Archive for the ‘health care’ Category

What Is The Meaning Of “Life?”

Wednesday, February 22nd, 2017

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. That to secure these rights, Governments are instituted among Men…” – The Declaration of Independence of the United States of America

“People with type 1 diabetes need to take insulin every day to stay alive.” – The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

““I must pay my mortgage.” If it’s a choice between the mortgage and the insulin, “It’s going to be the mortgage.” – 74-year-old Kathleen Washington. Some months, her insulin runs over $300 a month – more than she can afford.” – CBS This Morning, Anna Werner, 22 February 2017

As politicians and high-paid lobbyists dance around the Washington DC Tower of Babel debating the future of health care in America, here are three questions that, as far as I can tell, have yet to be asked:

  1. In the phrase, “Life, Liberty and the pursuit of Happiness,” what did the Founders mean by the word “Life?”
  2. Is good health care an “unalienable” right?
  3. Should Ms. Washington have to choose between paying her mortgage and buying her insulin?

Let’s begin by considering the phrase, “To secure these Rights, Governments are instituted.” Then, consider, “Pursuit of Happiness.” Those two phrases suggest that one of the prime responsibilities of Government is to insure nothing prohibits citizens from being able to seek Happiness. Everyone must have the opportunity to find Happiness for themselves, the key word being “opportunity.” Government doesn’t guarantee Happiness, just that we have the chance to land on it. It’s up to us, but Government must do all in its power to see that unreasonable impediments are not placed in our way.

But what about Life and Liberty? The Founders did not choose to put the word “pursuit” in front of Life and Liberty. What does that mean? If Life and Liberty are unalienable rights that Governments are instituted to secure, what must Governments do to accomplish the mission?

Consider Liberty. Government has created a national defense system to defend our country and, by extension, our Liberty. The Founders recognized taxation as the most equitable means of paying for this, and so every year each of us kicks in our share (although this might be debatable) to guarantee our unalienable right of Liberty.

Now, think about Life.  Some may say Life is what national defense is all about, but, as I have shown, Liberty is more closely aligned with national defense. If the Founders wanted to make Life and Liberty go together, they would have written, Life and Liberty, not Life comma Liberty.

Then what does “Life” mean? For the answer to that center of the bull’s eye question, I turn to those great English philosophers, the Bee Gees: Life means Stayin’ alive. What should Government be doing to secure this first of the three unalienable rights for us? If Type 1 diabetics require insulin every day to stay alive, to continue Life, should Government guarantee they are only able to pursue it, as in the “pursuit of insulin?” Or, to secure the unalienable right of Life, must Government provide the insulin, paid for by taxation of all citizens, as it provides a national defense system?

It is unfortunate that these most basic of questions are not front and center in our nation’s capital. But to truly “secure” our “unalienable Right” to “Life” requires the goring of too many oxen (or, an unlucky Matador), as Joe Paduda writes in his blog today.

Pity the Republicans. They’ve caught Obamacare, like that dog that caught the bus, a trite phrase, but, in this situation, apt. They need to do something, but whatever they do, a large swath of America is going to pour fire and brimstone on their heads. Damned if they do, damned if they don’t.

Too bad. It didn’t have to be like this.

 

 

Barack Obama, I Have A Bone To Pick With You

Monday, February 13th, 2017

Dear Mr. Former President,

I’m writing about the Patient Protection and Affordable Care Act, which you signed into law six years, ten months and twenty-one days ago. That’s 2,519 days. Nearly seven years. Didn’t take but about two hours to become ObamaCare.

The law has saved lives and money, a lot of both. It’s allowed nearly 20 million people to become insured, most of them poor. Those people were able to get that insurance because the law helped them pay for it. The Medicare Hospital Insurance Trust Fund, which in the year before the law’s passage was projected to run out of money right about NOW, is good for another 12 years as of today, according to Medicare’s actuaries as reported by the Kaiser Family Foundation.

No lifetime caps, no pre-existing condition denials, kids on the plan until age 26, free preventive care, donut hole gone, I could go on.

