, which I am hoping will facilitate more outreach in this area.

Accountable Care Medicare Shared Savings Rules and How they Benefit Consumers

2011-04-29T12:01:00.000-07:00

Accountable Care Organizations and Medicare Shared Savings Program
The federal Department of Health and Human Services (HHS), which includes the Centers for Medicare and Medicaid Services (CMS), announced proposed rules for the much vaunted Shared Savings Program for qualifying Accountable Care Organizations on March 31st. What struck me about the program, was how much of the risk management formula was taken directly from the private insurance sector, which is an indication of a public/private hybrid for program management. Since it is my belief that we can provide optimal public services through this model, I am keen to evaluate, follow, and measure the results for this revolutionary change in health care delivery for Americans. This article explains the risk sharing mechanisms in the new program and what it may mean for consumers.
Private Sector Influence
The Centers for Medicare & Medicaid, which administer the largest health care program in the country, have created a health care program, called Accountable Care which requires clinical results within a certain range in order to get optimal reimbursement levels. Additionally, organizations which outperform the government set standards have an opportunity to receive a gain or a share of the unused funds. In the insurance business this is called retrospective financing, where the provider reimbursements and participant insurance rates are established based on certain assumptions by actuaries at the beginning of the plan year. About three months after the close of the plan year a final report is given, which illustrates the true performance compared to the expected levels. At this time the corporate insurance client either owes money or has a credit toward the new plan year. It is this type of accounting that CMS is using to gauge the “Shared Savings” for ACO participants. But before we examine the shared savings program let’s briefly review what it takes to qualify as an Accountable Care Organization.
Eligibility Rules for Accountable Care Organizations
Who is eligible to be part of an ACO? All clinicians in group practice arrangements, networks of individual practitioners, joint venture partnerships with hospitals and other professionals, hospitals who employ ACO professionals, Critical Access Hospitals, and any health care practitioner or entity receiving Medicare reimbursements for services are eligible for ACO status.
Potential Roadblocks in Achieving ACO Status
Rural and semi-rural areas may have difficulty with the ACO status (Wenatchee Valley Medical Center for eastern Washington comes to mind) because anti-trust hurdles must be cleared with respect to market share. I imagine the way an organization will address this is to make sure the mix of employed clinicians versus contracted ones meets the 50% or less rule for Primary Service Area standards. It also looks like the non-urban exemptions and critical access rules will allow organizations like these to qualify.
All organizations who wish to participate in the ACO program must maintain a minimum level of patient volume of 5,000 patients.
The Accountable Care Agreement is binding for Three Consecutive Years
Organizations participating in the ACO Shared Savings Program have a choice of two models, either the one-sided or two-sided version. The names are humorous to me, but let me explain where they come from in terms of insurance risk management programs. The one-sided program means the organization shares only in the “up-side” or gain for performance improvements under the contract. However, CMS always likes to be a little different and this more limited risk exposure is just for the first two years, after which the organization experiences the full risk sharing. The “two sided” model means the organization is exposed to both gains and losses from the beginning of the three year contract. This seems like a no-brainer, why would a clinic want to be on the hook for losses right away in a new Medicaid program? However there is more to it than that, because the potential for gain differs.
Government Incentive for Meeting Benchmarks
Using a complicated formula of a per-enrolled-patient-risk-adjusted cost benchmark CMS has created a financial incentive of 2% to 3.9% depending on the number of patients involved in the ACO. In my previous ACO article in September, I highlighted some of the clinical outcomes the agency was seeking, to be eligible for the shared savings. CMS has identified 65(yes, it is complex) quality measures in these five areas under ACO provisions:
1. Patient/caregiver experience
2. Care Coordination
3. Patient Safety
4. Preventive Health
5. At-risk population/frail elderly health

Conversely, in terms of shared losses, the organization’s cost basis must be 2% or more over the cap to be required to pay CMS a differential based on ACO patient performance. What is important is that the participating ACO organizations report their quality metrics using the Medicare Physician Quality Reporting System (PQRS) and also using an electronic health record or HER or EMR. This incentive system will allow Medicare, the administrator for the largest health program in the United States to make assessments and extrapolate information on its population, for better program management. This is a great thing for the consumer, which is anyone who is on Medicare now and all of us who are paying for Medicare. There is also an additional incentive to use the Medicare reporting system which is the equivalent of one half percent of the total clinician’s billing to Medicare for each eligible professional’s Medicare Part B fee (out-patient doctor’s visits). This is significant and should encourage providers to participate in the program. Another ACO rule states that at least 50% of primary care physicians must be users of a certified electronic health record by the beginning of the second year of the contract. (Tremendous opportunity for EMR companies). Another aspect of the ACO rules is public reporting of some of the quality measures, which will create a nationwide standard for health care quality measures.
The Centers for Medicare and Medicaid Services has anticipated that some organizations will have difficulty meeting 100% compliance, so they have a Corrective Action Plan process. The CAP process includes noncompliance warnings, special monitoring, and a formalized corrective plan. If an organization fails to meet the ACO compliance rules and is removed from the program, it must wait three years before re-applying for participation. The review process for noncompliance is rigorous and participating organizations must submit to period audits.
Consumer Benefits
One of the positive aspects of ACO reporting is the data which will be gathered in a standard format and shared in aggregate with participating Accountable Care Organizations. There are also methods to coordinate with other Medicare Demonstration Programs, to avoid “double-dipping.” Other Medicare Demonstration Projects include: the Independence at Home Medical Practice Demonstration, Medicare Health Care Quality Demonstration, Medical Home Demonstrations, Physician Group Practice Transition Demonstration, Community Home Health Teams supporting Patient-Centered Care, and various state initiatives supporting Medicaid patients with chronic conditions.
Conclusions for Consumers
The ground breaking requirements of the Accountable Care Organization Rules enacted in 2010 are the result of a peer review process since the International Order of Medicine’s infamous report on the poor patient safety record in many United States health care facilities. Consumers will start to have access to standardized reports on participating health care facilities clinical safety measures and patient care data. This is a tremendous step forward for American consumers, as transparency in reporting is one of the hallmarks of high quality organizations. Integrated health care organizations like Virginia Mason already provide detailed patient quality information and the CMS Shared Savings Program will help others achieve similar reporting and patient quality standards. This is an example of good governance at its best, with an incentive to respond to the consumer push for greater efficacy in patient care.

Hospital Quality-Checks & Balances

2011-03-22T11:51:00.000-07:00

Discerning Hospital Quality
The Center for Medicare and Medicaid Services(CMS) now requires health quality measures for specific clinical services, in order to recognize and encourage the best patient outcomes. Recognition will include greater financial reimbursement for those medical practices which conform to the CMS standards for clinical outcomes. This is yet another step in the right direction toward patient-centered-care as identified by the International Order of Medicine. This article highlights the primary hospital quality watchdogs in the United States and consumer tips on how to assess your hospital.
Organizations Measuring Hospital Quality
There are a number of ways to gauge your hospital’s quality, including accessing information from public sites, such as the Center for Disease Control, the Center for Medicare and Medicaid Services and the Health & Human Services Agency. There are also nonprofit organizations devoted to measuring hospital quality including; the Joint Commission for Hospital Accreditation Organization, National Quality Forum,Then LeapFrog Group and the Quality & Patient Safety Organization. Here are the crib notes for these organizations.
Private Sector Quality Watchdogs
Joint Commission
The Joint Commission for Hospital Accreditation is the pre-eminent organization for auditing and certifying hospital services in the United States. Obtaining its’ certification is an essential requirement for hospitals, which may lose reimbursement contracts and patients without the JCO recognition. The Joint Commission recognizes twenty-two hospital medical errors, which it has been tracking for patient safety purposes for 15 years.
National Quality Forum
The National Quality Forum is a non-profit group created by thirty-two health care organizations to develop consensus about hospital quality indicators and reporting. The NQF reviews twenty-seven patient safety metrics, but the information is not shared with the public.
Quality & Patient Safety Organization
The non-profit Quality and Patient Safety Organization or QuPS provides state-by-state analysis of patient safety initiatives by state governments. You can go to the site and see what your state has done to make your hospital safer.
Public Agency Quality Police
Agency for Health Research and Quality
The Agency of Health Research and Quality or AHRQ was created in 1999 to promote methods for improving health care quality in the United States. Though it doesn’t have any enforcement provisions, it does conduct research, award grants, and recognize health care groups with excellent performance.
Center for Disease Control
The federal Center for Disease Control established the National Health Safety Network in 2005. As of 2010, twenty-two states had adopted this method for reporting patient safety errors in hospitals and other inpatient facilities. Presently, 3,000 hospitals use this system, which make it the largest database for hospital errors in the United States. The data is collected for scientific review and specific facilities are not disclosed.
Center for Medicare & Medicaid Services
The Center for Medicare & Medicaid Services polices patient quality outcomes and publishes statistics, like patient mortality from pneumonia, heart failure, and acute myocardial infarction (AMI). However, mortality information alone is not a good measure of hospital quality or patient safety, because you would have to know the patient volumes as well as the morbidity or overall patient health. This information may be found at:
http://www.cms.gov/HospitalQualityInits/20_OutcomeMeasures.asp
One of the CMS sites that is helpful is the listing for certified organ transplant centers at: www.cms.gov/CertificationandComplianc/Downloads/ApprovedTransplantPrograms.pdf

Health & Human Services
The Health & Human Services Agency or HHS has a web site where you can find your hospital and compare clinical outcomes by diagnosis, to other facilities. This is a useful tool if you live in an urban area with multiple facilities, because you will literally be able to check their performance before your procedure. The link to this site is: www.hospitalcompare.hhs.gov

Other Public Sources for Hospital Certification Information
The American College of Surgeons publishes an on-line guide to Trauma Center Certification which is quite detailed because it explains the criteria for Level I Trauma Status. Also, university hospitals are teaching facilities and they typically have the highest status for trauma injuries. Information on your university hospital is available on its web site or through the State Department of Health.
Local Look
Washington State Hospitals which scored high in quality measures for 2009 data include: Virginia Mason, all of the Swedish Hospitals, University of Washington Medical Center, Harborview, Northwest Hospital, Seattle Children’s Hospital, Kadlec Hospital, St. Claire Hospital, and Mary Bridge Children’s Hospital. For information on how hospitals fared in your area, contact the healthpolicymaven by scrolling down to the comment tool or complete the form at: roberta@healthpolicymaven.com
Consumer Tips
The healthpolicymaven’s advice is to know-before-you-go for your surgical procedure and here are some helpful tips to figure out your hospital's quality score:
1.Look for public reporting of hospital medical errors as this is the highest degree of transparency and commitment to improve patient safety.
2.Hospitals which use a national model like the CDC’s National Health Safety Network are using a rigorously tested assessment model.
3.Find out if your state mandates public disclosure of patient safety errors and if it is available by facility.
4.The Center for Medicare & Medicaid publishes information on hospital performance, including infections, surgical errors, and discharge information.
5.Ask questions and do some research.

Closing Thoughts
This patient safety article may not seem that germane now that the country is in its third war and on its knees fiscally. However, the Chinese are paying our light bill, having mastered science and math and access to birth control. Meanwhile folks in the United States continue to debate teaching the science of evolution versus the dogma of religion in public schools. Is it any wonder the US doesn’t measure up to global standards for primary education?

Amending the 2010 Health Care Reforms Checklist

2011-01-30T13:29:00.000-08:00

Suggestions for Amending the 2010 Health Care Reforms
Now that the teeth gnashing is on-going over proposed changes to the health care reforms of 2010, this article addresses some areas for potential modifications. If any of you are under the delusion that everything will be repealed, wake-up, because the Medicare changes are essential to management of that costly federal entitlement program. I am speaking of the pay-for-performance initiatives where Medicare (Center for Medicare Services) pays more money to organizations which have fewer medical errors and re-admissions for patient procedures. I am referring to the Accountable Care Act will have a major impact on how medical care is organized, models for disease interventions, and the reporting of performance metrics(I wrote about this last fall). So, that stays, but the rest of this article addresses some of the things that could go or at least be modified.
Federal Insurance Purchasing Subsidies for Mandated Health Insurance
A few months ago I did an analysis of the federal insurance purchasing subsidies for the middle-class under the Health Care Affordability Act and it was pretty eye opening. Based on World Bank data the mean income in the United States is $47,240, which is the average income per person using 2009 Gross Nation Income data . Using this average income as a starting point, what kind of a subsidy would someone receive in 2014, when the insurance exchanges are in place and medical insurance is mandated? Families with seven or more children and incomes equal to 133% of the federal poverty rate will receive a federal subsidy equal to 97% of the insurance premiums. This seems fair to me, as that is a modest income for a huge family. However, the federal subsidies also are slated to provide assistance to folks who fall within 400% of the federal poverty level, which can be a very decent income. For example, someone who is single and earns $54,120 is eligible to receive 90.5% of their insurance premium paid for by the federal government. First of all if you are single and have that much income you ought to be able to scrape by. Secondly, this income is higher than most of the world averages and higher than the USA’s average per capita. But it gets worse, based on the 400% of Federal Poverty Level criteria people who earn up to $185,160 are eligible to receive the same federal subsidy if they have at least eight children. Now, I think by anyone’s standards someone with that income, which falls into the top 10% of all incomes in the country, is not poor. I can see giving a subsidy to a family of four with the $54,120 income or even higher, but not over $100,000!
Budget Saving Suggestion
Here is my suggestion, only provide medical insurance subsidies to people who earn up to 150% of the mean national income, which equates to $71,131 and is roughly equivalent to $73,835 for a large family in the federal poverty criteria. For people who want tax subsidies for families earning over $100,000 I say start eating beans or tuna noodle casserole, which I ate a-lot-of as a child.
Possible Places for Federal Budget Cuts
For crying out loud, it would be nice if both parties could focus on the real apocalyptic events for the country, such as the fiscal meltdown from a strong country with reserves to the largest national debt in history in eight short years. The real concern should be reducing the national debt by cutting spending so the country will have to do less begging for financing from China and other creditors. According to the non-profit Kaiser Foundation, 40% of the entire 2010 federal budget was for defense spending. To decrease that by 50%, just cut the discretionary defense spending budget which equals nearly 20% of the entire federal budget, and we can get the country back in fiscal shape in no time. The country needs to find a way to pay for its existing programs, like Medicare, Medicaid, and Social Security and reducing spending on other ones is required.
Of course the Medicare expenses are of concern and the changes to the program in 2010 are a start towards reworking that care model. The USA will move to a Medicare model which provides services for the treatments that are most effective and hopefully pays the physicians a decent fee. There is still much to be done on aligning clinical reimbursement in both the Medicare and Medicaid programs. The latter is very onerous, because the federal government dictates Medicaid benefits but provides grossly uneven support to the states which are charged with administering the program.
Focus on the Real Issues which have significant Cost/Benefit Ratios
It would be nice if the Democrats would quit focusing on who-is-shagging-who or what someone’s sexual orientation is, because I really don’t want them to tell me about it. As long as it isn’t a crime (certain southern states excepted) I don’t need to hear about it and this goes for anyone’s sexual persuasion, I don’t care to hear about your predilections. I prefer to focus on issues we have in common, such as education, health care, and oh, not-going-into-the-poor-house as a nation. Don’t ask, don’t tell, don’t care is where I am at in this tired issue.
Republicans, I am tired of having abortion as such a divisive issue and I question whether the paltry amount of federal money that is actually spent on abortions for Medicaid women who have been raped (one of the criteria) is the real problem. What would it take to make you folks quit yapping about this issue, a total ban on federal money? The big stink made about offering birth control options, not just abortion in the federal insurance exchanges far exceeds the estimated $1 cost-per-head factor for this provision. Although I think it is immoral to prevent poor women from seeking birth control options which are legal, I believe the rational and generous people of this country will rise to their aid through contributions to Planned Parenthood and women's health organizations. Of course I know the right wingers will still flail away state-by-state (I reported on this in a July article for an east coast distribution and in my November blog about state appeals to the health care reform mandates) attempting to demonize women who seek medical procedures for which they do not agree. We can at least aspire to have a more effective and civilized national conversation about resource allocations.
Current focus on re-defining rape is actually part of the Republican Agenda in Congress
It would be nice if the vagina control police would spend less time defining what constitutes the a rape of a female, thereby qualifying her for federal funding for an abortion under the tan-your-Hyde Amendment, and focus on delivering cost effective primary care to everyone. The discussions on whether drug or alcohol induced sex with an incapacitated female constitute rape are too prurient for this voter. To say nothing of the “men's room chats” about redefining what is considered incest in the case of sexual intercourse. In other words if your uncle coerces his thirteen-year-old-niece to have sex with him and she gets pregnant that may not be considered rape unless other physical violence was involved (barring rape or incest the girl would not be eligible for a federally paid abortion). Also, since when are thirteen year-old girls women? The marginalizing of women in America is in full force, what is next, wearing burkas?

This article was written by Roberta E. Winter, MHA, MPA a health policy analyst and independent journalist and may be reprinted with her permission.

Fatwa on the Fat Wallets; the Dismantling of the Middle Class in America

2010-12-19T06:13:00.000-08:00

How the latest proposed tax cuts lead to the dismantling of the middle class in America
President Obama’s latest capitulation to the greed of the Republicans is unparalled in the blatant disregard for the middle class of the United States. In the event you are just coming out of a coma let me enlighten you as to the facts on the Obama Tax Cut Proposal.
Social Security is being Dismantled
The financing mechanism for social security has been cut by 30%; further eroding the ability of this program to provide the funds for those who are retired, disabled, as well as for widows and children. This is not some abstract idea to me, as my son lost his father when he was an infant and it has been a long 14 years of scratching by. In order to pay for the current social security benefits the fund has to borrow money, to the tune of 112 million. The reduction in Social Security funding will mean our children will have to pay higher taxes in the future to make up for the funding shortfall, to say nothing of the fact I have paid into it since I was fourteen years old.
Impact on the National Debt
The United States overspending is financed by other countries, including China, who have now decided that the US debt is not such a good investment and they have raised the interest rate the US must pay (which is akin to a drop in the bond rating of the nation). This country is spending 39% of the entire 2010 annual budget on war and half of that is on a discretionary defense budget; since I no longer have a discretionary budget, I suggest we get rid of that expense and balance the budget like the rest of us.
Impact on the Average American
The impotent rational for the give-a-way to the rich was the extension of unemployment benefits to the 15 million people who are out of work, of which I am one. Why does there have to be a rational when the country is in a depression and job cuts are at every level both private sector and in all levels of government? Once again government is out of touch with the daily lives of its citizens.
According to the latest figures from the World Bank the average income in this country is $47,240 and the tax cuts provide less of proportional benefit to the average American, with $1,000 for those earning $50,000 and $2,000 for those earning $100,000. People who earn the former need the money more.
The entire spend for Medicare and Medicaid health care programs is only 23% of the budget and with current Social Security spending that adds another 20%, for a grand total of 43%. Yes, that is right folks; your government spends nearly as much on war as on all of the benefits, which you have paid for, for everyone else in the country. At least Obama has included health care in the benefit equation, but he capitulated on that too, by letting the insurance lobby create an expensive mess instead of more affordable national health care.
The top 3% don’t need the tax breaks and boo hoo on their estate taxes; they set up trusts, and use insurance to pay that tab anyway. And whatever happened to the adage you can’t take it with you?
Conclusion
It is about time the elected officials in this country started having more respect for the poor working stiffs, who are not getting ahead, instead of catering to the rich, who are obviously born under a different star. So Mr. Obama as you continue to spend 40% of the budget on a war that we never should have entered and dismantle my Social Security benefits, I look forward to opening that can of Friskies for dinner. The dismantling of the middle-class will bring a revolution to this country, for which I am prepared to serve. Ending on a positive note I salute Senator Bernard Sanders of Vermont for his nine and a half hour filibuster decrying the injustice of this tax proposal.

This article was written by Roberta E. Winter, MHA, MPA an independent health policy analyst and may be reprinted with her permission.

