JAMA Network | JAMA | Reshaping US Health Care: From Competition and Confiscation to Cooperation and Mobilization

 

In this issue of JAMA, 3 Viewpoints, by Powers et al,¹ Fuchs,² and Fisher and Corrigan,³ address problems, possibilities, and mechanisms for reshaping the US health care enterprise to better meet community needs at an affordable cost.

In their Viewpoint, Powers et al¹ grapple with a question as old as democracy: How can productive collective action, which is required for a state to succeed, emerge from the factional divisions for which protection is required for democratic principles to succeed?

The founding fathers of the United States debated this vigorously. In the most famous Federalist Paper,⁴ Madison favored a large republic in the hands of a meritocracy to counterbalance the passions of a majority “faction” that might overwhelm legitimate minority interests. Others wanted to protect states’ powers, arguing that smaller political units could be more responsive to local groups.

Madison defined a faction as “a number of citizens, whether amounting to a minority or majority of the whole, who are united and actuated by some common impulse of passion, or of interest, adverse to the rights of other citizens, or to the permanent and aggregate interests of the community.”⁴

Health care is ground zero for this problem, and the stakes are immense. Health care is a behemoth “faction” that controls one-sixth of the US economy and distorts the nation’s economic and political future. I recently ran as a candidate for governor of Massachusetts, and, in the course of an 18-month campaign, I saw vividly the effect of this dominating industry on the opportunities for the total well-being of a population of nearly 7 million people.

JAMA Network | JAMA | Reshaping US Health Care:  From Competition and Confiscation to Cooperation and Mobilization

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Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.

Thought I’d blogged this before, but this is from an excellent piece on Libertarianism’s most famous proponent and his own change in perspective later in life.

How could a thinker as brilliant as Nozick stay a party to this? The answer is: He didn't. "The libertarian position I once propounded," Nozick wrote in an essay published in the late '80s, "now seems to me seriously inadequate." In Anarchy democracy was nowhere to be found; Nozick now believed that democratic institutions "express and symbolize … our equal human dignity, our autonomy and powers of self-direction." In Anarchy, the best government was the least government, a value-neutral enforcer of contracts; now, Nozick concluded, "There are some things we choose to do together through government in solemn marking of our human solidarity, served by the fact that we do them together in this official fashion ..."

We're faced then with two intriguing mysteries. Why did the Nozick of 1975 confuse capital with human capital? And why did Nozick by 1989 feel the need to disavow the Nozick of 1975? The key, I think, is recognizing the two mysteries as twin expressions of a single, primal, human fallibility: the need to attribute success to one's own moral substance, failure to sheer misfortune. The effectiveness of the Wilt Chamberlain example, after all, is best measured by how readily you identify with Wilt Chamberlain. Anarchy is nothing if not a tour-de-force, an advertisement not just for libertarianism but for the sinuous intelligence required to put over so peculiar a thought experiment. In the early '70s, Nozick—and this is audible in the writing—clearly identified with Wilt: He believed his talents could only be flattered by a free market in high value-add labor. By the late '80s, in a world gone gaga for Gordon Gekko and Esprit, he was no longer quite so sure.

Robert Nozick, father of libertarianism: Even he gave up on the movement he inspired.

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Trends With Benefits | This American Life

An amazingly helpful look into what our disability program has become. Done with the usual attention to humanity and detail as we have come to expect from This American Life.

490: Trends With Benefits

Mar 22, 2013

The number of Americans receiving federal disability payments has nearly doubled over the last 15 years. There are towns and counties around the nation where almost 1/4 of adults are on disability. Planet Money's Chana Joffe-Walt spent 6 months exploring the disability program, and emerges with a story of the U.S. economy quite different than the one we've been hearing

Trends With Benefits | This American Life

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Are Americans Finding Affordable Coverage in the Health Insurance Marketplaces? - The Commonwealth Fund

Some good graphics and a chart pack on this topic. There are losers in this – higher income individuals and families who don’t qualify for significant subsidies under the exchanges.

By the end of the first open enrollment period for coverage offered through the Affordable Care Act’s marketplaces, increasing numbers of people said they found it easy to find a plan they could afford, according to The Commonwealth Fund’s Affordable Care Act Tracking Survey, April–June 2014. Adults with low or moderate incomes were more likely to say it was easy to find an affordable plan than were adults with higher incomes. Adults with low or moderate incomes who purchased a plan through the marketplaces this year have similar premium costs and deductibles as adults in the same income ranges with employer-provided coverage. A majority of adults with marketplace coverage gave high ratings to their insurance and were confident in their ability to afford the care they need when sick.

Are Americans Finding Affordable Coverage in the Health Insurance Marketplaces? - The Commonwealth Fund

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A Direct Primary Care Medical Home: The Qliance Experience

An innovative primary care model…

Who and Where A Seattle primary care practice accepting patients of all ages, staffed by internists, family physicians, and nurse practitioners.

Core Innovations In this direct care practice, in lieu of insurance, patients pay an age-adjusted monthly fee for unrestricted, comprehensive primary care. Patients have no copayments for visits. Low overhead allows providers to have small patient panels, giving patients better access and allowing more time per visit. The objective is to shift care away from expensive specialists and hospitals.

Key Results Qliance has established a viable, sustainable business model with low overhead and patient panels about a third the size of those of the average insurance-based family physician. This has allowed patients to enjoy much greater access and clinicians to delve much more deeply into patients’ health issues, do more research on health problems, work more closely with consultants when necessary, and work more intensively with patients on health change, leading to greater engagement of and satisfaction among clinicians.

A Direct Primary Care Medical Home: The Qliance Experience

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Why We Must Ration Health Care - NYTimes.com

Why We Must Ration Health Care - NYTimes.com:

You have advanced kidney cancer. It will kill you, probably in the next year or two. A drug called Sutent slows the spread of the cancer and may give you an extra six months, but at a cost of $54,000. Is a few more months worth that much?

If you can afford it, you probably would pay that much, or more, to live longer, even if your quality of life wasn’t going to be good. But suppose it’s not you with the cancer but a stranger covered by your health-insurance fund. If the insurer provides this man — and everyone else like him — with Sutent, your premiums will increase. Do you still think the drug is a good value? Suppose the treatment cost a million dollars. Would it be worth it then? Ten million? Is there any limit to how much you would want your insurer to pay for a drug that adds six months to someone’s life? If there is any point at which you say, “No, an extra six months isn’t worth that much,” then you think that health care should be rationed.

'via Blog this'

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In praise of placebos - Pittsburgh Post-Gazette

 

In alternative treatments, patients are told that “it will take time to regain your health.” Granted sufficient cultural authority, chiropractors and other alternative medicine practitioners could dissuade patients from risky and painful medical tests, dependence on addictive drugs and needless surgeries.