But you, sir, and your administration made a mess of what came after. Consider:

  • You did such a wonderful job of selling the ACA to the American public, that you got waxed in the 2010 mid-term elections. You lost the House big time, 63 seats, and also the super-majority in the Senate, six seats;
  • You had three and a half years to get Healthcare.gov ready, and what happened on 1 October 2013? A system crash that took months to fix. You were warned 18 times prior to scheduled launch that the project was mismanaged and in deep doo-doo, but your team did nothing;
  • You let a clever-as-a-fox, but dumb-as-a-doorpost former Governor of Alaska, of all places, get away with introducing Death Panels into the conversation, and to this day 29% of Americans still believe that lie;
  • You sat by and watched the House of Representatives vote 54 times to defund, delay or outright repeal the law you signed;
  • I could go on.

But it’s your failure to educate the American people and your failure to get down and fight for your signature legislation that bothers me the most. Maybe you should have demanded to get your cell phone back and taken to Twitter like the two-year-old who now sleeps in your used-to-be bedroom. Anything would have been better than the cerebral, thoughtful argument you brought to the battle. Right up there with the old knife to a gunfight thing.

And that is such a shame, because, sure, the law has flaws, but you could have fixed them if you’d been willing to approach the job like Lyndon Johnson, or even Harry Truman. But perhaps that kind of street fighting was beyond the Constitutional Lawyer, the Editor of the Harvard Law Review.

Obamacare had the potential, with a few tweaks here and there, to be a monumental achievement. Instead, it has had a tortured existence and may yet prove to be the only death panel victim.

But, wait. Hold on. Here’s a thought: It is looking more and more as if the Republicans, who now control all three branches of government (well, maybe not the Executive, after all) have become the dog that caught the bus. They do not appear to have a clue. For example, last Thursday the highly-respected Bob Laszewski wrote in his blog, “the repeal part is still on track to occur this spring, … likely in March.” But just the day before, the two-year-old with the Twitter account, who thrasonically said he’d repeal Obamacare on Day 1, told Bill O’Reilly we may not see any changes until sometime in 2018 (but they’ll be beautiful when they happen, really beautiful).

Here’s another thought: Maybe when the public actually begins to realize what it’s about to lose things will begin to change. Maybe when the 35% of Americans who still think Obamacare and the Affordable Care Act are different laws realize they are in danger of losing the Obamacare they hate as well as the Affordable Care Act they love, things will begin to change.

One can only “hope.”

Sincerely,

Tom

P.S. We miss you.

Health Wonk Review: The “words matter” edition

Thursday, January 12th, 2017

obamacare

 

Words matter. Right now, for good or bad, as the torch is being passed from one president to new one, one of the key platforms that PEOTUS ran on was eliminating Obamacare. But as the reality of that potential grows closer, social media is abuzz with debates. It would appear that some people didn’t fully understand what they signed up for. Going viral on Facebook, a poster celebrates the demise of Obamacare, patting himself on the back that he had the good sense to go with the Affordable Care Act instead. This person is not alone – witness the Twitter poster who berates Senator Murray: “Why don’t you shut up Murry. Stop Crying. You lost. We won. We are repleaing Obamacare, not the ACA.” We could post more examples, but you get the point. Polls have repeatedly demonstrated that words matter – the healthcare law is viewed much more favorably as the ACA than as Obamacare.  And a number of insureds don’t realize they are one and the same.  We may soon have the dubious privilege of learning how widespread this confusion is.

Wendell Potter also thinks words matter, and opines that poor communication was among the factors that got us to this point of repeal/replace. At healthinsurance.org blog, he says that “lazy, superficial reporting” – and poor communication from the Obama administration and Congressional Democrats – has kept most Americans in the dark about how repeal of Obamacare would affect them. Potter runs down a list of the health coverage problems Americans faced before ACA implementation … as a preview of the problems that the GOP will resurrect if they can repeal the law. Check out Back from the Future. (A sequel we’ll all hate.)

At Managed Care Matters, Joe Paduda tries to clear up some of the miscommunication with a Q&A aimed right at the insured. Joe has been engaged in a series of posts aptly titled ACA Deathwatch. In his most recent post, he tackles what ACA repeal will mean to the consumer in a basic Q&A format. He looks at post-repeal life under replacement plans, tackling issues like what will happen to your cost, will pre-existing conditions be covered, will plans be inclusive of all conditions, etc.

