Americans are held in suspense as each week approaching the 2016 election, a new potential political candidate is introduced to the growing pot of presidential hopefuls. Although the candidates remain unclear, one thing is for sure – healthcare reform will be a major debating point. With Medicaid expansions and the Affordable Care Act defining the past two terms, voters are still anticipating a bandaid for the seemingly struggling healthcare system. Physicians and patients are also eager to identify a leader who will be able to implement much needed changes. As more and more individuals throw their hats into the ring, it becomes every more important to understand their views on this issue. There are many more debates to come and this issue will certainly arise. While there is no perfect, unbiased resource for political issues, a good summary of the stance the candidates take on healthcare can be found here:
Assistant Program Director and Palliative Care guru Dr. Elizabeth Paulk gave an insightful Grand Rounds Lecture today about the history and ethics of physician assisted death (PAD) in this country. She talked in depth about the 1997 Oregon Death with Dignity Act and showed data about the types of patients who seek physician assistance in dying. She highlighted the case of Brittany Maynard, a 29 year old woman with glioblastoma multiforme who became an outspoken advocate for PAD and died by choice in 2014 after moving to Oregon. The Maynard case thrust the issue of PAD into the national spotlight and a 2015 Gallup poll showed an increasingly favorable public perception of PAD with 68% of Americans in favor. Physician assisted death is currently legal in Oregon, Washington, Montana, New Mexico and Vermont. Read more about the controversy and data surrounding PAD and about Brittany Maynard here and here. See Dr. Paulk’s slides for more information about this morally and legally complicated issue.
The Centers for Medicare and Medicaid Services (CMS) announced yesterday a proposal to reimburse physicians for counseling Medicare patients on end-of-life planning. This proposal follows the recommendations of multiple large physician and healthcare organizations including the AMA, ACP and AARP. The proposal is still pending and the final rule change is due November 1 with payments starting January 1.
Reimbursement for end-of-life planning was initially included in the early stages of the Affordable Care Act but was removed after strong political opposition from groups who argued that it would lead to the creation of “death panels”. Sarah Palin famously said during her 2008 presidential run “Government needs to stay the hell out of our end-of-life discussions”.
While many physicians already engage in end-of-life planning discussions with their patients, the establishment of a formal reimbursement structure would undoubtedly lead to increased utilization.
What are your thoughts? Would Medicare reimbursements change your willingness to engage in advanced care planning with your patients?
Today at morning report we discussed high value care and professionalism/managerial skills. We specifically noted a recent article published in JAMA by oncologist Dr. Ezekiel Emanuel from the University of Pennsylvania and an article in NEJM by Dr. Michael Porter of the Harvard Business School published in 2010. Click on the links below to read the articles!
“Higher income, higher educational attainment, and a cleaner environment are actually more important in determining patients’ well-being than health care services.” Dr. Ezekiel Emanuel
Very interesting article from The New York Times – Sunday Review published in May that discusses who actually is paid the highest in the healthcare industry, and it’s not always physicians! The article has some interesting graphics that nicely illustrate this. Check it out!
This past April, two podcasts were released by Freakonomics that took a closer look at randomized controlled trials and taking the approach of “less is more” in taking care of patients. The first podcast interviews Amy Finkelstein, an economist from M.I.T, who has been looking at the utility of conducting randomized controlled trials in studying health care delivery and uses the Oregon Medicaid Health Experiment as an example. In the second podcast, Dr. Anupam Jena (assistant professor at Harvard Medical School) is interviewed regarding a study he led that looked at outcomes in Medicare patients when specialists are away at a conference. Click on the links below to be directed to the podcast from the Freaknonomics website. Thanks to resident Sean Townsend for the reference!
“We are taking steps to align how these programs work,” said Andy Slavitt, acting administrator of the Centers for Medicare & Medicaid Services, which proposed the rules.
Privatized Medicaid has grown rapidly as budget-pinched states have responded to commercial insurers’ promise to deliver care for a fixed price. Most beneficiaries of Medicaid — state programs for the poor run partly with federal dollars — now get care through contracted insurers.