State by State Analysis of Patient Rights under 2010 Reforms

2010-11-02T11:00:00.000-07:00

State Reactions to 2010 Health Care Reforms
A virtual firestorm has ensued with state reactions to some of the federal government mandates under the health care reforms of 2010, from the Patient Protection and Affordable Care Act, the Public Health Services Act, and the Affordable Health Care Act for America. This article reviews two of these bones of contention, including the consumer protection aspects, which impact the Office of Insurance Commissioners and the reproductive rights provisions.
Consumer Protections under Federal Mandates
The federal government has awarded thirty million dollars in grants to the states to shore up their consumer protection services for health insurance policy holders. Since the insurance commissioners of each state are already charged with this duty, are staffed for it, and are funded by a tax on the insurance premiums for each insurer, I struggle with the necessity of this award. The insurance commissioner’s office for each state are very well funded and provide general revenue to each state well beyond their budget requirements. If those states aren’t able to staff appropriately for consumer protections, they should take this up with their state legislatures.
Upon reviewing the mandated consumer protections, they appear to reinforce existing protections in many states, but perhaps the standardization of the process is a good thing overall. Here are the new rules for an insured’s right to appeal a health insurer’s claim decision:
•Allows consumers to appeal when a health plan denies a claim for a covered service or rescinds coverage
•Gives consumers detailed information about the grounds for the denial of claims or coverage
•Requires plans to notify consumers about their right to appeal and instructs them on how to begin the appeals process
•Ensures a full and fair review of the denial
•Provides consumers with an expedited appeals process in urgent cases
These provisions are already spelled out in the Summary Plan Description which employers are required to distribute to medical plan participants as a federal reporting requirement under ERISA health and welfare plans. The new provisions codify what 44 states already have in operation for the outside appeal process. Still, the thirty million dollars to encourage compliance seems like overkill for the six states who are not already meeting these recommended standards, which were created by the National Association of Insurance Commissioners. Basically the new rules specify that the patient has a right to an independent review of a rejected claim. According to the Kaiser Foundation’s report on external reviews of insurance claims, the insured won 44% of the time on appeal. Certainly this is enough of an incentive for many patients to pursue a claim review, but one has to wonder, if it is a life saving treatment, the appeals process could still exhaust the patient’s treatment window for optimal efficacy.

Reproductive Rights under Federal Health Care Reforms
I reviewed legislation for all fifty states as of June 2010 and 86% of them had bills that were introduced to modify their compliance with the federal insurance exchanges and other mandates, to be rolled out in 2014. Basically here is what the fuss is about; the federal standards state that Medicaid and the insurance exchange plans will cover reproductive procedures. Of course this includes abortion and birth control. Since the Hyde Amendment restricts any federal money from paying for abortion, this means the insurance exchanges and Medicaid plans could include abortion coverage but the states or private employers would pay for it. This has raised the hackles of a lot of people, who do not want to be told what to do when they are going to pay the tab. According to a 2003 survey on contraceptive care provided by insurance programs, 87% of private employers offered coverage for abortion services, which covered approximately 46% of the U.S. population. Since the majority of private employer medical plans already cover abortion and birth control procedures for their female workers, this standard is not new. What is new is the government’s attempt to offer the same reproductive rights to low income women through Medicaid and the subsidies for eligible employers. Many of the states are objecting to the federal requirement that they must offer poor women the opportunity to receive birth control treatment. Why don’t you just keep them barefoot and pregnant? Here are my winners and losers on the reproductive rights bills:
Most female friendly regarding reproductive autonomy
Current Laws
Colorado Law 1021 requires insurers to cover contraceptives if they provide maternity coverage. Wisconsin SA458 improves sex education for youth.
Under Consideration
Illinois- Senate Bill 2482 requires insurance companies who provide prescription drug coverage to include coverage for contraceptives. House Bill 6205 codifies the right to abortion even if Roe-v-Wade is overturned. Bill 6205 also assures the right of Medicaid women to receive contraceptives and abortion as needed. House Bill 6842 blocks some access to reproductive health care under federal health reform stipulations.
Let’s give a shout out to South Dakota for proposing insurance companies cover contraceptives, but also for expanding Medicaid for pregnancy related services. Other states who seek to expand Medicaid for low income women are Alaska and Illinois.
The following states have bills stipulating improvements in sex education, emergency contraceptives upon request (morning after pill), and insurance reimbursement for contraceptives: Pennsylvania, New York, Missouri, Minnesota, California, and Hawaii.
Most paternalistic states regarding female reproductive autonomy
Current Law
Providers Can Decline to Provide Contraceptive Services
The following states have enacted laws which allow health care providers (pharmacists or clinicians) to decline to provide birth control services: Idaho S1353 enacted 3/29/2010 and Oklahoma S1891 signed 4/2/2010.
No Abortions under Private Insurance Plans Either
Under current law, the following states do not allow private insurance funding for abortion services; Kentucky, Missouri, Oklahoma, Idaho, and North Dakota. If you are unfortunate enough to live in North Dakota, now is a good time to consider moving over to the healthier and wealthier Minnesota neighbor, though I must confess I am a former Minnesotan.
No Abortions in Health Insurance Exchanges
States which have enacted laws that restrict abortion and other contraceptive services under state health insurance exchanges include Arizona and Mississippi.
Arizona- S1305 enacted 4/24/2010, prohibits insurance companies participating in the insurance exchanges from offering abortion and S1001 signed 4/1/2010, blocks portions of the federal health care reforms. If that isn’t charming enough, S1305 also prohibits insurance companies who cover state employees from offering abortion coverage.
States Seeking to Limit Birth Control specifically for Low Income Women
Virginia H30 passed 5/17/2010 limiting access to abortion for Medicaid eligible women and
Colorado L1311 prohibits the payment of abortion for Medicaid participants.
Pending Bills Restricting Reproductive Rights
North Carolina currently has a law that allows insurance companies to refuse contraceptive coverage, N.C. 1068 and also restricts access to contraceptives in school health services (let's keep those teen pregnancies coming). The coupe de tat’ Bill 890 makes an unborn child a crime victim separate and apart from the mother, legalizing the fetus status as an individual. North Carolina also introduced a bill on 3/31/2010 requiring all pregnant women to get an ultrasound, regardless of efficacy, to submit to a state lecture on fetal development, and to wait 24 hours before termination. Also a bill was introduced on 4/13/09 to prohibit state employees and teachers from having an abortion paid for by state medical plans. I wonder if the school boards can still fire teachers who become pregnant out of wedlock as well. Double winner here, ladies, cross your legs in NC. Bill 1157 would restrict funding for low income women on Medicaid, by not covering birth control services. A bill introduced on 6/17/2010 would block federal health care standards for women. Finally, Bill 431 would require parental consent in writing before getting an abortion. Let’s see, your parents may have a different religion, different sexual orientation, and you may not even be living with them, but you need their permission? How does this work for foster kids and run-a-ways?
Additional States that seek to limit access to sex education, contraceptives, fair access to birth control for low income women (Medicaid), and to criminalize abortion are:
Alabama, Louisiana, Virginia, Colorado, Nevada, New Mexico.
Does this really matter when the 1977 Hyde Amendment has continually been ratified and every federal budget limits payment for abortion procedures except in the case of rape, incest, or a life threatening situation? The tan-your-Hyde amendment has also been broadened to include no federal reimbursement for abortion for federal employees, women in the military, or for Indian Health Services. The latter is a real confounder since American Indian Tribes are considered sovereign nations, yet are conscripted to obtain health care from the occupying nation with opposing values. The 2010 reproductive rights provisions matter because the states can choose different provisions for abortion financing and service availability through the insurance exchanges and Medicaid programs. There is also specific language to protect clinicians who do not want to provide abortions, but no language protecting those who do. This is another example of unequal rights in the land of the not-so-free. The most onerous task is the mandate to attach a separate premium for abortion costs and to bill it as an addendum to the exchange plans. This seems like a lot of work for the estimated $1 additional cost per eligible woman, but that may be another way for the federal government to discourage abortions. What is next, wearing the letter A on our blouses? The shame attached to a common birth control method and often medically necessary procedure wastes a lot of resources that could be better spent on improving primary care across the board. For example, building a robust sex education program into the school system and providing contraceptive options to the sexually active population.
There will be other issues the states will argue about for health care reform implementations, but I thought we would start off with the most litigious and now the healthpolicymaven is signing off with condom in hand.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

High Risk Medical Insurance Federal Mandates

2010-10-21T10:52:00.000-07:00

Comparison of State High Risk Medical Pools to the Federal Mandate for Pre-Existing Condition Insurance Plans or PCIP's
Recently I had the opportunity to listen in on the nonprofit Commonwealth Fund webinar about how state high risk insurance pools compare to the recent federal mandates for Pre-existing Condition Insurance Plans. The federal PCIP plans are a transition into the nationwide health care reforms mandating all people are covered regardless of their health and without waiting periods for medical insurance. The federal PCIP program started in July 2010 and runs to January 2014, when the national mandates for all insurance plans are slated for activation. This article addresses the plan differences and identifies which states have existing publicly managed health care plans for individuals the insurance industry didn’t want to serve, the uninsurable. Hallelujah, for all of you folks with real health problems, somebody cares, and you can thank the government.
Federal Mandates for PCIPs
The federal PCIP regulations require that all insurance plans be offered without waiting periods for pre-existing conditions, as I have previously reported. They also mandate that these individuals may not be charged a surcharge premium for their risk, in other words you can’t discriminate based on someone’s health. The maximum out of pocket cost for covered medical services per individual under the federal plan is $5,950 per year. The coverage must be nationwide, which probably means some insurance companies will not participate in the plans, which is fine. In order to be eligible for coverage under the federal plan, you must have been uninsured for six months. The federal plan does not offer a high deductible medical plan option of $5,000 for example. State high risk pools are not impacted by the health care reform mandate as they are not insurance companies or insurance plans, but nonprofit self insured funds.
States with Existing High Risk Medical Pools
Wisconsin-WHIRP
The information in this analysis comes from a presentation by Amie Goldman, CEO of WHIRP or Wisconsin Health Insurance Risk Pool. The oldest high risk pool for medical insurance is the State of Wisconsin’s, started by the enterprising cheese makers in 1980, which provides medical coverage for 18,300 participants. Their composite premiums are equal to the private market rates for medical insurance in their state, even though they insure the “high risk” people. Also since they are a nonprofit entity, they do not have to pay the state insurance premium tax, which is an administrative saving. The monthly premium for a 50-54 year old is a mere $277, significantly less than other states. In terms of what their participants want for coverage, they prefer the first dollar benefits. Wisconsin has not noticed any adverse selection, where someone signs up, gets their procedure done, and then dumps the coverage. Wisconsin also does a lot of outreach to health care providers and benefit specialists (insurance agents) to promote their plan. Their director did state that low income folks are still more likely to be uninsured (no kidding, let’s see we'll pay the electricity bill or the insurance). Essentially the chronically uninsured are not able to afford to pay for the premiums (poverty sucks).
New Mexico-NMMIP
The information in this review was presented by Deborah Armstrong, JD, director of the New Mexico high risk medical program. Since New Mexico is a less populated state, they only have 8,200 people enrolled in their high risk health care plan. According to their director, their most popular plan has a $500 deductible. Of their population, it is expected that 1,000 will enroll in the federal high risk pool. Their premium rate (cost) for a 54 year old person is $495 per month, which is less expensive than the new federal risk pool. New Mexico provides financial subsidies for low income people enrolling in their high risk health care pool. Administratively they do promote their product and recently AARP did a mass mailing about it. The state also pays a broker fee to encourage insurance agents to market the program.
Washington-WSHIP
Washington State has had a high risk medical plan since 1987, which basically covers all of the people who the private insurance sector did not want to cover and those who can afford the premium. The plan almost evaporated in 2000 due to financial problems at the state and federal level, but with some revisions, it still exists today. And Washington State was selected as the administrator for the federal interim plan or PCIP, until the 2014 health care reforms are fully implemented. The Washington State pool is funded by assessments on insurance companies, based on their premiums charged to customers. Premiums charges to medical pool participants are allowed to be 10% higher than market rates and cover 33% of the pool’s claims. The rest of the plans cost is paid by insurer assessments and there is no state revenue funding. According to Washington’s WSHIP report, about 5% of applicants for market rate medical insurance are rejected and of those, 20% have the resources to enroll on the state plan. According to the 2009 annual report of plan performance, the top diagnosis claimed were all cancer related. For pharmaceutical charges, 58% were HIV/Aids related and these represented 9% of the top prescription drug categories of expenses. Washington’s plan is split into Non Medicare and Medicare Eligible products. For purposes of this analysis, the focus is on Non Medicare products. Since I have already used the 50-54 year old age group for pricing, I am also illustrating that here, because at this age it is more likely medical conditions will exist that may make those persons ineligible for market rate insurance. Monthly premiums for a non smoking person in this age bracket would pay $986/month for a $500 deductible health plan and $476 for a $2,500 deductible health plan. Overall enrollment in Washington’s risk pool was 3,578 people in 2009.
Federal High Risk Medical Plan Rates
$500 and $2,500 deductible plans
Child only premium-$324/$161 for nonsmokers(straight off the federal register)
Child only monthly premium-$327/$162 for smokers (By looks of the small premium difference thankfully there are not too many kids smoking.)
Youth to age 24, nonsmokers, $377, $177 and for smokers,$431 and $207
Age 25-29, nonsmokers, $423, $200, and for smokers, $489 and $232
Age 30-34, nonsmokers, $489, $233, and for smokers, $566 and $271
Age 35-59, nonsmokers, $567, $273, and for smokers, $657 and $316
Age 40-44, nonsmokers, $671, $328, and for smokers, $784 and $382
Age 45-49, nonsmokers, $822, $402, and for smokers, $952 and $464
Age 50-54, nonsmokers, $986, $476, and for smokers, $1,143 and $556
Age 55-59, nonsmokers, $1,157, $563 and for smokers, $1,342 and $653
Age 60-64, nonsmokers, $1,355, $655 and for smokers, $1,577 and $769
65 Plus, nonsmokers, $1,355, $655 and for smokers, $1,577 and $769
Conclusion
The majority of the states (36) have tried to address the “at risk” population of people with serious medical conditions who are unable to obtain medical insurance, which drastically impacts their ability to receive adequate medical treatment. For information on what your specific state is doing, go to the insurance commissioner web site and look for State High Risk Medical Pool or something similar. Or call the customer service number of your state's insurance commissioner’s office and ask about it.

The Brave New World of Accountable Care Organizations

2010-09-20T11:17:00.000-07:00

Brave New World for Health Care in America
Recently I attended a health care conference, sponsored by ECG Management Consultants, on the impact of accountable care as mandated by new government regulations for quality and transparency. An accountable care organization is a clinical group that receives a patient management fee from Medicare in exchange for improved patient oversight and quality standards. In short, this is pay for performance, not only for procedure. All of the panelists at the conference were in agreement that the health care paradigm has shifted irrevocably. There was much discussion around organizational adaptation for integrating quality measures in reporting and contracting, including one from a clinician in attendance, who decried the poor reimbursement for solo primary care practitioners. Essentially he was told that only clinicians whose model meets the new requirements for reporting and care metrics will be able to adapt. Wow, pinch me, did someone running a health care organization really say that in public? This is definitely the first time I have been in a conference where all of the experts were in agreement and publicly stating the old model for doing business in health care is dead, which is to treat and bill for services, based on usual customary and reasonable charges. It is no longer adequate to do a good job with your patients; you have to be able to demonstrate that with your quality metrics. Certainly some clinicians will choose to retire, others will join larger clinics to be able to compete, and some will be the leaders in this adaptation. The Everett Clinic comes to mind, a leader for decades in the provision of affordable care to a diverse patient population, and with excellent quality measures, as reported by Leapfrog and other quality watch dogs.

The medical community, as represented at the conference, is anxious to adopt a new compensation model beyond the fee for service practice and though it will be a process of adaptation to include medical home and other primary care provisions into a reimbursement model, it is happening. The accountable care organization provisions encourage health care entities to reduce waste, provide measureable improvements in care, and improve the end stage of life care process. The first article I wrote in my health care column in 2007, was about end-of-life-care and the impact on the patient as well as the cost to society, with my brother as the benchmark for the shift away from prolonging life regardless of quality.

Conference speakers from Monarch HealthCare, Brown & Toland Physicians, The Everett Clinic, and Premera Blue Cross were in agreement on the following principles derived from the recent health care reforms:
1.Health care decisions will be driven by the individual and less so by the corporations.
2. We are going to have to provide a lot more care to an aging population for less money.
3. The system has to make meaningful cost management changes.
4.One of the big costs that need to be confronted is inappropriate end of life care due to the absence of medical directives, lack of palliative care programs, and general lack of awareness on the part of patients.
5.Other cost vectors that need to be controlled are reducing unnecessary procedures, allocating technology more efficaciously, and reducing excessive administration costs.

Government Processing Speed
Concerns raised by this group of health care administrators include the speed with which the Center for Medicaid Services, CMS will be able to process all of these changes. It took a year and a half for them to measure the Everett Clinic’s results in a demonstration project. Since the scale and degree of health care changes are significantly greater with the 2010 health care reforms, one has to wonder how many years it will take for the reporting to occur, let alone system integration.
New Medical Model
The model for an effective health care delivery organization will have to include these criteria to succeed in the new health care environment in the United States:
1.Clinically integrated multispecialty physician networks
2 An economic model to manage risk and deliver patient value
3.Immersion in evidence based medicine
4.Successful communicators of their value
Benchmarks for America’s New Health Care Program
The United States’ ability to compete for goods and services on a global scale demands a more efficient health care system, because we cannot continue to spend 20% more than everyone else for health care. Several countries have managed private insurance programs for the provision of health care including; The Netherlands, Switzerland and Taiwan. The USA would be wise to observe how these models function and to adapt best practices. One thing that is clear, despite the catcall for subsidizing health insurance costs, these other countries provide subsidies, up to 40% of the premiums, depending on the income level and location of the enrollee. So to all of the whiners who criticize insurance subsidies for the middle class, if you want an inclusive national medical program using private insurance, this is a mandatory element, so get over it! It is in the best interest of everyone for the focus to remain on how those dollars are spent and on the value we are getting for improved health care, for example, managing hypertension to reduce the incidence of kidney dialysis, which costs a minimum of $50,000 per patient. If we improve our health care model and deliver care more efficiently we can bring down the relative per capita cost of health care over time.