At Health Affairs Blog, Joe Antos and Jim Capretta look at the The Problems with “Repeal and Delay”, warning that the most likely end result of repeal and delay would be less secure insurance for many Americans and procrastination by political leaders. They lay out the possible legislative scenario that this would follow and document the problems:

“To build a functioning marketplace, and to provide a ready path for all Americans to get health insurance, it is necessary to put together a coherent series of policies across Medicaid, employer-sponsored insurance, and the non-group insurance market. A workable plan will necessarily touch on all of these areas, and will be lengthy and politically contentious. That may not be ideal from a political perspective, but the alternative is incoherence and half-measures that will lead to a system that many Americans will view as worse than the ACA status quo.”

At Colorado Health Insurance Insider, Jay Norris offers a street level view of the level of scrutiny that all things ACA have been under in his post Connect for Health Colorado and the OIG Audit Report. Apparently, the Office of Inspector General (OIG) released an audit report (the full report is here) regarding Connect for Health Colorado’s use of federal start-up funding. This funding was provided for state-run exchanges to get their operations up and running in 2013 and 2014. A poorly worded title on the front page of the report, combined with clumsy explanations in the report gave the media and anti-ACA folks a lot to complain about. Jay dissects the details, asking whether at least some of this falls under the much ado about nothing category.

Of course, not everyone is a fan of Obamacare or we wouldn’t be engaged in these political brouhahas in the first place. In a post entitled Flatline at InsureBlog, Patrick Paule “pulls back the curtain on the fiasco known as Open Enrollment v4.0. Disappointing!”

We do have at least a few entries that aren’t focused on the fate of the Affordable Care Act.

At Health Care Renewal Blog, Roy Poses looks at Dr. Tom Price and finds him wanting, in his post Follow the Money: Nominee for Secretary of Health and Human Services Traded Health Care Stocks and Owned Tobacco Stocks While in Congress. For the uninitiated, Roy is a longtime critic and caller-outer of conflicts of interest as they relate to physicians – something that he as a physician himself is fairly passionate about. He finds the current HHS nominee a little too cozy with big pharma, biotech, device companies and health insurers. But that’s just the least of what Dr. Roy finds objectionable … read up so you can be informed and ready for Tom Price’s cabinet hearing schnduled for January 18.

At Health Business Blog, David Williams says that concierge medicine is well-established in primary care, and now it’s coming to the specialties, too. Concierge pioneer Wayne Lipton explains how the “hybrid” model works and how primary care and specialty practices differ: Concierge Cardiology: podcast interview with Wayne Lipton.

At HealthBlawg, David Harlow ponders whether “Big Data” is too big to analyze productively – reasonable minds may differ. David draws some interesting analogies and concludes that computing power has indeed caught up with our data-generation runaway train. See: Of Borges and Big Data, Or: Is Big Data Too Big?

At Heatlh System Ed Blog, Peggy Salvatore finds bright spots for healthcare in the future, noting that no matter how the economy or politics turn, there are a few constants where people can have some control. Technological advances and wellness movements can help improve national health without increasing the cost of healthcare. See Healthcare’s Future: Population Health and Information Technology.

At The Healthcare Guys, Abhinav Shashank says that as eventful as last year was for the healthcare industry, expect a lot of surprises are in 2017, too. He cites the 21st Century Cures Act and MACRA as transformational legislation, and looks at potential trends and issues we are likely to see in the coming year. See: Healthcare 2017: What Does the New Year Have in Store?

At Healthcare Economist, Jason Shafrin brings us a great video short which reviews a recent publication in JAMA that details health care spending: Health Care Spending is Complicated.

Here at Workers Comp Insider, we forgo our own submission (OK, we’ve been goofing off in the new year) in favor of a post from our friends and colleagues at Work Comp Psych Net. We realize that workers comp is just a sliver of the overall healthcare budget, but we find it an important segment, dealing as it does with the health and safety of American workers. One thing that differs in the occupational arena is healthcare treatment is always working to an outcome, ideally a successful recovery and return to work after a work-related injury or illness. Mental health issues are often  impediments to a smooth recoveries because they are so often not factored in at all. Work Comp Psych Net sheds a light on progress in this area in the post Psychosocial Issues And How To Deal With Them.