The 653-page rule, which also would require states to establish quality ratings for Medicaid plans, constitutes the biggest regulation change to Medicaid managed care in more than a decade. The National Association of Medicaid Directors, a group of state officials, called it a “milestone.”
One proposal would require plans to assume, for rate-setting purposes, that they will spend at least 85 percent of their revenue on medical care.
Such a “medical loss ratio” target is similar to that required under the health law for other plans — but with a key difference. Unlike health plans sold through the law’s online marketplaces and elsewhere, Medicaid plans wouldn’t have to rebate the difference if they spend less than 85 percent.
But states would still “need to take that into account the next year” when they set new rates, thus limiting profits later, said Vikki Wachino, CMS deputy administrator. CMS is a division of the Department of Health and Human Services.
Jeff Myers, CEO of Medicaid Health Plans of America, an industry group, criticized the inclusion of the medical loss ratio standard, which supporters promote as ensuring plans spend a minimum amount on care instead of executive salaries and shareholder profits.
“We don’t believe a nationwide MLR is appropriate,” Myers said. A uniform profit standard across diverse states could limit plans’ ability to spend administrative dollars to fine-tune care coordination and quality, he said.
Generally, however, “we are very supportive of the direction they are going,” he said of CMS. He particularly praised the proposal to better align the Children’s Health Insurance Program, or CHIP, which aids families with children with moderate incomes, with Medicaid.
Led by giants such as UnitedHealthcare, Anthem, Aetna and Centene, private Medicaid plans generated nationwide operating profits of $2.4 billion last year, according to regulatory data compiled by Mark Farrah Associates and analyzed by Kaiser Health News.
Advocates for the poor have complained that HHS’ regulation of Medicaid managed care has lagged behind the industry’s growth. Industry profits have sometimes come at the expense of denied care and inadequate doctor networks, they say.
A study last year by HHS’ inspector general found that half the doctors listed in official plan directors weren’t taking new Medicaid patients. Among doctors who were, one fourth couldn’t see patients for a month.
In Tuesday’s rules CMS proposed new standards for network adequacy that also allow wide flexibility to states. States would have to certify at least annually that Medicaid managed-care patients have sufficient access to doctors and hospitals, based on standards for numbers of medical providers per member, maximum distances required to travel for care and other criteria.
“This latest proposed guidance ensures that health plans and states have the flexibility to structure their programs and benefits to meet the unique health needs of their enrollees,” Dan Durham, interim CEO of America’s Health Insurance Plans, an industry lobby, said in a prepared statement.
Sarah Somers, an attorney with the National Health Law Program, which has long urged updates to federal regulations, praised proposed safeguards for Medicaid members with disabilities and limited English ability.
“The regulations governing network adequacy have some positive aspects,” she added. “But we are concerned that they do not contain the specificity that we recommended.”
The proposal also would establish a quality-rating system, perhaps similar to the star scores assigned to Medicare coverage for seniors, so members could compare plan performance. However Wachino said it was too early to tell what the ratings would look like.
Margaret Murray, CEO of the Association for Community Affiliated Plans, a group of not-for-profit Medicaid companies, said she was disappointed the quality standards wouldn’t apply to traditional Medicaid run by the states as well as private Medicaid plans.
“We think that managed care will come out ahead in that comparison,” she said.
In a victory for industry, the rules also propose to loosen marketing restrictions on insurers that offer Medicaid coverage as well as plans sold through the health-law marketplaces.
Some companies are counting on capturing customers moving from Medicaid to commercial plans or vice versa as the members’ incomes fluctuate. The new regulation would make it easier for insurers to let Medicaid beneficiaries know that the same company sells a plan through the marketplace.
The rules published Tuesday are only proposals. HHS will take comments until late July and issue final rules later.
Kaiser Health News (KHN) is a nonprofit national health policy news service.
Doctors called it the black hole.
If their low-income or uninsured patients needed specialty care, they put in a referral to the massive Los Angeles County health care bureaucracy and then waited — for weeks or even months. It could take eight months to see a neurologist, more than three to see a cardiologist.
To speed things up, doctors at county and community clinics urged their patients to go straight to the emergency room, the unofficial back door for specialist appointments. That way, patients could bypass the long waits and get the recommended colonoscopy or CT scan. But that route was expensive and burdensome to ERs.