This makes what chiropractors do secondary to what they prevent. True natural healing may involve distracting patients with a good story and avoiding medical interference. Spinal manipulation at least gives patients time, reassurance and permission to recover — without a costly back surgery that often has no greater probability of success than time and encouragement. (Of course, alternative medicine can become the new dependence — and the new form of bloated expenditure — as “regaining health” creeps into ongoing treatment for “maintaining health.”)

The greater theme here is that so much of our health and well-being lies in our connection with others. My study found that people receiving care — even if it was sham therapy in a control group — showed greater improvement over those stuck on a waiting list.

The logical conclusion is that we are more resilient and more likely to recover if we have a plausible explanation of why we hurt and when the pain might end, and if we know that someone cares. How many other conditions might also require just patience, community and time to heal?

In praise of placebos - Pittsburgh Post-Gazette

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Why More, Not Fewer, People Might Start Getting Health Insurance Through Work - NYTimes.com

Why More, Not Fewer, People Might Start Getting Health Insurance Through Work - NYTimes.com: "The law’s best-known and least-liked provision — the “individual mandate” — is probably causing the trend. For the first time, people must buy insurance this year or be subject to a tax penalty. In Massachusetts, a similar requirement changed the employer-sponsored insurance market in two ways, said Sharon Long, a senior fellow at the Urban Institute, who has studied the state’s experience.

First, it encouraged more workers who were already being offered health insurance to take it — an effect roughly analogous to what Walmart is experiencing. Second, it actually induced more employers to offer coverage to their workers — because, Ms. Long believes, workers began to demand insurance once they were required to have it. Over all, the percentage of Massachusetts residents with employer-based insurance went to 65.6 percent in 2008, when the health care law was up and running, up from 61 percent in 2006."



'via Blog this'

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Expansion of Mental Health Care Hits Obstacles - NYTimes.com

 

LOUISVILLE, Ky. — Terri Hall’s anxiety was back, making her hands shake as she tried to light a cigarette on the stoop of her faded apartment building. She had no appetite, and her mind galloped as she grasped for an answer to her latest setback.

In January, almost immediately after she got Medicaid coverage through the Affordable Care Act, she had called a community mental health agency seeking help for the depression and anxiety that had so often consumed her.

Now she was getting therapy for the first time, and it was helping, no question. She just wished she could go more often. The agency, Seven Counties Services, has been deluged with new Medicaid recipients, and Ms. Hall has had to wait up to seven weeks between appointments with her therapist, Erin Riedel, whose caseload has more than doubled.

“She’s just awesome,” Ms. Hall said. “But she’s busy, very busy.”

The Affordable Care Act has paved the way for a vast expansion of mental health coverage in America, providing access for millions of people who were previously uninsured or whose policies did not include such coverage before. Under the law, mental health treatment is an “essential” benefit that must be covered by Medicaid and every private plan sold through the new online insurance marketplaces.

Expansion of Mental Health Care Hits Obstacles - NYTimes.com

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Opinion: UPMC’s costly divorce from Highmark - Pittsburgh Post-Gazette

On Jan. 1, UPMC will achieve its long-sought divorce from Highmark. The separation will undoubtedly disrupt care, add untold stress and potentially harm thousands. UPMC, in refusing even to negotiate a renewed contract, has plainly driven the breakup.
UPMC’s grounds for divorcing Highmark are tenuous. In testimony to the Legislature, UPMC complained that Highmark threatens to injure UPMC by “steering” patients to the “now-struggling” Allegheny Health Network, which Highmark has supported to serve as competitive foil to UPMC.
UPMC further explained, “Western Pennsylvania simply has too many hospital beds, and any gain in admissions at one hospital must come at the expense of other hospitals.”
In brief, UPMC believes competition against Highmark is good, but competition against UPMC is bad. UPMC touts creation of the UPMC Health Plan as “a competitive thorn in Highmark’s side,” but derides its own competitors as malevolent meddlers. As once explained by its CEO, UPMC’s goal is to create a “benevolent monopoly.” Unfortunately, monopolies are rarely benevolent, and there is nothing suggesting that UPMC would forgo (untaxed) profits for the public good.

Op Ed Columns - Pittsburgh Post-Gazette

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Assisted suicide debate in United Kingdom: House of Lords on death with dignity.

In spite of their soul-destroying socialism, the Brits engage in a civil, constructive debate over an emotionally charged subject. So that’s how it’s done…

Last month, a spellbinding 10-hour debate to legalize physician-assisted dying took place in Britain’s House of Lords. Since Americans are unfamiliar with this legislative body, it bears mention that most peers in the upper house of Parliament have been appointed for life for their experience in public service or for their outstanding level of achievement in a given field. Accordingly, many of the bills introduced are not shackled by political constraints, as is the case in the U.S. Congress, but instead address urgent social issues that warrant and receive thoughtful consideration.

Assisted suicide debate in United Kingdom: House of Lords on death with dignity.

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Non-profit hospital CEOs' compensation rises again | Modern Healthcare

The hutzpah is amazing!

Despite the ongoing public ire aimed at executives at not-for-profit healthcare systems because of their multimillion-dollar pay packages, their salaries and total cash compensation continued to rise at a far faster clip than average worker salaries in 2012—the most recent year with full data available.
Boards and compensation consultants continue to cite market forces—the need to keep up with peers to hold onto skilled healthcare leaders—as the main reason for the increases.
Total cash compensation grew an average of 24.2% from 2011 to 2012 for the 147 chief executives included in Modern Healthcare's analysis of the most recent public information available for not-for-profit compensation. Of those 147 CEOs, 21, or 14.3%, saw their total cash compensation rise by more than 50%.

Non-profit hospital CEOs' compensation rises again | Modern Healthcare

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Adventures in ‘Prior Authorization’ - NYTimes.com

 

DEAR Doctor,” the letter from the insurance company began. “We are writing to inform you that a prior authorization is required for the medication you prescribed.”

That’s usually where I stop reading. Thousands of these letters arrive daily in doctors’ offices across the country. They are attempts by insurance companies to prod doctors away from more expensive treatments and toward less expensive alternatives. To use the pricier option, you need to provide a compelling clinical reason.

In theory, this is a reasonable way to control costs by making it harder to prescribe costlier medications. In practice, it is a wasteful administrative nightmare, a cavalcade of recurring paperwork, lengthy phone calls and bureaucratic battles.

One study estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. Other studies have suggested that prior authorizations could cost individual practices tens of thousands of dollars a year.

