Kaiser Health News - Stories (Full text)

How Will The ‘Unbanked’ Buy Insurance On The Exchanges?

Sarah Varney — Mon, 20 May 2013 20:32:03 GMT

When movie stars become unbankable, they’re no longer a slam dunk at the box office. When investments become unbankable, they’re relegated to the junk pile. For ordinary Americans deemed unbankable, those who don’t have a traditional checking or savings account, it can be hard to simply pay bills. And that is about to become a big problem for those who also lack health coverage -- and for the health insurance companies trying to sell them coverage. After all, how do you sell a product to a customer who has no way to pay you?

One in five households in the United States, or about 51 million adults have only a tenuous relationship with a traditional bank, relying instead on check-cashing stores and money lenders, according to the Federal Deposit Insurance Corporation.

The new federal health law which requires most Americans to carry health insurance starting in January presents a particular problem for those households, since most health plans accept a credit card for the first month’s premium payment and then require customers to pay monthly with a check or an electronic funds transfer from a checking account.

Those options won’t work for the so-called “unbankables” looking to purchase health coverage with federal subsidies through online insurance marketplaces, said Dan Schuyler, a director at Leavitt Partners, a firm that is advising private insurers and states on how to comply with the law. “You don’t want to take these millions of unbankable people through the entire enrollment process and then at the end of line say, ‘Ok the only way you can pay for your share of the premium is with a bank account number,’” he said.

The consequences could be severe: After all, when your cable gets turned off, you miss The Walking Dead or Pawn Stars. When your insurance is canceled, starting next year, you’ll be breaking federal law and liable for any medical bills.

Researchers who study consumer financial behavior say people have good reasons to spurn banks. New immigrants, for example, may have distrusted the banks in their home country and brought that skepticism with them to the U.S., and moderate income earners on tight budgets have been stung, they say, by bounced checks when banks unknowingly re-order their transactions. The overdraft fees and checking account fees charged by traditional banks can upend the delicate, and often precarious, financial balance of these households.

“The bank account is extremely stressful when you don’t have a job that’s reliable,” said Tran, a 25 year-old community organizer and Ivy League graduate who lives south of San Francisco, California.

Her current employer does not offer her health benefits, and she was turned down, she said, when she applied for health coverage on her own. Tran hopes to get hired to a full-time position and asked that we use just her last name so it didn’t give her bosses a bad impression.

Tran said when she took her new job and no longer had direct deposit, Bank of America began charging her, up to $12 a month. “I was not happy with the charges,” she said.

Consumers who will be required to purchase health coverage will need payment options that are simple, easy and affordable, say consumer advocates and health care experts.

“I think there is a dawning awareness that this is a large problem,” said Brian Haile, senior vice president for health policy at Jackson Hewitt Tax Service. Up until last year, Haile was wrestling with this problem on behalf of the state of Tennessee where he served as director of the Insurance Exchange Planning Initiative. “We raised these issues with the federal government well over a year ago and in a series of about four or five letters.” Haile said he did not get much of a response then.

Indeed, neither the Affordable Care Act, nor any other federal health laws, require health insurers to accept all forms of payment, including credit cards or the cash-loaded, pre-paid debit cards that people without bank accounts often rely on. Federal officials are wary of doing anything to discourage insurance companies from selling plans on the exchanges, say current and former state health officers who have pressed the U.S. Department of Health and Human Services for a ruling.

One of the largest players on the new exchanges is likely to be WellPoint, a Blue Cross and Blue Shield licensee. In an email, a WellPoint spokesperson said the company was “evaluating expanded payment options to members.” Other health plans, including Cigna and UnitedHealthCare, urged state officials in planning documents to allow companies to set their own payment policies.

Federal health officials issued a letter in April stating that all health plans selling coverage in the federally-run insurance marketplaces in 28 states will have to accept payments in ways that do not discriminate against their customers, but did not prescribe what those payments should be.

Insurance carriers are in a pickle since the transaction fees for credit cards and pre-paid debit cards can run as high as 4 percent. If only one company takes the plunge, its costs are likely to be higher, scaring away customers.

Pre-paid cards, popular with low-wage workers, come with other potential hazards. “If you accept re-loadable debit cards, are you in fact getting folks with lower health status?” said Haile. “That’s a real risk when you’re in the insurance business. So you can’t be the only one picking up those risks.”

Haile has called on federal official to set a uniform national standard requiring all insurers to accept all forms of payment, including credit cards, pre-paid cards and money orders.

Massachusetts, several years ahead of the rest of the country on health insurance reform, prohibited credit cards on its online marketplace because the fees were too high, said Jon Kingsdale, former executive director of the Massachusetts Health Connector. Consumer advocates who want moderate-income families to have easy payment options are themselves wary of credit card late fees and high-interest charges for those who can’t pay off their monthly balance.

For now, it is a problem with no elegant solution. Pre-paid debit cards and credit cards could be options if the federal government steps in to negotiate lower rates with the card companies as it did for tax payments to the Internal Revenue Service, say consumer advocates.

As for Tran, she pays her student loans with a money order, and figures she might do the same when she’s required to buy health insurance starting in January. “I hope I’ll get a permanent job with benefits by then,” said Tran. “You hope for the best and plan for the worst.”

With High Deductible Health Plans, It Pays To Shop Around For Care

Michelle Andrews — Mon, 20 May 2013 09:54:00 GMT

When Maria and Vadim Brodsky's then 7-year-old daughter needed an MRI two years ago to examine a tumor in her head, they took her to a hospital in their health plan’s network and were dismayed to receive a $4,500 bill.

The couple had a $6,000 deductible on their family plan. And even though the bill was reduced to $3,000 — the price the provider and insurer had agreed to by contract — the Brodskys had to cover all of it.

Maria Brodsky and her two daughters Sarah, 9, left, and Rachel 10, right, in the kitchen of their Huntington Valley, Pa., home (Photo by Ed Hille/Philadelphia Inquirer).

The following year when their daughter needed another MRI, the Huntingdon Valley couple took her to a standalone facility and put the procedure on a credit card. The total bill: $600.

Welcome to the new world of health insurance where high deductible plans are growing more popular and the consumers in those plans often have an incentive to haggle with providers.

Although many plans still protect people from high out-of-pocket costs for care, these days an increasing number of consumers have cheaper, high deductible plans where they must cover the first $1,000, $5,000 or even $10,000 of care before insurance kicks in.

For this group, it pays to shop around, say experts.

"It's definitely worth it to look at different hospitals or outpatient services, because prices can vary dramatically," says Carrie McLean, senior manager of customer care at eHealthInsurance.com, an online vendor.

Five years ago, 12 percent of workers faced a deductible of at least $1,000 for single coverage. Today more than a third do, according to the Kaiser Family Foundation’s 2012 survey of employer-sponsored plans. Increasingly, a high-deductible plan, often linked to a tax-advantaged health savings account, is the only insurance offered on the job, even at big companies that have long offered generous coverage.

Proponents of high-deductible plans say consumers will make more cost-conscious health care choices if they have to spend more of their own money. According to an analysis by the Robert Wood Johnson Foundation, consumers in such plans cut their medical spending by between 5 and 14 percent. But results were mixed on whether they cut back only on unnecessary care or on treatment that was needed.

As patients increasingly owe a bigger share of the bill, "providers and patients have gotten creative about paying out-of-pocket costs," says Mark Rukavina, a principal at Community Health Advisors in Boston who consults for nonprofit hospitals. "The price that appears on an invoice may be fluid."

Insurers in recent years have helped ease some of the burden by only billing consumers for the companies' lower contracted rates just for the companies’ lower, contracted rates. And the Affordable Care Act takes some pressure off by requiring many health plans to cover preventive services without applying those charges to the deductible. Still, high bills are a fact of life.

One effective way patients can cut costs is by agreeing to pay cash at the time a service is provided. Many doctors and hospitals offer such "prompt pay discounts."

"If they're willing to pay in cash and I don't have to wait six weeks for reimbursement [from the insurer], I'll reduce the bill by 10 to 25 percent," says Dr. Joseph Mambu, a family physician in Lower Gwynedd, Pa.

Patients who pay hospitals within 30 to 60 days of billing — the time frames vary — can often get up to a 30 percent discount, adds Rukavina.

It's also worth asking a hospital about their financial assistance policies, says Rukavina. They're not necessarily only for uninsured patients. "Many have policies for the uninsured as well as underinsurance and might provide relief for the amounts due after insurance has paid," he says.

Paying directly, however, can have downsides because it bypasses the insurance claims process, advocates warn. For one thing, those immediate payments won’t be applied to the deductible, so if the patient has more medical expenses later in the year, he or she won’t get "credit" for the amount spent. And, if there's an error in the bill, you may not find out about it.

"If you don't use your insurance, the bill won't be reviewed [by the insurer] for errors," says Pat Palmer, the founder of Medical Billing Advocates of America, which helps consumers resolve medical billing problems.

Some patients are willing to take those chances to snag a "cash" discount.

Typically, consumers' medical bills are adjusted to reflect the contracted rate that the provider has agreed to accept from the insurer. This lower rate is applied even when consumers are paying 100 percent of the bill because they haven’t yet satisfied their deductible.

That's how the Brodsky family's first bill was reduced.

Still, it doesn't hurt to ask. "As consumers, we shop around for just about everything else," says Martin Rosen, executive vice president at HealthAdvocate, a company in Plymouth Meeting, Pa., that gives consumers clinical and administrative help to navigate the health system.