It’s a problem across the nation: Specialists are hard to find for many patients, and even harder to afford. Sick people may grow sicker as they wait for appointments, causing them unnecessary discomfort and making treatment more costly in the long run. Diabetics may suffer with untreated foot ulcers, raising the risk of amputation; patients with abnormal chest X-rays may turn out to have cancer.
With a million patients a year depending on Los Angeles County for health care, local officials decided they had to act. Hiring scores of costly specialists wasn’t an option. So in 2012 they created a program called eConsult, modeled after a system at San Francisco General Hospital, to streamline the referral process.
In L.A. County, a program run by L.A. Care Health Plan, allows for a Web-based conversation between primary care doctors and specialists that can include the exchange of medical records and photographs. The specialist typically responds to inquiries within three days and a decision on a referral soon follows.
Much as a triage nurse clears the way for accident victims in a crowded ER, clinics would use guidelines for each specialty — created by specialists and primary care doctors working together — to determine who needs an appointment and how quickly. The primary care physicians can continue to care for the remaining patients, consulting with specialists electronically.
Three years later, it’s clear the program hasn’t been a panacea. Most patients in Los Angeles County still need face-to-face appointments with specialists, and there still aren’t enough of them to go around. But both primary care doctors and specialists say things have gotten better.
The county quickly realized its hypothesis was right — about 30 percent of patients referred by providers at county and community clinics didn’t actually need to see a specialist in person. Primary care doctors said they now have a clear way to communicate with specialists about their patients. And when patients do get to the specialist’s office, more have the necessary lab work or tests so the appointments are more efficient.
Overall, doctors agree that the electronic referral system has improved both communication and collaboration among doctors on both sides. And primary care doctors say the new system is far better than the old days, when they would have to “beg, borrow and plead” to get appointments for their patients.
Wait times for specialists in general also have dropped, although a small number of patients with nonurgent health issues still may have to wait up to six months for appointments, according to the county’s specialty care director, Dr. Paul Giboney.
COSTS COULD GO UP
In L.A. County, about 10,000 eConsult requests come in each month across more than 40 specialties. The program has the potential to become a national model: Giboney said health leaders in Illinois, Alaska, Connecticut and elsewhere have contacted him to ask about how the county’s program works.
But some primary care doctors have argued that they don’t have the skills, time or resources to manage patients who need more advanced care. In addition, the system isn’t set up to pay community physicians for the added work, tests or procedures that specialists request before seeing patients.
“Without any extra reimbursement, those costs are hitting the primary care providers,” said Dr. Richard Seidman, chief medical officer at Northeast Valley Health Corp., which runs several community clinics.
EConsult works better for some specialties than others. For example, an endocrinologist may be able to advise a doctor on how to manage the complications of diabetes or a cardiologist can suggest ways to manage a heart murmur but an ophthalmologist can’t treat cataracts through an electronic conversation. Nearly 90 percent of patients referred to ophthalmology end up with an in-person appointment.
Nevertheless, Dr. Lauren Daskivich, an ophthalmologist with L.A. County, said she no longer has to try to interpret one-line referrals and can more easily figure out what type of eye doctor a patient needs to see and how soon. “For the first time, we have actually been able to triage how urgently they need to get in,” she said.
Nationwide, the problem of access to specialists has eased somewhat due to the Affordable Care Act, which enabled more than 16 million people to get insurance. But the health law didn’t cover everyone, most notably people living here illegally, and specialists may not take the insurance that patients have.
Electronic consultation by itself can’t resolve the access problem for poor patients, said Dr. Nwando Olayiwola, associate director of UC San Francisco’s Center for Excellence in Primary Care, who studies these efforts nationally. “It solves a huge part of the problem but it doesn’t solve all of it,” she said.
For now, the Los Angeles County health care system is still overburdened. One doctor put it simply: Technology doesn’t solve the problems that were there before technology.
At the UMMA Community Clinic in South Los Angeles, more than 40 percent of patients remain uninsured and some have been in the queue for a specialist appointment for months. The clinic’s Dr. Cesar Barba says he’s grateful there is a way to talk to specialists and identify those who need to be seen more quickly.