Private Sector Exemptions from 2010 Health Care Reforms and the Wellness Mandate

2010-09-02T12:24:00.000-07:00

Private Sector Exemptions from 2010 Health Care Reforms and the Wellness Initiative
According to an article in the New England Journal of Medicine, 57% of private employer plans are ERISA self insured plans and are exempted from many of the 2010 health insurance coverage mandates, since these plans are not considered insurance. This means most of the large employers out there will continue to manage their own health care programs as they have in the past. Smaller employers will be the ones most impacted by the insurance mandates and often, they are the least able to pay. The federal subsidies help some small employers, but if you have over 25 employees you are required to provide the expensive first dollar coverage and pay a significant portion of the cost. Perhaps the small employers will elect to pay the penalty rather than play in this pool. It is also worth noting that a lot of start-up companies and nonprofit organizations fall into this size category and their funding is quite restricted.
Cost to Produce the Baseline Surveillance
The impact on the health plan’s cost will of course be a factor in the hiring of new employees. Though it is illegal to discriminate against older workers, one has to wonder why a small employer wouldn’t consider age when it would impact the cost of their medical plan. Even under the Obama reforms age is still a factor in establishing a community rate for the price of a health insurance plan. Yet another nail in the coffin for anyone who is over forty and looking for work. As a student of government policy making I am wondering if the unintended economic consequences were fully considered with this 2010 health care mandate for small employers to buy expensive front-end loaded insurance for their employees.
Encouraging the Desired Effect
I favor the carrot incentive method much more than the punishment stick and keeping the tax deductions for health and welfare plans is critical to employer sponsorship, as well as keeping some flexibility in plan design so the smaller businesses, both for-profit and not-for-profit can participate. The federal subsidies apply only to very small employers with 25 or fewer employees and are targeted to firms with 10 and under workers, which is understandable from a budget standpoint. It is telling that the government considers small business only those with less than 50 employees (the standard most likely to be adopted by the majority of the states), who are exempt from the penalties for not providing medical insurance plans. In the private sector, employers with less than several hundred employees are considered small and in my insurance career, several companies considered all firms with less than 2,000 employees to be small employers. This difference in standards is based on the volatility of the claims performance data and the management required in order to replicate a similar outcome for the smaller firm versus a larger client.
Wellness Care Mandates
Though I understand the importance of providing primary care, which means early detection of costly diseases like high blood pressure (which is a precursor to kidney failure and cardiac problems) through annual exams, perhaps having them provided by insurance companies is not the most effective method. The insurance industry is deft at managing large risks and not at providing disease surveillance or wellness. Any efforts to do so by insurance companies involve add-on commission based products that are provided through a third party and generally not well integrated into program performance. You can bet that plenty of insurance agents are selling wellness programs now that the coverage is a government mandate, but what is the efficiency of this model, other than to make more money for the insurance industry?
Better Way to Provide Wellness Services
Another way to provide disease audit and management could include using public health nurses or clinics to do the surveillance, which would protect the privacy of the individual and provide key surveillance information for a community trying to manage its health care. Since large employers may already use on-site clinics to provide the wellness services, the small employer sector needs a better model for identification of at-risk employees. Also, the public health programs need an infusion of capital and this would be a great way to take the old “school nurse program” and create a community nurse program nationwide. As someone who went through a Minnesota winter with untreated bronchitis I wish there would have been a school nurse in my high school. I would love to see a cost benefit study on using public health programs and federally qualified clinics to provide the wellness services versus the insurance industry products. Everyone likes to complain about the inefficiency of government programs, but the financial support of federally qualified health centers through federal grants has proven so effective it has been reauthorized by three presidencies. Public health programs have been on the front lines in addressing health risks for a hundred years. These programs are effective and they don’t require sophisticated and costly marketing schemes to pitch their results, but they could use your advocacy.
For those of you who have a fear of public health, I can attest to the efficacy of the program as I have been a customer of Seattle Public Health on many occasions, for my travel immunizations (they have the best travel clinic), for primary care treatment when I have been without insurance, and for referrals to other medical facilities, when no one in the private sector would see me. At least with the Obama protocols many of the uninsured will have medical insurance, which will at least enable them to get a private sector physician to schedule an appointment. The Obama health reforms are creating a new baseline for health care design and reporting and maybe in the long run it will empower consumers.
For more information on how the states are reacting and their regulatory authority for the federal health reform mandates, read the September 15th article in my contributing column for the life sciences newsletter of the east coast consulting group Tag44.com at http://www.tag44.com/newsletters/ls%20newsletters.asp?cat=lifescience.
This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Evidence Based Planning and the Obama Protocols

2010-07-20T09:46:00.000-07:00

Evidence Based Planning: How it Impacts Health Care
EBP: What it is
Evidence based planning is the catch phrase of the health care reform movement and this article explains what it means and how it is applied in health care processes. The Institute of Medicine or the IOM defines quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge”. Evidence based planning is harnessing the enlightenment gained from sharing scientific and medical practice information and using it to optimize clinical and operational procedures to improve results. The health care reform mandates in 2010 have provisions for increased transparency and optimization of service delivery, which can only be achieved by deploying the best practice protocols by diagnosis, whether it is heart disease or diabetes through the evidence based planning process. Certainly the words “best practice” are not offensive, but the beast rears its head when someone other than the local practitioner suggests a change in practice or patient protocols. However, this method of protocol review is an ongoing drama that has been and continues as the singular best method to reach out and impact treatment patterns. Large integrated health care organizations like Kaiser, Group Health Cooperative, or the Veterans Administration already have working committees who meet regularly to review data, test protocols, make recommendations for changes, and deploy the innovations throughout the organization. Hospitals also have multi-disciplinary committees who meet to figure out how to enhance patient outcomes by reviewing and adopting the best data driven practices and not all clinicians are happy about changing their patient practices as a result of the scrutiny.

Health System Impact
Evidence based planning is the practice of critical review of scientific literature (study data) to obtain advances in medical care protocols and then developing a method for localized testing and adoption within a health care facility or system. EBP is a process, not a single product driven task. The act of planning is a verb and applying best practice evidence in that process enhances institutional performance metrics. This means that patients who are the beneficiary of best practices live longer and with fewer complications than those who don’t, by a population standard.

Reducing the Patient’s Chance of Dying
As an example, when I was working on my MHA degree I took an evidence based planning course at the University of Washington School of Public Health and our EBP project reviewed data on Secondary Myocardial Infarctions (heart attacks) to develop a plan to reduce the likelihood of the second heart attack. We reviewed a significant body of information, including several dozen peer reviewed articles, and a European study which had measured time to treatment and long term prognosis for myocardial infarction patients . In our EBP project we learned that if patients registered in a follow-up program, especially a national database (like the Minnesota Heart Institute Registry), saw a cardiologist for medication management, and obtained appropriate medication, their chances of a second heart attack were 6% less than patients who did not follow these protocols. Our research included a comprehensive review of 40,684 admissions in Pennsylvania hospitals from a study in 1993 . The study cited an estimated cost savings to the Pennsylvania Medicaid program was $71,970 just by improving compliance for prescribing and administering beta-blockers. We also discovered that MI patients who obtained their three month follow-up visit were 57% less likely to die than patients who did not come in for their check-up. A retrospective cohort study (means they are reviewing historical patient data to draw conclusions) in Scotland, showed a significant difference in patient outcomes post discharge if they were treated by a cardiologist. Now it doesn’t take a rocket scientist to figure out this is a huge difference in performance, which has a significant impact on the cost of health care, when you consider that the Association of Health Research for Quality (AHRQ) estimates that 50% of Americans die from heart disease.

Implications for Medicare, which is the single largest cost driver in US Health Care
Heart disease is expected to remain the leading cause of death for the USA until 2020. By improving the outcome of cardiac patients we can save literally, millions of lives, and this is accomplished by evidence based planning. The beta-blocker protocol alone could save state Medicaid agencies 3.7 million dollars in a single year. This is an example of how government policy, drives reimbursements that impact which treatments patients receive, which can be life saving as well as monetarily more effective.

Another example of the application of evidence based planning was in 2005, when Medicare created incentive reimbursements ($6,000 per patient) for the administration of the drug tPA within three hours of a stroke, because patient recovery and mortality were significantly improved by this process. This was a way to get the attention of hospital administrators and improve surveillance and dispensing of this drug within the window of time to provide the biggest clinical impact.

Currently Medicare has demonstration projects reviewing how to improve chronic disease management for diabetics and other disease management programs, to improve patient management and Medicare health system management.

Why We Want Evidence Based Planning
The value we will get for our health care contributions, whether they are premiums, tax allocations, or fees for direct services are directly affected by the efficiency and cost of services in any health care system. It is in our best interest in terms of patient mortality (death) and morbidity (other complications) to seek care from institutions who are openly seeking to adopt the best practices world-wide for the management of your condition. The 2010 health care reforms under the Obama Administration specify and encourage the communication of performance metrics and the adoption of best practice clinical protocols to give you the best value for your money. Sounds great, so why isn’t everyone excited about this process to save money and improve our clinical outcomes when we have treatment? The conservative think tank Heritage Foundation, criticizes the Institute for Comparative Effectiveness, created by the Obama reforms to use population based research, as I previously explained in my cardiac example, as a bureaucratic intervention. This is not an accurate statement as evidence based planning is a science based discipline reviewing published studies under the Cochrane Central Registry of Controlled Trials and Medline Database among others to discern performance difference of significant impact on populations. The Institute for Comparative Effectiveness will review these science findings, make comparative information available to clinicians, insurance companies, and patients as a part of enhancing communication about patient procedural outcomes and system processes. The agency will coordinate with the National Institute of Health, NIH and Agency for Health Research and Quality, AHRQ as well as other expert sources to assimilate, measure, and distribute data on optimizing medical system performance. Why wouldn’t you want to have a resource to cull and present current international data about disease management and procedural outcomes? Sure it will cost a bit of your tax dollars, but a lot less than the ordnance in Iraq or Afghanistan.

The Institute for Comparative Effectiveness
The real value in the Institute for Comparative Effectiveness is the initiative in linking economic cost benefit analysis to health care delivery protocols in order to reveal the most efficacious methods. This means cutting waste, reducing unnecessary procedures, resourcing facilities appropriately (we don’t all need the DaVinci surgical robot), and improving surveillance of illness to slow disease progression. Yes, it will put the spotlight on health care suppliers, insurance companies, and other providers, but if we really intend to address the grossly high cost of the United States health care system(more than any other country and with poorer results in many areas), this is necessary. The folks who are using the scare tactics about evidence based medicine are trying to get a toe-hold in the “old each-practice-doing-what-it-wants” method of dispensing health care. That process is too expensive and the degree of variations in dispensing health care in this haphazard fashion do not create the same proportion of patient improvements as adopting optimal best practices for a society. Medicare did the right thing by rewarding hospitals who were administering tPA for stroke victims within the optimal window for efficacy and hopefully this new institute will help identify and spread other improvements to American health care as well. This is a first step in some analysis on effective cost cutting measures for United States health care.

What you can do
Use your fingers and do some research on the internet, go to reputable sites like AHRQ or NIH and educate yourself about your condition before your follow-up appointment after your initial diagnosis. When you meet with your clinician, ask about best practices and see what they say. If you are uncomfortable with the response, ask more questions, or consider getting a different clinician. You can have an impact on your health and your wallet if you do a little bit of research and ask the investigative questions. And to those who say evidence based planning is bad, I hope you visit a health care facility that isn’t using global best practice protocols. Good Luck!

This article was written by Roberta E. Winter, MHA, MPA, a health policy analyst in Seattle, Washington and may be reprinted with her permission. 7/13/2010

Government Regulations for Employer Health Care Mandates by September 23,2010

2010-06-17T20:53:00.000-07:00

Health Care Reform Mandates by September 23, 2010
The most recent federal guidelines on the administration of the Patient Protection and Affordable Care Act and the Public Health Service Act are actually requiring All existing health and welfare plans to offer the following benefit mandates:
 Elimination of any lifetime limits on coverage for all medical plans
 Inability to rescind medical coverage for insureds except in the event of fraud
 Must include children of the insured through age 25
 Immediate coverage for children with preexisting conditions(no waiting periods)

The rules state that restrictions on dollar limits for conditions, will be mandated as well, TBD. These will be revealed by the plan anniversaries one would hope.

One could start to feel a bit verklempt(forgive my poor Yiddish), but again, the laws of economics dictate that the government steps in where there is private market failure. Currently, the American public feels that the insurance sector, representative of the private market has failed in providing basic coverage for families. It is not just about the money, its about the health care continuum.

Grandfathered Plan Status
The regulations state that health plans which make significant changes will lose their grandfathered status as far as the exceptions to the other health plan mandates. This appears to be a sticky wicket, but prohibitive actions include:
• Cannot significantly cut or reduce benefits; so you can raise rates and mandate benefits but they can’t change their plans to keep afloat?
• Cannot raise co-payment charges, even a $30 to $50 change will trigger this intervention, so I think many employers will just bail on health insurance.
• Cannot significantly raise deductibles, apparently more than 20% is prohibitive. This does not make any sense as employers might fund health purchasing accounts with high deductibles, which are very cost effective.
• Cannot significantly lower the employer contribution to employee health plans; again mandates raise costs in a BAD economy and employers can’t pass on any of it? OK kids, I was in the insurance business when they still used carbon paper and my deductible was based on my income.

Required Transparency of Plan Changes
One of the provisions that does make sense, is the requirement of employer sponsored plans to distribute notices to plan participants if they are subject to a grandfathered plan status.

Apparently there are 133 million American’s with employer sponsored plans that would come under this regulation (100 or more FTE’s under 5500 reporting requirements). The Obama Administration predicts that 70% of businesses fall under the “grandfathered status” but this could drop to as little as 30% because of the compliance challenges.
Medical Inflation
Allowable Changes in Co-payments will be tied to medical inflation, so up to 19% in 2011, which is much higher than the rest of the world and is not sustainable.

The insurance exchanges still appear to be a long way off and it is questionable if they are being designed by anyone who actually understands risk management and the insurance business. If your hiring standards are prejudiced toward other government workers and political considerations, are you really hiring the best utility workers for such a major social policy change by excluding the private sector?

Well, that is all for now, this is the health policy maven signing off, and you know I always tell the truth.
Thanks for your attention.

Citations:
http://www.dol.gov/federalregister/HtmlDisplay.aspx?DocId=23967&AgencyId=8&DocumentType=2

This article was written by Roberta E. Winter,a Seattle health policy consultant and may be reprinted with her permission.

2010 Health Reform Implementation Guidelines

2010-05-30T20:34:00.000-07:00

Health Care Reform Compliance Guidelines
This article addresses the implementation schedule for the health care reforms that apply to private health insurance plans under the Patient Protection and Affordable Care Act and the Public Health Service Act stipulations. It is important to note these new provisions impact both self-insured and fully insured group health insurance plans and are incorporated into ERISA and IRS rules.
Compliance Mandates for 2010
1. COBRA- this provision has been extended from nine months to fifteen months for eligible participants and their dependents. If you were unemployed before February 28, 2009, you may be eligible for a COBRA benefit extension for your group insurance benefits and a federal subsidy for the insurance premiums. The COBRA subsidy was enacted under the American Recovery and Reinvestment Act of 2009 and requires eligible employees to pay a minimum of 35% of the COBRA premium expense (as opposed to 100% previously). Employers are required to administer the extension for qualifying employees and their family members.
New Plans Adopted in 2010 must Conform
2. Most of the health care reform provisions are not effective until 2014, however for health plans that begin on or within six months of the enactment date of the law(s), October 1, 2010 is the compliance target.
Extending Medical Insurance for Adult Children
3. Medical coverage for adult children can be extended from age 23 to age 26 for children who are covered dependents, whether or not they are married or filing separate tax returns, and is effective in 2010. Plans which existed prior to March13, 2010 will have until January 1, 2011 to comply with the mandated plan change for covering adult children. The question is will those adult children be able to adversely select against the parent’s medical plan based on their health needs? For example, if the child has coverage through employment, can they refuse that coverage in favor of the parent’s plan? So parents, your married kids who are living in their own residence can now be covered on your medical plan. It seems like they will never leave the nest.
Uniform Benefit Explanations-2012 Target Date
Uniform Explanations of Coverage must be provided by either the health plan insurance provider or the plan administrator and an electronic summary must be available. Personally, I think this is a good thing. In 1999, when I was building web sites for paperless plan communication and documentation, most insurance companies were not embracing the paperless process. It makes sense when the health care delivery system is converting to electronic medical records that the insurance industry also converts to paperless plan benefit information. This requirement will simply be an enhancement of the Summary Plan Description materials employers have to provide now. Also, if corporations are offering employee benefits it is incumbent on the group to provide understandable plan benefit information and one would hope the participants are already getting this kind of information. The Uniform Benefit Explanation code requirements will be provided by Health and Human Services within 12 months of enactment of the law, which means by March 2011, for published guidelines. Employers will have 12 more months to comply, so at a minimum that would mean March 2012 or at the plan anniversary, which could mean as late as January 2013.
Compliance by 2014
Mandates for Health Insurance Plan Changes Effective in 2014
The Patient Protection and Affordable Care Act, section 1304(b) stipulates that the group insurance market is divided into two segments for administration of the law, groups with over 100 employees, and those with fewer than that. There is a provision that allows states to designate that firms with less than 50 employees will be considered their standard for the small group exemption definition. This exception means small employers will not have to pay the per-employee tax (roughly $166.67/FTE/month Re. the Reconciliation bill amendment) if they don’t offer insurance to full time employees. It is expected that most states will accept the more liberal 50 and under criteria. Other provisions that will impact group medical plans include:
1. Group Health Insurance Plans Cannot Impose Annual Limits on Medical Benefits.
2. Health Insurance Plans Cannot Rescind Coverage except in cases of fraud or misrepresentation.
3. Preventive care must be provided without any co-payment.
4. Pre-existing condition clauses are not permitted.
Insurance Company Reporting Compliance Dates
5. Effective in 2014, Transparency and disclosure of claims utilization rate setting, and other financial data for insurance companies and third party administrators will be standardized. Those identified as insurance administrators or companies will have to provide the same information to the public, in an electronic format, which the government run health insurance exchanges are also required to provide. This includes clear explanations of claims payment standards, financial data disclosure, plan enrollment statistics, rate development information, participant cost-sharing, out of network payment information, and participant rights under the act, as determined by Health and Human Services. Though this is a comprehensive health care transparency law, much of this information is already available to plan administrators and this just codifies it and makes understandability a program performance value. For health care consumers this is a good thing because they will be able to see how their premium contributions are spent.
Plan Reporting Changes by 2014
6. Nondiscrimination rules previously only required under Section 105-H Executive Health Care Plans will now apply to fully insured group health plans and will be phased in by 2014. We can expect to see some new reporting requirement, including a nondiscrimination test probably under a provision in the Department of Labor Form 5500 filings.
7. Codification and reporting of health plan quality will be required by 2014, but no standards are expected from Health and Human Services until 2012. The standards will most likely address disease management programs for high cost chronic diseases like diabetes, hypertension, and COPD. Also, health promotional activities will be required to develop reporting standards. Case management will also be reviewed, as health programs that perform better will be rewarded for quality. Medicare has stipulated an increase in Medicare payments for quality indicators, which will ultimately be adopted in the private insurance sector as well. Complex health care systems already have sophisticated quality measurement programs, so the purpose of this provision is to spread the process improvements throughout the United States. Quality measurement is an important criterion for efficacy of program value and performance. I expect quality reporting to be included in the DOL 5500 reporting standards by 2014.
8. Claims utilization ratios and expenditures from health plans will have to be reported, but this is already available for most firms who have 100 or more employees enrolled on their health and welfare plans, so this is a standardization process. What is new is the requirement that insurers post a minimum loss ratio if they want to work in the insurance exchange market. This will encourage insurers to leave the small group marketplace, which will mean small employers will be relegated to the government insurance exchange offerings. A local nonprofit insurance group in Washington has already decided to leave the small group market and lay off about 25% of its workforce.
9. Uniform External Review Model
Health plans must have an acceptable external audit process, such as the one recommended by the National Association of Insurance Commissioners, which is a consumer protection process.
Observations
The Patient Health Safety Act quality reporting provisions will benefit health care patients who will see more quality indicator reporting. It is valuable to have knowledge of surgical and recovery outcomes by facility before going under the knife. In a perfect world this information will only be a click away in two years, but expect that the implementation for non-alpha organizations will be several years away and 2014 is the target date for mandatory compliance.
Get used to the term “Portal” as the federal government is using this euphemism to describe the mega web site it is creating for the Health Insurance Exchanges, which will serve as a one-stop-shop for various public and private health insurance programs. Portal pricing and plan information as stipulated in Section 2718 of PSACA will apply to plans with inception dates of September 23, 2010 and later. A phase-in period will apply for existing health and welfare plans. Currently data collection is on-going from state insurance commissioners, insurance companies, and Medicaid officials and Health & Human Services is expected to have a preliminary program activated by June 14th, with a “live date” by the July 1, 2010 statutory deadline. High Risk State Insurance Pools (providing health insurance for people who were considered uninsurable in the private sector and ineligible for a public plan) were to have reported their data to state insurance commissioners by May 21, 2010. There must be a lot of overtime at HHS right now!
When I first started writing this article I thought it would be a breeze, but the density of the changes is significant, so if it is a challenge for this policy analyst, I can only imagine how private sector plan administrators will feel. Ideally the government will hire some insurance experts to implement the rules in an effective manner, but that may require private sector experience, and governments are loath to hire anyone from the “for profit” world. My fingers are crossed hoping that some efficiency will emerge from this tsunami of change.
This article was written by Roberta E. Winter, MHA, MPA, a health policy consultant in Seattle and may be reprinted with her permission.
Citations
http://www.hhs.gov/oic/regulations/webportal.html