Among other tips:

You are more likely to negotiate a lower price for care that's not covered by insurance or that's done by an out-of-network provider, say experts. "Usually patients are very successful in appealing [higher charges for] any out-of-network providers that took care of them while at an in-network facility," says Palmer.

Insurers often have different discount deals with different types of facilities, says Palmer. At a standard radiology practice, the discount for an MRI may be only 20 percent, she says, but it can be 40 percent at a standalone imaging facility. Charges at teaching hospitals are often higher than at other facilities, she says. "Look to have the service done outside the hospital or hospital-owned facility," says Palmer. "It's often going to be less expensive."

Drug prices vary widely, even for generic drugs. A recent Consumer Reports analysis compared prices at 200 pharmacies for five common generic drugs. The variation between the highest and lowest priced stores was a hefty $749 for the five drugs. The takeaway: shop around.

Dawn Herbert, 41, of Philadelphia saves a $14 copayment each month by filling her prescription for generic birth control at Walmart instead of CVS. "Whatever the insurance is paying for that drug, Walmart is considering it payment in full," she says.

Feds Make It Easier For States To Enroll Poor Under Health Law

Phil Galewitz — Sat, 18 May 2013 13:03:00 GMT

The Obama administration is making it easier for states to sign up the poor for health coverage – and to help those people stay covered.

On Friday, it informed state officials that they could simplify enrollment in Medicaid, the federal-state program for the poor, to handle the onslaught of millions of anticipated enrollees next year when the health care law expands coverage. The administration said the changes are geared to states that are expanding their programs, but they may also be adopted by others.

At least 22 states have committed to expanding Medicaid, one of the chief ways the law extends coverage to the uninsured, and several more are undecided, according to consultant Avalere Health. The Supreme Court made expansion of Medicaid optional, and some Republican-controlled states have opted against it.

In a letter to state officials, federal Medicaid Director Cindy Mann laid out several ways states might streamline enrollment for adults, including using data people have already submitted to qualify for foods stamps – a practice that a few states permit for children.

States may also allow adults to stay enrolled in the program for up to a year, even if their income changes, she said.

Allowing adults to stay in the program when their income changes is a “big deal,” said Alan Weil, executive director for the National Academy for State Health Policy. He said it was likely to reduce the large number of people churning in and out of the program, which interferes with their ability to get care. Thirty-two states now use this option for children.

In states moving forward with the expansion, residents with incomes up to 138 percent of the federal poverty level -- or about $33,000 for a family of four -- will be eligible for coverage. About 13 million people are expected to enroll in Medicaid starting next year, according to the Congressional Budget Office.

Mann’s letter outlines several options state can use to streamline enrollment and retention. “Enrollment strategies that target individuals likely to be eligible for Medicaid, and for whom eligibility information is already in the state’s files, provide important advantages both for uninsured individuals and for states,” she wrote.

To help states deal with the demands of increased enrollment, they will have the option in the first three months of next year to extend the Medicaid renewal period by up to 90 days. That means that if an individual on Medicaid comes up for renewal on Feb. 1, their eligibility could be extended to May.

“This is part of our longstanding ongoing effort to continue to simplify and streamline enrollment and renewal in Medicaid, said Donna Cohen Ross, a senior policy adviser at the Centers for Medicare & Medicaid Services (CMS).

Cohen Ross said the administration is employing lessons learned from enrolling children in Medicaid. Louisiana and South Carolina, for instance, have used the food stamp strategy to help sign up thousands of children, but states have not previously had the option for adults.

Similarly, CMS said states can use existing government data to sign up parents whose children were already enrolled in Medicaid.

The IRS' Role In The Health Law Comes Under Scrutiny

Fri, 17 May 2013 15:24:00 GMT

Mary Agnes Carey talks to Joanna Kerpen, a partner at the law firm McDermott Will & Emery, about the role of the IRS in implementing and enforcing provisions of the health law after recent revelations the agency inappropriately targeted conservative groups that were seeking tax-exempt status.

>> Listen to audio of this interview.

MARY AGNES CAREY: Good day, this is Health on the Hill. I’m Mary Agnes Carey. The role of the Internal Revenue Service in implementing the 2010 health care law has come under fire on Capitol Hill. Recent revelations that the IRS has inappropriately targeted conservative groups seeking tax-exempt status has caused some Republicans to say that the agency can’t be trusted to implement the health care law. Many Americans may not even realize that the IRS has a role in the health law, also known as the Affordable Care Act. With us today to discuss the issue is Joanna Kerpen of the law firm McDermott Will & Emery. Thanks so much for joining us.

JOANNA KERPEN: Thank you for having me.

MARY AGNES CAREY: Before we talk about the IRS, we should say that it’s not the only federal agency overseeing the health care law. What are the other agencies and how do they interact with the IRS?

JOANNA KERPEN: Well, because the health care reform law made such sweeping changes to not only the Internal Revenue Code, which the IRS is responsible for, but also to ERISA and the Public Health Services Act, the Department of Health and Human Services and the Department of Labor have been, and will continue to work with the IRS in implementing the changes made by the health care reform law and enforcing a lot of the provisions. However, that being said, because there have been such a great amount of changes to the Internal Revenue Code, the IRS has a very substantial role in implementing the changes under the health care law and enforcing them.

MARY AGNES CAREY: So moving to the IRS, what are the agency’s responsibilities concerning individuals and the health care law?

JOANNA KERPEN: Well, for example, in 2014, individuals are going to be required to carry a minimum level of health insurance coverage or be subject to a penalty. The IRS will be the agency that is responsible for enforcing that penalty and collecting the amounts from the individuals. In addition, as part of the minimum coverage requirement for individuals and the minimum coverage requirement that employers be required to provide to individuals, there will be the need to determine whether or not individuals are eligible for a health insurance premium tax credit, and the IRS will have the responsibility for determining who is eligible for the health insurance premium tax credit.

President Barack Obama spoke Wednesday from the White House about a change of leadership at the Internal Revenue Service after allegations that the IRS targeted conservative groups (Photo by Alex Wong/Getty Images)

MARY AGNES CAREY: The law also places some new responsibilities on employers. What are they and how is the IRS involved?

JOANNA KERPEN: There are several new requirements for employers that interplay with the IRS’s enforcement provisions and governing provision. In 2014, for example, employers are now going to be required to provide coverage that is affordable to employees. And if they do not provide this coverage, they will be subject to a penalty. The IRS is responsible for setting out the rules and guidance for employers in providing this coverage as well as enforcing the rule and collecting the penalty payment from the employers.

In addition in 2018 there will be a tax on what they call Cadillac plans, the high value cost coverage that can be provided to individuals, and the IRS will be responsible for enforcing that rule and collecting any penalties for coverage in excess of the Cadillac plan tax limit. In addition, starting in 2012, which would have been the W2 that was provided in January 2013, employers were now required to include certain information on annual W2s, specifically the value of the group health plan benefits. So beginning with that W2 that was provided in 2013, the IRS has now been tasked with recording all the values of the group health plan benefits that have been recorded on the W2s.

MARY AGNES CAREY: Republicans on Capitol Hill have said that the current controversy over excessive IRS scrutiny of some conservative nonprofits means that the IRS can’t be trusted to implement the Affordable Care Act in a fair manner. Do you think that those arguments will have any lasting impact on implementation of the health care law?

JOANNA KERPEN: I can't speak to whether or not the arguments will have any impact on the implementation. However, I just think that the recent events and disclosures by the IRS of the conduct shows that it is in fact possible for the IRS to behave in this manner. However, that doesn’t mean that they are going to in the future and with regards to the future requirements that are coming out. But you never know.

MARY AGNES CAREY: That's absolutely true. In Washington, you never do know. Thanks so much Joanna Kerpen of the law firm McDermott, Will & Emery.

JOANNA KERPEN: Thank you.

Oklahoma Law Reflects Divide Over End-Of-Life Issues

Michael Ollove, Stateline — Thu, 16 May 2013 12:38:27 GMT

TULSA, Okla. – University of Tulsa law professor Marguerite Chapman has been studying end-of-life issues in Oklahoma for three decades and has come to a conclusion: “It’s getting almost to the point that you need a government permit in order to die in this state.”

Certainly, dying has gotten a lot more complicated here, the result of a unique measure passed by the Oklahoma legislature and signed into law last month by Republican Gov. Mary Fallin.

Modeled after legislation written by the National Right to Life Committee, the law says that patients who are disabled, elderly or terminally ill cannot be denied life-preserving treatments if they or their health proxies want it.

The law also prohibits health care providers from making medical decisions based on the assumption that “extending the life of an elderly, disabled, or terminally ill individual (is) of lower value than extending the life of an individual who is younger, nondisabled, or not terminally ill.”

Idaho is the only state with a similar law, but with a crucial distinction. It says the wishes of the patient or proxy must be followed “unless such care would be futile.” The Oklahoma law contains no such qualifier.

Supporters say the Oklahoma law will prevent doctors from acting against the wishes of desperately ill patients and their families who want the battle for life to continue. Critics counter that it will inhibit doctors from discussing the full range of options to patients near the end of life, raising the likelihood that they will undergo invasive, costly and often futile medical interventions with the pain and risks those procedures entail.

At the other end of the spectrum from Oklahoma, the Vermont legislature this month passed a bill legalizing physician-assisted suicide. Oregon and Washington have similar laws, the result of ballot initiatives approved by voters.

Philosophical Divide

Although the Oklahoma law received little attention at home and has gone virtually unnoticed elsewhere, it revisits a philosophical divide that has periodically gripped the nation. On the one side is the palliative and hospice care movement which holds that terminally ill patients should be able to forgo high-risk, low-odds treatments in favor of comfort care at the end of life. On the other side is a branch of the right-to-life movement which believes that doctors are inclined to withhold life-preserving treatments when, in their opinion, a patient’s life has lost its “value.”