Soapbox: As bloggers, we all enjoy speaking our mind.  As political discourse grows increasingly heated, we think it’s worth  this short PSA: Support the First Amendment and freedom of the press. Journalism isn’t free.  You can purchase great editorial cartoons like the one we use in this post at cagle.com. We’d also encourage supporting the Committee to Protect Journalists with donations. Journalists die for that freedom we enjoy.

Next issue: Jan. 25, 2017 – Joe Paduda – Managed Care Matters

The election’s impact on health care: ACA, workers comp, Medicare

Monday, November 14th, 2016

Joe Paduda posted a roundup of opinions on the results of last week’s election, with contributors sharing their thoughts on how the GOP’s sweep will affect health care, health reform, and the health care system: The election’s impact on health care – experts opine.

Before wading in to the fray, Joe reminds us that health care accounts for one-sixth of our GDP, and that it is an incredibly complex, deeply entrenched business.

Joe is a brave man with his crystal ball. Also on his blog, today he takes a look at Trump and workers’ comp. Last week, he offered his initial take on TrumpCare.

Over the weekend, we learn that Paul Ryan plans to phase out Medicare in 2017. Ryan says “What people don’t realize is because of Obamacare, medicare is going broke, medicare is going to have price controls because of Obamacare, medicaid is in fiscal straits.” His proposed “phase in” is contemplated as part of the plan to repeal Obamacare.

Josh Marshall notes:

First, Ryan claims that Obamacare has put Medicare under deeper financial stress. Precisely the opposite is true. And it’s so straightforward Ryan unquestionably knows this. The Affordable Care Act actually extended Medicare’s solvency by more than a decade. Ryan’s claim is flat out false.

Second, I’ve heard a few people say that it’s not 100% clear here that Ryan is calling for Medicare Phase Out. It is 100% clear. Ryan has a standard, openly enunciated position in favor of Medicare Phase Out. It’s on his website. It’s explained explicitly right there.

People voted for change, but it’s not clear that they contemplated a private Medicare system as part of that change.

2016 White Paper Evaluates Commonwealth Care Alliance

Monday, July 18th, 2016

In April, 2016, I authored a post about Commonwealth Care Alliance (CCA), a Massachusetts HMO dedicated to serving the Dual Eligible population. Duals qualify for both Medicare and Medicaid, and CCA has been the nation’s incubator for how to do that. The Boston-based HMO operates a Senior Care Option plan for Duals over the age of 65 and an Affordable Care Act demonstration project, called One Care, for Duals younger than 65. I’ve been a CCA Director since its inception in late 2003.

Now, with the support of the Robert Wood Johnson Foundation, JSI Research & Training, Inc., has published an extensive evaluation of CCA’s visionary and groundbreaking efforts to treat the nation’s sickest of the sick and poorest of the poor.

In JSI’s words:

The provisions in the ACA were designed to achieve the Institute of Health Improvement’s Triple Aim of improving patient experience of care and the health of populations while reducing the overall cost of health care.

The 22-page White Paper’s thrust centers around CCA’s “Social ACO” model of care. JSI describes the Social ACO approach this way:

These approaches are based on the idea that improving health and cost outcomes of vulnerable populations will necessitate incorporating health, behavioral health, and social services into the ACO model. Social ACOs serve populations with complex and often unmet social and economic needs that impact health outcomes and health system utilization, including needs related to housing, food security and nutrition, legal assistance, employment support, and/or enrollment assistance.

As I noted in April, Duals represent only 4% of the nation’s population, but consume 34% of its health care dollars. They present a societal problem begging for a solution. The Affordable Care Act offers revolutionary innovators like CCA the chance to prove their worth. So far, as the JSI paper suggests, CCA’s approach is spot on. Here’s JSI’s conclusion:

As a pioneer of the social ACO approach, its (CCA’s) story offers insights into the factors and processes that promote successful realization of the Triple Aim for other emerging ACOs focused on complex patient populations.

Payment and delivery reform promises to transform care for the nation’s most vulnerable citizens. This is needed more than ever given rising healthcare costs and continued fragmentation of the care system. CCA’s social ACO model represents one approach to caring for some of the highest risk populations, though even this approach has had to be adapted extensively for the dual-eligible population under 65. Given its longevity of refining a care model, a global capitation payment model and a culture of innovation to care for high-risk, vulnerable populations, CCA’s experience is relevant to any provider organization seeking to transform care for high-risk populations.