Insurance Changes from the Patient Protection and Affordable Care Act

2010-03-26T09:17:00.000-07:00

How Insurance Companies, Employers, and Insureds will fare under the PPAC Act
Some of the legislators think the healthcare reform bill, signed by President Obama is a catastrophe, but from this angle it looks like a big win for the insurance industry. Though lots of things are missing from the bill, such as cost containment, this is the single biggest health care reform since Medicare was enacted in 1965. This article reviews how the current Patient Protection and Affordable Care Act impacts the insurance industry and its offerings.
Top 10 changes to the Insurance Industry with the PPACA law
1. Creation of the Federal Supplementary Medical Insurance Trust, funded through a panoply of new taxes to provide subsidies and expansion of health insurance programs, both government and private sector for the uninsured.
2. Medical insurance is now required for most U.S.A. residents (AKA lots of new customers!!!)
3. Removal of excessive waiting periods prior to commencement of insurance coverage
4. Removal of lifetime limits on benefits for medical insurance contracts
5. Insurers Required to post a Minimum Loss Ratio if participating in federal health plans like Medicare Advantage plans.
6. Extension of healthcare benefits for children to age 26
7. Closure of the prescription drug "donut hole" exclusion for Medicare recipients
8. Drug Rebates are provided for oral medicines that are re-formulations of existing drugs in an attempt to lower the cost of certain prescription medications
9. Establishment of health insurance exchanges and drug purchasing cooperatives
10. No changes in Cafeteria Plans until December 31, 2013

Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008. But no matter how you look at this provision, it mandates more people buy medical insurance, which is a HUGE win for the insurance sector.
Funding of Insurance Mandates
The healthcare reform bill uses health insurance as a means to improve access to health care services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums.
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for the health care industry. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll, although the Obama Administration forecasts an additional 32,000,000 will obtain some form of health insurance, either government or private sector with this bill. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Medicaid Changes
Medicaid changes are a bright spot for healthcare providers as more people will be eligible for Medicaid, versus having no healthcare coverage now, which should reduce the stress on the under-funded population pass-through costs to private sector insurance participants. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans.
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Individual Penalties for Residents who do not Obtain Health Insurance
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax.
The combination of insurance tax subsidies, coerced employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast the level at this time. According to Hewitt Associates, when the COBRA subsidy kicked-in, enrollment increased by 20% for those beneficiaries. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Insurance Company Tax
Insurers will be assessed a premium tax to help pay for the provisions of health care under the Patient Protection and Affordability Act. Basically there is a formula that excludes certain activities from tax, has an offset, and has provisions for insurers that derive 80% or more of their revenue from low-income (re. Molina Healthcare), elderly (Medicare supplements), and disabled populations.
Health Insurance Luxury Plan Tax
High cost or "luxury" health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. If the cost of your health insurance exceeds that threshold a tax will be assessed on the residual. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family, which is indexed for medical inflation. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor? This tax may force some plans to reduce some benefit levels to comply.
Medicare Changes
Medicare enrollees benefit by the following changes in reimbursements:
1. Closure of the prescription drug "donut hole" exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs.
2. Changes in Medicare Advantage (HMO) payments
Qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Transparency about plan expenses and administration costs
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government.
5. Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status. This is part of Medicare’s efforts to improve primary care for Medicare patients by strengthening the primary care relationship.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
Other New Taxes
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive and will be passed directly through to the ratepayers and healthcare consumers. Also, in a nod to medical tourism, since this is an excise tax, even if you obtain healthcare outside of the United States, the device, if manufactured in this country, you will pay the tax.
Estate and Trust Tax
A tax equal to 3.8% will be levied on estates and trusts
Administrative Changes
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts. I just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.
This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.

How Hospitals will fare under the 2010 Public Health Service Act

2010-03-23T14:38:00.000-07:00

Listening to some of the law makers you would think the healthcare reform bill, signed by President Obama was an apocalypse now, rather than a process, albeit a messy one, of change in our democracy. Certainly lots of things are missing from the single biggest healthcare reform (cost containment) since the initiation of Medicare in the sixties, but this article reviews how the current Public Health Services Act impacts hospital systems. And you can thank-me-in-advance for compressing the 153-page bill into only 4 pages for you to digest.
Medicare Changes
Medicare changes will have an impact on hospitals, as the majority of their patients are typically Medicare eligible.
1. Closure of the prescription drug "donut hole" exclusion under Medicare Part D
Medicare enrollees who have used all of their prescription drug allowance will be reimbursed up to $250 to close this loophole. This reimbursement will be allowed once per year per enrollee for Medicare Part D drugs. Also, the difference in cost sharing between generic and name brand drugs will continue at 7% until 2020 when it will increase to 25% for Medicare participants.
2. Changes in Medicare Advantage (HMO) payments
There is a planned phase out of indirect costs associated with medical education for medical plans with capitated rates (HMO’s) and replaced by modified benchmarks. This is an extremely complicated calculation, which I won’t cover, except to say that qualifying counties will receive increased allowances, based on enrollment.
3. Quality rankings will impact Medicare Payments
Healthcare facilities with a quality ranking of four or higher will receive increased reimbursement from Medicare. Reimbursements will also depend on Medicare Advantage plan enrollment by county.
4. Changes in Medicare Administration
Under the Public Health Services Act, Medicare Advantage plans are required to have a claims loss ratio of 85% of premiums or the plan will have to pay a penalty to the government. This provision applies to insurance companies or health systems that include sponsored health plans.
5. Market Basket Update for reimbursements
The Medicare Market Basket is a reimbursement adjustment category and under this act, the percentage point adjustment will be as follows: .03 in 2014, .02 in 2015 &2016, and .75 in 2017-2019. Have fun with that you svengallis of finance & accounting.
6.Physician Ownership Referral (Medical Home Provision)
This provision requires provider agreements to be signed for patients, designating a medical home status, but for hospitals that have a high proportion of Medicaid patients, implementation has been delayed until December 31, 2010.
7. Changes in Imaging Payments
This is a modification to the current schedule of reimbursement for imaging services, beginning 2011, a 75% utilization rate will be assumed for this service for Medicare patients. Department managers in laboratory and X-ray units will want to review this to assess the impact on revenues and budget.
8. Repeal of Medicare prepayment medical review limitations.
Disproportionate Share Funding
For hospitals that serve indigent populations, making them eligible for Disproportionate Share Funding from the federal government, the current reduction is 1.5% and this will become 1% in 2014 and then increase to 2% in 2017. Though it appears that states with heavy indigent and Medicaid populations will feel this DPS reduction less than wealthier states, because of a complex modification formula. Hospitals with a low percentage of uninsured patients will experience a reduction in this reimbursement. Everybody has to share the pain I guess.
Medicaid Changes
Medicaid changes are a bright spot for hospitals as more people will be eligible for Medicaid, versus having no insurance now. Granted Medicaid reimbursement is marginal, it is still better than no reimbursement, so this will increase viability of some hospitals, especially in the cities. The healthcare reform bill increases the allowance for the Federal Medical Assistance Percentage or FMAP for Medicaid Managed Care Plans. This is for the calculation of reimbursement for primary care physician services, which will benefit clinics especially. The formula for the FMAP change is as follows:
2014-50%
2015-60%
2016-70%
2017-80%
2018-90%
2019-100%
Under fee-for-service reimbursement plans, family medicine, general internal medicine, and pediatric practitioners will also have increased reimbursement for primary care services.
Tax Subsidies and Funding of Insurance Mandates
The healthcare reform bill uses health insurance as one of the means to improve access to healthcare services for individuals and as such, provides federal tax credits to taxpayers to assist with the cost of the health insurance premiums. Here is the schedule for tax credits to finance health insurance purchasing:
Federal Poverty/ Level Premium Assistance/ Final Assistance %
Up to 133%/ 2%/ 2%
133% to150%/ 3%/ 4%
200% to 250%/ 6.3%/ 8.05%
250% to 300%/ 8.05%/ 9.5%
300% to 400%/ 9.5%/ 9.5%
For hospital systems, if more patients have access to insurance, there will be less uninsured services provided, which is a stabilizing factor for healthcare. What remains to be seen, is how many of the 48,000,000 uninsured will be able to afford insurance for their families and will actually enroll. To encourage participation, the law stipulates a tax penalty for those residents who don’t enroll in an insurance plan.
Healthcare Purchasing Subsidy for Low Income Residents
For individuals who are not eligible for Medicaid or Medicare, but qualify for subsidized insurance purchasing, here is the subsidy range under the Patient Protection and Affordability Act, section 1402:
Household Income/ Insured’s Responsibility/ Subsidy
133% of FPL/ 3%/ 97%
Up to 400% of FPL/ 9.5%/ 91.5%
Pay or Play Provisions for Taxing Employers Who Don’t Offer Health Insurance
The Patient Protection and Affordable Care Act amended section 4980H of the Internal Revenue Code to provide tax assessment penalties for employers with fifty or more employees, who do not offer health insurance for their employees. The penalty will be between $2,000 and $3,000 per eligible employee, depending on the size of the employer. For some employers, it will still be worth it to avoid the expense of a medical insurance plan, which would cost over $5000 per employee and over $12,000 per family. According to the Kaiser Foundation’s Statehealthfacts.org, the cost for a single employee’s health insurance was $4,386 and the cost for a family was $12,298 in Washington State in 2008.
Health Insurance Luxury Tax
High cost or "luxury" health plans will have to pay an excise tax up to 40%(yikes), based on an expected premium, with risk adjustments for that area. The formula for determining which plans are high cost will be based on a per employee factor derived from Blue Cross/Blue Shield industry standards, which are age/risk/sex adjusted. Currently this threshold is $10,200 for an individual and $27,500 for a family. It is difficult to understand how this will help lower health costs, it seems to me it will just encourage employers to pass more costs onto their work force, who are already financially strapped. What are we doing, punishing the good guys who have great healthcare? Why not just mandate design elements with co-payments as opposed to only addressing the spend factor?
Individual Penalties
Section 4980H of the Internal Revenue Code also provides that individuals who do not elect health insurance will be subject to a tax penalty, which would run between $325 and $695, depending on modified adjusted gross income levels.
The combination of tax subsidies, employer contributions, and required individual insurance plan participation should help reduce some of the uninsured expenses which health systems experience, although it is difficult to forecast at this time. Many people may choose to pay the penalty rather than buy insurance because it is less expensive to pay the tax. Also, individual participation in regional purchasing cooperatives is going to depend on how well those plans are communicated and ultimately, the cost of the plans.
Medical Device Excise Tax
Medical devices, meaning cardiac pacemakers and such, will now be taxed at 2.9% of the purchase price. Orthopedic devices presumably are included in this category. Exceptions to the tax include; hearing aids, glasses, contacts, and over-the-counter devices purchased at the drug store. This tax will simply make these devices more expensive.
Durable Medical Equipment Oversight
Durable Medical Equipment suppliers will be subject to an additional 90-day period of claim review, due to a high degree of suspected fraudulent activity in this supply sector. So, I guess this means they will be getting paid later.
Fraud Detection
The Commission of Medical Services in HHS is going to compare notes with the Internal Revenue Service as an enhanced Medicare fraud detection procedure.
Any semblance of privacy we had was lost with the post-911 anti-terrorist provisions, so lets just add this to the list of big brother invasiveness.
Medicare Tax Increase
It should come as no surprise that there is an increase in the Medicare payroll tax, from 2.9% of total payroll to 3.80%, split evenly between the employee and the employer. Given the state of the Medicare fund, a bigger tax increase is warranted, and is probably on its way.
On a closing note, the Public Health Services Act imposes a slew of new taxes on corporations, individuals with investment income, and trusts, lets just hope there is transparency in the spending of those funds and that is does actually go towards health care for those who need it.

This article was written by Roberta E. Winter, MHA, MPA, an independent healthcare consultant in the Pacific Northwest region of the United States, and may be reprinted with her permission.

Obama Signed the most significant Healthcare Reform Bill since the Creation of Medicare

2010-03-22T11:14:00.000-07:00

Whew! I must say I am surprised that any agreement was reached on a healthcare bill, but President Obama was presented with a bill and he signed it. Having read all 153 pages of the bill, I am NOT going to write one review of the bill, but this week, I will break it down into three articles. The first article will feature healthcare changes for hospitals, the second article will address insurance changes, and the third article will showcase how these regulatory changes will impact consumers. The only way to digest this mammoth piece of legislation is in smaller bites. So watch for more from the healthpolicymaven this week.

Medical Tourism and Quality Measures

2010-02-03T11:19:00.000-08:00

Medical Tourism or the exportation of health care services and procedures is in full swing in the United States consumer driven health care movement. Since deregulation of the airlines with the Reagan administration Americans have increasingly become global travelers and consumers, so why not health care services as well? This article explores the private sector health care population that is seeking health care outside of the United States and examines some quality issues.
Previously Americans seeking health care overseas were expatriates working offshore, residents with family ties in other countries with westernized medical services, or the wealthy. Since 2000, there has been a tremendous increase in middle class Americans seeking medical services abroad. Approximately twenty billion dollars annually are spent by U.S. residents who obtain medical care off shore. The primary medical services accessed outside of the U.S.A. purview are cosmetic surgery, orthopedic repairs, cardiac procedures, organ transplants, and fertility treatments. These are also high profit services for medical facilities in the United States. Insurance companies, largely at the behest of privately insured employers, are including coverage for medical procedures provided off shore at an increasing rate in their contracts. Even the nonprofit hospital group, Christus Health in the Southwest purchased a hospital in Mexico, in order to offer lower cost procedures within their network. This triad of insurance companies, employer groups, and USA health care providers has created a tsunami of change in the provision of health care.
In 2003, I conducted research on medical tourism for Seattle Cancer Care Alliance and Fred Hutchison Cancer Research Center, for a marketing project to encourage transplant patients to obtain care in Seattle. At that time, no thought was given to patients seeking transplant procedures outside the United States for the exportation of medical care. My survey included facilities on the east and west coasts. Though I was very enthusiastic about the potential for business development for world class transplant centers, this was not shared by my direct reports. I recall how a Miami Florida facility had a very advanced patient support system, including housing, interpretation, and other assimilation services. How things have changed in a mere seven years, now United States transplant facilities must compete with international facilities who are obtaining Joint Commission International accreditation, and can offer the same services as U.S. health centers for less than half of what the same services would cost in the states, inclusive of travel expenses!
The next step to assuring a safe process for adventurous or maybe even frugal patients, who seek medical care outside U.S. oversight, is to identify quality indicators on a global scale, and incorporate quality measures into certification, and contracting of services throughout the globe. India and Thailand both have international centers that cater to western patients and other countries are rapidly developing their ability to serve global patients.
For any medical procedure involving surgery, infection is one of the risks, and is a frequent complication post-op. Infection rates by procedure and facility should be tracked and reported in a transparent manner for a primary quality indicator. A second indicator would of course be mortality, incidence of death, again, by procedure and facility. A third quality indicator would be the re-admission rate for complications from a procedure, which could include complications from co morbidities and device or surgical failure rates. Another quality indicator would be certification of facilities and clinical staffers. A part of this certification should include the frequency with which they perform the contracted procedures and their patient success and failure rates. Meaning, surgeries that go as planned as well as those with unintended consequences, including death. Cost or value should also be included in the scorecard for determining an international medical center’s performance. Administrative functioning and efficiency should also be considered in contracting for quality with an international facility. Finally, the patient’s experience should also be included in a facility’s quality assessment. These seven criteria provide a good basis to create a quality benchmark from which to gauge an off shore healthcare facility’s excellence prior to contracting for services.
Though all of these criteria are important in attempting to pre-qualify an international medical facility’s ability to perform as contracted, the patient’s health status and mobility are also essential elements of any surgical intervention. Insurance companies, who incorporate medical tourism into their contracts, should require a U.S. physician to examine each patient’s ability to seek services at a non-local facility. If the patient may be certified as healthy enough to seek services off shore, then the insurer would approve the procedure. Also, U.S. physicians are reluctant to release patients to clinicians they do not know and facilities for which they are unfamiliar. Insurance companies and health care providers should find ways to build confidence between professionals as needed. I won’t address the legal implications of off shore medical services, but I am sure it is just a question of time before a malpractice or wrongful death suit is filed under medical tourism.
This article was written by Roberta Winter, MHA, MPA, President of Praevalere Inc., a Seattle based health care consulting firm, and may be reprinted with her permission.

Hope for the Holidays

2009-12-03T10:34:00.000-08:00

Bring It On 2010
With the country seemingly fomenting from one crisis to the next this past year, many of us are looking forward to a new beginning, let’s bring on that extra digit for 2010! This article highlights what one family did to make a difference in a social need, providing a little hope for the holidays.
Nursing Shortage
As the United States population continues to age, more of us will become hospital patients, which is of concern given the current 135,000 nursing vacancies across the country. Despite the economic downturn, a shortfall in nursing supply continues and is expected to grow to 260,000 in the next fifteen years. Which means, when we are older and more vulnerable, who will be there to care for us?
Mid-course correction
Donna grew up a middle child of seven, in the Great Lakes land of Swedes and Norwegians. When she became an adult she had seven children, four of them before age 24. After several cross-country moves she returned to school and completed her R.N. program shortly before her fiftieth birthday. She worked for 25 years as a charge nurse in a community hospital before retiring. During that time she absorbed the changes of many for-profit corporate takeovers and saw a decline in the quality of care due to decreased staffing in the facility. Finally, she retired at age 72, not out of fatigue, but from frustration with the diminishing resources available to care for increasingly more vulnerable patients.
One Person Can Make a Difference
For Donna’s seventieth birthday, a scholarship was created in her name through the Texas Nursing Association. The award was designed to finance nursing school for community college enrollees who are displaced homemakers. The first scholarship recipient was a survivor of both Hurricanes Katrina and Rita and mother of three children. Despite the loss of her home and damage to her school she stayed on track for completion. The second scholarship was just granted in November, to a fifty-year-old woman who is just entering nursing. Each year, Donna contributes significantly to the fund, even though she is now a retiree, but most importantly, helping someone else still inspires her.
One person, one family, reached out to a community to address the need to recruit and train more nurses in the long term. In a more immediate sense, two families are better off now than before. Thanks Mom.
Happy Holidays to all and to all a good night!