Spearheading the effort to pass the law was Tony Lauinger, the courtly, frosty-haired chairman of Oklahomans for Life, who is regarded by even his political opponents as being the consummate gentleman with considerable influence in the Oklahoma legislature.

In an interview, Lauinger expressed deep suspicions about physicians, even though he is married to one, the father of another, and the father-in-law of a third. “In many states,” the one-time seminarian said, “this phenomenon has become more prevalent, with people saying they want life-preserving care being overridden by providers who, I guess, feel they know best.”

Lauinger didn’t mention any actual cases in Oklahoma where a doctor had refused life-preserving treatment despite the protestations of the patient or family members. The bill’s chief sponsor in the House, Rep. Dennis Johnson, a Republican, talked about an Oklahoma doctor wanting to take an elderly patient off a ventilator despite his wife’s protests.

Despite sharply divided opinions during the bill’s debate, the measure passed easily, 41-2 in the Senate and 85-11 in the House.

“We are starting to see a trend nationwide,” Johnson said. He said that the law’s origins go back to the case of Terri Schiavo, the Florida woman in a vegetative state whose husband and parents battled in court for seven years over his desire to remove her feeding tube.

The husband prevailed and the feeding tube was removed in March 2005 to the consternation of activists in the pro-life and disability movements. Schiavo died within days.

Is Law Pro-Life?

Despite Lauinger’s involvement, some who identify themselves as anti-abortion say they are unhappy with the law that they regard as contrary to compassionate medical treatment at the end of life.

“Endorsing futile care in the name of being pro-life is to me the antithesis of pro-life,” said Donna Spivey, a medical social worker with the palliative care team at Hillcrest Medical Center in Tulsa who considers herself resolutely anti-abortion. “This law is not going to benefit them; it will cause harm to them.”

While the Oklahoma State Medical Association remained neutral on the final bill, Jennifer Clark, palliative care director at the University of Oklahoma’s School of Community Medicine here, emerged as the leading medical opponent of the legislation.

The law, she said, is based on a faulty premise about a doctor’s role at the end of life. “Palliative care medicine elicits a person’s goals and value systems and works with that patient and the patient’s providers to determine what the best options are to meet those goals and values in the context of the medical situation,” Clark said.

Her concern, she said, is that the law will force doctors to perform surgeries with extremely low chances of success but high risk for death or further harm to patients already in fragile condition. “There are situations where we cannot take that person to surgery because we think it’s certain death, but under this law, we’d have no choice,” Clark said. “It asks us to violate our primary oath which is first to do no harm.”

Inhibiting Doctors

Palliative care experts fear the new law will prevent doctors from having honest and candid conversations with patients at the end of life to make the medical condition completely clear and the various options and the ramifications of each. Elise Dunitz Brennan, a prominent health care attorney in Tulsa, said she fears doctors will now refuse to inform patients or their proxies of the true risks of some of those procedures for fear of being seen as violating the law.

“If you try to educate a health proxy about the alternatives, when does it become going against the proxy’s wishes versus trying to provide education?” Brennan said. “This law totally interferes with the collaborative decision-making process.” She said she now would advise her physician clients not to raise objections to risky surgeries if that’s what a patient or proxy wants.

At the urging of the state’s medical association, the bill’s sponsors agreed to an amendment that says that injunctions granted against doctors for violations under the act cannot be construed as an automatic finding of negligence against that doctor. Brennan said, however, that the provision won’t protect doctors from negligence lawsuits from family members.

Will Doctors Leave?

Although supporters of the bill said the law will not interfere with advance directives in which patients specify what treatments they want or don’t want in dire medical circumstances, Brennan said she doesn’t believe those documents will guarantee that proxies won’t use the new law to override the patient’s wishes if the patient can’t communicate.

In her argument against the law, Clark of the University of Oklahoma said that she fears it will prompt doctors to leave the state, which already ranks among the 10 states with the lowest number of doctors per resident.

Frank Gaffney, a Tulsa cardiologist, said he is thinking of leaving because of the law. The previous week he had had a very sick patient with a poor chance of survival. He told the patient’s family that the man had a very slim chance of surviving an invasive cardiac procedure that Gaffney believed offered the merest chance of saving his life and a high risk of ending it.

The family insisted on the surgery. “If you’re not allowed to say this might be futile, you put a physician in the position of murdering someone,” Gaffney said. He performed the surgery; the patient died.

Senate Confirms Tavenner To Head CMS

Wed, 15 May 2013 23:01:00 GMT

KHN's Mary Agnes Carey talks with Jennifer Haberkorn of Politico Pro about the Senate's confirmation Wednesday of Marilyn Tavenner to head the Centers for Medicare and Medicaid Services and the challenges she will face.

>> Listen to audio of this interview.

MARY AGNES CAREY: Welcome to Health on the Hill, I’m Mary Agnes Carey. Today the Senate confirmed Marilyn Tavenner to lead the agency that oversees Medicare and Medicaid. Tavenner now becomes the first confirmed head of the Centers for Medicare & Medicaid Services since 2006. With us to discuss this development is Jennifer Haberkorn of Politico Pro. Thanks Jennifer for being with us.

Tavenner (Photo via HHS)

JENNIFER HABERKORN, POLITICO PRO: Thanks for having me, Mary Agnes.

MARY AGNES CAREY: Marilyn Tavenner had a much easier time than her predecessor, Don Berwick, who was President Obama’s first nominee to head CMS. Why?

JENNIFER HABERKORN: You’re right. It was really like night and day. Don Berwick ran into a ton of opposition once it became public that he made comments in support of the British health care system. Marilyn Tavenner, on the other hand, did not have a history of controversial statements. If there are skeletons in her closet, no one has really found them yet. She had a relationship with the Hill; she was at CMS for several years before her confirmation hearing at Senate Finance [Committee], which went swimmingly.

There was also a significant amount of time between the health law’s passage when politics, particularly over health care, was at its peak on Capitol Hill. Don Berwick on the other hand, came up shortly after the health law passed, when emotions were very raw. So, it really was night and day – totally different situations.

MARY AGNES CAREY: While many Republicans supported Marilyn Tavenner’s nomination today on the Senate floor and House Majority Leader Eric Cantor also supported her, before the Senate could vote on Marilyn Tavenner’s nomination, she had to overcome objections of a key Democrat. Can you tell us about that

JENNIFER HABERKORN: That’s right. Tom Harkin, one of the health law’s greatest supporters on Capitol Hill objected because the Obama administration keeps taking money out of the Prevention and Public Health fund, which is kind of his baby in the health care reform law. And he put a hold on Tavenner’s nomination, meaning it couldn’t come up for a vote on the Senate floor for about a week.

He made it clear that he supported Tavenner’s nomination, but wanted to do this to make a point. And senators have done before on other nominations. He wanted to make a point that the Prevention and Public Health Fund should not be touched anymore.

MARY AGNES CAREY: Why hasn’t CMS had a confirmed administrator since 2006? What’s been the hold up there?

JENNIFER HABERKORN: It's mostly been politics. There was a Republican nominee who came up at the end of the Bush administration. It looked like he was about to get confirmed and then at the last minute a Medicare regulation came out that angered some Senate Democrats and they effectively stopped his nomination.

There was Don Berwick, who we talked about, was nominated by President Obama and ran in to Republican opposition. Health care is an easy target, politically. The Centers for Medicare & Medicaid Services has one of the largest budgets in the federal government and has a lot of authority. With that there is a lot of things to criticize. So those nominees have gotten hung up. And there's also been moments when presidents have decided not to nominate anyone at all. When President Obama was first elected, it took him several, several months before he put up a nominee.

MARY AGNES CAREY: What difference do you think Marilyn Tavenner's confirmation will make in the implementation of the health care law?

JENNIFER HABERKORN: I don't think it will make a significant difference, particularly because she has been in this job in acting capacity for about a year and half already. But at the same time, these Republican senators, particularly the ones who voted for her, can now call her up and say "Where are you on such and such provision?" and "I have problems with the health law on this aspect, what are you going to do about it?"

And just having her in that confirmed role makes it a more even-handed conversation. She's been confirmed. She's gotten that senator's vote and they need to have a conversation. But in the grand scheme of things, it won't change too much.

MARY AGNES CAREY: Speaking of the health care law, Department of Health and Human Services Secretary Kathleen Sebelius has caused some concern on Capitol Hill about her efforts to raise money to implement the law. What's the latest there?

JENNIFER HABERKORN: Right now a lot of Republican senators are paying a lot of attention to the issue and expressing concerns that it could be illegal for her to go to companies that she regulates. HHS has said it has contacted providers and religious groups to promote the health care law and that it is legal under the Public Health Service Act to encourage programs that promote public health. I think we are going to see continued attention on the issue. It's not going to go away. Right now a lot of the oxygen on Capitol Hill is taken up by Benghazi and the IRS. But definitely they are going to come back to this and we might see Secretary Sebelius have to answer questions publicly about what happened.

MARY AGNES CAREY: Thanks so much Jennifer Haberkorn of Politico Pro.

JENNIFER HABERKORN: Thank you.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

How A Florida Medical School Cares For Communities In Need

Greg Allen, NPR News — Wed, 15 May 2013 17:31:00 GMT

If it's a Monday, you can usually find Dr. David Brown parked next to a lake in Miami, spending the day inside a 36-foot-long RV. He's not on vacation.