The eConsult system helps, but it “is not the ideal,” Barba said. “The best solution is if we had more specialists. That would be ideal.”
Kaiser Health News (KHN) is a nonprofit national health policy news service.
SPARKS, Nev. — Paramedic Ryan Ramsdell pulled up to a single-story house not far from Reno’s towering hotels and casinos in a nondescript Ford Explorer.
No ambulance, no flashing lights. He wasn’t there to rush 68-year-old Earl Mayes to the emergency room. His job was to keep Mayes out of the ER.
Mayes, who has congestive heart failure and chronic lung disease, greeted Ramsdell and told him that his heart was fluttering more than usual. “I had an up-and-down night,” he said.
“Let’s take a look at it,” the paramedic responded, carrying a big red bag with medical supplies. “We’ll put you on the monitor.”
Since Mayes was released from the hospital a few weeks earlier, paramedics had visited him several times to monitor his heart and lungs and make sure he was following his doctor’s orders.
“With these guys coming by and checking me all the time, it makes it so much better,” Mayes said. “When they leave, you know where you stand.”
Not Always An Emergency
Ramsdell is part of an ambitious plan in Reno to overhaul the 911 system to improve patient care and cut costs. By using specially trained paramedics, health officials hope to help reduce avoidable trips to the emergency room and fill gaps in health care. They also hope to connect 911 callers — particularly repeat ER users — to the regular health care system.
Around the country, the role of paramedics is changing. In various states, they’re receiving extra training to provide more primary and preventive care and to take certain patients to urgent care or mental health clinics rather than more costly emergency rooms. Ramsdell and others in his program, for instance, spent 150 hours in the classroom and with clinicians learning how to provide ongoing care for patients.
The changes are driven by the 2010 health law, which aimed to cut spending, expand patient access and improve quality of care. The federal government is funding the Nevada project and others in Arizona, Connecticut, Washington state and elsewhere.
These projects face some challenges. The American Nurses Association and other professional organizations have raised concerns about whether paramedics are receiving enough extra instruction to provide direct care. Some programs need government waivers or legislation to exempt them from restrictions on what paramedics can legally do. In addition, insurers and the government only pay for ambulances and paramedics if people are transported to the hospital.
Perhaps the greatest obstacle, however, is changing the habits of those who call 911 even if they aren’t experiencing an emergency.
“It is really changing the public perception,” said Jim Gubbels, CEO of the Regional Emergency Medical Services Authority, which is spearheading Reno’s project. “We have a fire truck and an ambulance going to a toothache. We are trying to redirect those folks.”
Using a $9.8 million federal grant, Gubbels’ agency launched three different projects. In addition to providing paramedic home visits and offering patients options besides the ER, the agency started a nurse-run health line to give people with health questions another number to call in non-emergency situations.
An early evaluation by the University of Nevada, Reno, which was based on insurance claims and hospital data, shows that the projects saved $5.5 million in 2013 and 2014. They helped avoid 3,483 emergency department visits, 674 ambulance transports and 59 hospital re-admissions, according to the preliminary data. The federal government plans to do its own evaluation.
One of the most successful ventures has been the nurse health line, said Trudy Larson, director of the university’s School of Community Health Sciences. About 2,000 calls a month have come from patients concerned about such problems as stomach pain, flu symptoms or falls.
At the call center on a recent afternoon, one man called with leg pain, wanting to know if he should go to the emergency room. A woman caller had lost her prescriptions and wanted to know where she could get new ones.
“There was a real need for a readily available, easy-to-access source of health information,” Larson said. “It was really clear that 911 was not the solution.”
Reno’s pilot projects have shown that paramedics and emergency medical technicians can help connect patients to the right level of care, said Kirk Gillis, a vice president at Renown Health, which runs hospitals and urgent care centers in Reno and Carson. Readmissions have dropped in part because of the care paramedics are providing to patients with congestive heart failure and chronic obstructive pulmonary disease, he said.
“When someone doesn’t need the expertise and expense of an ER, it’s important to have alternative care providers,” he said.