Retort to Change in Breast Cancer Prevention Protocols

2009-11-19T13:01:00.000-08:00

This week, lurid headlines were in all United States papers proclaiming a government charged task force of "experts" recommended rolling back frequency of breast mammograms from annually to once a decade if you are age 40 or wait fifteen years if you are age 35. My first reaction was WTF, followed by; I wonder how much they paid for this study. Since I am twice a breast cancer survivor, I consider myself to be somewhat of an "expert" and I have a health policy background. According to the Center for Disease Control, 74.6% of women in the United States who were forty and older received mammograms in 2005. The latest recommendation published in the Annals of Internal Medicine could have an adverse impact on the mammography rate for American women. In order to be fair, let us examine this from a rational perspective.
The most salacious reason cited for reducing the prevalence of mammography in pre-menopausal women was the potential harm of the screening process. Excuse me, you mean the harm of having to obtain a second mammogram because of careful screening and a potential false positive result? This is a good thing as the level of scrutiny for abnormal breast tissue is high in order to save lives. If these folks are concerned about the radiation exposure, the exposure from the sun is worse and certainly contributes to more incidence of cancer than prophylactic breast radiation. Or perhaps it was the horror of the stereo tactic needle biopsy, about as challenging as a blood draw. What exactly are the harmful effects this panel of experts was talking about, a poke in your boob? Or are women really so shallow that a mark or scar on their breast is more important than surveillance for a potentially fatal disease.
In 1993, when I had my first BC diagnosis, I was told that 6,500 women who were under age forty in the United States died from the disease each year, and that I was an anomaly. I was also given literature on how slow growing the disease was and that it primarily impacted grandmothers. Since I was 35 at the time, I decided to do my own research, finding European data on treatment for pre-menopausal women. I knew several women who had died of this disease at the time and the only thing we had in common was an education and a career, which typically meant late or not-at-all child bearing. In my case there was no family history of breast cancer that was disproportionate with the general population.
The proviso this panel of experts make that high-risk women should obtain mammograms excludes one consideration, we don’t typically know who these people are, unless they have been to an oncologist, which would include mammography. The difficulty in preventing cancer mortality is due in part to the elusiveness of the disease indicators and the optimal way to prevent deaths is to have broad population cancer surveillance. Breast cancer mortality is affected by patterns of early detection and quality of care. According to a recent report in the Cancer Journal for Clinicians, which reviewed breast cancer data from 1996 to 2006, breast cancer mortality is declining in the United States. The article also reviewed global breast cancer data and noted the mortality reduction in breast cancer cases was indicative of the early screening, detection, and therapeutic treatments. Why would the United States want to reduce the gains made in saving lives with this virulent form of cancer?
In 2003, ten years after my initial diagnosis, my oncologist informed me, that I had the same type of cancer in my other breast. At that time I was 46 and based on the recommendations from the aforementioned expert panel, I would have come under the high-risk category and have been able to obtain a mammogram with regularity. Of course I would have died at age 36 without my initial mammogram, since baseline mammograms for women under age 50 are not a recommendation from the panel. At the time of my second diagnosis, I was a graduate student in a top ten public university and a widow with a seven-year-old child. Mammography, which I had annually, was the thing that saved me both times. Was my life not worth saving, according to this panel it was just an anomaly.
Second finding, breast self-exams are not beneficial in diagnosing early stages of breast cancer. Duh, someone finally figured this out. First of all if there is a lump in your breast and you can feel it, that is a big tumor. Mine was two centimeters and I couldn’t feel it at all. Secondarily, many lumps are benign or noncancerous. Finding a lump is not an effective early detection method for cancer.
Thirdly, the inference that the emotional trauma from a potentially false positive mammogram is too overwhelming for females smacks of condescension. Aren’t women responsible for their own health? Why not let women make decisions after they have all of the facts. Note to self, the American Cancer Society does NOT agree with these new recommendations to curtail mammography for women that are under age fifty. For those females who feel that having their boob squeezed is not worth potential cancer prevention, that may not be the most well informed choice, but it their option.
Fourth finding, that mammograms for younger women aren’t reliable because of the difficulty in scanning dense breast tissue. What a bunch of huey! I had less than 17% body fat during my initial diagnosis, which found the presence of abnormal tissue in my first mammogram. Mammograms can be performed for women with all breast densities, especially by the better centers. It is helpful to have your "boob shot" taken at the same center so they become familiar with your tissue anomalies. Also, for those professionals who feel they are challenged with imaging more youthful breast tissue, become competent at your job.
Finally, I am concerned about the implications for insurance reimbursement, which may choose to limit coverage for breast cancer diagnostic procedures for women under age fifty. Hopefully some university professor is currently assigning a cost benefit analysis project about mammograms for women under age fifty. In conclusion, for women who may not feel they can cough up the money for a mammogram, I ask you, what is your life worth? Also, there are nonprofit organizations like the www.cancerlifeline.org that have funds to pay for these services. If in doubt, get a second opinion, and keep asking questions until you feel informed about your own health.

European Country going back to Private Insurance

2009-10-07T13:00:00.000-07:00

PBS had an interesting program about The Netherlands Health system last night. The Netherlands (Dutch), has been on the cutting edge of a number of health care issues over the years, including policies for physician assisted suicide for the terminally ill and allocation of resources for maternity and child care. Recently, the Dutch decided to switch from a single payer health care system to an open market, privately insured system, where every resident has a health care budget. This approach could work for the United States, but a number of changes would have to be made to the insurance regulatory infrastructure. This article addresses those system delivery concerns.
Question of Scale
First of all, lets talk about scale, The Netherlands is a tiny country compared to the United States, with excellent public transportation and health services in place for the entire country. In the USA, if you have a car, transportation is excellent, though costly, but access to healthcare in rural and poor areas is much more limited in America than in The Netherlands. Secondly, the country has the same health care insurance standards for everyone in the country, not fifty different standards like the states.
Health Insurance Regulation
In America, the Insurance Commissioner of each state regulates the health insurance industry and though commissioners have a national organization with some standardization recommendations, each state is free to do what it wants for health insurance regulation. There is very little standardization in health care insurance or service delivery in the United States, which is partly the cause of the incredible disparity in cost of care per capita compared to other industrialized countries. Also, about half of the USA health care system is financed by private employer plans and for those employers who choose to take some risk and self insure their health plans, there is an exemption from most of the insurance commissioner regulatory authority. So, this begs the question, how would you standardize the process? The answer is an amendment to the ERISA law, which created this health insurance loophole in the first place. Though it may be easier just to do the pay or play and provide the allowance/subsidy as needed, than to dictate benefit design to these stakeholders.
Lack of Standardization
It is one thing for The Netherlands to take its existing long established policies on basic care, palliative care, and eldercare and change their financing system, but the USA doesn’t yet have standardized policies for health care services. Also, since the administrative cost for private insurance is about three times that of the largest government run program, Medicare, it is hard to see how administrative savings will be made in this scenario. The government has more control to drive system delivery changes with Medicare than it would have with several hundred insurance companies. I can just see the marketing geniuses working on their differentiation campaigns now.
Potential Applications from Netherlands Style Market Based Health Plan
The Dutch have a few options to select from for health care insurance, from basic, to deluxe, and pay an individual cost accordingly. Dental, vision, and luxury services are in the latter package. The United States health care reform movement should require a minimum level of care for all of its eligible residents, including primary care, hospitalization, and prescription drugs. A secondary plan may include basic dental and vision services, whereas the deluxe plan could include better coverage in those areas. One consequence of providing an individual health care allowance is the individual would have to take more responsibility in accessing and choosing health care. Theoretically this policy would reduce unnecessary services.
Evidence Based Treatment
In The Netherlands, new prescription drug and other treatments are subject to an administrative review to determine medical evidence and efficacy of the intervention before approving the treatment. This concept would also be a sound mechanism to thwart excess profiteering in the U.S. health care system. Though some patients may be concerned that they are not receiving the latest treatment, this does not necessarily mean their treatment isn’t effective. There are many instances in health care where a lower tech treatment is just as effective as the more technological one. For example, in wound care, the individual vacuum devices that are affixed to the patients wound are less costly and often more effective than hyperbaric treatment. U.S. citizens have to learn to access quality data when making health care decisions.
Universal Availability of Health Quality Data
Though alpha health care organizations, like Virginia Mason Medical Center, have been integrating quality reporting into their system for years, there is limited national standardization of quality reporting. The NQA or National Quality Association has good data available, but it has not been integrated into all health care delivery systems. Quality measures are complex, but leading health care organizations, like Seton Family of Hospitals, a division of Ascension Health, have incorporated quality into their program development measures for years. If you look at medical standards nationally, each specialty has its own education group that advocates for certain treatment protocols. Perhaps the start of a national standardization movement for basic health care is to create a roll-up of these separate quality measures and continue to refine the process.
Accountability and Reporting
Again, given the scale of The Netherlands compared to the U.S.A. and the fact they migrated from a standardized program initially, their reporting issues are less problematic than for the U.S. migration into a standardized health program. Reporting simplicity, transparency, and auditing would be crucial to maintaining equity in a national health care program. Given the Unites States recent bouts with criminal banking activities and the usual health care fraud scams, the importance of tracking private insurance payers is even more crucial. Since the banking industry has wanted to get into the health care industry for years, this may be their opening, so beware of the foxes in the hen house.

Pay or Play or Pay and Pay; Obama versus Baucus Health Plans

2009-09-18T09:27:00.000-07:00

Baucus Health Plan
Senator Baucus of Montana broke away from his committee to present his approach to a United States health care overhaul. His plan proposes a complicated series of benefit changes in Medicare/Medicaid, along with taxes on health care suppliers, employers, and individuals, depending on the health care scenario. It is like trying to look through depression era glass for the economy in this approach. First of all, I don’t think adding more taxes to an already expensive health care delivery system will make it less expensive. If anything, this type of proposal will drive more people into the government option Obama plan.
Both the Obama and Baucus health plans rely on the employer system for health care financing, as opposed to a program based on individuals selecting their health plan from regional cooperatives, with a tax credit allowance, and some employer allowance. I am often asked why we expect employers to provide health care in the USA and my only answer is, "because that is the way it is now." It would be interesting to hear what employers, both large and small think about their preferred level of contribution to health care for their workers. According to the Employee Benefit Research Institute’s 2009 Health Confidence Survey, 83% of their constituent’s support a public health option. An employer mandate for a national health plan gleans 75% support as well. This organization is a conservative, employer, and insurance based entity, so if this is what their subscribers are saying, Brunhilde has finished her aria, and the curtain is coming down on the current health care marketplace.
Similarities
Similarities between the Baucus and Obama plans include the following features: guaranteed ability to obtain coverage regardless of pre-existing conditions, less predatory pricing based on gender and age, and a reduction in the uninsured populations. These are all good mechanisms to get more people eligible to obtain treatment, so their medical conditions can be better managed and less expensive in the long run.
Differences
Baucus recommends the use of nonprofit health care purchasing cooperatives (Community Health Plans or Health Maintenance Plans), to meet the needs of the uninsured population. Does he mean HMO’s or CHP’s? The problem with spreading the cooperative method to the entire United States population is scale; these are localized primary care provider organizations, not national health care institutions. Also, Community Health Plans deliver primary care at a lower cost than HMO’s although their history is briefer. The Obama public option would have the advantage of existing scale with the government already providing a number of health care services. The government is in a position to negotiate the largest discounts for supplies (theoretically) and prescriptions. Since insurance companies will be prohibited from dropping sick individuals from their plans and they will be required to accept all new applicants, there will be some attrition in the number of providers. Depending on your economic perspective, this is either an intended or unintended consequence of the policy change.
Medicare Reform
Obama’s plan expressly closes the gap in prescription drug coverage for seniors, called the donut hole, which is good. I also like his intent to improve quality and care coordination for Medicare recipients. Most of us will be on Medicare coverage someday and that is when we will experience our highest health care expenses. Since the costs for Medicare are escalating beyond sustainability, as a population we should be reviewing this program for efficiencies as a part of our national health care reform initiatives.
Things I would change in Medicare payments include the following:
-Establish an evidence based payment policy for orthopedic treatments (including hip transplants), that considers value delivered over life expectancy
-Tighten up on medical supply payments for motorized wheelchairs and other areas of abuse
-Optimize government purchasing power for the Medicare prescription program
-Stop paying for Viagra on Medicare (increases the risk of a cardiac event)
-Align reimbursements with optimized treatment protocols, which offer sound clinical results and affordable treatments
Finally, I would also institute a fee schedule for Medicare premiums based on earnings, which was voted down by the AARP years ago. Note to the AARP, look you are relying on the current taxpayers to finance your health care, and you are going to have to compromise a little. Be nice to the young people, we will need them when we are old.
My verdict on the Baucus Plan is that it is DOA, but it certainly contributes to an improved level of discussion on health care reforms, when someone else had the guts to reveal his plan. Like the Greek God of wine, Senator Baucus, I raise a glass to you.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission, 9/17/2009

Insurance is Not Health Care

2009-09-03T19:20:00.000-07:00

To listen to the vitriol regarding health care reforms for Americans, you would think we were in the civil war again. I have noticed a number of trends in blogs and citizens meetings on health care reform and thought I needed to speak up.
Number one, insurance is not health care, it is a financing vehicle for people to pay for health care and this is available to approximately half of the United States population. In order to obtain "private health insurance" many conditions must exist such as:
1) The employer offers health care
2) The employee actually makes a living wage and can afford the premiums
3) A health insurance company serves their area and is accepted by clinicians and hospitals
4) The person is not disabled or otherwise uninsurable
5) Or an individual policy may be available in their region or rural locale
Obviously a lot of employers are not offering health insurance, which is representative of the "private health care system" we have now. As an example, I know someone who worked up to thirty-six hours a week for a nonprofit organization which refused to consider that fulltime employment, so they could exclude that employee from eligibility for the health plan. This represents a market failure in economic terms and thus encourages the government to step in to make up for private market lapses. This is an example of the abuse that happens everyday in business and why the Obama Administration is advocating a pay or play policy for employers. Yes, it is time that employers pay for health insurance or contribute into the regional pool for those workers.
Number two, it does matter when you access health care, because obtaining appropriate care in a timely manner not only saves lives, it saves society money. By refusing to provide basic health care to United States residents we are merely choosing to pay more later for manageable conditions. Examples of these are breast cancer, prostate cancer, prenatal care, hypertension, and diabetes. The current United States health policy, which does not provide fair and equitable access to primary care for all residents, is effectively saying we will pay more later for residents who have these conditions and defer treatment. For example, a young couple, in Arizona, did not have insurance when she became pregnant with twins, yet both of them had jobs. Consequently, she was not able to obtain optimal prenatal care, which resulted in a delay in diagnosis, with potentially tragic results. This lapse in treatment was not their fault, it reflects our shortsightedness as a people that we choose to pay the higher cost for our lack of effective treatment for those who need health care.
Number three, for those Rambo-types who think they can provide for their own health care on a pay-as-you-go basis, I would be willing to bet that you don’t have a chronic disease or a sick child or failing parent. All you have to do is look at the number of individual bankruptcies filed in this country for health reasons to understand the impact on people who were no longer able to pay. A person’s inability to afford health care is not some moral failing, it is a combination of poor health policy and opportunity or just plain bad luck.
Finally, all of the examples I gave have happened to someone in my family. I am sure the rest of you can think of similar examples in your families too. Can’t we put aside partisan differences and work together to improve health care access and delivery for everyone?

Overhauling Healthcare Czarina Style

2009-08-18T15:16:00.000-07:00

Overhauling Health Care Czarina Style
The United States is known for its wastefulness of consumer goods and energy resources but the excess in our health care system is beyond comparison by all global measures. It is incomprehensible that informed citizens would chose to squander our national resources given a reasonable choice. This dilemma was aptly cited as a national crisis in the National Academy of Sciences Report to President Bush. It is essential that the correct problems be addressed in order to solve resource allocation and equity of distribution in US health care. This analysis explores various perspectives and clarifies what elements have the greatest opportunity for sustained change in the US healthcare system.
Enhancing healthcare and delivering a more affordable product are not mutually exclusive. The polarization that occurs between the public and private healthcare camps only serves to undermine progress for better consumer outcomes. Sean Sullivan’s characterization of prescription drug coverage policies for Medicare patients was inaccurate and inflammatory. Several major insurers in Washington State offer Medicare supplement policies with open enrollment provisions, regardless of insurability annually. Coverage for prescriptions is offered under the contracts. University of Washington Professor Sullivan’s assertion that coverage was only offered by fly-by-night companies to insomniacs was incorrect. Additionally, his assessment that insurance companies put small pharmacists out of business was also inflamed by his personal ire. Insurance companies serve as third party administrators for their clients and they have a fiduciary obligation to provide the most attractive contracts for their clients. This means if they can negotiate an RX discount and offer lower drug prices from a Prescription drug wholesaler, they are going to strike a deal. It is not the responsibility of the insurance company (ies) to support drug stores, large or small. Business failure for any small business is common, because of reduced margins and flawed business plans, but other industries lack the convenience of uncontrollable health care costs for their business failure.
Public perception that everyone in health care is making a profit is grossly in error. Of the remaining insurance companies in the healthcare business, profits are uneven and inconsistent. Profits generated are from business linked to health care contracts, not from the administration of those contracts. Biotechnology companies are another industry in health care that is an extremely volatile sector. Many providers in health care operate on a not-for-profit basis, hospitals, clinics, and insurers. The only segments of health care that seem to be consistently profitable are the drug companies and medical supply companies. Politicians tend to attack industries for sound bites and voter approval rather than the more laborious work of regulatory reform. It is far easier to criticize the health care system and its components than it is to promulgate change.
Much debate ensues about the percentage of United States Health care that is publicly versus privately financed. This is a circular argument as in a democracy the public investment is paid for by private taxpayers. The focus should not be which sector is paying as much as how can we work together to do a better job of administering, selecting, and distributing health care in our country. In order to move forward on a system renovation we need to agree on what as a country, we do well in health care. Below is my list of excellence in health care within the USA:
Creating new technologies to treat specific diseases
Promoting popular healthful practices, like anti-smoking campaigns and dental hygiene
Innovation of health care administration over the world wide web
Minimal wait times for services
A wealth of resources spent on experimental procedures to prolong life
Fairness dictates agreement on what the United States does not do well and here is my selection for the dubious honor:
Cover all citizens
Provide affordable health care to all citizens, but especially in the private sector
Provide excellent pre-natal care regardless of economic circumstances
Judiciously spend money on treatment of viably challenged patients
Develop and distribute effective medical treatments to the population regardless of social demographics
Administer national health resources efficiently