Achieving the Triple Aim of improving the health of America’s dual population while lowering the cost of doing so is a rabbit-out-of-the-hat trick of the first order, but, at least to this point, Commonwealth Care Alliance seems to be onto something that will do just that.

One final thought: On the eve of our two presidential conventions, it would be nice if, at some point in all the bloviation, a cogent discussion regarding health care were to be had. And I’m talking about something other than, “On Day 1 we’re going to repeal Obamacare.”

But I wouldn’t bet on that happening. Would you?

In Oklahoma, The Times, They Are A’Changin’

Tuesday, May 17th, 2016

In Oklahoma, we are now witness to a confluence of events, unintended consequences of perhaps misguided political and business decisions, that are shakin’ the windows and rattlin’ the walls, to paraphrase the great Bob Dylan. And I’m talking actual and metaphorical.

On the actual side, consider this. Prior to 2009, Oklahoma averaged two earthquakes a year of a magnitude greater than 3.0. Last year, there were more than two a day. Cornell University Seismologists studying this say the rise in earthquakes is unprecedented in terms of sheer volume as well as in how fast the number grew. A 60 Minutes investigation revealed that Oklahoma’s biggest industry, Oil and Gas production, is the likely culprit. Why? Because when oil is pumped out of the ground, wastewater comes with it. A lot of wastewater. Billion of gallons of the stuff. So, rather than put the state under water, industry pumps all that wastewater back deep into the ground where it seeps into and around the faults and techtonic plates causing plate shifting which results in all the earthquakes.

A 2015 earthquake study from Stanford University reported:

“Stanford geophysicists have identified the triggering mechanism responsible for the recent spike of earthquakes in parts of Oklahoma – a crucial first step in eventually stopping them,” wrote Ker Than for the Stanford Review.

“In a new study published in the June 19 issue of the journal Science Advances, Stanford Professor Mark Zoback and doctoral student Rall Walsh show that the state’s rising number of earthquakes coincided with dramatic increases in the disposal of salty wastewater into the Arbuckle formation, a 7,000-foot-deep sedimentary formation under Oklahoma.”

As I write this, the U. S. Geological Survey reports a 3.8 magnitude quake hit about 28 miles northeast of Oklahoma City on Sunday. And for good measure, two other slightly less severe quakes struck within eight hours earlier than the 3.8 quake.

On the metaphorical side, a different kind of earthquake, a political one. And by that I mean the abrupt turnaround of Oklahoma’s Governor Mary Fallon and the Republican controlled legislature regarding adopting Obamacare. Seems the state is nearly bankrupt in terms of funding health care. Hospitals and nursing homes face closure. It is a crisis of monumental proportion. But wait – there’s the Obamacare cavalry coming over the crest of the hill! Politicians now realize that federal funding for Medicaid expansion (Governor Fallos says it’s not an “expansion;” it’s a “realignment.”) looks like a pretty good port in the storm. Naturally, critics are lining up to decry the move, but the legislature appears to be coming around to it.

Who knew? Perhaps when next I look out my 3rd story window pigs will be flying by.

The Sickest Of The Sick, The Poorest Of The Poor

Tuesday, April 5th, 2016

They comprise less than 4% of the nation’s population, yet consume nearly 34% of health care dollars. Sixty percent are age 65 or older. About 40% are younger people with ADL-qualifying disabilities. More than half fall below the federal poverty level. Almost half never graduated high school. Nearly two-thirds are female. Fifty-eight percent are white/non-hispanics.

They are America’s “Dual Eligibles,” our fellow citizens who qualify for both Medicare and Medicaid benefits. Technically, because they’re Duals, they are not the “uninsured.” Still, they sit smack dab in Obamacare’s bulls eye.

In 2003, here in Massachusetts, a pioneering visionary decided to create a non-profit HMO that would offer as its sole product a Senior Care Option plan aimed at the over-65 Dual population. As a former head of the Long-Term Care Division within the Commonwealth’s Medicaid Program, Mass Health, Dr. Bob Master knew a lot about the Duals and the many challenges they presented. Somehow, he convinced a few academics and business people to join his brand new Board of Directors for his Quixotic quest. I was one of them.

In the early days, the hunt for funding was all-consuming, but against considerable odds, funding was found, and, with the support of CMS and Mass Health, an incubator for the nation was born – Commonwealth Care Alliance.