Brown is chief of family medicine at Florida International University's medical school. The RV is the school's mobile health clinic.

With community-based health care a central part of its curriculum, Florida International University's medical school turned an RV into a mobile health clinic so that students could treat families in neighborhoods where medical care is scare (Photo by Greg Allen/NPR).

Every Monday it's parked at the Royal Country Mobile Home Park in northwest Miami-Dade County. "It's a beautiful place right here," he says. "But this is not a wealthy community."

Brown helps direct FIU's Neighborhood HELP program. It's part of the school's curriculum that connects medical students with families in neighborhoods where medical care is scarce.

Students visit families in their homes where they conduct examinations and provide basic care. But some things are better done in a clinic. So the medical school bought its own RV. "We're able to bring free basic primary care to our households relatively close to their community," Brown says.

In one of the RV's exam rooms, third-year medical student Veronica Alvarez met recently with patient Maritza Flores. Flores has diabetes and high blood pressure. With help from the school's faculty, Alvarez has been treating her since January.

Flores says with Alvarez's encouragement, she's begun exercising more and has improved her diet. And, thanks to FIU's doctors, she's begun taking medication for her diabetes and high blood pressure. In just a few months, Alvarez says, she's seen a big improvement. "The high blood pressure and the diabetes together is what you worry about," Alvarez says. "And now, her diabetes is well-controlled and her hypertension is well-controlled as well."

Over the last decade, a pressing need for new doctors has led many universities to open medical schools. Seventeen new schools have been accredited since 2005, and several are looking at new ways to train doctors.

When it was founded just four years ago, Florida International University took on a mission — to improve the health of nearby communities. Another focus for the school is to train more doctors in primary care.

Nationally, there's a shortage of primary care doctors — one that's expected to worsen as millions more Americans get access to health care under the Affordable Care Act.

But Dr. John Rock, the medical school's dean, says the two missions go together. Sending students out to treat patients in their communities teaches them the art of primary care.

FIU just graduated its first class from the medical school. Nearly half of the students, Rock says, are doing residencies in primary care.

Several other new medical schools are also developing programs that allow students to develop ongoing relationships with patients. And there are others that, like FIU also have a social mission — to improve the quality of life in medically-underserved communities.

In Miami, that includes places like Miami Gardens, where med student Danny Castellanos got to know a family that has 10 members, including a great-grandmother and five children.

Castellanos saw the family as part of a team that included a faculty advisor, a nursing student and a social worker. One of the first things they did was get all of the children qualified for Medicaid, which paid for their coverage.

Over the three years, Castellanos became involved in the healthcare of the entire family, including most recently the great-grandmother. She's now taking part in a telemedicine pilot program.

Castellanos says the school installed an electronic unit in the household. "It has a screen," he says. "It has a camera. It has a blood pressure cuff on it, a stethoscope which allows us to hear the heart sounds. We just ask her to place it in certain areas on her chest, ask her to put the blood pressure cuff on. And we get those kind of readings electronically."

The telemedicine pilot will be evaluated for its cost-effectiveness.

But, overall, FIU's Rock says the school's focus on improving the health of targeted communities already is a success.

And for families in the program, the benefits are even more tangible. They're much more likely now to receive regular checkups and less likely to use emergency rooms. "We also have increased health literacy, so they have a keen understanding of what some of the issues are," Rock says.

Doctors Transform How They Practice Medicine

Ankita Rao — Wed, 15 May 2013 10:03:00 GMT

Dr. Thomas Bellavia transformed his traditional medical practice in Hasbrouck Heights, N.J., into a so-called medical home where patients are seen by teams of doctors and nurses. He says it has paid off in better, more coordinated care for his patients and healthier income for the nurse practitioners and physicians in his group.

Dr. Mark Holthouse took a different tack -- limiting his El Dorado, Calif., clinic to 400 patients a year, and adding services such as acupuncture and fitness coaching. He said he and his team now spend more time with patients, who pay a monthly fee of $220 for a package of basic services, on top of what their insurance plans reimburse the practice.

Like Bellavia and Holthouse, many doctors are changing how they work in response to turmoil in the health care system. Both newly minted and veteran physicians face economic uncertainty amid sharpening demands from the government and insurers to improve quality while curbing costs – trends that accelerated under the 2010 health care overhaul.

The buzz, and anxiety, in the medical profession is palpable – trade magazines tout new coping strategies, doctor groups discuss the transformation of practices. Physicians are experimenting with business models and new practice techniques, hoping to find work that is both financially and personally rewarding.

Dr. Thomas Bellavia

"It's not just the financial piece," said Dr. Susan Turney, president and CEO of the Medical Group Management Association, the nation's largest membership group of medical practice managers.

"It's also the clinical -- it's bridging a gap so you can make the best decisions all around."

The changing landscape is reflected in the growing number of doctors who are employed by others, rather than working for themselves. Consulting firm Accenture reported in 2012 that the proportion of independently practicing physicians, working in groups or solo, will fall to 36 percent this year. One-third of those will choose a subscription-based model like Holthouse's.

The majority, though, are seeking steadier salaries and hours: about 91,300 doctors and dentists were employed by community hospitals in 2010, according to the American Hospital Association, 30,000 more than in 1998.

But clinicians remaining independent must invest and innovate.

Bellavia’s goal of offering integrated care has cost him an estimated $300,000 since 2011 for staff training and equipment. The medical home model’s focus on preventive care includes newer technologies, like a weighing scale that reports a patient’s weight directly from home to the clinic, and reminders to patients of routine diabetes or cancer screenings. The Heights Medical Center, as the practice is called, has also expanded from two to five doctors and nurses, and hired a patient coordinator who organizes doctor visits, referrals and prescriptions.

With a medical home accreditation from the nonprofit National Committee for Quality Assurance, the Heights receives higher reimbursement payments per patient from insurance companies like Horizon Blue Cross Blue Shield of New Jersey and Aetna.

"It was all experimental," Bellavia said. "I had to transform my staff and the way I practice. But it has paid me back considerably."

While Bellavia figured out how to increase his insurance reimbursements, doctors like Holthouse are trying to insulate themselves from the insurance system and government budget cuts.

In 2005, Holthouse started what is sometimes called a functional medical practice – a setup that incorporates acupuncture, herbal medicines and a nutrition and exercise program. He soon found that the only way to remain profitable was to increase the number of patients treated at the practice, now called the n1Health Center for Functional Medicine -- something he thought would compromise the quality of care.

"We couldn't deliver the kind of care we wanted to with regular insurance," he said.

With the subscription, or concierge, model that he introduced in January, Holthouse will treat about eight to 10 patients a day who pay about $2,600, in addition to the reimbursements paid by their insurance plans. By contrast, each provider at Heights Medical Center treats up to four patients per hour. Holthouse also has an herbal pharmacy with supplements and nontraditional remedies, and an acupuncturist on staff as part of his effort to offer alternative treatments along with traditional medicine.

Patients at Holthouse’s practice are still responsible for an insurance copayment for medical services that aren’t covered under the monthly fee, which accounts for basic diagnostic tests, physicals and screening. Despite the monthly costs, Holthouse said his patients supported the changes after the practice held 15 “town hall” meetings to explain the new model.

"By the time we did the conversion, one hundred percent understood why we were doing it," he said. "They feel like they're getting time and quality care."

He also said that patients were spending less on medications and hospital fees, making the subscription a worthwhile investment.

Holthouse, like Bellavia, does not accept patients with Medicaid, the state-federal program for low-income people, because of the low reimbursement rates. He puts little confidence in the federal government when it comes to paying physicians fairly or streamlining the high cost of health care– one impetus for choosing the subscription-based model.

But James Doulgeris, a health care strategist at research and marketing firm HCP, said physicians who adopt innovative practices will benefit from the federal health law, because it gives financial incentives to doctors and hospitals that hold down costs while improving quality.

"It's a 180-degree change, but physicians will have a great incentive to provide optimal care and focus on wellness," he said.

Holthouse, however, is not convinced. "Unless you remain independent, you will have no say in what kind of medicine you practice," he said.

Hospitals, Testing Companies Face Questions About Value Of Community Screenings

Julie Appleby — Tue, 14 May 2013 10:00:00 GMT

Hospitals hoping to attract patients and build their brands are teaming up with medical-screening companies to promote tests aimed at consumers worried about potentially deadly heart disease or strokes.

What their promotions don't say is that an influential government panel recommends against using many of the tests on people without symptoms or risk factors. The panel says such screenings find too few problems to outweigh their drawbacks, which include false positive results, follow-up procedures and potentially unnecessary surgery. Other medical experts warn that the tests could needlessly raise health-care spending.

Inova Health System, one of the Washington, D.C., region’s largest hospital networks, is partnering with a screening company called HealthFair to blanket the region with direct mail and advertisements promoting a $139 package of what it describes as “five life-saving tests for heart disease and stroke.” The tests, which usually are not covered by insurance, are performed in specially equipped buses, operated by HealthFair, that carry the Inova logo and travel to different locations.

Inova Health System partners with screening company HealthFair, which provides specially equipped buses to run tests aimed at finding heart and stroke risk factors. This bus, painted with Inova’s logo, conducted recent screenings in a church parking lot in Manassas, Va. (Photo by Karl Eisenhower/KHN)

Similar programs by other hospitals are taking place in dozens of cities across the country, including Richmond, Va., Tyler, Texas, Marin, Calif. and the suburbs of Chicago.

"A lot that ends up being found is clinically of no importance at all," said Steven Weinberger, executive vice president and chief executive of the American College of Physicians.