Sobering Up Safely
The 911 call came in midday on a Thursday. A man had fallen in a local casino and hit his head.
When the ambulance arrived, paramedic Jordan Carter quickly realized that the man was drunk. Carter and emergency medical technician Kristie Hilton did a brief assessment and helped load him onto a gurney. The man with a thick, grey beard and half-closed eyes slurred that he’d been drinking “whatever they served.”
Carter checked the man’s vital signs and determined that there weren’t any immediate medical problems or underlying health issues. “The man’s blood pressure and oxygen level were normal. He knew where he was.”
Carter asked if he wanted to go to a detox facility rather than the emergency room. He agreed. “They’ll give you a place to sober up safely,” Carter told the patient.
Outside the Reno Community Triage Center, Carter and Hilton helped him to his feet. He tumbled through the door as Carter explained the situation to a nurse. “Stay out of trouble, okay?” Hilton said to him before hopping back in the ambulance.
Before the grant, Carter said the only option for intoxicated patients was the emergency room or jail. And if the patients didn’t need any medical care, they just took up beds that could have gone to people with true emergencies.
“It’s better to take him to a place that’s built to treat him,” Carter said. “And it keeps us out on the street.”
The paramedics and EMTs follow strict medical protocols on when to offer other choices to patients. For example, if their heart rate or blood pressure is too high, that requires a trip to the hospital. If patients are eligible for another option but want to go to the hospital, paramedics will follow their wishes.
Although the Reno agency has 16 partners who offer non-emergency care, including an orthopedic clinic, two primary care clinics and an urgent care center, the facilities may not have space or be open when patients need them. If the patients want to – or need to – go to an emergency room, Carter tries to help them avoid future calls.
On a recent day, he took back 56-year-old Tommie Jones, who had already been to the emergency room several times in two months. She’d called because her blood sugar was high and she’d left her insulin at home. On the way, Carter urged her to bring a small diabetes kit with her wherever she went.
Carter said the patients don’t always know how to manage their illnesses, so they wait until they are really sick and then end up in the hospital. “Then the cycle happens again,” he said.
‘A Whole Different Mindset’
Ramsdell is trying to break that cycle for Earl Mayes. Mayes lives alone with a talking cockatiel and a miniature pinscher named Chip. A magnet on the refrigerator reads, “How is your heart health level today?” A basket filled with prescription bottles sits on his kitchen table.
Mayes, a retired truck mechanic, had a pacemaker put in eight years ago. He was healthy until last year, when his lungs filled with fluid.
“I was breathing like a locomotive,” he said. “I never knew you could drown from the inside out.”
The paramedics started visiting Mayes after his release from the hospital last year. Mayes told them he didn’t need their help. That didn’t last. Mayes ended up back in a hospital bed.
After his latest release, Mayes said he followed all of the paramedics’ instructions. He took walks. He stopped eating salty foods. He wrote down his daily weight.
“I got scared,” he said.
During their recent visit, Ramsdell checked Mayes’ vital signs and listened to his lungs. “No water – nice and clear all the way through,” Ramsdell said.
But when he did an electrocardiogram, Ramsdell discovered that Mayes’s heart rate was higher than normal. He told Mayes he would call the cardiologist.
Mayes said he likes being able to call paramedics on their business line day or night. “If I get in trouble, I just have to pick up the phone and I get a straight answer.”
As for Ramsdell and his coworkers, they’ve had to adjust to their new role. They were used to transporting patients to the hospital – not leaving them at home. “We had to change to a whole different mindset,” he said.
But Ramsdell said it was a shift he was glad to make. “People heal better and heal faster if we are able to treat them at home.”
Blue Shield of California Foundation helps fund KHN coverage in California.
Recently the NY Times had an article commenting on the unforeseen consequences of cost-sharing among patients with chronic illnesses like diabetes, hypertension, and heart disease. This is based on a recent study from The National Bureau of Economic Research that observed patients with higher cost-sharing for medications tend to cut back on them which can have deleterious consequences – more ER visits, hospitalizations, and complications from their chronic illnesses. This would then lead to more healthcare spending which is what cost-sharing was meant to decrease. Check out the article below and click on the link above to the study!