Adventures in ‘Prior Authorization’ - NYTimes.com

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Busting the seven great myths of poverty

A nice summary of many of the most common myths about the poor, then this:

The United States, the richest country in the world, spends only 6.3% of the federal budget on public assistance. Fraud in the SNAP program is a single penny on the dollar. Public assistance programs are some of the most well-run, efficient programs in government. Yet we continually hear from the right and the left that these programs are a waste of our tax dollars. Instead of worrying about that $4.45 a day our less fortunate neighbors are getting as a part of their SNAP benefits, we should be more concerned with corporate welfare in which wages have been artificially depressed due to a minimum wage that has not kept pace with inflation. If we truly want to reduce the number of people on public assistance, we must raise the minimum wage and index it to inflation.

Until that happens, let's show a little compassion for those who are less fortunate. Believe it or not, they did not ask to be poor.

Busting the seven great myths of poverty

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Fertile ground for Medicaid pitch- The Washington Post

Remote Area Medical back in western Virginia, as the battle to expand Medicaid rolls on…

The three-day clinic, which relies on more than 1,000 volunteers, will serve as many as 3,000 people before it ends Sunday. The vast majority of patients — more than 70 percent — come for dental care, Brock said.

Every year, hundreds of people have every one of their teeth pulled there. Then they put their names into a denture lottery, with the hope of being picked to get a set of false teeth made for them at the next year’s event. Forty-six people were picked from a list of 700 to get dentures this year.

“They pull thousands of teeth here. At the end, they’ll have buckets of teeth,” said volunteer Jennifer Lee, Virginia’s deputy secretary of health and human resources and an emergency room doctor.

Medicaid expansion would not fully alleviate the dental situation. Medicaid does not cover routine dental care for adults or dentures. But Medicaid does pay for emergency tooth extractions, so patients would not have to wait a year to have a bad one pulled.

“I just had an 18-year-old have a full mouth extraction because she’s never had dental care,” said Beth Bortz, who runs the Virginia Center for Health Innovation. “It’s not unusual.”

She said patients often want their good teeth removed, too, because they associate teeth with pain. She said health-care providers counsel them to keep them.

- The Washington Post

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They have health insurance but may not understand it

 

WASHINGTON - Nine months after Americans began signing up for health insurance under the Affordable Care Act, a challenging new phase is emerging as confused enrollees clamor for help in understanding their coverage.

Nonprofits across the country are being swamped by consumers with questions. Many are low income, have never had insurance, and have little knowledge of the health-care system. The rampant confusion poses a potential hurdle for the success of the health law:

If many Americans don't understand health insurance, that could hurt their ability to use their benefits - or to keep their coverage altogether.

A federal program to help consumers has also run out of money.

They have health insurance but may not understand it

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At NewYork-Presbyterian Hospital, Its Ex-C.E.O. Finds Lucrative Work - NYTimes.com

 

When Dr. Herbert Pardes retired as president and chief executive of NewYork-Presbyterian Hospital in 2011, the institution honored him at its annual “Cabaret” fund-raiser. More than 1,000 guests dined on wild mushroom soup catered by the restaurateur Danny Meyer and listened to Kelli O’Hara, a star of “South Pacific,” serenade them with Rodgers and Hammerstein, Sondheim and Berlin.

But there were more thanks to come.

The next year, Dr. Pardes earned $5.6 million, which included $1 million in base salary, a $1.8 million bonus for his final year as chief executive and more than $2 million in deferred compensation, according to hospital tax records. That exceeded the amount earned by Dr. Pardes’s successor, Dr. Steven Corwin, who made $3.6 million that year.

Three years after retirement, Dr. Pardes is still employed by the hospital as the executive vice chairman of its board of trustees, a position that compensation experts say is rare in the nonprofit world, though much more common in for-profit companies

At NewYork-Presbyterian Hospital, Its Ex-C.E.O. Finds Lucrative Work - NYTimes.com

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Insurers Once on the Fence Plan to Join Health Exchanges in ’15 - NYTimes.com

 

In a sign of the growing potential under the federal health care law, several insurers that have been sitting on the sidelines say they will sell policies on the new exchanges in the coming year, and others plan to expand their offerings to more states.

“Insurers continue to see this as a good business opportunity,” said Larry Levitt, a health policy expert at the Kaiser Family Foundation. “They see it as an attractive market, with enrollment expected to ramp up in the second year.” Eight million people have signed up for coverage in 2014, and estimates put next year’s enrollment around 13 million.

In New Hampshire, for example, where Anthem Blue Cross is the only insurer offering individual coverage on the state exchange, two other plans, both from Massachusetts, say they intend to offer policies next year. Harvard Pilgrim Health Care, a nonprofit insurer with 1.2 million members, said it expected to participate in the exchanges in both New Hampshire and Maine for the first time and to add Connecticut to the mix in 2016.

Insurers Once on the Fence Plan to Join Health Exchanges in ’15 - NYTimes.com

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The giant problem American health care ignores - Vox

 

Adrianna McIntyre: Can you start by summarizing the core message in your book — what is the "paradox" in American health care, and how do you start to unravel it?

Lauren Taylor: The paradox that we outline is one that a lot of readers will be familiar with: that the United States has very high health-care costs, and in many cases middling — and sometimes lousy — health outcomes when you look at certain metrics. These are metrics — like infant mortality and life expectancy — where, when you look across developed nations, we're really at or near the bottom.

People cited this paradox before our book, and tried to explain it in any number of different ways. That included rationales like, "Well, U.S. health outcomes are bad because too few people have insurance" or "because prices are just high."

What our book tries to do is offer another reason that hasn't been talked about much in health policy: maybe "health spending" isn't telling us the whole story. Maybe we need to look at a broader summary of what resources nation puts in to support population health.

To do this, we included social services spending in our study, which captures things like housing, food assistance, and job training. The ratio of health to social-service spending was more predictive of several outcomes than health spending alone. This led us to suggest that social-service spending — and, more broadly, attention to the social determinants of health — could be a missing piece in the health reform discourse.

The giant problem American health care ignores - Vox

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BBC News - Do doctors understand test results?

Don’t cheat!

But it's not just that doctors and dentists can't reel off the relevant stats for every treatment option. Even when the information is placed in front of them, Gigerenzer says, they often can't make sense of it.

In 2006 and 2007 Gigerenzer gave a series of statistics workshops to more than 1,000 practising gynaecologists, and kicked off every session with the same question:

A 50-year-old woman, no symptoms, participates in routine mammography screening. She tests positive, is alarmed, and wants to know from you whether she has breast cancer for certain or what the chances are. Apart from the screening results, you know nothing else about this woman. How many women who test positive actually have breast cancer? What is the best answer?

• nine in 10
• eight in 10
• one in 10
• one in 100

Gigerenzer then supplied the assembled doctors with some data about Western women of this age to help them answer his question. (His figures were based on US studies from the 1990s, rounded up or down for simplicity - current stats from Britain's National Health Service are slightly different).