Rather than arguing about whom pays for the present health care system, lets deescalate the situation by identifying what we as a nation agree on for good and poor outcomes and processes in the system. A nonpartisan group with broad representation from the healthcare industry, government, and academia need to work on creating a more efficient system. Polarizing the debate along political lines serves to delay any real reform. An atmosphere of respect would go a long way to gaining greater receptivity for trade offs in reform issues. Health care reform is by no means a win win situation for everybody. Instituting a national mandated health care program could produce the following winner and losers:
Winners
Uninsured
Employees of small employers
Not for Profit Hospitals/health care providers
Senior Citizens
Families
Losers
Small employers(depending on cost)
Unions (one less bargaining chip)
Drug companies
Single employees
This is by no means a complete list, but here is my rational for the categorizations.
Uninsured
First of all, the uninsured, estimated at forty two to forty eight million, would emerge as clear winners in a government mandated health care approach. The uninsured are made up of the unemployed and working citizens who do not have access to affordable healthcare but are not poor enough to be covered by Medicaid. It should also be noted that the nation would win in an indirect fashion by covering these members, as maintenance of health is less expensive to provide than emergency room care, often the only care mode available to this constituency. An additional tax or a reduction in tax spending in another area would be required to cover the uninsured, so to that extent the tax subsidizers would lose here. In my financial calculations of a single payer health system, I estimated it would cost twenty-eight dollars as of October 2002, per paycheck to cover the uninsured.
Employees working for Small Employers
Small employers are least able to pay for employee benefits and are less likely to subside family health care costs, so I believe employees of small employers would gain more from a nationally mandated proposal than their employers. Small businesses would fight this mandate tooth and nail with the prediction that millions of jobs would be lost due to the increased cost of the new tax. In truth, this would only adversely affect the employers who are not taking care of their employees. Other small employers may find the single payer plan to be less costly than current options and simpler administratively. For industries like farming, which employs a significant migrant worker population we would expect the price of food to increase in the USA or a reduction in local jobs in that industry.
Large Employers
I am defining large employers as those with 500 or more employees. It is my belief that these businesses would benefit from the simplicity of a single payer plan and the cost would not exceed what they are already paying. The existence of Leapfrogsuggests that large employers are very concerned about the present health care system of public private resources effectively managing health care. Large employers would also win because a mandated benefit would remove some of the power of unions to dictate benefits and costs to corporations. Conversely, I perceive the unions would lose because they would lose a bargaining chip. Labor unions are already suffering from lack of differentiation and loss in membership, so a national healthcare policy would only exacerbate the problem.
Hospitals
For purposes of analyzing the impact of a uniform adequately funded national healthcare program, I am only addressing hospital outcomes. Presently under the hodgepodge funding arrangement, hospitals are struggling to survive, especially in rural areas. With a guarantee of funding, assuming fair DRG schedules, stability would enhance this sector of the industry. It is possible for profit hospitals could lose some margin, but that would depend on how they marketed their services. A single payer system would not mandate that hospitals be not-for-profit. Ancillary services like cosmetic surgery could still be paid for on a private basis. Virginia Mason in Seattle Washington has an extensive cosmetic surgery business for example. Hospitals that have excellent outcomes could be selected as magnet facilities for certain procedures and may not have to spend as much money on promotion, so they could win as well. Hospitals with poor outcomes or redundant services would lose and potentially close in an economically efficient system. It would probably take years to achieve this result.
Senior Citizens and RX Use
Presently senior citizens spend about 25% of their income on prescription drug costs. There are several reasons for this hardship; drugs are a favored method of treatment in the USA, an aging population, and the high cost of prescriptions due to financing of research and corporate profits. If a single payer health care system were in place, the drug developers would not be able to charge whatever they want for medications. This would lower the cost to seniors and other RX users. Of course the well financing corporate darling drug companies, who have consistently produced profits of 20%, would lose in this proposal. Their argument would be we couldn’t finance research to save lives if we don’t have the ability to recoup our initial investment. Some would argue they would be forced to leave the USA to produce their products, so jobs would be lost. Still, because of the degree of education and expense in developing these biotech facilities, they are all near major academic medical centers, so it is doubtful all of the drug companies would leave. Finally, France is a major developer of new drug therapies, so invention is possible with a socialized heath care approach. Invention and public health are not mutually exclusive.
Families
One could argue that citizens with families would benefit more under a single payer government mandated health care approach than childless employees. Based on my calculations, the average increase in payroll tax would be seventy-two dollars per pay period, which is less than the cost of providing family health coverage in private employer plans. Most employees are paying several times that amount to cover their dependents for insurance. So, families would be clear winners. Childless citizens may argue they are not getting the requisite benefit, but the increase in payroll tax is no different than the subsidy of lower income retirees and widows with Social Security Benefits now. The SSI and Survivors benefits are disproportionately geared to provide a greater income replacement ratio to citizens earning less than the social security cap. In other words, a low-income worker will have a higher income replacement ratio than a higher earning worker.
Where do we go from here
The solution to get all of these disparate groups invested in the idea that a single payer reform is a viable idea is to be ready to bargain and offer some trade offs. My suggestion is don’t try to have the government take over everything, at least not initially. This would be politically explosive and untenable. I suggest that providers continue to operate in their current form, but the coalition of public and private interests decides on the mandated benefit levels and sets prices. So, the government lays the ground rules for what is acceptable. Doctors and hospitals can continue to operate in their current form, but without the billing hassles for reimbursement and greater economic security from tort reform and price regulations. I also suggest that all present forms of government provided healthcare stay the same, but with improved funding for the poor. However, the administration of all nongovernment health care plans would change in my proposal as health czar. I am advocating a government contract for private administration of a nationalized heath care program. This would appease the major insurance companies who have invested millions in infrastructure for claims payment systems and eliminate the weak organizations. It would allow private industry to raise capital for a paperless conversion for claims payment, with all citizens enjoying the benefit. I am envisioning regional health administrators, with perhaps seven regions in the United States. This would also give the citizens the security of knowing that everything wouldn’t change under a single payer proposal. By allowing all parties to be represented at the negotiating table we can invent a more efficient and equitable health care system in the USA. I believe we can achieve close to universal coverage and more affordable coverage for all with the integration of public and private resources.
This article was written by Roberta E. Winter, MHA, MPA in October 2007 and may be reprinted with her permission.

2008 Election Recap

2008-11-05T14:18:00.000-08:00

Wow! Eighty percent of registered voters in Washington State showed up at the polls yesterday. The 2008 elections were a Republican’s nightmare, since high voter turn out typically means higher Democratic voters. America saw record numbers of voters across the country. Especially heart warming was the increase in new voter registration. As someone who has never missed a presidential election, I applaud this improvement in public participation in our democracy.

There were a number of issues that I blogged on in the past year, which were impacted by yesterday’s election(s). Here are the highlights:

Death with Dignity Approved
Former Governor Booth Gardner’s Death with Dignity Initiative in Washington State was approved with a 58% majority. This means that terminally ill patients, who obtain at least two medical opinions, can elect to end their suffering with the administration of lethal drugs.

McCain defeated
Senator McCain’s health care platform to eliminate the tax-free nature of employer provided health care through an individual health care credit program hit a sour note with the public. As I predicted in May, this health policy approach contributed to his defeat by freshman Senator Barak Obama.

Obama’s Health Care Platform
President elect Obama favors a "play or pay" approach for employers to provide health insurance coverage to all employees. Large employers would be required to offer health insurance to their workers or else they would be assessed a tax of 6% of payroll, which would go into a health care purchasing fund. Small employers would receive federal assistance to obtain health care for their workers, through regional purchasing cooperatives. Barak’s plan is to keep the public/private partnership we now have for health care, but to strengthen efficiencies and improve quality. He is an advocate of renegotiating Medicare prescription drugs under one federal contract, which would lower the cost of prescription medications for seniors. The pharmaceutical industry is most assuredly gearing up for heavy lobbying in Washington. Though President elect Obama does not favor mandating health insurance, his plan does include a series of provisions that would help millions more Americans have access to health care. This process will alleviate some of the pressure on hospitals, which have been burdened with the lion’s share of unfunded care.

Rossi Defeated
The impetus for my original blog was Washington State gubernatorial candidate, Dino Rossi’s lack of support for basic health care for poor children under the federal SCHIP expansion last year. Democratic Governor Christine Gregoire, a strong supporter of health care subsidies for the needy, defeated Mr. Rossi. Governor Gregoire expanded primary health care for poor children in Washington State under her first term and we can all breathe a sigh of relief this will not be undercut.

In conclusion, the public has spoken and it does see a role for government support and advocacy for its citizens, which is a reversal of the Bush Administration’s policies. Let us not forget to look at improving health care delivery efficiencies, not the least of which include the over use of technology and renegotiating Medicare drug coverage. At least with Mr.Obama we have someone who will listen to all parties before making decisions.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

McCain Seeks to Eliminate Employer Health Plans

2008-05-04T12:30:00.000-07:00

Presidential Candidate John McCain presented his healthcare reform ideas on April 30th, to a Tampa, Florida audience. True to his style, Senator McCain has taken a polarizing approach to health care reforms, by seeking to eliminate private employers from the provision of health care in America.
Here are the highlights of his reform ideas:
1. McCain would eliminate the tax preference for employer provided health insurance. Instead of a tax deduction for private employers to provide health insurance, he would offer a tax credit to taxpayer households, $2,500 for individuals and $5,000 for a family.
2. Individuals would purchase health insurance plans on the open market(s).
3. A guaranteed access plan would be available to all, even the unhealthy, whom private insurers would seek to exclude from coverage.
4. He is not in favor of a national health care plan.
5. He would encourage support of health savings accounts.
6. McCain seeks to reform Medicare reimbursements by bundling payments to physicians by disease or diagnosis.
7. Like everyone else, he encourages the proliferation of electronic medical records.

Analysis
Though private employers provide less than half of all the health care for USA residents, a disproportionate share of funding for health care services comes from the private sector. This discrepancy is partially due to the significant uninsured population in the country, which accesses health care through hospitals, thus causing those providers to increase their charges for paying customers, to make up for unreimbursed care. Additionally, government programs like Medicaid and to a lesser extent, Medicare, do not fully reimburse health care providers for their costs, which increases the burden of healthcare financing to the private sector health care system. Senator McCain, by removing the economic incentive for employers to provide health care, will encourage employers to cease providing group medical insurance. The spread of risk over large employer and collectively bargained groups at least provides some stability to the private health care system, which would be jeopardized by his individual market based approach.
McCain has stated that insurers have been taking advantage of healthcare consumers and by creating an individual health care purchasing climate, citizens will be better off, through increased competition in the private insurance marketplace. Need I remind him of the Medicare HMO debacle when the government provided incentives to insurance companies to recruit Medicare applicants to their HMO plans? In this scenario, enterprising insurance companies thought they could profit by insuring Medicare customers on the government’s capitated reimbursement formula only to realize they couldn’t manage the risks. All but a handful of insurers subsequently dumped their customers back into the marketplace, forcing retirees with chronic conditions to change providers yet again. Consumers were not better off with the marketplace approach to care; they were disrupted, in some cases jeopardizing their health. The insurers found managing the population was more difficult than they had anticipated. Though McCain’s health care reforms do not address Medicare, one wonders how an individualized health insurance purchasing market would improve care and reduce cost for individuals and families. One of the basic tenants of risk management is adhering to the "law of large numbers", which means we are better off pooling our resources in fewer large groups than splintered smaller ones. McCain’s health care platform does not seem to support the spread of risk over large populations, but rather "cherry picking" by smaller entrepreneurial insurance companies.
In terms of optimizing government purchasing, his plan adds complexity to the current regulatory climate for health insurance, by creating more entry points for health care initiation. One of the problems with efficient health care delivery in the United States is the variance in administration by virtue of 50 different insurance commissioner’s and their policies on health care underwriting, financial reporting, and administrative oversight. This would seem to be exacerbated by increased variables in his healthcare reform proposal. An open market for individual health care purchasing would increase complexity over the current employer driven marketplace, in terms of communication to households as well. If we consider the different educational levels of individuals, not to mention language barriers, how would this be handled efficiently and efficaciously?
Senator McCain’s ideas to change the Medicare reimbursement process by bundling per case have merit, because managing a patient with chronic disease should be done on a macro basis, not per line item for each transaction. Of course, accommodating patient acuity and cost-of-living factors into reimbursements for disease management would be key to fairness. No mention is made of how Senator McCain would align reimbursement with desired outcomes.
Guaranteed Access to Health Insurance is already provided in some states, like Washington, where the risk pool for individuals who can’t get health insurance through individual markets is managed by the state. The problem with this approach is the cost of the health care is prohibitively expensive for many people, yet these individuals are not poor enough to qualify for the state’s Basic Health Plan or Medicaid programs. McCain provides no specifics on how the federal government would address these concerns, other than to say he would work with the individual states.
The healthpolicymaven believes Senator McCain will experience fierce opposition from union representatives, the insurance industry, and many large employers. Once an organized media campaign is financed by these stakeholders, his health plan and maybe his presidential aspirations will go the way of Clinton’s first term national health plan. I am also betting voters won’t want to lose their employer health plans without a much clearer idea of what they will be getting from Mr. McCain and his advisors, one of whom is Carly (the hammer) Fiorina.

Assessing the Real Cost of Health Care in America

2008-02-11T15:56:00.000-08:00

Assessing the Real Cost of Health Care in America
We can’t measure the real cost of any public program, unless we consider the economic factors, such as opportunity cost, which is the cost of spending excessive resources on health care that could otherwise go to something else. In order to do this, lets look at what other industrialized countries have in per capita income and what they are spending for health care. Based on 2006 income data the United States is no longer the wealthiest country per capita. Norway is the wealthiest country with $53,100 dollars of gross national income per person, compared to the USA’s $44,200 per person. Ireland is third with an income of $41,300 per person. What is interesting is both of these countries have national health care plans and higher taxes than in the United States. When you compare spending on health care, citing the Journal of Health Affairs article published in June of 2004, Norway spent $2,920 per person compared to the United States $4,487 per person, and Ireland spent $1,935. Even Switzerland, with its high cost of living and land locked economy, spent considerably less than the United States, at $3,322 per person in that year.

Cost of USA Healthcare Impedes Economic Growth
Health care costs are frequently measured against Gross Domestic Product, which is the sum of what we produce in the United States. As a former farmer’s daughter, I grew up owning the ethos that we are what we produce. Gross domestic product per person is also greater in Norway than in the U.S.A., with $102,400 per person versus $90,700. (Ireland’s GDP is not on the top 13 list, so I have not listed it.) Even when you look at GDP per hour worked, the United States is not in the top three. Here is that breakdown; Norway $72.70/person/hr., Belgium $56.10/person/hr., Netherlands $52.10/person/hr., France $51.30/person/hr. and then the United States with $50.60/person/hr. There are a variety of ways to measure the value of a gross domestic product, such as per person per hour worked or just per person, but either way, the United States is no longer preeminent in GDP. When you couple that with the loss of the dollar in value throughout the world, (the Euro is worth 50% more than the U.S. dollar now), the cost of America’s existing health care system must be examined as an impediment to real economic growth.

USA Spending on Health Care
The argument against a cohesive national health care plan is often based on the presumption that financing national health care would be excessive, but in fact, all of the countries that have national health care programs spend less than the United States. It is time we as a nation look at what we are getting for our health care investment. Lets review the current financing mechanisms for health care in this country, including; federal programs, employer sponsored health care plans, and individually funded health care. Citing the most recent Kaiser Foundation reports for health care spending here is the breakdown for the United States Health Care Budget excluding Medicare:
Medicaid- (05 data)- $4,202 per individual
SCHIP Medicaid (05 data)-$-1,509 per child
Employer Plans (06 survey)-$4,479 per individual
$12,206 per family
Individual Plans (04 data)-$3,331

Determine What We Are Getting
No matter how you look at health costs in the United States, we are spending much more than any other industrialized country. Using this comparison of current health care programs and their costs, the reader should conclude they have a minimum budget of $3,397 per person for health care. As a society we need to determine the best way to finance our health care, which is already paid for by the individual through taxes, direct contributions, and increased costs in goods and services to cover corporate benefit programs. The question on the lips of everyone then becomes "What am I getting, not just what is the cost of the program."

Assessing Hidden Costs
To reveal the true cost of any program you have to do a solid cost/benefit analysis, which takes into account hidden costs like pass-through expenses for inadequate reimbursements to clinicians. An example of a hidden cost is when Medicaid fails to adequately pay hospitals or physicians for services, thereby requiring those providers to recoup higher fees from other patients in order to stay solvent. Other hidden costs include re-insurance for catastrophic claims for private plans, which the government could subsidize through a stop-loss guarantee and save employers about 5% in administrative expenses. Other areas of expense include plan administration and claims payment, which could be streamlined by requiring regional health care organizations to offer uniform benefits, and standardized claims processing. This could generate another savings of 3% to 6%. This combination of changes then creates the budget for allocating health care benefits, such as covering everyone for primary care.

Budgeting National Health Care
I did a quick calculation on how our health care investment, which averages $3,758 per person (excluding Medicare), compares to the average USA wage, and it is 7.68% of the average wage. So, if employers were going to continue to contribute to the cost of national health care, their share would be about half of that, or close to 4% of wages. This could be paid by contributions to a mandated benefit plan or through a payroll tax increase, but I am betting employers would rather contribute to a health plan than pay more taxes. Individuals would pay half of that figure also. For people who are of low income, the federal government would subsidize their cost. In this way we would have the start of an equitable health care financing system, where the budget is transparent, and inclusive of everyone. So, the next time you hear someone talking about health care costs, make sure you consider the whole picture, not just the insurance premium and not just the tax contribution.

This article was written by Roberta Winter, MHA, MPA and may be reprinted with her permission.

Recap on Presidential Candidate Health Care Reform Platforms
Deciphering Health Care Reform Platforms
This is part four in a series on the health care reforms as stated by Clinton, McCain, and Obama. I review wage and tax, as well as Medicaid and private health plan cost data. Briefly here are the summaries of the candidate health care reforms:
Clinton
Would extend health coverage to all residents through a combination of Medicaid/SCHIP expansion, employer mandates, and federal subsidies. Clinton would allow U.S.A. residents to enroll in the Federal Employees Health Benefits Plan if they do not have employer-sponsored coverage.
Who Pays
Clinton would require large employers to offer health insurance to their employees. She would also require residents to have health insurance. Clinton would limit tax cuts for taxpayers with incomes over $250,000 per year and use the revenue generated to pay for the federal subsidies for health care, like Medicaid expansion. She also estimates a reduction in expenses for payments to hospitals for the uninsured, probably through reduction in disproportionate share reimbursements.
McCain
McCain would not extend health coverage to all residents, but he would expand Veterans Benefits.
Who Pays
McCain want to change clinician reimbursements through the creation of a single fee for coordinated patient care, as opposed to the current DRG reimbursement based on billing per item. This reimbursement might benefit primary care providers more and possibly specialists who work with chronic diseases, like diabetes. It may not be to the benefit of all physicians however as some current reimbursements would either be eliminated or reduced. He indicates he would reform the tax code, including the elimination of tax preferences for employer paid health benefits. He would also provide a tax credit for individuals to obtain health insurance. He advocates medical savings accounts and high limit catastrophic insurance coverage with multi-year contracts.
Obama
Obama would require all children to have health insurance or to be covered on the Supplemental Childrens Health Insurance Plan, SCHIP. He would also require employers to offer health insurance coverage or to contribute to the cost of the public health plan alternative. Obama does support mental health parity, which would be a big plus for hospitals, who are the refuge for the mentally ill who can’t obtain other treatment. Obama would offer to federal reinsurance to employers, to protect them from significant medical claims. This provision would be very attractive to employers who are currently struggling with an unstable re-insurance marketplace.
Who Pays
Employers would be required to pay for the cost of health insurance under the Obama plan. Obama would also discontinue tax cuts to those with incomes over $250,000/year. He has not specifically identified revenue recapture under projected savings for health care reforms, but he does talk about gains through efficiencies.

Crib Notes on Health Care Platforms for Clinton, Obama, and McCain

2008-02-05T12:24:00.000-08:00

Leading Presidential Candidates-Clinton, McCain, Obama
Proposals for Health Care Reform
This week’s column analyzes the leading presidential candidates Senators Hillary Clinton, Barak Obama, and John McCain proposals on health care reforms and how their ideas would address these five questions:
1. Access to Care
2. Optimization of Government Purchasing for Medicare and other Programs
3. Reimbursement Alignment for Desired Clinical Outcomes
4. Streamlining the Health Care System Administratively
5. Financing Health Care for all

Access to Care
The three questions that must be addressed in order to answer the access question are:
Do the proposed changes provide health care coverage for all residents, or at least a close approximation of that?
Secondly, do their proposals address adequacy of reimbursements for health care clinicians and facilities?
Thirdly, are there enough clinicians to meet the increased demand for primary care and other services from changes in health care access and if not, what is being proposed by the candidate?
Mandate for Universal Health Coverage
Yes, for Clinton and to a lesser extent, Obama, and no for McCain in mandating health coverage. Clinton would require every resident to have health insurance coverage and require large employers to provide employee health care or contribute to the cost for it. Obama would require employers to offer meaningful coverage or contribute to the cost of the public health plan.
Expand SCHIP, Children’s Insurance under Medicaid
Yes for Clinton and Obama, no for McCain.
Create a National Public Health Plan
Obama would create a National Health Insurance Exchange for small businesses and individuals without access to other public programs, to offer health insurance through private plans or the new public plan. Clinton would offer a similar health choice menu for public or private plan enrollment. McCain would not do either.
Reimbursement Reforms impacting Access
McCain’s position to reimburse Medicare and presumably Medicaid on a single fee for coordinated care, could help increase access to more pediatricians and other primary care providers.
Nursing Pipeline to Assure Adequate Supply
Clinton and Obama propose an increase in federal funding for training more nurses. Obama also proposes improvements in reimbursements, training grants, and loans for health care professionals.