Such screenings “not only can raise [health care] costs, but also can lead to additional testing that is harmful,” Weinberger and two co-authors wrote in the Annals of Internal Medicine journal in August, calling hospital involvement without disclosing potential downsides “unethical.”

But Inova and other hospitals say the screenings help raise awareness of heart disease and stroke and spur important discussions between patients and their doctors. Consultants say they are also a way to create community good will and draw new patients and revenue.

"We know the incidence of finding a disease where the patient has to do something about it today, or tomorrow, or next week, is very low, but that's not why we engaged in the screening," said David Spinosa, an interventional radiologist and medical director of the Inova Heart and Vascular Institute. “If people learn they have early signs of a disease -- if their physicians know that -- then they have an opportunity to aggressively modify their risk factors.”

Spinosa said that about 45 percent of the 8,000 people screened since the program's inception had some abnormal finding, mostly on the mild side; critical problems were uncovered in fewer than 1 percent of cases.

Inova doesn't pocket anything from the testing; in fact, it pays HealthFair to put the Inova logo on the buses. But patients can sign a form allowing someone from the hospital group to contact them to discuss abnormal findings, and a list of Inova doctors is available on the buses.

"It's a way to promote brand awareness and have someone sitting there who can say, 'I have just the doctor for you,' " said Mitch Morris, of Deloitte, a consulting firm whose clients include hospitals. “If they hook someone up with a primary care physician, that sets up in many cases a lifetime of patronage to that health system."

David Andrews, marketing and public relations manager at Inova Fairfax Hospital, declined to say how much the five-hospital chain pays HealthFair, or how many referrals it gets as a result of the testing.

“Hospitals want to do outreach. They feel they need to,” said Joelle Reizes, global communications director at Life Line Screening, an Ohio-based firm that partners with 180 hospitals to offer screenings. [But] there's also a philosophical debate here: Do people have a right to know what's going on inside their bodies and have screenings they feel are right for them?”

Why Some Tests Are Controversial

Hospitals have long done screenings, sending mammogram units to community events and sponsoring health fairs, where people can get their blood pressure tested. There is widespread agreement that some tests -- such as those for high blood pressure and diabetes -- are safe and effective and that they lead to better health outcomes.

But the five-test basic package advertised by HealthFair is much more elaborate. It includes ultrasound tests for blockages of the carotid artery and weak spots in the abdominal aorta; a resting electrocardiogram, or EKG; a test of elasticity of the arteries; and another for blockages in arteries serving the legs, a condition called peripheral arterial disease. Similar test packages are offered by Life Line Screening and its hospital partners.

The U.S. Preventive Services Task Force, an independent government panel charged with evaluating such care, recommends against routine use of four of the five tests in adults without symptoms or risk factors. The panel does support the ultrasound looking for abdominal aortic aneurysms -- but only for men age 65 to 75 who have smoked.

Additionally, two of the tests -- EKGs and ultrasounds for blocked carotid arteries -- are among 130 procedures that a coalition of 19 physician organizations say are overused and should be questioned by both patients and their doctors.

False-positives, or results that erroneously indicate disease, are more likely when screening widely for a condition that affects only a small percentage of people – for instance, narrowing of the carotid artery, a risk factor for stroke estimated to affect about 1 percent of people over age 65.

Because the condition is so rare, the task force estimates that 4,348 people would need to be screened with both ultrasound and a follow-up magnetic resonance imaging test to prevent a single stroke.

The test “is potentially selling false reassurance to some people and at the same time, it’s really frightening others,” said Glen Stream, board chairman of the American Academy of Family Physicians, which lists the carotid test as an overused procedure. “Let’s say a patient is 65 years old and has a 60 percent block. It might have been 60 percent since that person was 40 and hasn’t changed.”

‘These Tests Don’t Do Harm’

HealthFair CEO Terry Diaz said in an e-mail that early detection of risk factors for heart disease and stroke saves lives, and HealthFair’s data “clearly indicate that a large percentage of the asymptomatic population do, in fact have unknown disease processes forming.”

Of 220,000 tests the company performed in a recent nine-month period, 11.6 percent showed mildly abnormal results and another 2.1 percent had results at least moderately abnormal, according to data provided by the firm.

Diaz's statement notes that many of the country's almost 50 million uninsured people cannot afford regular health care. "HealthFair was created to fill this gap" by offering relatively low-cost testing packages and then partnering with hospitals to contact those with abnormal results, it says.

Diaz said the company, based in Winter Park, Fla., follows the recommendations of the American College of Cardiology Foundation and the American Heart Association on which patients should get screening tests. He added that while further study is needed to "truly determine the effectiveness of those tests in determining cardiovascular risk, the ACCF/AHA clearly supports the screenings that HealthFair performs."

HealthFair staff member Jasmin Reed takes Tim Blauvelt's blood pressure, one of the tests the Manassas resident received during his recent appointment, held inside the firm's specially equipped bus. (Photo by Karl Eisenhower/KHN)

But the groups' guidelines do not support routine screening of the general public with some of the tests HealthFair promotes.

Spokeswomen for the two groups confirmed that their guidelines recommend against the measure of arterial stiffness for adults without symptoms. The guidelines say the carotid artery test is reasonable only for those with some risk factors.

A check of the peripheral arteries could be appropriate if a patient has trouble walking or had non-healing wounds or leg pain when resting. A third test -- the resting EKG -- "may be considered" to assess cardiac risk in adults without symptoms, the guidelines say.

John Gordon Harold, president of the American College of Cardiology, said in an e-mail that the guidelines from his group and the heart association do not endorse HealthFair or any other screening company. "Neither organization recommends broad screening or specific drugs, devices or companies in those guidelines," he said.

Screening proponents say the efforts are worthwhile despite the small number of serious problems found in part because they spur important discussions between patients and doctors.

"These tests don't do harm. People are not exposed to radiation," said Johnna S. Reed, vice president of business development at Bon Secours St. Francis's Health System in Greenville, N.C., which began doing screening programs with Life Line Screening a year ago. "I want people to have this information."

Worried Consumers Sign Up

Fear of stroke or heart attack is what draws many people to screening programs, including Thomas White, 29. The Chantilly, Va., resident recently paid $350 for a package that includes the five basic tests, along with several others checking for risk factors for heart disease.

“I’ve had several coworkers who have had heart problems,” said White, who had the tests at an Inova/HealthFair bus parked in a Walmart parking lot. “One of them died. I’m a family man, so I wanted to make sure I’m ok.”

White, who has no health insurance, said he would try to find a doctor to discuss the results. He admits that what he really needs to do is quit smoking.

Corrinne Naranjo, 66, of Centreville, said the tests were worth the time and money.

“How many people are walking around with diabetes and don’t know they have it? Or heart problems?” she asked.

All of the patients at the HealthFair bus the morning White and Naranjo were there said that direct mail or newspaper advertisements had prompted them to sign up for the tests. Some of the mailings included a cover letter that said “80 percent of strokes can be prevented” -- a figure questioned by some experts, including HealthFair’s medical director.

“I’m not aware of any study that proves that number,” said Geoffrey Toonder, a retired cardiothoracic surgeon, whose signature appears on the mailing.

More Limited Screenings At Other Hospitals

Area hospitals that do not participate in the HealthFair promotion provide more limited screenings for heart disease and stroke risk, and in most cases the tests are free.

Suburban Hospital in Bethesda, Md., for example, offers free screenings for abnormal or diseased veins in the legs. After a quick visual exam, patients with potential problems might be referred for ultrasound tests, for which the patient would have to pay, said Andrew Schulick, a vascular surgeon. Suburban does not sponsor the screening packages offered by HealthFair or Life Line.

Schulick said that in his opinion screening the general population is not "achieving a whole lot in terms of improving community health, because you're not going to find a lot of people" with problems. He said that anyone older than 60 with risk factors -- such as hypertension, a history of smoking, diabetes, high cholesterol or a family history of heart disease or stroke - are "the folks who ought to get screened."

Shady Grove Adventist and Washington Adventist sponsor some tests that the U.S. Preventive Services Task Force recommends against as a broad screening measure, including ultrasounds of the carotid arteries and checks for peripheral arterial disease.

(Photo by Karl Eisenhower/KHN)

The hospitals, part of Adventist HealthCare, say they offers the tests free at least twice a year and ask patients if they have any risk factors, including being older than 50, smoking and having diabetes, or high blood pressure or cholesterol, said Kathleen Coleman, the system's Cardiac & Vascular Outreach Coordinator for Health & Wellness.

And a few hospitals are actually moving counter to the trend, deciding to scale back or end their heart risk and stroke screenings.

Thomas Jefferson University Hospital in Philadelphia, for example, is wrapping up a year-long screening effort with HealthFair this month, according to spokeswoman Lee-Ann Landis.

While the effort did promote brand recognition, it uncovered too few serious health problems and resulted in too few referrals of new patients to be continued, said Landis. About 20 patients of about 5,000 screened sought additional help through Jefferson, she said.

HCA Virginia Health System in Richmond plans to end its general community screening program through HealthFair, but it will offer the service to employers that request it, said spokesman Mark Foust.

“We want all of our public screenings to be completely appropriate,” he said.

Coverage Problems Could Still Remain For Young Adults

Michelle Andrews — Tue, 14 May 2013 10:00:00 GMT

Supporters and critics of the Affordable Care Act seem to agree on at least one thing: Allowing young adults to stay on their parents' health plans until they reach age 26 is a smart move. The change, which took effect in the fall of 2010, has resulted in more than 3 million young people gaining health insurance.