1. The probability that a woman has breast cancer is 1% ("prevalence")
2. If a woman has breast cancer, the probability that she tests positive is 90% ("sensitivity")
3. If a woman does not have breast cancer, the probability that she nevertheless tests positive is 9% ("false alarm rate")

In one session, almost half the group of 160 gynaecologists responded that the woman's chance of having cancer was nine in 10. Only 21% said that the figure was one in 10 - which is the correct answer. That's a worse result than if the doctors had been answering at random.

The fact that 90% of women with breast cancer get a positive result from a mammogram doesn't mean that 90% of women with positive results have breast cancer. The high false alarm rate, combined with the disease's prevalence of 1%, means that roughly nine out of 10 women with a worrying mammogram don't actually have breast cancer.

I’ve often argued, when consumer choice and consumer driven health care are brought up as the solution for our health care woes, that doctors don’t even know how to make reasonable decisions so how can we expect lay people to do it?

 

BBC News - Do doctors understand test results?

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Our unrealistic views of death, through a doctor’s eyes - The Washington Post

 

Doing something often feels better than doing nothing. Inaction feeds the sense of guilt-ridden ineptness family members already feel as they ask themselves, “Why can’t I do more for this person I love so much?”

Opting to try all forms of medical treatment and procedures to assuage this guilt is also emotional life insurance: When their loved one does die, family members can tell themselves, “We did everything we could for Mom.” In my experience, this is a stronger inclination than the equally valid (and perhaps more honest) admission that “we sure put Dad through the wringer those last few months.”

At a certain stage of life, aggressive medical treatment can become sanctioned torture. When a case such as this comes along, nurses, physicians and therapists sometimes feel conflicted and immoral. We’ve committed ourselves to relieving suffering, not causing it. A retired nurse once wrote to me: “I am so glad I don’t have to hurt old people any more.”

Our unrealistic views of death, through a doctor’s eyes - The Washington Post

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The Role Of Sales Representatives In Driving Physicians’ Off-Label Prescription Habits – Health Affairs Blog

 

Off-label prescribing is widespread in Canada and the United States. One in nine prescriptions for Canadian adults are for off-label uses with the highest percentages coming from anticonvulsants (66.6 percent), antipsychotics (43.8 percent), and antidepressants (33.4 percent). Overall, 79 percent of the off-label prescriptions lacked strong scientific evidence for their use.

For 160 drugs commonly prescribed to U.S. adults and children, 21 percent were for off-label indications totaling 150 million prescriptions. In this case, 73 percent had little to no scientific backing and once again psychoactive drugs such as gabapentin had the highest level of off-label use.

Moreover, doctors do not seem to know what are and are not approved FDA use for many of the drugs that they prescribe. Now an article published in the June issue of Health Affairs by Ian Larkin and colleagues points to active promotion by sales representatives as one reason for the widespread off-label use of antipsychotics and antidepressants in children.

The Role Of Sales Representatives In Driving Physicians’ Off-Label Prescription Habits – Health Affairs Blog

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JAMA Network | JAMA Internal Medicine | The Political Polarization of Physicians in the United States: An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

 

Conclusions and Relevance Between 1991 and 2012, the political alignment of US physicians shifted from predominantly Republican toward the Democrats. The variables driving this change, including the increasing percentage of female physicians and the decreasing percentage of physicians in solo and small practices, are likely to drive further changes.

• 

• 

• 

• 

Figures in this Article

Although few systematic analyses have been conducted on the political behavior of physicians in the United States, it is often assumed that they sit to the right on the political spectrum. Generalizing from the American Medical Association’s strong opposition to the 1965 passage of Medicare, the belief is that physicians share the wariness of Republicans about government interventions, particularly in health care.^1,2 Ostensibly, this outlook persists today.³

Given the scarcity of data and alert to the many changes in the composition and organization of the physician workforce, we examined physician contributions to presidential and congressional political campaigns from 1991 to 2012. Information on campaign contributions to federal elections is publicly available. The data illuminate patterns of support of physicians for Democratic and Republican candidates and how these patterns compare to those for all donors.

Between 1991 and 2012, campaign contributions in the United States increased substantially. Inflation-adjusted to 2012 dollars, contributions from all individuals increased from $716 million in 1991 to 1992 to $4.64 billion in 2011 to 2012, a 6.5-fold increase. Contributions from physicians increased at a greater rate, from $20 million to $189 million, or by nearly 9.5 fold.

We grouped contributions by the 2-year congressional election cycles. There are important differences in voter participation between midterm election years and presidential election years; for example, people with low incomes are less likely to vote in midterm elections.^4(pp130-133) Contributions also varied between midterm and presidential years, with greater contributions in presidential years.

Over our 22-year study period, the composition of the medical profession changed—most notably, there were more female physicians and fewer solo practitioners^{5- 7}—and politics in the United States became increasingly polarized.⁴ We hypothesized that the increased number of female physicians and the changes in medical practice altered the patterns of political partisanship within the profession.

JAMA Network | JAMA Internal Medicine | The Political Polarization of Physicians in the United States:  An Analysis of Campaign Contributions to Federal Elections, 1991 Through 2012

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The gift of hospice - Pittsburgh Post-Gazette

An op-ed I wrote about the difficulty of navigating the hospice benefit in these days of increased scrutiny…

There are those who continue to pose the question: If hospice is meant to be end-of-life care, why do some patients get “discharged?”

The answer is two-fold. One reason is ever-changing patients and illnesses.

A growing percentage of hospice patients have illnesses with outcomes that are hard to predict. In the past, cancer was the dominant hospice diagnosis. Now, the portion of hospice patients with cancer — one of the more-predictable diseases — has declined. Today, non-cancer diagnoses (such as dementia or heart disease) account for more than 63 percent of hospice admissions, according to the National Hospice and Palliative Care Organization.

The other reason for discharge is simply that reputable hospice organizations are paying close attention to the new rules. Most hospices are more careful than ever about the patients they admit and the patients they keep in their care.

The gift of hospice - Pittsburgh Post-Gazette

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What Has PAMED Done to Improve Tort Reform in Pennsylvania?

Pennsylvania has made amazing strides in medical liability reform WITHOUT CAPS! Follow the link to see the  summary of opportunities that other states can pursue without damaging victims’ rights.

What Has PAMED Done to Improve Tort Reform in Pennsylvania?

Most Pennsylvania physicians — more than 93 percent according to a 2009 study published in the Journal of the American Medical Association —report that they continue to engage in defensive medicine as a result of the state’s hostile medical liability environment.

Physicians often ask us, “What has the Pennsylvania Medical Society [PAMED] done to address this problem in the past and what are you doing now to achieve meaningful tort reform in Pennsylvania?”

What Has PAMED Done to Improve Tort Reform in Pennsylvania?