Optimization of Government Health Care Programs
McCain’s List for improving existing government programs
1. Adopt malpractice reforms
2. Strengthen health care anti-trust laws
3. Improve transparency in pharmacy pricing
4. Change health insurance marketing from state to national oversight
5. Support public health initiatives for chronic disease prevention, health education, and reductions in obesity, diabetes, and smoking.
Clinton’s list for improving existing government programs
1. Permit the federal government to negotiate RX prices for Medicare directly with drug manufacturers
2. Change patent laws to increase the availability of generic drugs
3. Limit pharmaceutical advertising to consumers
4. Encourage disclosure of medical errors with liability protection for physicians
5. Support more federal funding for reducing health disparities and developing quality measures
6. Strengthen consumer protections for long-term care
Obama’s list for improving existing government programs includes
1. Promotion of generic drug programs
2. Allowing importation of drugs from other countries
3. Direct negotiations with drug companies for the Medicare program
4. Reform malpractice
5. Strengthen anti-trust laws in health care
6. Creation of an independent institution for review of medical errors, to establish quality standards, and create measures.

Reimbursement; Paying for Desired Clinical Outcomes
McCain’s List
1. Change clinician reimbursements to a single coordinated payment for care, rather than fee for service
2. Bar payment for preventable medical errors or mismanagement by health care providers
3. Provide Medicare payments for patient care coordination and prevention
Clinton’s List
1. Provide federal recognition for physician driven certification for best practices and incentivize quality through an increase in federal reimbursements for Medicare
2. Would not pay for preventable infections and other medical errors
3. Reduce reimbursements on the Medicare Advantage Plan to the equivalent of Medicare, which is considered inadequate compensation by many physician groups
Obama’s List
1. Reduce Medicare Advantage Plan reimbursement to the same level as Medicare, which could impare access to primary care.
2. Creation of a new public health plan, similar to the federal employee’s health plan, which could be expensive.
3. Obama does not specify how he would reward clinicians for chronic disease management or other health care goals.

Streamlining Health Care Administratively
McCain’s List
1. Creation of a uniform electronic medical records standard
2. Advocates national standards for insurance regulation, not state
3. Encourage alternate forms of access and licensing for providers
4. Establish national standards for measuring health outcomes
Clinton’s List
1. Require all private insurance carriers to offer coverage on a guaranteed issue and renewable basis, creating one national standard
2. Move to establish community rates, rather than variations based on health and other factors
3. Require private insurers to meet minimum loss ratios, which means a high value of every dollar collected would have to go for consumer benefits
4. Require coverage for preventive care
5. Encourage regional purchasing cooperatives, where states can band together for optimal purchasing and stabilization of health care financing
6. Establish national standards for prevention of health disparities, technology for electronic medical records, chronic care management, best practices, and medical error disclosure
Obama’s List
1. Create a National Health Insurance Exchange for residents to obtain coverage through private or public health plans.
2. Require health insurance coverage to be guaranteed issue and that the plans meet standards for benefits and quality.
3. Maintain existing state health care reforms if they meet the minimum standards for the national health plan.
4. Creation of an independent quality institute for health care, to analyze data, and promote ways to minimize health chronic disease
5. Promote new models for addressing physician errors along with reforming malpractice laws

Financing New Health Care Ideas
One of the key components of any health care reform is the financing. Presently health care is provided through the FICA Medicare tax, which is matched by employee and employer, state taxes for Medicaid, general funds from the U.S. government, employer contributions, and individual contributions. In a later issue, I will review how all of these stack up, but for now, here is a summary of the top three candidate’s ideas for financing health care reforms.
Senator McCain
1. Finance health care expansions by reforming the tax code, including eliminating tax preferences for employer paid health benefits
2.Allowing individuals to purchase multi-year health care contracts through Health Services Accounts (medical savings accounts)
3. Advocates a tax credit for individuals and incentives to obtain insurance coverage
4. Contain costs through changes in provider reimbursements, tort reform, and quality improvements
5. Senator McCain did not have a budget posted for his reforms as of January.
Senator Clinton
1. Require individuals who earn more to pay more for a national health care program
2. Tax subsidy to help families obtain health insurance
3. Would not phase out employer provided health plans, but would require large employers to provide health care
4. Senator Clinton estimates her reform package would cost a 110 billion a year after it is fully implemented, but has identified 21 billion saved by the reduction of uninsured and existing Medicaid payments to hospitals. She has identified another 54 billion in revenue recapture by limiting the employer paid health insurance tax exclusion and limiting the tax cuts for individuals with incomes over 250,000.
Senator Obama
1. Expand federal programs and create the National Health Insurance Exchange
2. If employers do not offer health care to employers, they would be required to contribute to the cost of the federal option for their employees
3. Obama’s annual estimate for the cost of his health plan reforms is 65 billion, which is half of Clinton’s. This seems grossly unrealistic when you consider that just covering the 46 million people who are uninsured, at the cost of the average private employer plan of $4,479 per year would equal 206 billion.

In conclusion, of the three candidates, Hillary Clinton has been the most explicit and realistic in terms of what her health care proposal would cost, initially, and ultimately.
Since the financing of health care reforms is very complicated, the next posting at http://healthpolicymaven.blogspot.com will review various budgets for the proposals. All reference material for candidate positions was gleaned from the Kaiser Family Foundation web site at: http://www.health08.org/D-Side-By-Side_01_31_08.pdf

Top Three Presidential Candidates Health Care Reform Proposals

2008-02-03T16:15:00.000-08:00

Leading Presidential Candidates-Clinton, McCain, Obama Proposals for Health Care Reform
Two weeks ago I wrote an article about the five fundamental questions that need to be asked in order to design optimum health care reforms in the United States. This week’s column analyzes the leading presidential candidates Senators Hillary Clinton, Barak Obama, and John McCain proposals on health care reforms and how their ideas would address these five concerns:
Access to Care
Optimization of Government Purchasing for Medicare and other Programs
Reimbursement Alignment for Desired Clinical Outcomes
Streamlining the Health Care System Administratively
Financing Health Care for all

Access to Care
The three questions that must be addressed in order to answer the access question are:
Do the proposed changes provide health care coverage for all residents, or at least a close approximation of that?
Secondly, do their proposals address adequacy of reimbursements for health care clinicians and facilities?
Thirdly, are there enough clinicians to meet the increased demand for primary care and other services from changes in health care access and if not, what is being proposed by the candidate?
Of the three presidential candidates, Clinton, Obama, and McCain, only one opposes a mandate for health coverage and that is Republican McCain. Of the two leading Democratic candidates, Clinton would require every resident to have health insurance coverage and require large employers to provide employee health care or contribute to the cost for it. Obama would require all children to have health insurance and require employers to offer "meaningful" coverage or contribute to the cost of a public health plan. There would be limited change in access to health care with McCain’s stance, while Obama and Clinton would increase the number of people who could afford to access health care via insurance due to mandates and subsidies. In terms of expanding existing public programs, Clinton and Obama would expand Medicaid and SCHIP, the supplemental children’s insurance program, whereas McCain would only expand Veteran’s benefits. Obama would create a National Health Insurance Exchange for small businesses and individuals without access to other public programs, to offer health insurance through private plans or the new public plan. Clinton would offer a similar health choice menu for public or private plan enrollment.
McCain’s position to reimburse Medicare and presumably Medicaid on a single fee for coordinated care, could help increase access to more pediatricians and other primary care providers. If private insurance would become more available to a portion of the uninsured, this would allow these individuals to obtain care more readily than through Medicaid.
In terms of investing in health care infrastructure to increase the supply of nursing and other health care professionals, McCain does not address this, but Clinton and Obama propose an increase in federal funding for training more nurses. Obama also proposes improvements in reimbursements, training grants, and loans for health care professionals.

Optimization of Government Health Care Programs
To create more value from currently funded government programs, McCain would encourage risk-adjusted payments for Medicaid, coupled with private insurance. He also alludes to alternative forms of access and different licensing for providers. For cost containment he would adopt malpractice reforms, health care anti-trust laws, transparency in pharmacy pricing, and change regulation from state to national for health insurance marketing purposes. McCain would also support public health initiatives for chronic disease prevention, health education, and reductions in obesity, diabetes, and smoking.
Clinton’s platform permits the federal government to negotiate RX prices for Medicare directly with manufacturers, change patent laws to increase the availability of generic drugs, and limit pharmaceutical advertising to consumers. She would also encourage disclosure of medical errors with liability protection for physicians. Clinton would also support more federal funding for reducing health disparities, developing quality measures, and strengthening consumer protections for long-term care.
Obama’s ideas for optimizing government programs include promotion of generic drug programs, allowing importation of drugs from other countries, and direct negotiations with drug companies for the Medicare program. He would also reform malpractice and strengthen anti-trust laws in health care. Like Clinton, he supports the creation of an independent institution for review of medical errors, to establish quality standards, and create measures.

Reimbursement; Paying for Desired Clinical Outcomes
McCain would change clinician reimbursements to a single coordinated payment for care, rather than fee for service. He would also bar payment for preventable medical errors or mismanagement by health care providers. He would also provide Medicare payments for patient care coordination and prevention.
Clinton would provide federal recognition for physician driven certification for best practices and incentivize quality through an increase in federal reimbursements for Medicare. Like McCain, she would not pay for preventable infections and other medical errors. She also wants to reduce reimbursements on the Medicare Advantage Plan to the equivalent of Medicare, which is considered inadequate compensation by many physician groups.
Obama would reduce Medicare Advantage Plan reimbursement to the same level as Medicare, which could impare access to primary care. He also advocates creation of a new public health plan, similar to the federal employees health plan, which could be expensive. (Clinton talks about using the federal employees’ plan as a model too.) Obama does not specify how he would reward clinicians for chronic disease management or other health care goals. Obama has concentrated on the consumer and insurer aspects of health care, but does not seem to have spent much time reviewing clinician impacts.

Streamlining Health Care Administratively
All three candidates support deployment of a national medical records standard, but McCain does not specifically allocate federal funds in his platform. McCain advocates national standards for insurance regulation, not state, which would allow more competition from vendors. This would also allow national standards and certification for health insurance offerings. He would encourage alternate forms of access and licensing for providers and establish national standards for measuring health outcomes.
Clinton would require all private insurance carriers to offer coverage on a guaranteed issue and renewable basis, creating one national standard. She would also move to establish community rates, rather than variations based on health and other factors. Clinton would require private insurers to meet minimum loss ratios, which means a high value of every dollar collected would have to go for consumer benefits. She would also require coverage for preventive care. She would encourage regional purchasing cooperatives, where states can band together for optimal purchasing and stabilization of health care financing. Clinton would establish national standards for prevention of health disparities, technology for electronic medical records, chronic care management, best practices, and medical error disclosure.
Obama would create a National Health Insurance Exchange for residents to obtain coverage through private or public health plans. This is a first step in creating a national platform to educate consumers on health care options, setting one standard instead of fifty. Like Clinton, he would also require coverage to be guaranteed issue and that the plans meet standards for benefits and quality. The exchange would conduct the evaluations and communicate the values. He would maintain existing state health care reforms if they meet the minimum standards for the national health plan. He would support the creation of an independent quality institute for health care, to analyze data, and promote ways to minimize health chronic disease. Obama would also promote new models for addressing physician errors along with reforming malpractice laws.

Financing New Health Care Ideas
One of the key components of any health care reform is the financing. Presently health care is provided through the FICA Medicare tax, which is 1.651% of wages, matched by employee and employer, state taxes for Medicaid, general funds from the U.S. government, employer contributions which are heavily subsidized by tax deductions, and individual contributions. In a later issue, the healthpolicymaven will review how all of these stack up, but for now, here is a summary of the top three candidate’s ideas for financing health care reforms.
Senator McCain would finance health care expansions by reforming the tax code, including eliminating tax preferences for employer paid health benefits and allowing individuals to purchase multi-year health care contracts through Health Services Accounts (medical savings accounts). He also advocates a tax credit for individuals and incentives to obtain insurance coverage. He would contain costs through changes in provider reimbursements, tort reform, and quality improvements. Senator McCain did not have a budget posted for his reforms as of January.
Senator Clinton would require individuals who earn more to pay more for a national health care program. She would provide a tax subsidy to help families obtain health insurance. She would not phase out employer provided health plans, but would require large employers to provide health care. Senator Clinton estimates her reform package would cost a 110 billion a year after it is fully implemented, but has identified 21 billion saved by the reduction of uninsured and existing Medicaid payments to hospitals. She has identified another 54 billion in revenue recapture by limiting the employer paid health insurance tax exclusion and limiting the tax cuts for individuals with incomes over 250,000.
Senator Obama would expand federal programs and create the National Health Insurance Exchange. If employers do not offer health care to employers, they would be required to contribute to the cost of the federal option for their employees. Obama’s annual estimate for the cost of his health plan reforms is 65 billion, which is half of Clinton’s. This seems grossly unrealistic when you consider that just covering the 46 million people who are uninsured, at the cost of the average private employer plan of $4,479 per year would equal 206 billion. How is he going to cover the 46 to 50 million uninsured without a significant budget increase?

In conclusion, of the three candidates, Hillary Clinton has been the most explicit and realistic in terms of what her health care proposal would cost, initially, and ultimately.
Since the financing of health care reforms is very complicated, the next posting at http://healthpolicymaven.blogspot.com will review various budgets for the proposals. All reference material for candidate positions was gleaned from the Kaiser Family Foundation web site at: http://www.health08.org/D-Side-By-Side_01_31_08.pdf

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

How to Obtain Health Care Without Insurance

2008-01-29T15:19:00.000-08:00

For the 50 million people without insurance in the United States, this blog is for you. How do you obtain health care if you have no insurance? There are four basic methods for accessing care sans health insurance financing and they are; pay with cash or credit per clinical visit, frequent public health centers in urban areas, access community health centers in rural and metropolitan areas, and use the old standby, hospital emergency departments. The average person who is without insurance may feel there are no options other than paying out of pocket for treatment and worse yet, frequenting the emergency room for care. The lack of health insurance does limit the number of clinicians who will serve the patient, but there are two institutional remedies in America, the public health system and federally qualified health clinics. Both of these organizations are designed to provide primary health care on an as-needed basis for under-served populations, including the uninsured.

CHC-Community Health Center
Community Health Centers were authorized in 1975 to promote health care for medically under-served populations. There are 3,709 federally qualified health care centers in the United States and 89 are in Washington State. One of the most famous federally qualified health centers is the Pike Market Clinic. Other well-known FQHCs in the Puget Sound area are Puget Sound Neighborhood Health Centers and SeaMar Clinics. These clinics must periodically reapply for federal funding to support the health care they provide to rural and poor urban communities. The centers also have to conform to certain governance standards, including community representation on the board, and auditing for government grant compliance. Not all "community health centers" are federally qualified health centers. The federal agency Health Resources Services Administration (HRSA) rate community health centers number one for outcome driven results, which means good value for their patients. The Bush Administration has continued to support CHC’s and increased relative funding for them. Patients must have a primary care provider in a community health clinic in order to have continuity of care. Patients will be expected to contribute to the cost of their care based on their level of household income. Also, the community clinic typically has an on-site pharmacy, so the patient can get his or her prescription filled there as well. All Community Health Clinics with pharmacies offer discounted pharmaceutical pricing, because of a federal provision called 340B Drug Pricing.

PHD-Public Health Department
Public Health Departments are most robust in larger cities, like Seattle, WA or Portland, OR but smaller communities, like Bremerton, WA have public health programs as well. In smaller communities the health department may be more involved in disease surveillance and health inspection of public facilities. However, even in smaller cities the health department is involved in emergency planning, executing public health directives like childhood immunizations, and disease investigation( like E Coli). In urban areas residents can go to the public health clinic for primary care, just like they would go to their family doctor, but payment for services is based on a sliding fee scale according to the patient’s income. Lab work is often done on the premises to save money for the health department. Both community health clinics and health departments also accept insurance for reimbursement. You might wonder why someone would choose to go to a public health department if they have insurance and the answer is convenience and also continuity. For example, if a patient has immunization records at the health department, it may be easier to continue to maintain those in one location.

DSH-Disproportionate Share Hospital
The urban poor do frequent the emergency departments of urban hospitals in droves, which is costly for the community and the facility. Consequently the federal government created a program called disproportionate share funding for hospitals that are designated as serving this population. This is a federal subsidy for hospitals so they can continue to provide care for patients who can’t pay and have no where else to go. There are 1,291 disproportionate share hospitals in the United States and 12 of those are deemed critical access hospitals in Washington State, according to the Health and Human Services administrative agency HRSA. The DSH facility in Seattle is Harborview Medical Center.

340B-Discounted Prescription Drug Program
Qualifying health care facilities are eligible for 340B drug discounts based on the 1992 Veterans Health Care Act. So, you can go to a community health clinic or the public health department or in a true emergency situation, the DSH hospital, for treatment. To obtain discounted prescription drug costs go to a community health clinic with its own pharmacy or to a DSH hospital. You do not have to be admitted to the hospital to have your script filled in the hospital pharmacy. Your script should be 25% to 40% less expensive at these facilities, than at your local pharmacy.

Take Charge of Your Health
The next time you need health care and are without insurance, consider the community clinic and public health alternatives to the emergency department of a hospital. The hospital ED is expensive, will require a lengthy wait (several hours), and misplaces resources for primary care, which are geared to urgent care. According to the Washington State Hospital Association hospitals in the state incurred 217 million dollars in costs for charity care in 2005. Remember there are health care alternatives to the emergency department, right in your neighborhood, accessible to all, and reimbursement is based on your income. Be smart about your health, its better for everybody.

This article was written by Roberta E. Winter, MHA, MPA and may be reprinted with her permission.

Five Things you need to ask yourself about Health Care Reforms

2008-01-19T18:24:00.000-08:00

Since 2008 is an election year, there will be much attention on domestic issues and the elephant in the room is health care reform. This healthpolicymaven blog reviews five fundamental questions and their importance in creating a more effective health care system for Americans.
Does everyone have access to some type of primary care?
Is the United States government optimizing its purchasing power for public programs?
Are provider reimbursements in line with health care goals?
Is there a mechanism for eliminating unnecessary and costly redundancies in a fragmented delivery system?
Is the financing of health care for the country adequate and equitable?

Access to Care
First of all, access to care is not the same as access to health insurance. Health insurance is one of the financing mechanisms for health care, it does not provide care. Secondly, access means adequacy of supply in relation to the demand for services, especially primary care services. Presently there are significant shortages of nurses, obstetricians, pediatricians, and mental health professionals for the juvenile population in the United States. Increasing the demand for health care services without provisions for stemming shortages in providers will only exacerbate the lack of access.
The United States could improve access for its residents by increasing funding to universities, enabling more professionals to be developed in areas of shortages. Since universities are publicly funded, it is incumbent on the state legislatures to have the political will to act. Do we have to wait until facilities close before we address the supply issue? Another critical element for access is alignment of reimbursements with social needs, such as pediatrics. Presently medical schools throughout the United States encourage doctors to pursue specialties because of the high cost of a medical education and the ability to earn more money. As a society this disparity can be addressed in two ways, by reducing tuition costs for professionals going into areas of need, and by increasing Medicare and Medicaid reimbursements for targeted services.

Optimizing Government Purchasing
The largest single provider for health care in the United States is the government, through its Medicare, Medicaid, Veterans Administration, and Community Health programs. As such, the federal government has the greatest influence on reimbursements for providers and ultimately, what the health care consumer pays for services. Changes in Medicare drive changes in private health care plans as well. One of the areas where the government failed to utilize its mass purchasing power was in the Medicare Prescription drug program, which was enacted in 2006. Medicare subscribers now have a limited prescription drug benefit, but at market prices. This is a failure of a monopoly to exert its purchasing power, which has cost the taxpayers millions. Is it unreasonable to expect the prescription drug industry to offer a group discount to its largest customer base? This practice is deployed in private industry all of the time. When I worked for a large hospital network, one of the performance improvement efforts was to optimize bulk purchasing for pharmaceuticals. The Bush Administration failed to negotiate effectively with the pharmacy industry. For consideration of a proposed deep discount for Medicare pharmaceuticals, the government could offer streamlined administration for the pharmacy industry as an enticement to lower prices.