Starting next year, young adults will have more options for coverage in addition to their parents' plans. But despite the expanded choices, some may continue to face problems commonly associated with their age group—coverage for mental health issues, substance abuse and maternity care.

A recent study illustrated the extent to which young people may previously have had difficulty obtaining care. It found that those who enrolled in their parents' plan after the health law passed were more likely to have claims for maternity, mental health and substance abuse services than adult children who were already covered by their parents' plans. Experts note that adult children who joined their parents' plans may have had unmet treatment needs before they had the option to join Mom and Dad's plan. Individual health plans they might have applied for typically refuse to cover people with preexisting conditions. They also generally don't cover maternity care.

The study, published by the Employee Benefit Research Institute, examined the 2011 claims of one large employer that covered more than 200,000 workers and their family members. Before the health law provision went into effect, unmarried student dependents could remain on the worker's coverage until age 23, but most non-students had to find other insurance after they turned 19.

More From This Series Insuring Your Health

The EBRI study found that nearly 700 young adults enrolled in their parents' plan after the health law was passed. The average health-care spending for those adult children was $2,866 in 2011, 15 percent higher than spending by dependents who were already on their parents' plan. This newly enrolled group was also more likely to have costs related to pregnancy, mental health and substance abuse than their peers.

Next year, health plans will no longer be able to turn people down because they have preexisting medical conditions. This will free young people to shop around for individual coverage on state-based exchanges or the private market if they don't want to stay on their folks' plan. All non-grandfathered individual and small-group plans will have to cover 10 "essential health benefits," including maternity and newborn care and mental health and substance abuse services.

In addition to the comprehensive plans available on the exchanges, young people up to age 30 will have the option of choosing a catastrophic plan there. The plan will cover preventive services without any cost sharing as well as three primary care doctor visits. The plan covers the essential health benefits, though only after a $6,350 deductible is met.

Despite such requirements, some coverage isn't assured. For example, employers in the large-group market don't have to cover the essential health benefits. Young women enrolled in such plans might find themselves without maternity coverage if they become pregnant. The Pregnancy Discrimination Act of 1978 requires employers with 15 or more workers that offer insurance to cover maternity care. But the law doesn’t cover dependent children. Dan Priga, who heads the performance audit group at human resources consultant Mercer, estimated that roughly 70 percent of self-funded employers who pay their workers’ claims directly don’t offer maternity coverage for dependent children.

Medicaid may be an option for some of these women. The joint state-federal health program for low-income people generally provides coverage for pregnant women with incomes up to 185 percent of the federal poverty level. By counting a pregnant woman as a household of two, that ceiling is $28,693 in 2013.

If she meets income requirements, the Medicaid program can also "wrap around" a young woman's parents' policy and provide maternity coverage her parents' plan lacks, says Karen Davenport, director of health policy at the National Women's Law Center. "It's not necessarily a seamless, easy thing to do," says Davenport, "but it would cover the gaps."

Potential gaps in mental health and substance abuse coverage under the health law are addressed to a large degree by the Mental Health Parity and Addiction Equity Act of 2008, experts agree. The law requires employers with more than 50 workers to ensure that patient costs and coverage for mental health and substance abuse services are equivalent to those of other covered medical services. Providers are awaiting final federal regulation on implementation of that law.

But there's a catch: Many mental health counselors and addiction specialists who provide outpatient services don't participate in any health insurance plans. So even though a health plan may offer coverage, some people must pay out of pocket for their care.

For example, up to half of physicians who specialize in treating addiction don’t take insurance, estimates Stuart Gitlow, president of the American Society of Addiction Medicine and a psychiatrist in private practice.

"I could get more money by taking insurance, but I'd also have greater expenses," he says.

Insurance coverage does make a difference in inpatient care, says Gitlow, such as when someone enters a facility to go through a process of detox and rehab.

But most people with addiction problems don't require that level of care, he says.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

Oregon's Medicaid Lottery: A Participant's View

Jordan Rau — Fri, 10 May 2013 14:55:00 GMT

A study of Oregonians who won a 2008 state lottery to get Medicaid benefits has sparked an intense debate about the value of expanding health care to the poor and about the benefits of health insurance in general. The researchers reported in the New England Journal of Medicine last week that those who gained Medicaid coverage used more health services than low-income residents who had not been accepted into the program. But the Medicaid enrollees did not show significantly better blood pressure, cholesterol and blood sugar levels than the other group, although they had lower rates of depression.

After winning the lottery, Mary Carson, 55, was accepted into the Oregon Health Plan, the state's Medicaid program, in 2011. She and her partner live with her three children. They earn about $1,000 a month by making and selling replicas of historic battle knives used in the Civil War and the two World Wars, doing odd jobs and providing respite care for people with cancer. Her comments on a popular blog about some of her own experiences on Medicaid have garnered some attention.

Kaiser Health News interviewed Carson by phone this week. The following is an edited transcript of the interview.

Q: Where did you go for health care before you won the Oregon lottery?

A: There was a low-income clinic that would see people without health insurance, so that’s where I was going when I had no health insurance. They would see people for $25 a visit, so that was enough to keep my prescriptions filled. I have high blood pressure and depression so I need three or four different medicines. I’ve gone to some of the clinics for people with no insurance: a giant group of people in a basketball court, trying to get their tumors looked at. It was just so depressing and doesn’t seem very American and seems wrong.

Q: How did lacking insurance affect your medical care?

A: At one point I needed some cortisone for my asthma and they wanted to do a complete heart work-up to make sure that my troubled breathing wasn’t congestive heart failure. You're always telling them, "No, no, no, this is the only thing I want." It's like trying to buy the burger with no fries at McDonalds. You have this resistance all the time, because doctors and nurses look at you with these big soft eyes and say, "But it would be so important to know your level of cardiac health, I'm really concerned. I'm sure the doctor there will work out something and make payment arrangements." And it sounds so good and you do it and it never works out. The discount isn't there or you fill out something wrong and all of a sudden you have a $300 bill in collections. So you have to make sure none of that happens to you.

Q: When you went on Medicaid and could afford blood tests, what did you learn?

A: I found out I have really low Vitamin D levels, that my cholesterol isn't really good, but it's not really bad. There are things I need to change in my eating and exercise. My blood sugar, I'm pre-diabetic, just on the edge of needing diabetes medication, so I need to watch what I eat. It's hard to eat really healthy when you're on food stamps because you get $3 a day for groceries and you're not going to get a whole lot of lean meat and vegetables for $3 a day.

Q: How has your health changed since you went on Medicaid?

A: Over the course of nine months or a year I was able to drop two different blood pressure medicines, which is nice because they had side effects I didn’t like. So I'm down to half a pill of one of the medicines and my blood pressure is still stable. For about a five-year period I thought my thyroid medicine was too low and I couldn’t afford the doctor visit to have the lab slip to have the labs read to get a new prescription. That whole procedure is about $300 so I just stayed with the same medicine. With Oregon Health Plan I was able to go back to the doctor and when she said wanted check my thyroid levels I could say, "Yes, I'll go to the lab and get that done." They were low again. I was able to get that increased and that made a big difference in how much energy I had and how much better I felt.

Q: Has Medicaid helped you address all your health issues?

A: One of the problems I'm having is I need to find someone to prescribe my antidepressants. This clinic is nice but the doctors don't want to prescribe antidepressants, so I need to find a psychiatrist to do an evaluation. And I'm having a really hard time finding someone who will see me while I'm on OHP. I've been working on this since last fall, and I still can't find a doctor who will see me.

Q: If you had hadn't won the Medicaid lottery, where do you think you'd be financially and medically?

A: Financially, I'd be maybe $100 a month poorer. I would not be monitoring my blood sugar. I would not be paying as much attention to my cholesterol. I probably would have lost some weight but I don't think I would have lost so much, and I don't know if I would have been so good at keeping it off. I'd be much more anxious about what could go wrong. One of the things you get in Oregon is you get your teeth cleaned and X-rayed once a year. I hadn't been to the dentist in six or eight years except to have a tooth pulled. So it was really nice to have my teeth cleaned and find out I don't have cavities and don't need my teeth pulled. My father died of melanoma and there's a lot of melanoma in my family—one of my sons had skin cancer when was he was 15—and so that's a worry. Being able to go to the doctor and have my moles checked was a big weight off my mind. I'm a lot surer I'm going to be able to make it to 70 without being crippled or in a wheelchair and not being able to take care of myself.

And there's something about just feeling like you're part of regular life. There's a lot of emphasis on how everyone should be healthy and everyone should live longer, and you don't want to be a burden on society. If you don’t have medical insurance, you're kind of not part of that. It's hard to explain, but there's an element of participating in society that being able to go to the doctor gives you. Everybody always asks everyone how you're doing, and to be able say "My doctor says I’m doing really well," that's nice, instead of being in a group of people and saying, "Well, I don't really go to doctors."

Q: The Oregon study did not find significant health improvements for those who won the Medicaid lottery versus those who did not, with the exception of improvements in self-reported depression. Some commentators have seized on these findings to argue that having Medicaid does not lead to better health. Do you agree with that?

A: Some people have completely lost track of what health insurance is supposed to be. We're talking about somebody being able to get their broken arm fixed if they fall out of a tree. My blood pressure is still not perfect, but over the last two years I have stopped taking two different blood pressure medicines and am only taking half of a third. That is a health improvement but it doesn't necessary show up in the study. My blood sugar is not perfect, but it's more consistently in the right zone. But according to the study, I haven't improved.