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Navigating Medicare Policy on Physical Therapy and Other Services - NYTimes.com

 

For years, some people on Medicare had difficulty getting insurance coverage approved for physical therapy, occupational therapy and other treatments. The prevailing approach was that if the therapy was not helping to improve a patient’s condition, then it was not eligible for coverage.

“They’d get denied because they weren’t improving, or because they had plateaued,” said Judith Stein, executive director of the Center for Medicare Advocacy, a nonprofit consumer group. The situation was especially difficult, she said, for patients with chronic or degenerative conditions, like Parkinson’s disease or multiple sclerosis.

That is changing, as a result of a 2013 settlement of a lawsuit that the center and others brought against the secretary of the Health and Human Services Department, the parent agency of the Centers for Medicare and Medicaid Services, which oversees Medicare. The suit claimed that Medicare billing contractors were inappropriately denying coverage for “skilled” care by applying an “improvement” standard as a rule of thumb.

Because of the settlement, the agency updated its policy manuals last year. The revisions make clear that if treatment is needed to prevent or slow further deterioration in a patient’s condition, “coverage cannot be denied based on the absence of potential for improvement or restoration.” The update applies to therapy provided in nursing homes, in outpatient clinics and at home. (The agency maintains that the revision was not a change, but was made to “clarify” what had been existing Medicare policy.)

Navigating Medicare Policy on Physical Therapy and Other Services - NYTimes.com

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Hospitals wounded by politics - Opinion - The Times-Tribune

 

Scranton’s three hospitals are among more than one-third of hospitals statewide that lost money in 2013. More than half of the state’s hospitals had profit margins lower than 4 percent for the year, the threshold for sustainability according to the Pennsylvania Health Care Cost Containment Council.

It’s a trend that likely will continue statewide through 2014 and beyond unless the Corbett administration abandons its politically inspired resistance to the Affordable Care Act’s expansion of Medicaid.

The losses have multiple causes, but one key driver is the rising cost of uncompensated care — treatment for patients who have no private or public insurance and cannot pay.

According to the council, known as PHC4, Pennsylvania hospitals provided more than $1 billion in uncompensated care in 2013, a 5 percent increase over 2012.

Gov. Tom Corbett foolishly has rejected a portion of the federal health care law which, in other states that have accepted it, has begun to diminish levels of uncompensated care and provide hospitals with much-needed revenue.

Under the ACA, the federal government pays 100 percent of the cost of Medicaid expansion to cover uninsured low-income workers in the first two years and covers 90 percent of the cost thereafter.

It’s an extraordinary deal for states. In Pennsylvania, it would have pumped about $17 billion into the health care economy through 2019, including about a $1.6 billion direct reduction in the amount of uncompensated care. That reduction likely would be higher because many people now receiving treatment at hospitals would have insurance enabling them to see other providers first.

Hospitals wounded by politics - Opinion - The Times-Tribune

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Medicine’s Top Earners Are Not the M.D.s - NYTimes.com

THOUGH the recent release of Medicare’s physician payments cast a spotlight on the millions of dollars paid to some specialists, there is a startling secret behind America’s health care hierarchy: Physicians, the most highly trained members in the industry’s work force, are on average right in the middle of the compensation pack.
That is because the biggest bucks are currently earned not through the delivery of care, but from overseeing the business of medicine.
The base pay of insurance executives, hospital executives and even hospital administrators often far outstrips doctors’ salaries, according to an analysis performed for The New York Times by Compdata Surveys: $584,000 on average for an insurance chief executive officer, $386,000 for a hospital C.E.O. and $237,000 for a hospital administrator, compared with $306,000 for a surgeon and $185,000 for a general doctor.


And those numbers almost certainly understate the payment gap, since top executives frequently earn the bulk of their income in nonsalary compensation. In a deal that is not unusual in the industry, Mark T. Bertolini, the chief executive of Aetna, earned a salary of about $977,000 in 2012 but a total compensation package of over $36 million, the bulk of it from stocks vested and options he exercised that year. Likewise, Ronald J. Del Mauro, a former president of Barnabas Health, a midsize health system in New Jersey, earned a salary of just $28,000 in 2012, the year he retired, but total compensation of $21.7 million.
The proliferation of high earners in the medical business and administration ranks adds to the United States’ $2.7 trillion health care bill and stands in stark contrast with other developed countries, where top-ranked hospitals have only skeleton administrative staffs and where health care workers are generally paid less. And many experts say it’s bad value for health care dollars.

Medicine’s Top Earners Are Not the M.D.s - NYTimes.com

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Paper: Gov. Tom Corbett health plan would need 700 workers

 

HARRISBURG (AP) — Gov. Tom Corbett’s Healthy PA, an alternative to expanding Medicaid, will require the state to hire more than 700 new employees, a newspaper reported Monday.

The figure was far higher than most states have experienced and came as a surprise to some experts in public policy, The Philadelphia Inquirer said.

Most of the new hires would be caseworkers in offices scattered around the state, said Bev Mackereth, Corbett’s public welfare secretary. She said that under Pennsylvania’s system, the caseworkers do more than in some other states, including evaluating those who sign up for potential eligibility for other benefits as well.

She said in an interview Monday that Pennsylvania also trails some other states in automation, which adds to the cost.

“We’re getting there, and we’re not where other states are,” she said. “Some states have everything automated — it’s very easy for them to do.”

The newspaper said the state has estimated about 605,000 people would be newly eligible under Healthy PA. The first-year cost of the 700-plus new hires will be just over $30 million, much of it subsidized by the federal government.

Mackereth said the additional personnel costs would be more than covered by the estimated Healthy PA savings of $125 million.

The Department of Public Welfare estimates it would require even more new workers — about 1,200 of them — to expand Medicaid under the President Barack Obama’s landmark health care law.

Corbett, a Republican seeking a second term this year, is waiting to hear back from federal regulators about Healthy PA. It would use Medicaid expansion money to provide private insurance coverage for the same group of people. Those private insurers would be able to operate without some of Medicaid’s coverage rules.

Paper: Gov. Tom Corbett health plan would need 700 workers

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Geisinger Health Plan enrolls more than 20,000 through Obamacare - themorningcall.com

 

Geisinger Health Plan, a health insurance company serving Lehigh, Northampton and 39 other Pennsylvania counties, added more than 20,000 members during the first open-enrollment period under the federal Affordable Care Act, the company announced Monday.

"We are extremely happy with the number of individuals who selected Geisinger Health Plan for their health insurance coverage," says David Brady, vice president of health care reform and commercial business development. "We felt it was important to offer individuals who were shopping on the marketplace a choice of coverage options that focused on quality and customer service. Based on our results, Pennsylvanians agreed."