Reimbursement Alignment with Desired Outcomes
One of the problems with health care access is the primary payer for health care, the government, does not reinforce primary care delivery with adequate financial reimbursements. Until this changes we will not see a major increase in supply of pediatricians, obstetricians, and other primary care providers. The entire Medicare reimbursement system is based on paying for transactions, like surgical procedures, and not for wellness driven processes. It is not fair to expect physicians and other providers to offer health services for free or at a financial loss. There is no other sector of the economy that is expected to offer services for free or in a nonviable manner. This problem drives family practitioners out of business. Ideas for improving the reimbursement methods include paying a stipend for continuity of care over a period of years, not just per visit. Also, recognize best practices and incorporate that into the rewarded financial allocations. Medicare is experimenting with recognizing diabetic care and other chronic disease management programs differently, and this is a step in the right direction.

Streamlining the Healthcare System
The United States has 50 different health care systems, because each state has its own insurance and Medicare practices. This creates unnecessary burdens on benefit administrators in the private and public sectors. One way to streamline health care is to establish common templates for claims processes, as has been done by the Health Care Forum in Washington State, a consortium of healthcare providers who work towards process improvements. Another method is to encourage adoption of electronic processes, which all major health care entities are already doing. The question is, how many different standards do we need? For private sector suppliers of electronic medical records and claims administration, differentiation in services is essential to their success, but this is not in the best interest of the consumer, as it adds to the ultimate cost for plan administration. It would be more effective to create regional purchasing pools for health care, where the electronic platform, claims process, and deployment will be standardized. Standardization saves time, reduces errors, and is a common element of effective business practices. An example of a regional purchasing pool would be the Pacific Northwest WAMI Region, which includes Washington, Alaska, Montana, and Idaho, but could also include Oregon.
All health purchasing cooperative gains would be cycled through to residents of each state participating in a health care purchasing cooperative. Financial success through regional purchasing pools would include the following elements:
Saving money in administration expenditures
Reduced volatility in health insurance premiums
Reductions in expenses from mass purchasing
Other criteria for success would include simplified claims processing, because we do not need 50 different claims adjudication systems. Private payers, like insurance companies and third party administrators could have an opportunity to administer these regional contracts, through a competitive bid process. Ultimately, reducing differentiation will optimize administrative simplification and administrative efficiency.
Due to brevity, this article does not address the need to review the unnecessary deployment of technology, for example, the excessive use of Magnetic Resonance Imaging and unnecessary procedures. These services respond to a complex system that recognizes procedures for higher reimbursements, avoidance of malpractice claims in our tortuous society, consumer demands, and a highly incentivized medical supply sector.

Financing Healthcare
Presently the United States has a fragmented method of financing health care services to its residents, including; government programs, private insurance plans ($12,106 is the average premium for a family according to the nonprofit Kaiser Family Foundation), individual contributions, and unpaid services. Services that are paid with payroll taxes include Medicare and state workers compensation taxes. Other government programs, like Medicaid are funded through state general funds, federal allowances, and sin taxes from alcohol and cigarette consumption. Ways to finance a national health care mandate to cover all residents include: increasing the FICA/FUTA payroll tax, creating a new tax, like a Canadian Value Added Tax, or using an income tax method.
According to the Kaiser Foundation 2007 Primer on Health Care Costs, premiums for private sector health care grew 87% between 2000 and 2006, which is four times the rate of wage growth. Every person covered on a private health insurance plan is paying for services that are not reimbursed to hospitals and other providers, due to gaps in Medicaid reimbursement and the uninsured. The current method of paying for health care in America is not sustainable. The question that should be asked isn’t how much more will a national health care mandate cost, but how will we deploy our resources? We are already spending the money, just not effectively or fairly. How much longer are Americans willing to spend 25% more for health care than any other country, with 12% of the national population lacking basic access to health care, and millions of people without primary care? The present health care delivery system uses resources from both the private and public sector disproportionately to the benefits for most participants. It is time for a change in health care delivery, but lets look at making sound systemic changes, not just add-ons to a poorly designed system.

This article was written by Roberta E. Winter, MHA, MPA

Former Governor's Death With Dignity Initiative

2008-01-11T20:16:00.000-08:00

Booth Gardner, former Washington State Governor is campaigning to have physician-assisted suicide legalized in Washington State. Since the New York Times published an article on his initiative the same week the healthpolicymaven posted an article about palliative care and medical directives, a closer look at the ramifications of the proposed legislation follows.

Gardner is traveling throughout the state soliciting support for an Oregon style assisted suicide law, which would allow physicians to provide patients with suicide medication dosing under very specific circumstances. A similar measure was put before Washington voters in 1991 and defeated by 54% of the voters. Though suicide is legal in Washington, physician aided death is not.

Here are the provisions for the proposed Death with Dignity referendum if it copies Oregon State Law:
-Permits legally competent patients who are at least eighteen years of age, state residents, and who suffer from a terminal disease, to obtain lethal prescriptions
-The patient must make two requests to end to their suffering, with at least a fifteen day separation between the pleas
-Patient must obtain two separate opinions from physicians indicating the patient has less than six months to live
-Would allow Physicians to prescribe a lethal dose of medications to patients, but not administer the drugs
-The state would track the number of assisted suicides, just as it tracks other causes of death

Prevalence
Oregon’s Death with Dignity Law was passed with a 51% majority in 1994, and enacted in 1997 after overcoming legal challenges. Oregon has reported just 292 assisted suicides over the last ten years. Though 455 people in that time frame obtained prescriptions for lethal medications, only 64% acted on the desire to end their life. When you compare the number of Oregonians who died a natural death from similar causes, less than one tenth of one percent of the residents opted for assisted suicide.

Difference between terminal sedation and euthanasia
It is important to differentiate terminal sedation from euthanasia and both practices were analyzed in a Netherlands study in 2006. In the Netherlands study, clinical practices were reviewed for 410 physicians and their patients who were primarily diagnosed with cancer. The report showed that patients who requested euthanasia were typically more concerned about loss of dignity and were less anxious (15%) than patients requesting sedation (37%). Physicians reported that terminal sedation had shortened participant’s lives by one week in 27% of the cases, whereas 73% of the euthanasia cases were shortened by a week.

Vulnerability
Opponents of suicide frequently express concerns that the uninsured and vulnerable will be taken advantage of with a formalized right to assisted suicide. First, lets hope the United States decides to provide health care for all of its residents in the near future. Secondly, since such a small portion of the population who are eligible for assisted suicide in Oregon and elsewhere, actually make this election, there is minimal financial incentive for a health care system to hasten the death process. Using the Netherlands example of a life reduced by one week, we could apply the Medicare reimbursement to the number of patients who would make that choice. This scenario would depend on whether or not the patient was in an acute care or long-term care facility and the location of the facility. Lets assume all of the patients were Medicare eligible and use the Oregon average of 38 assisted suicides per year to calculate the potential reduction in Medicare charges. According to the Washington State Hospital Association, the average Washington State hospital payment under Medicare was $4,603 in 2005, with an average length of stay of 4.37 days. Based on the Netherlands study we could assume Washington might save $1,053 per day or $7,373 per patient, by avoiding a week of inpatient care for end-of-life treatment. In this example, the maximum savings to Medicare would be $280,183 for this population over an entire year.

Who else does it
Other countries have legalized assisted suicide protocols, foremost of which is Netherlands, who report 2,000 assisted suicides per year. Netherlands is the only country that also permits legal euthanasia. In 2002, the Council of Europe conducted a comprehensive survey on assisted suicide provisions, which found eight countries that responded they did not outlaw the practice of assisted suicides. However, only four countries had legal and transparent provisions for assistance with suicide: Netherlands, Switzerland, Belgium, and Oregon State in the U.S.A.

Certainly some practitioners in the medical profession may raise concerns about violation of the Hippocratic oath for assisting patients with suicide. However, in a 1998 survey of oncologists, the Journal of the American Medical Association reported 16% indicated they had anonymously assisted in patient suicides. So, it would seem the practice of helping patients end their suffering is not new, just lacking in formality for Washington and other states. Gardner needs to have 225,000 signatures by July to get this initiative on the ballot in November.

The Cost to Die; An Insiders View on Terminally ill Patients and Advanced Directives

2008-01-03T16:09:00.000-08:00

February 2, 2008, is the one-year anniversary of my brother’s death, due to the collapse of his pulmonary function following complications from a kidney transplant. Because he couldn’t breathe on his own, following a failed final course of treatment for the pneumonia, the decision was made to remove his breathing tube. It took approximately three weeks from the time of his initial plea until he was at peace. Though Russell entered the Hospital with a Do Not Recessitate (DNR) and had instructions on what he would agree to for treatment, the process of allowing a patient to die on his own terms is not a simple one. My sister, an experienced hospice nurse, held his medical power of attorney. Once the family had gathered we discussed his wishes and everyone was in agreement. A meeting with a member of the ethics committee of the hospital was required, followed by explicit instructions for the transplant unit. With each shift change we needed to make sure the directives for no additional interventions were respected. The failure of a transplant patient is hard on everyone in the unit as the intensity of the care creates bonds between the patient and the staff. When the day came to allow my brother to pass, we surrounded the hospital bed, the anesthesiologist administered some morphine, and he breathed shallowly until he went from white to gray in the space of a few minutes.

Though we were all grateful that he was allowed to ease his suffering and die with dignity, the complexity of the process confounds those who must navigate the health care system. Even though we had several family members present with significant health care expertise, an entire family in agreement with the protocol, written Advanced Directives upon admission, and an informed patient, it was still mentally and organizationally difficult taking the final step. I note there was one family in the transplant unit, whose elderly father had been on life support one month prior to my brother and was still there when we left. The lesson is; though your paper work may be in order, you will still need to navigate each exchange in the care continuum with people who are trained to cure. Sometimes death is the only way to alleviate the suffering of a love one.

According to the Agency for Health Care Research and Quality, 36% of the health care expenditures in the United States are for Medicare patients, who comprised 13% of the population in 2002 and are expected to grow to 30% by 2030. Increasingly these patients are left to die in hospitals because there are no family members, absent family, or lack of facilities for patients requiring end stage of life care. We have plenty of conversations about quality of life in health care but what about a good death? Is being hooked up to machines, wasting away immobile, and suffering from bed sores a life of quality?

Alternatives to hospital deaths for the terminally ill include in-home hospice care, long term care facilities with hospice programs, private duty nursing, and of course, family member care. According to the Kaiser Family Foundation’s June 2007 report on Medicare Spending, 30% of all expenses paid in 2004 were for long term care facilities. The average cost per beneficiary was $12,763. Average spending in the last year of life was $22,107 for Medicare recipients. Only 2% of Medicare reimbursements went for hospice care, 4% for home health care and 5% for skilled nursing facilities in 2006. This means the balance of 19% of the long-term care expenditures went to pay for hospital services for patients with long-term stays. Given the growth in our Medicare population and the ability for hospitals to keep patients alive longer with increasingly invasive procedures, as a society we need to review the equity of this spending pattern and the efficaciousness for patient care.

One of the alternatives to inpatient acute care for the terminally ill is in-home palliative care. In July of 2007, the Journal of American Geriatrics published the results of a study assessing patient satisfaction for in-home palliative care versus inpatient care. The randomized trial was sited within two different HMO organizations located in two states, for patients who were diagnosed with a year or less to live. The study showed an increase in patient care satisfaction and a reduction in the use of medical services and corresponding cost of care for end stage treatments. Perhaps more importantly, the patients who received in-home care were less likely to visit the emergency department or be admitted to the hospital, than patients treated through typical acute care modalities.

One of the challenges in determining health care policy is to assign values to patient health and intervention outcomes. A Canadian study, published in December of 2006 reviewed valuation methods for assessing human life outcomes. The Canadian study suggested setting a common threshold of cost effectiveness that could be applied to all health care interventions. Since health care resources are limited, based on the ability to pay, either through taxes, premiums, or direct reimbursement, examination of the value achieved for a publicly funded health care program seems reasonable. Medicare data indicates that more than 16% of all health care expenditures is spent in the last month of life. Methods currently used in the United Kingdom and Canada include weighing year of life gained to the cost of the services. The legal community has become adept at valuing human lives for tort actions, so certainly the health care community can work towards a reasonable method for measuring value versus the cost of the intervention.

In March of 2007, Congressman Towns introduced a bill, Physician Assistants Continuity of Care Act, to allow Physician Assistants to order post hospital care, home health services, and hospice care under the Medicare program. The impetus for this action was a perceived delay in appropriate patient care because PA’s were not allowed to recommend these services. Not only would this provision provide continuity of care for the patient, but it would also save Medicare unnecessary expenses. The bill was voted down in March.

Barriers remaining to improve palliative care in hospital settings include quality of life and a dignified death. There are hospital based palliative care programs with specific programs for end-of-life treatments and demonstrated cost savings, as cited in the Evidence Base for Developing a Palliative Care Service article published in the Medsurg Nursing Journal in June 2007. These include the development of a multi-disciplinary support team for terminally ill patients, separate hospice wings for acutely ill and terminal patients, alignment of patient care with the patient’s wishes, and a hospital consulting service for the administration of palliative care off-site. The following criteria were listed as success factors of palliative care programs:

Early discussions on end-of-life procedures/processes
Patient outcomes include less time spent in intensive care units
Avoidance of unnecessary tests and procedures
Better pain management through measures linked to patient satisfaction surveys and medical record integration
Reduction in the length of stay
Reduction in hospital charges
Reduction in hospital readmission

In conclusion, since we have a huge population ready to become Medicare eligible and there are proven methods for addressing end-of-life care besides acute hospital settings, isn’t it about time the United States develops some standards for delivering appropriate palliative care to terminally ill patients?

Holiday Health Care

2007-12-23T08:02:00.000-08:00

National health care, that is what Americans need,
NO! vested interests said, rationing will come,
We won’t be able to get the extra labs we love,
Planned delivery in our health system indeed.

Better to have legions showing up at the ER
Without insurance or basic primary care,
How much longer must the poor and vulnerable wait,
Until Medicaid funding is no longer there?

Health care is a business claimed the suppliers,
What would we do if we lose some of our buyers?
Better risk management of course, that’s what we need,
Excluding high-risk cases said company greed,

Drug distributors are worried about their pipeline,
New dependencies to create for the consumer,
Sure to fuss over medication change rumors,
Reduced supply increase the consumer whine,

Everything available to everyone does not work,
When we ought to give the right treatments without shirk.
Pass through taxes from under funding payers,
Paying much higher premiums for unfunded care,

Let’s continue to spend twenty-five percent more
For health than any other country without fail,
How much longer can this health system sustain?
Talk of health care system change makes everyone sore,

American care is already bursting at the seams,
Diabetes, mental health, and other diseases
Often unmanaged, left to patient devices,
Emergency care only for greatest extremes,

Consequences to the consumer community,
Poorer health outcomes and higher long term costs,
How apropos for the land of great excesses,
Making sense of spending and health disparity,

Health care subject to economic utility,
Little help without access to a facility.

We can get more value for our health care dollar,
But more of you are going to have to holler,
To our legislators to bring relief in sight.
Wishing Health care for all and to all a good night!

This verse was written by Roberta Winter, MHA, MPA
December 22, 2007

SCHIP veto, Rossi Response

2007-12-12T07:37:00.000-08:00

Last month our illustrious president, George Bush voted not to provide health care for 900,00 low income children by vetoing the expansion of the Supplemental Childrens Health Insurance Plan, known as SCHIP. According to the nonpartisan nonprofit Kaiser Family Foundation, in 2005 there were 46.1 million people under the age of 65, without insurance in the United States. Of that group, only 25% are eligible for state Medicaid programs, including the SCHIP. Fifty six percent of the uninsured are not eligible for public health care programs but need financial assistance to purchase health insurance or health care. This means that if you are a family of four and earn more than $20,650, you are over the Federal Poverty Level. The SCHIP guidelines allows families earning no more than 200% of the FPL rate or $41,299, to apply for Medicaid coverage for their children. The proposed federal expansion for SCHIP would have allowed families with incomes up to 300% of the federal poverty level (about $61,950) to apply for Medicaid coverage for their children. The presidential veto of this legislation caused a schism among Republican legislators and considerable ire with Democratic representatives as well. The fallout of this decision was felt throughout the country, including Washington State where Dino Rossi, the loser in the last gubernatorial election and who is running for governor again commented on the President’s decision.
According to CounterIntelligence journalist, John Feit, gubernatorial candidate Rossi had this to say, "The majority of the children that are going to be coming on (to SCHIP expansion) are either illegal or currently have health insurance from the private sector." This article addresses the inaccuracies of Mr. Rossi’s statement, though one has to wonder about Rossi’s Catholicism and whether or not he is adhering to Catholic principles when he views children of immigrants who are living in this country as less valued than children who were born in America.
Here are the facts Mr. Rossi:
Your assertion that uninsured children have access to insurance coverage through private employers is wrong. The Kaiser Commission on Medicaid and the Uninsured reviewed this very question in 2007 and here is what they found:
Fact-The majority of the uninsured (56% according to the 2007 findings) are not eligible for public programs for health care and have incomes below 300% of the Federal Poverty Level. Of the six million children who live in poverty (200% of FPL), seventy percent live with families with parents who work, largely for small employers. Small employers do not offer health insurance to their employees at the same frequency as larger employers and fewer employers are offering coverage to their employees. The Kaiser Survey of Employer Sponsored Health Benefits for 2007 shows a precipitous decline in the proportion of small employers offering health insurance to their employees. For firms with fewer than ten employees, only 45% offer health insurance now, down from 56% in 1999. For all firms with less than two hundred employees, only 59% report offering health insurance today, versus 65% in 1999.
Your assertion that the expansion of SCHIP for families with incomes up to 300% of the FPL would disproportionately cover "illegals".
Fact- According to the Kaiser Commission, 85% of the pool of children who would be eligible for the SCHIP expansion are native United States citizens. Additionally, most new immigrants are excluded from Medicaid coverage during their first five years of residency, except for emergency treatment. Finally, the Deficit Reduction Act of 2005 requires residents to show proof of citizenship when applying for Medicaid, which also applies to SCHIP.
Rossi’s assumption that private employers are indeed making health insurance available and affordable for families living at 300% or less of the federal poverty level.
Fact-Most of the families who earn 300% or less of the federal poverty level are employed by small employers, many of whom do not offer insurance. According to the 2007 Survey of Employer Sponsored Health Benefits, the average cost for an individual enrolled in an employer sponsored health plan in the United States is $4,479 and $12,106 for a family of four. Since employees are usually expected to pay a significant portion of their health care premiums under private employer benefit plans, how can a family of four earning less than $ 41,300 per year afford medical insurance? The budget in this chart assumes the employee is expected to pay all of the cost for his dependents enrolled on insurance.

Family of Four Budget
Income Ceiling for SCHIP Expansion
$ 61,949
FICA & Medicare
4,740
Taxes at minimum rate after credits
7,981
Net available for living expenses
$ 49,228
Expenses
Housing
12,000
Utilities
3,000
Phone, cable television
591
Food
10,950
Transportation-inc. repairs, insurance, parking, maintenance, payment or lease
10,000
Savings/retirement-3% minimum
1,858
School expenses
500
Clothing
500
Personal care-hair cuts, etc,
1,000
Miscellaneous-repairs, etc,.
1,200
Subtotal for living expenses
$ 41,599
Net available for Health care
$ 7,629
Health Care Costs
Healthcare copayments
250
Health insurance premiums (employee, spouse & 2 children)
12,106
Subtotal health care expenses
$ 12,356
Net After Purchasing Health care
$ (4,727)

Since you are wrong on so many levels about your health care assumptions, is this what we can expect from your gubernatorial ambition? Next time get your facts right.

This article was written by Roberta E. Winter, MHA, MPA, who is a graduate of the University of Washington School of Public Health and the Evans School of Public Affairs.