Most of the people who are going to be on Medicaid are going to be working. What are you supposed to do if you're working at McDonalds' 30 hours a week? You're working all the hours they give you. Why shouldn't they be able to go to the doctor? Why should they have to lose everything they own if they break their arm and have to go to the emergency room? Everybody can't go to college and get a good job. Somebody is always going to work in the nursing home. Somebody is always going to work part-time at JC Penney even though they want to work full time, because the store only wants them there on Saturday and Sunday. Those people need to make enough money to live on, they need to have enough food to eat and they need to be able to go to the doctor when they're sick.

jrau@kff.org

Colorado Exchange Board Spars Over Federal Funding

Eric Whitney, Colorado Public Radio — Fri, 10 May 2013 09:54:00 GMT

Here's the question making the rounds in Colorado: Is the state asking for enough start-up money from the federal government for its online health insurance marketplace?

The Colorado State Capitol (Photo by Alexander Meins via Flickr).

Consumer advocates are worried the answer is "no."

Statehouse Republicans, on the other hand, think it’s asking for far too much.

Colorado exchange CEO Patty Fontneau is playing Goldilocks, saying the $125 million federal grant request she wants to send to Washington is just right.

Colorado is bumping up against a May 15 deadline to apply for its third and final federal grant to launch its insurance exchange, recently re-branded as Connect for Health Colorado.

The $125 million request, if granted, would push total federal funding for Colorado’s exchange over $185 million.

Consumer advocacy groups, including the broad coalition known as the Colorado Consumer Health Initiative, think the request should include more than the current $10.5 million line item for a customer assistance network to help people buy policies in the exchange and figure out if they’re eligible for premium subsidies. Nationwide, funding for the online marketplace's consumer assistance will vary widely between states.

If Colorado’s network is underfunded, "frustration and withdrawal from a few will lead to withdrawal from the enrollment process by many as word spreads about long wait times or impersonal or inadequate assistance ultimately leading toward bad press for the exchange," CCHI wrote in one of three letters the state’s exchange board received from consumer groups criticizing proposed navigator funding levels. Navigators are the people who will provide help to individuals seeking to buy insurance through the exchange.

“The long-term viability of the exchange strongly depends on its success in the first year when Coloradans initial experiences will shape their impressions of the exchange for years to come,” echoed a letter from a second coalition that includes AARP, Boulder County and safety net health care provider Denver Health.

Exchange CEO Fontneau responded that Connect for Health Colorado is budgeting more for navigators than the $10.5 million in the federal grant request. She expects an additional $4 million to $6.5 million will be channeled to the exchange from administrative fees assessed on each policy sold, about $22 per year per policyholder. The exchange has also requested more than $2 million for the program from private foundations.

GOP Concerned About Tax Burden

Some Republicans have the opposite concern: that Colorado is requesting too much federal money.

Colorado’s exchange, "should be funded through operating revenue, it’s not fair to put the burden on the federal taxpayer," says Dr. Mike Fallon, a physician-entrepreneur Republican lawmakers appointed to Colorado’s exchange board. He’s angry that Colorado increased its grant request after learning in January that the grant could be used to fund operations beyond 2014.

“What we were going to pay for ourselves we’re now asking the feds to pay for,” he said.

Fallon doesn’t have enough allies on the board to modify its very pro-White House bent, but his opposition to the pending grant request this week stirred the body’s most fiery debate yet.

Other board members, including the head of the state’s Medicaid agency who serves in an ex-officio role, said the state should err on the side of asking for more money than it estimates it will need and return any unused funds.

But guessing the amount the state will need is difficult. If a relatively high number of people use the exchange immediately after it opens, a lot of revenue will be generated that can be used for operations. But if enrollment numbers are initially low, the state will need to lean on federal funding more to maintain the new infrastructure.

Fallon scoffed at suggestions that Colorado should ask for a high number and then pay back any unused federal funds.

“I believe your intentions are genuine,” he told a fellow board member, “but I’m cynical any government body will not spend” every dollar it has.

Fallon’s anger was echoed by Republican state lawmakers on a special exchange oversight board who reviewed the grant request Tuesday.

State Rep. Bob Gardner said the size of the request “leaves me fairly speechless."

“We were given to understand that we were running the leanest, most cost-effective exchange in the country,” Gardner said, “so it’s disappointing.”

Other members of the committee seemed incredulous that the exchange would need another nine-figure sum after Colorado’s legislature had only days earlier approved the $22 per policyholder per year fee, as well as agreeing to send it any remains from the state’s now-disbanding high risk insurance pool.

“If [the exchange] were a private concern I think you’d be looking for a job,” Republican Senator Kevin Lundberg told exchange leaders Tuesday. He and other oversight committee members were under the impression that the exchange wasn’t planning to request additional funding beyond that in the measures approved by the state legislature. Democrats on the committee said they never heard that as those bills moved through the legislative process.

Republican Senator Ellen Roberts was angry that the committee’s sole meeting this legislative session came just one day before the session ended. And being asked to sign off on an 80-page federal grant request just days before its submission deadline clearly displeased her.

“The timing is horrible,” she said, “I’m almost without words.”

Republicans on the oversight committee are essentially powerless to thwart exchange board decisions this year. The state law that created the oversight committee allows its co-chairs to approve exchange board actions. This year, with Democrats controlling the state House and Senate, that means both of those seats are held by Democrats.

And Democrats on the committee stood up to defend the grant request.

“We as Colorado taxpayers are paying” to fund exchanges nationwide, said Senator Jessie Ulibarri, “and if we choose not to use it, one of our neighboring states can apply for and receive those funds to set up their own exchanges, and then we’ll have an increasing cost for access to health care for our own residents.”

Colorado’s $125 million exchange grant request to Washington is still in draft form. The exchange board will hold a phone conference Friday to work out any details before submitting it in time to meet the May 15 deadline.

This story is part of a collaboration that includes Colorado Public Radio, NPR and Kaiser Health News.

California Weighs Expanded Role For Nurse Practitioners

Pauline Bartolone, Capitol Public Radio — Thu, 09 May 2013 09:51:01 GMT

As state governments get ready for the Affordable Care Act coverage expansion, some are taking a close look at their networks of health care professionals to make sure they will be able to meet increased demands as more people gain health insurance. California is one of 15 states expected to consider legislation this year that would give advanced practice nurses more independence and authority.

Nurse Practitioner Tina Clark examines Anastacia Casperson during a follow-up appointment (Photo by Andrew Nixon/Capital Public Radio).

Tina Clark is a nurse practitioner at Glide Health Services, a clinic in San Francisco's Tenderloin district, a low-income section of the city. Glide is run by nurses with advanced training. A physician visits the clinic 12 hours a week, to sign forms and consult on difficult cases. Even under current law, Clark can see patients without a doctor in the room.

Anastacia Casperson, who has struggled with homelessness and drug addiction, came to the clinic because she was alarmed about swelling in her legs. Clark spends a half hour with Casperson, gives her a prescription for a diuretic and talks to her about quitting smoking. Casperson says she's been coming to this clinic for a few years.

"They have compassion for a client. They have understanding for a client," Casperson says. "I like the nurses here because they're like one big family, and they all work together."

Right now, California law says nurses must follow procedures set after consulting a doctor. But lawmakers are considering eliminating that requirement. And that idea doesn't sit well with some doctors.

"Nurses and nurse practitioners are a very, very important part of the health care team, but they are part of a team," says Dr. Paul Phinney, President of the California Medical Association.

Phinney’s group is opposed to allowing more independence for nurses. He says they don’t have as much training and may not know as much about testing and technology as doctors.

Plus, he says, there’s nothing in the bill that would require the empowered nurses to go where they are needed most.

"I would be very surprised if -- should this bill pass -- that all of a sudden, you'll see a massive egress of nurse practitioners out into medically-underserved areas. I just don't see that happening," he says.

But University of California San Francisco health care economist Joanne Spetz says research shows otherwise.

"Nurse practitioners are more likely to practice in settings that serve large shares of Medicaid patients, and they’re somewhat more likely to practice in rural communities," Spetz says.

Nurse practitioners can be trained much more quickly than a physician, and their compensation is lower, Spetz points out.

"So when a legislature is looking at the insurance of hundreds of thousands of people and the demand for care that those people are going to have, getting health professionals to meet their needs as quickly as possible and as cost-effectively as possible is a real need," Spetz says.

The next step for the California bill on nurses is a hearing in the state Senate Appropriations committee on Monday.

This story is part of a partnership that includes Capital Public Radio, NPR and Kaiser Heath News.

Health Perks Geared To Top Workers Could Trigger Penalties Under Health Law

Julie Appleby — Thu, 09 May 2013 09:51:00 GMT

Many executives have long enjoyed perks like free health care and better health benefits for themselves and their families. But under a little noticed anti-discrimination provision in the federal health law, such advantages could soon trigger fines of up to $500,000.

Employers “should be more concerned about this than anything else” in the law, because many are in violation and the penalties can be stiff, says Jay Starkman, chief executive of Engage PEO in St. Petersburg, Fla., which offers human resources services and advises clients on the health law.

The provision says that employers who offer more generous benefits to highly paid workers could face fines of $100 a day for every worker who doesn’t get the perks, up to $500,000.

It applies to employers who buy benefit packages for their firms from insurers. Those who self-fund their coverage, who tend to be larger firms, already face similar restrictions under Internal Revenue Service rules which pre-date the law.

To make sure his own small company complies with the law, Starkman began paying $600 in premiums toward his family’s coverage last month, putting him on an even playing field with his 60 employees.

He says the rule makes sense, noting that executives are likely to get little sympathy from the public.

“The right way to handle it is to have the same benefits for everyone,” he says, noting that firms can increase wages to managers or executives to cover their additional costs.