Geisinger Health Plan offered 26 plans on the federal marketplace and GeisingerMarketplace.com, its private site, the company said in a statement.

Geisinger Health Plan enrolls more than 20,000 through Obamacare - themorningcall.com

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Cost of Treatment May Influence Doctors - NYTimes.com

 

Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.

The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.

“We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room,” said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.

Cost of Treatment May Influence Doctors - NYTimes.com

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AMA, 51 Other Medical Organizations, oppose Gun Violence, Duh.

Letter from AMA and 51 other Medical Organizations. PDF here.

January 8, 2013

The President

The White House

1600 Pennsylvania Avenue

Washington, DC 20500

Dear Mr. President:

The undersigned medical organizations, together representing the vast majority of practicing physicians and medical students in the United States, share the nation’s grief and sadness over the recent tragic school shootings in Connecticut. As physicians, we see first-hand the devastating consequences of gun violence to victims and their families.

We offer our experience and expertise in finding workable, common sense solutions to reduce the epidemic of gun violence—indeed the overall culture of violence—in America. We also urge the nation to strengthen its commitment and resources to comprehensive access to mental health services, including screening, prevention, and treatment.

The investigation into the Connecticut shootings is still continuing, and the issues surrounding such violence are often complex and can vary significantly from case to case. Strategies for preventing gun-related tragedies must also be complex and carefully considered. The relatively easy access to the increased firepower of assault weapons, semi-automatic firearms, high-capacity magazines, and high-velocity ammunition heightens the risk of multiple gunshot wounds and severe penetrating trauma, resulting in more critical injuries and deaths. Even for those who manage to survive gun violence involving these weapons, the severity and lasting impact of their wounds, disabilities and

treatment leads to devastating consequences for families affected and society, and contributes to high medical costs for treatment and recovery. Renewing and strengthening the assault weapons ban, including banning high-capacity magazines, would be a step in the right direction.

Many of the deaths and injuries resulting from firearms are preventable. More resources are needed for safety education programs that promote more responsible use and storage of firearms. Physicians need to be able to have frank discussions with their patients and parents of patients about firearm safety issues and risks to help them safeguard their families from accidents. While the overwhelming majority of patients with mental illness are not violent, physicians and other health professionals must be trained to respond to those who have a mental illness that might make them more prone to commit violence.

Funding needs to be available for increased research on violence prevention in general, and on the epidemiology of gun-related injuries and deaths in particular, as well as to implement available evidence-based interventions. Of equal importance is providing sufficient access to mental health services. While we strongly supported the passage of the Mental Health Parity Act of 2008, unfortunately, the promise of better access to psychiatric treatment will not be a reality absent requisite federal and state funding. This effort should be combined with an education campaign that reduces the stigma of seeking mental health services.

Newtown, Connecticut has now been added to the sad litany of recent mass shootings, including Columbine, Virginia Tech, Fort Hood, Arizona, and Aurora. As we come together as a nation to mourn the most recent victims of senseless gun violence, we must make a real and lasting commitment to work together on meaningful solutions to prevent future tragedies. We stand ready to work with Congress and the Administration to make progress in protecting our communities, especially our children, from this epidemic of violence.

Sincerely,

American Medical Association

American Academy of Child and Adolescent Psychiatry

American Academy of Family Physicians

American Academy of Pain Medicine

American Academy of Pediatrics

American Academy of Urgent Care Medicine

American College of Emergency Physicians

American College of Mohs Surgery

American College of Occupational and Environmental Medicine

American College of Osteopathic Internists

American College of Phlebology

American College of Physicians

American College of Preventive Medicine

American College of Radiology

American College of Surgeons

American Congress of Obstetricians and Gynecologists

American Geriatrics Society

American Osteopathic Association

American Psychiatric Association

American Society for Clinical Pathology

American Society of Plastic Surgeons

Association of American Medical Colleges

College of American Pathologists

North American Spine Society

Renal Physicians Association

Society of Critical Care Medicine

The Society of Thoracic Surgeons

 

California Medical Association

Colorado Medical Society

Connecticut State Medical Society

Medical Society of Delaware

Medical Society of the District of Columbia

Illinois State Medical Society

Maine Medical Association

MedChi, The Maryland State Medical Society

Massachusetts Medical Society

Michigan State Medical Society

Minnesota Medical Association

Nebraska Medical Association

Nevada State Medical Association

Medical Society of New Jersey

New Mexico Medical Society

Oklahoma State Medical Association

Oregon Medical Association

Rhode Island Medical Society

South Dakota State Medical Association

Tennessee Medical Association

Texas Medical Association

Vermont Medical Society

Medical Society of Virginia

Washington State Medical Association

Wisconsin Medical Society

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Even Critics of Safety Net Increasingly Depend on It - NYTimes.com

It speaks for itself…

LINDSTROM, Minn. — Ki Gulbranson owns a logo apparel shop, deals in jewelry on the side and referees youth soccer games. He makes about $39,000 a year and wants you to know that he does not need any help from the federal government.

He says that too many Americans lean on taxpayers rather than living within their means. He supports politicians who promise to cut government spending. In 2010, he printed T-shirts for the Tea Party campaign of a neighbor, Chip Cravaack, who ousted this region’s long-serving Democratic congressman.

Yet this year, as in each of the past three years, Mr. Gulbranson, 57, is counting on a payment of several thousand dollars from the federal government, a subsidy for working families called the earned-income tax credit. He has signed up his three school-age children to eat free breakfast and lunch at federal expense. And Medicare paid for his mother, 88, to have hip surgery twice.

Even Critics of Safety Net Increasingly Depend on It - NYTimes.com

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Rand Paul Blocks Surgeon General Nominee For Saying Gun Violence Is A Public Health Threat | ThinkProgress

Rand Paul Blocks Surgeon General Nominee For Saying Gun Violence Is A Public Health Threat | ThinkProgress



Rand Paul, of course, has no concept of a physician's duty to help safeguard the health of actual people, both on an individual and population (public health) basis.

“As a physician, I am deeply concerned that he has advocated that
doctors use their position of trust to ask patients, including minors,
details about gun ownership in the home… Dr. Murthy has disqualified
himself from being Surgeon General because of his intent to use that
position to launch an attack on Americans’ right to own a firearm under
the guise of a public health and safety campaign.”


But Paul is actually out of step with most physicians. The idea that
gun violence is a danger to public health is utterly uncontroversial
among doctors’ groups, academic institutions that focus on public health, and children’s safety advocates.
Although Paul criticizes Murthy’s position that physicians and
pediatricians should ask patients about the presence of guns in their
households, the American Medical Association (AMA) adopted a resolution in 2011
officially opposing any law that bars doctors from having open
conversations about gun safety and the risks of having firearms in a
household with their patients.