Bob immediately set out to prove that Duals could achieve significantly better health and well-being at lower cost if they were cared for in a home-based regimen by highly trained teams of providers. And between 2003 and 2014, CCA produced eye-popping proof of concept results. For example, thirty-day hospital readmission rates for these sickest of the sick and poorest of the poor consistently beat Medicare’s overall rate. CCA achieved annual Medicare star ratings of 4.5 or better (Because of Senior Care Option demographics, it is statistically impossible for the company to achieve a higher rating).

CMS took note. And when medical, academic and political luminaries were crafting the Affordable Care Act, Bob was instrumental in convincing them Duals were a target not to be missed.

Consequently, the Affordable Care Act created demonstration projects in nine states from California to Massachusetts to see whether it’s possible to improve the health of all Duals, those over the age of 65 as well as under it, while reducing their health care costs. A tall order, indeed, because it had never been done before.

CMS and Mass Medicaid issued a humongously big RFP. Commonwealth Care Alliance answered it and won the right to play in the new sandbox, called One Care. The year 2014 was spent in preparing. For example, in order to be ready, the company had to double the size of staff (there are now more than 800) and train the newbies to successfully manage CCA’s unique model of care. That was not easy.

In early 2015, we opened the floodgates to the state’s thousands of Duals under the age of 65. Since then, it’s been a thrilling ride, because throughout 2015 CCA had a few near-death-experiences. But with the help of both CMS and Medicaid we were able to negotiate the potholes and speed-bumps, and now, after more than a few sleepless nights, the company cares for more than 17,000 Duals with Medicare and Medicaid premium of more than $850 million. In essence, CCA is beginning (barely) to do well by doing good. To my mind, if the Affordable Care Act, Obamacare, does nothing more than significantly improve the lot in life of the nation’s Duals while lowering their cost of care, it will be a success of the first order.

Now, it’s time to turn the reins over to a new era of leadership. Last Friday, we had a retirement party for Bob Master where CCA employees who could free themselves from work for a couple of hours came to Boston to say hail and farewell. Many came on their own time. There was a great big cake and a lake-full of diet soda and coffee, but no dignitaries, just current staff and a number of Directors. The Chair of the Board said nice things about Bob and the ride we’d all been on. I described how, after all this time, Bob and I had discovered less than a year ago over lunch that, in addition to growing up in the next town to each other, we had been comrades in arms back in the late-60s in Vietnam; in the same Division, even, at the same time. Funny, that.

Many employees read stories they’d prepared for the occasion. Honest tears were shed. Bob gave an extemporaneous speech that was heartfelt and touching. He thanked all who had joined in the noble quest, many by name. Then he rode off into the sunset.

But the work goes on.

 

 

 

 

New Health Wonk Review, New Host: ACASignups.net

Thursday, March 24th, 2016

Charles Gaba has posted an all-new Health Wonk Review: ACA Anniversary Edition! at the ACASignups.net blog. It’s an eclectic and robust issue covering an array of topics.

Charles is a new host to HWR and we are delighted with his participation – particularly on this, the 6th anniversary of the Affordable Care Act. Health wonks, policy analysts and the mainstream news media alike all turn to Charles and ACASignups.net to track enrollments in the Affordable Care Act, aka Obamacare. In addition to numbers tracking, his site’s blog is a favored stop. Go there to check out this week’s Heath Wonk Review but also to poke around his site. If it’s not a regular bookmark yet, it should be!

Health Wonk Review: 2015 Holiday Edition

Thursday, December 17th, 2015

We’re happy to host this year’s holiday edition of Health Wonk Review. But before we get to the meat and potatoes, we like to check in on The Santa Index to see how the Big Guy is faring. We’re happy to report that he got a raise of 3.8% or $3,130, bringing his annual wage to $143,054, which seems pretty paltry when you consider that “he’s a manufacturing executive, professional shopper, sleigh driver, delivery person, list checker, and heads a customer service department for nearly 2 billion children.” Insure.com calculates his life insurance needs but we learn nothing about whether he’s getting health coverage through the ACA or not. He engages in some very hazardous work, has adopted some bad health habits — too many cookies, driving too fast and lack of seat belts, to name a few — and has a quite a few risk factors, so he’d likely benefit from the lack of restrictions on pre-existing conditions.