In fact, just yesterday, the American Academy of Pediatrics (AAP)
issued new guidelines recommending that households with children who are
diagnosed with depression should remove guns and ammunition from their homes entirely.

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Fear Mongering With Medicare - NYTimes.com

 

The Obama administration’s proposed cuts to Medicare Advantage plans — the private insurance plans that cover almost 30 percent of all Medicare beneficiaries — are fair and reasonable. As it happens, they are also mandated by law. Yet Republicans, sensing a campaign issue, are telling older and disabled Americans that the administration is “raiding Medicare Advantage to pay for Obamacare.” The health insurance industry, for its part, is warning that enrollees will suffer higher premiums, lower benefits and fewer choices among doctors if the cuts go into force.

Some of this could in fact happen, although the industry has cried wolf before and continues to thrive. But the key point is this: Over the past decade, enrollees in Medicare Advantage have received lots of extra benefits, thanks to unjustified federal subsidies to the insurance companies. Now they will have to do with somewhat less, unless the insurers are willing to absorb the cuts while maintaining benefits. Enrollment in these private plans, offered by companies like UnitedHealth and Humana, has more than doubled since 2006, in part because of lower premiums and extra benefits, like gym memberships, that are not included in traditional fee-for-service Medicare.

Fear Mongering With Medicare - NYTimes.com

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Cabbies Hail For Health Insurance | NBC 10 Philadelphia

Getting health insurance in spite of Gov. Corbett!

About 80 percent of the nearly 5,000 taxi drivers in the city did not have insurance prior to the Affordable Care Act going into effect, said Ronald Blount, president of the Unified Taxi Workers Alliance of Pennsylvania.

"They were pretty much on their own," he said. "If a driver was hit by a drunk driver, the taxi auto insurance doesn’t cover the driver.”

"They’d be stuck with big medical bills,” added Blount, who said many drivers are plagued by “silent killers” like diabetes, high blood pressure and high cholesterol since many eat while on the go and are sitting for most of the day.

In an effort to enroll as many cabbies as possible, the TWA teamed up with two nonprofits focused on health care, Healthy Philadelphia and Get Covered America, to hold regular enrollment and information sessions.

Cabbies Hail For Health Insurance | NBC 10 Philadelphia

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Congressional Budget Office Report Finds Minimum Wage Lifts Wages for 16.5 Million Workers | The White House

I couldn’t understand why the CBO estimated job losses with a minimum wage hike. It’s because they seemed determine to ignore the literature on the subject:

6. CBO’s estimates of the impact of raising the minimum wage on employment does not reflect the current consensus view of economists. The bulk of academic studies, have concluded that the effects on employment of minimum wage increases in the range now under consideration are likely to be small to nonexistent. CBO also agrees that the employment effect could be essentially zero, but their central estimates are not reflective of a consensus of the economics profession. Specifically:

• Seven Nobel Prize Winners, eight former Presidents of the American Economic Association and over 600 other economists recently summarized the literature on the employment effects of the minimum wage in this way: “In recent years there have been important developments in the academic literature on the effect of increases in the minimum wage on employment, with the weight of evidence now showing that increases in the minimum wage have had little or no negative effect on the employment of minimum-wage workers, even during times of weakness in the labor market.”
• The pioneering research in this area was conducted by John Bates Clark Medal winner David Card and Alan Krueger, who published a study in the American Economic Review in 1994 finding that fast food restaurants in New Jersey did not cut back employment relative to Pennsylvania after the former State raised its minimum wage. They concluded, “We find no indication that the rise in the minimum wage reduced employment.”
• The Card-Krueger research was generalized by Arindrajit Dube, T. William Lester, and Michael Reich who compared 288 pairs of contiguous U.S. counties with minimum wage differentials from 1990 to 2006. Based on this, researchers found “no adverse employment effects” from a minimum wage increase.
• A recent literature review of the extensive published work on the minimum wage concluded: “[W]ith 64 studies containing approximately 1,500 estimates, we have reason to believe that if there is some adverse employment effect from minimum-wage raises, it must be of a small and policy-irrelevant magnitude.”
• Another recent review of the theory and evidence on the minimum wage by John Schmitt at the Center for Economic Policy Research concluded that “The employment effects of the minimum wage are one of the most studied topics in all of economics. This report examines the most recent wave of this research – roughly since 2000 – to determine the best estimates of the impact of increases in the minimum wage on the employment prospects of low-wage workers. The weight of that evidence points to little or no employment response to modest increases in the minimum wage.”

Overall the logic for the finding that raising the minimum wage does not result in large adverse impacts on employment is that paying workers a better wage can improve productivity and thereby reduce unit labor costs. These adjustments, along with others that firms can make, help explain why the increase in the minimum wage need not lead to a reduction in employment. Higher wages lead to lower turnover, reducing the amount employers must spend recruiting and training new employees. Paying workers more can also improve motivation, morale, focus, and health, all of which can make workers more productive. In addition, by reducing absenteeism, higher wages can increase the productivity of coworkers who depend on each other or work in teams. In addition, businesses can adjust in other ways rather than reducing employment (for example, by accepting lower profit margins).  CBO’s estimates do not appear to fully reflect the increased emphasis on all of these factors from the recent economics literature.

Congressional Budget Office Report Finds Minimum Wage Lifts Wages for 16.5 Million Workers | The White House

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Bounced From Hospice - NYTimes.com

Good piece about the dilemma faced by all hospices – is this patient going to die within 6 months?

One can sympathize with hospice organizations caught in this squeeze. Determining which patients will likely die within six months has always been difficult, especially with conditions like heart disease or dementia, whose trajectories can be unpredictable. To avoid being penalized if they guess wrong, hospices are taking no chances.

At least, that’s true of hospices operating according to the regulations and honoring the movement’s historic mission. The Post attributed much of the jump in discharges to the way for-profit hospices have come to dominate the field, enrolling ineligible seniors for long stays to bolster corporate bottom lines, then dumping them to evade Medicare sanctions. (The Times has also reported on growing hospice costs.) Whistleblowers and the Justice Department have sued several large national chains to stop these practices.

But I worry about families who have agonized about the decision and finally called for help, then feel betrayed when hospice withdraws, even though their relatives can regain hospice care when they decline further. They shouldn’t get caught in this crossfire.

Bounced From Hospice - NYTimes.com

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Medicare rules create a booming business in hospice care for people who aren’t dying - The Washington Post

Long article about hospice, and the possible abuse of the system by for-profit hospices.

Hospice patients are expected to die: The treatment focuses on providing comfort to the terminally ill, not finding a cure. To enroll a patient, two doctors certify a life expectancy of six months or less.

But over the past decade, the number of “hospice survivors” in the United States has risen dramatically, in part because hospice companies earn more by recruiting patients who aren’t actually dying, a Washington Post investigation has found. Healthier patients are more profitable because they require fewer visits and stay enrolled longer.