via giphy.com: http://work.neongsan.com/

via giphy.com: http://work.neongsan.com/

 

Affordable Care Act

All is calm, all is bright? Let’s get to the controversies right out of the gate:

At Health Affairs Blog, opponents of the Affordable Care Act propose an alternative plan and to enact major reforms to the tax treatment of employer-sponsored health care, Medicaid, Medicare, Health Savings Accounts, and other areas. In their post Improving Health And Health Care: An Agenda For Reform, authors Joseph Antos, James Capretta, Lanhee Chen, Scott Gottlieb, Yuval Levin, Thomas Miller, Ramesh Ponnuru, Avik Roy, Gail R. Wilensky, and David Wilson say that their plan would “reorient health care policy away from bureaucratic regulation and toward the preferences of patients and consumers.”

However, at least one of our wonks has a bone to pick with one of the study authors. At ACASignups.net, Charles Gaba calls out Avik Roy in a recent post for data “disingenuousness” in his critiques of the Affordable Care Act, and again in a follow-on post for lack of acknowledgment of the problems.

In another matter that many use to signify the death knell of the ACA, United Health has made headlines with its rumblings of pulling out of the exchanges. Would such an exit mean that the that the ACA isn’t viable or is United just not up to the challenge of fierce competition? At Health Business Blog, David Williams offers his perspective in his post United pulls out of ACA exchanges: Should we care?

At Colorado Health Insurance Insider, Louise Norris looks at whether or not open enrollment for health insurance plans should end by December 31 and finds she’s recently changed her mind. Previously, she supported consumers having a chance to review and change auto-renewed plans if they learn that changes resulted in a plan that isn’t quite what they expected. While she still supports as much leeway as possible in plan selection during open enrollment, she explains how the system can be gamed and what the long-term implications for adverse selection and rate volatility would be if open enrollment continues after the coming year’s plans have already started to take effect.

In another hotly contested ACA issue, the Supreme Court has agreed to hear Little Sisters of the Poor Home for the Aged v. Burwell, the latest legal challenge to Obamacare’s birth control mandate. Amy Lynn Smith explains what a win for the plaintiffs could mean for millions of Americans in her post at healthinsurance.org Blog, How millions could lose birth control coverage.

At InsureBlog, Hank Stern is thinking about men’s issues. He reports that the new “healthcare freebies” list is out but notes that “once again men’s health is omitted. But they still get to pay.” Check out his post Still sexist after all these years.

via Ryan Todd at http://christmasgifs.org/artists/todd/

via Ryan Todd at http://christmasgifs.org/artists/todd/

How Docs Get Paid

At Managed Care Matters, Joe Paduda says that changes in the way that providers are reimbursed are painful, but they are necessary. He offers a brief explainer of different methodolologies and tells us the three things we should know about what’s happening with provider reimbursement

How will Medicare reform provider payment going forward? Will they tie payment to quality? If so, how will benchmarks be defined? What about providers who participate in multiple quality incentive programs? In Reforming Medicare Provider Payment, Jason Shafrin of The Healthcare Economist investigates these questions and more.

At The Population Health Blog, Jaan Sidorov looks at the Limits of Financial Incentives for Docs. He examines a recently published study showing that financial incentives did not have as big an impact on physicians as commonly imagined. Jaan argues that’s because physicians live by more than bread alone.

via gify.com: www.werobbanks.com

via gify.com: www.werobbanks.com

Compliance, Data and Legal Matters

David Harlow takes his role in “preventive law” seriously in reminding all members of the “regulated community” to get their affairs in order. At HealthBlawg, he posts about recent enforcement activity by “the federales,” which shows that they mean business when it comes to HIPAA compliance and enforcement: Third Time’s a Charm: Triple-S and its Data Breaches. David says this should serve as yet another reminder that when they eventually kick off the long-promised audit program, covered entities and business associates are likely to feel the sting.

Remember the good old days, when times were simpler, and health technology was all about electronic patient records? Not today. Peggy Salvatore points out that world of health technology is about telemedicine, wearables, data collection and privacy. In her post at Health System Ed Blog, she looks at the challenge of how the health system sould harness all this unstructured patient data: Challenge: Consumer Healthware and the Glut of Unstructured Patient Data. 