The proportion of patients who were discharged alive from hospice care rose about 50 percent between 2002 and 2012, according to a Post analysis of more than 1 million hospice patients’ records over 11 years in California, a state that makes public detailed descriptions and that, by virtue of its size, offers a portrait of the industry.

The average length of a stay in hospice care also jumped substantially over that time, in California and nationally, according to the analysis. Profit per patient quintupled, to $1,975, California records show.

This vast growth took place as the hospice “movement,” once led by religious and community organizations, was evolving into a $17 billion industry dominated by for-profit companies. Much of that is paid for by the U.S. government — roughly $15 billion of industry revenue came from Medicare last year.

At AseraCare, for example, one of the nation’s largest for-profit chains, hospice patients kept on living. About 78 percent of patients who enrolled at the Mobile, Ala., branch left the hospice’s care alive, according to company figures. As many as 59 percent of patients left the AseraCare branch in nearby Foley, Ala., alive. And at the one in Monroeville, 48 percent were discharged from the hospice alive.

Medicare rules create a booming business in hospice care for people who aren’t dying - The Washington Post

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The French way of cancer treatment | Anya Schiffrin

An account of cancer care in France.

When my dad began to get worse, the home visits started. Nurses came three times a day to give him insulin and check his blood. The doctor made house calls several times a week until my father died on December 1.

The final days were harrowing. The grief was overwhelming. Not speaking French did make everything more difficult. But one good thing was that French healthcare was not just first rate — it was humane. We didn’t have to worry about navigating a complicated maze of insurance and co-payments and doing battle with billing departments.

Every time I sit on hold now with the billing department of my New York doctors and insurance company, I think back to all the things French healthcare got right. The simplicity of that system meant that all our energy could be spent on one thing: caring for my father.

That time was priceless.

The French way of cancer treatment | Anya Schiffrin

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Doctors Abusing Medicare Face Fines and Expulsion - NYTimes.com

 

WASHINGTON — The Obama administration is cracking down on doctors who repeatedly overcharge Medicare patients, and for the first time in more than 30 years the government may disclose how much is paid to individual doctors treating Medicare patients.

Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services, said that “recalcitrant providers” would face civil fines and could be expelled from Medicare and other federal health programs.

In a directive that took effect on Jan. 15 but received little attention, Ms. Tavenner indicated that the agency was losing patience with habitual offenders. She ordered new steps to identify and punish such doctors.

A recalcitrant provider is defined as one who is “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” Cases will be referred to Daniel R. Levinson, the inspector general at the Department of Health and Human Services, who has authority to impose civil fines and exclude doctors from Medicare, Medicaid and other programs. 

Federal officials estimate that 10 percent of payments in the traditional fee-for-service Medicare program are improper. That would suggest at least $6 billion a year in improper payments under Medicare’s physician fee schedule. But Malcolm K. Sparrow, a Harvard professor and an expert on health care fraud, has said the losses could be greater because the official statistics “fail to accurately capture fraud rates” in Medicare.

A new section of the Medicare manual encourages the use of fines to penalize doctors who generate a pattern of claims for goods and services that they know or “should know” are not medically necessary. Providers can also be barred from Medicare if they bill the program for “excessive charges” or for services substantially in excess of patients’ needs.

In a new report, Mr. Levinson said Medicare officials and contractors should focus on doctors with the highest Medicare billings because they often received improper payments. He said that about 300 doctors received more than $3 million each in yearly Medicare payments and that one-third of them had been singled out for special reviews because of questionable billings.

Doctors Abusing Medicare Face Fines and Expulsion - NYTimes.com

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Pennsylvania isn't serious about expanding Medicaid. How do we know? - latimes.com

 

Pennsylvania Gov. Tom Corbett has lately been getting credit in the political press for being one of those Republican governors coming around on the expansion of Medicaid under the Affordable Care Act. Advocates for the underprivileged can't understand why.

They're right to wonder. Corbett's "Healthy Pennsylvania" plan, which was released for public comment this week, is a sham. It would reduce health benefits for many of his neediest citizens and impose punitive conditions on their coverage. It requires waiver approval from the federal government that's almost certain to be refused, because some of its provisions are in flagrant violation of federal law. And even if it were approved, Corbett waited so long to put his plan together that it probably couldn't be implemented until 2015. In the meantime, 500,000 of his citizens will be medically uncovered.

"He's being very disingenuous," says Joan Alker, executive director of the Center for Children and Families at Georgetown University. "He knows a lot of this proposal is not approvable" under federal law.

Corbett's proposal shows that many Republicans still aren't done posturing with their citizens' lives, even as some have done the right thing--among them Gov. John Kasich of Ohio and Jan Brewer of Arizona. Some GOP governors, like Rick Perry of Texas and Bobby Jindal of Louisiana, seem determined to take their neediest citizens all the way down--they're not budging on their refusal to expand Medicaid coverage.

Corbett wants to have it both ways. He intends to masquerade as a feeling governor intent on bringing healthcare to the masses at practical cost. But beneath the fancy dress lies a cynical politician who knows his plan isn't practical. If it gets rejected he'll blame the Obama administration. "We tried," he'll say. "But they blocked us." Don't be taken in.

Pennsylvania isn't serious about expanding Medicaid. How do we know? - latimes.com

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Patients’ Costs Skyrocket; Specialists’ Incomes Soar - NYTimes.com

 

CONWAY, Ark. — Kim Little had not thought much about the tiny white spot on the side of her cheek until a physician’s assistant at her dermatologist’s office warned that it might be cancerous. He took a biopsy, returning 15 minutes later to confirm the diagnosis and schedule her for an outpatient procedure at the Arkansas Skin Cancer Center in Little Rock, 30 miles away.

That was the prelude to a daylong medical odyssey several weeks later, through different private offices on the manicured campus at the Baptist Health Medical Center that involved a dermatologist, an anesthesiologist and an ophthalmologist who practices plastic surgery. It generated bills of more than $25,000.

“I felt like I was a hostage,” said Ms. Little, a professor of history at the University of Central Arkansas, who had been told beforehand that she would need just a couple of stitches. “I didn’t have any clue how much they were going to bill. I had no idea it would be so much.”

Ms. Little’s seemingly minor medical problem — she had the least dangerous form of skin cancer — racked up big bills because it involved three doctors from specialties that are among the highest compensated in medicine, and it was done on the grounds of a hospital. Many specialists have become particularly adept at the business of medicine by becoming more entrepreneurial, protecting their turf through aggressive lobbying by their medical societies, and most of all, increasing revenues by offering new procedures — or doing more of lucrative ones.

Patients’ Costs Skyrocket; Specialists’ Incomes Soar - NYTimes.com

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