Calling medical malpractice “bloggers crack” or the gift that keeps on giving, Bradley Flansbaum dedicates his post at The Hospital Leader to examining the results of the recently released Medscape 2015 Malpractice Report, and he his colorful interpretation: More Med Mal Sustenance

Brain Neong San http://christmasgifs.org/artists/san/

Brain Neong San http://christmasgifs.org/artists/san/

Faulty Ethics at Play

Roy Poses is a health care rabble rouser and we mean that in the most positive way.  At Health Care Renewal, he’s shining a light on “highly unethical” medical trials that involved multiple academic medical centers, including some of the most prestigious in the US – yet which received scant media attention. The studies involved sleep deprivation on physician-trainees. Trainees previously worked up to 36 consecutive hours, which new rules now limit to 16 hours. This increased the number of patient hand-offs, so the study goals were ostensibly to assess a method to reduce the hand-off problem. But Roy makes the case that the trials may have violated several major components of the Nuremberg Code, the set of principles for ethical research that were developed in response to Nazi medical-trial atrocities. Learn more at Drinking the Managerialists’ Kool-Aid? – Why Did Medical Educators Launch Trials of Increased Sleep Deprivation of Physician Trainees Apparently in Violation of the Nuremberg Code?

Finally, we have our own submission, a post by Tom Lynch in which he extends kudos to Work Comp Central’s Greg Jones for his ongoing reportage of the Michael Drobot case. If you are unfamiliar with this half billion dollar fraud case in which docs were given kickbacks for referring patients to surgery and legislators were bribed, you can catch up at this post and an earlier one, Workers’ Comp Fraud: The Drobot Case Grinds On.

James Curran http://christmasgifs.org/artists/curran/

James Curran http://christmasgifs.org/artists/curran/

 

See you in the New Year

This is the final edition of HWR for 2015 so we extend our best wishes for t holiday season. Our wonkers will be back bright and early in the new year: Look for a Jan. 14 edition by Hank Stern at InsureBlog.

 

 

Kudos And Thanks To Work Comp Central’s Greg Jones

Wednesday, December 9th, 2015

Work Comp Central’s Greg Jones has relentlessly followed and reported on the Michael Drobot case in Southern California, a case that fairly oozes greed and sleaze.

For the uninitiated, Michael Drobot’s Pacific Health Corporation owned two hospitals, Pacific Hospital of Long Beach and Tri-City Regional Medical Center in Hawaiian Gardens. For around 10 years, he paid kickbacks to a number of doctors for referring spinal fusion patients to Pacific Hospital of Long Beach for surgery. In February, 2014, Drobot pleaded guilty to making the kickbacks, which are illegal, and for charging California’s workers’ compensation system, the U.S. Department of Labor and about 150 workers’ compensation insurers somewhere in the vicinity of $500 million dollars for the surgeries over the ten year period. At that time, we wrote about this with Honor Sold, Trust Betrayed: Unbridled Greed in California.

Drobot is also charged with bribing state senator Ron Calderon for his help in easing one of the SB 863 requirements, which we don’t need to go into here. Calderon has pleaded not guilty, and that case is moving through the system.

Throughout this sordid business, Greg Jones has been there, providing a valuable service with his spot-on reporting, most recently last week with his story (subscription required) that a number of the doctors who took the kickbacks, at $15,000 a pop, also had filed “more than 15,000 liens with a total claimed value of $93.8 million.” To get that story, Jones had to wade through what must have been a steamer trunk full of documents.

Personally, I owe a debt of gratitude to Mr. Jones. He found two errors in my post of 30 November, Workers’ Comp Fraud: The Michael Drobot Case Grinds On. I had written that the kickback scheme involved both of the Drobot hospitals. That was wrong. They only happened at Pacific Hospital at Long Beach. Also, I had written that Drobot had pleaded guilty to bribing Calderon. He did not. He is charged with doing it, and both he and Calderon have pleaded not guilty. Before Work Comp Central ran my post, Greg found the errors and made edits to correct them, for which I am grateful.

The Drobot case is complicated and it represents the bottom of the workers’ compensation bird cage. However, the solid reporting of Greg Jones shines an arc light on the sorry mess and will help to improve the system so that in the future the Drobots of the world will think twice about this kind of criminality.