But business owner Steve Diddams worries that complying with the provision could erase his profits.

Diddams, owner of seven Diddams Party & Toy retail stores in California, has about 100 employees, most of whom are paid hourly and who don’t get health insurance. But because he offers about 20 managerial workers HMO coverage, he might fall afoul of the discrimination rule. He could also be subject to a $2,000 per worker penalty for not offering coverage to his hourly employees, although lawyers say they’re not sure he would face fines for both.

Raising his prices to cover the cost of expanded health coverage really isn’t an option. “Our customers are moms with kids, and it comes to a point where they are not going to pay $2 for a balloon,” Diddams says.

The anti-discrimination provision is technically in effect now, but the IRS says it will not impose penalties until it completes regulations and issues guidance about how the provision will be enforced.

Employers are likely to have until 2015 to figure out whether they comply, says Terry Dailey, a partner at Mercer, a benefit consulting firm.

The IRS rule offers guidelines explaining who is a highly paid employee, and says a plan discriminates if it favors such workers in terms of eligibility or benefits.

There are differences between the IRS rule and the federal health law provision. For example, if a self-insured firm is found to violate the IRS rule, the employees getting more generous benefits could end up paying taxes on their value. In contrast, the federal health law imposes fines on the employer, most of whom are expected to be small and mid-sized firms.

Congress likely saw the provision as “an additional deterrent to [employers] picking and choosing” who gets health coverage,” says attorney Timothy Tornga, of Mika Meyers Beckett & Jones in Grand Rapids, Mich., who advises employers.

Those penalties “fall especially hard on the small business population,” and may encourage some small firms to switch to self-funding their medical coverage, says the Small Business Coalition for Affordable Healthcare, which represents firms involved in agriculture, food service and retail, in comments submitted to the IRS.

In seeking comments, the IRS asked employers and others how to define “benefits.” Do they include, for example, not just the coverage provided, but how much employees pay toward those costs? Some firms, for example, charge executives less than other employees – or nothing at all – toward coverage. Would that count as being discriminatory?

Some groups don’t think so, and are urging the IRS to exclude the employee contributions from its calculations. Benefits are “limited to only those goods and services that are payable by the plan,” says the American Benefits Council, a trade association for employers.

The U.S. Chamber of Commerce, saying the older IRS rules that the federal law builds upon are unclear, rarely enforced and “unworkable,” wants the agency to replace them entirely rather than issuing rules “similar” to them.

Mercer’s Dailey says there are no good national statistics on how many employer plans might be considered discriminatory under the law.

Any fully insured plan that existed before the health law, and which has not been significantly changed is “grandfathered” and therefore exempt.

“We don’t see … [discriminatory policies] every day, but it’s not infrequent,” he says. “There will be many employers who will need to look at their plan designs and potentially make changes.

Medicare Lags In Project to Expand Hospice

Jordan Rau — Thu, 09 May 2013 09:51:00 GMT

Despite a three-year-old order from Congress, Medicare has yet to begin an experiment to expand hospice services to allow beneficiaries to continue potentially lifesaving treatments to see if it would save money while improving the patients' quality of life.

The demonstration project would eliminate one major reason that people are reluctant to take up Medicare's hospice benefit: they have to first agree to forgo curative treatments such as chemotherapy.

Nurse Rachel Haenel embraces terminally ill patient Jackie Beattie, 83, at the Hospice of Saint John in 2009 in Lakewood, Colorado. A demonstration project would allow those getting hospice care under Medicare to also receive curative care at the same time (Photo by John Moore/Getty Images).

Many rapidly declining patients delay entry into hospice until their final days as they exhaust their treatment options, according to studies.

Others end up dying in hospital intensive care units, which are expensive and generally not geared to making the terminally ill as comfortable as possible.

The 2010 health law required Medicaid to pay for joint hospice and curative treatments, called concurrent care, for children. More than half the states have taken steps to implement that in the joint federal-state program for low-income residents. It also instructed the secretary of Health and Human Services to select up to 15 sites to test concurrent care for patients in Medicare, which provides health coverage to seniors and disabled people. That test is to last for three years, but Medicare has yet to take any concrete steps toward beginning it.

"It is missing an opportunity," said Dr. Randall Krakauer, an Aetna executive who helped establish that insurer’s concurrent care program for people with private coverage. "Our own experience is when you do liberalize the hospice benefit, it does not cost you extra and it may actually cost you less."

Krakauer said several years ago, Aetna asked Medicare for permission to expand the program to the 448,000 elderly enrolled in its private Medicare Advantage plans—with Aetna promising to pay for any extra costs — but never got a response. "We are very interested in participating in this," he said.

Officials at the Center for Medicare & Medicaid Innovation, which is supposed to oversee the project, declined to discuss why the project has not begun or when it would start. "CMS has expressed its commitment to implementing a project that will test new ways of delivering hospice care to Medicare beneficiaries," the agency said in a written statement. "This demonstration would allow beneficiaries to receive both palliative and curative care at the same time, which could provide better overall care to the patient."

J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Association, said that in private conversations officials say they want to move ahead. "We are still very hopeful that they are interested in conducting the study," he said.

Even with its restrictions, hospice is one of the fastest growing parts of Medicare. In 2011, 1.2 million Medicare beneficiaries used the benefit, double the number a decade before. Medicare spent $13.8 billion on hospice, with an average per patient of $11,342.

Hospice advocates have long argued that palliative care, which focuses on easing pain and not trying to prolong life, is not only more humane but also less expensive. A study, published in March in the journal Health Affairs by a team of researchers led by Dr. Amy Kelley, found that when patients enrolled in hospice three months or longer before they died, Medicare’s expenses were lower than for those who never used the benefit.

The average expense to Medicare of those patients enrolled between 53 and 105 days was $22,083 for those in hospice compared to $24,644 spent on those beneficiaries who did not elect the benefit.

It's not clear whether allowing Medicare recipients to receive curative and palliative treatments at the same time would save money. Aetna estimated it saved 22 percent on people under 65 who were part of its broad program with hospice and more curative care. But no one has been able to do a rigorous study of how it will play out for Medicare patients. The health law requires Medicare not to spend more money on the patients in the demonstration project than it otherwise would have.

In a report to Congress last year, the Medicare Payment Advisory Commission wrote that "it is uncertain whether this type of approach would yield savings" without closer management of the services that Medicare beneficiaries choose.

Some health policy experts privately fear that delay may have a political component. End-of-life care is an acutely sensitive subject given the hyperbolic accusations of "death panels" that some opponents lobbed at the health law during the debate in 2009 and 2010.

"Is it residual anxiety related to the whole death panel thing, or is it a matter of money? Who knows," said Dr. David Casarett, a professor at the University of Pennsylvania's Perelman School of Medicine and director of Penn's hospice and palliative care program. "The effect is very negative for end-of-life care in the country. The way hospice is designed now may have worked fine 30 years ago, but it doesn’t work now and we need to think about alternatives."

jrau@kff.org

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Health Law’s Medicaid Expansion And Online Marketplaces Offer Veterans New Care Options

Michelle Andrews — Tue, 07 May 2013 09:58:00 GMT

Military veterans will have more health insurance options under the Affordable Care Act, but some vets, like many Americans, may still struggle to find affordable, accessible care that meets their needs.

Roughly 40 percent of the 22.3 million military veterans receive health-care services from the Veterans Health Administration, which operates a nationwide network of medical centers, hospitals and clinics.

More From This Series Insuring Your Health

Many veterans are eligible for both VA health care and Medicare, Medicaid or Tricare, the health plan for active and retired military and their families. About half of veterans have private insurance; approximately one in 10 veterans younger than 65 are uninsured.

Veterans who were honorably discharged after being on active duty for at least two years may qualify for VA health services. Since funding for the VA health program is limited, however, priority is given to veterans who have service-related disabilities or low incomes.

Although there are no premiums for VA health care, some veterans may owe co-payments for services. Veterans who return from active military duty are typically eligible for free VA health care for five years.

Under the Affordable Care Act, most people will have to have health insurance starting in January or pay a penalty. Veterans who are enrolled in VA health care won't have to buy additional coverage, although they can supplement their coverage if they want to.

Mike Sage, 64, a Vietnam War combat veteran, pays $15 per visit for primary-care services and $50 for specialist care at the VA clinic near his home in Monmouth, Ill. Prescription drugs are $8 for a 30-day supply. But his wife, Kay, like many veterans' spouses, doesn't qualify for VA health care. They plan to check out the policies offered on the Illinois health insurance exchange this fall to see if there's a better option than the catastrophic-coverage plan with a $5,000 deductible that she currently carries.

Sage was relieved to learn that his VA health care counts as coverage under the ACA. "As long as I'm not subject to a penalty [for not having insurance], we'll do some comparative shopping for her," he says.

Kay Sage might qualify for a premium tax credit for coverage on the exchange if the couple's household income is between 100 percent and 400 percent of the federal poverty level ($15,510 to $62,040 for a family of two in 2013), according to the Treasury Department.

The expansion of Medicaid under the Affordable Care Act -- which states are currently wrestling over whether to implement -- could also affect veterans' health care. The law allows the expansion of the federal-state program for low-income people to include adults with incomes up to 138 percent of the federal poverty level ($15,856 in 2013).

According to an analysis published by the Urban Institute last month, four in 10 uninsured veterans have incomes below 138 percent of the federal poverty level, potentially enabling them to qualify for Medicaid if their states expand the program. Most of those veterans have incomes below 100 percent of the poverty level.

"For these veterans, it's critical that their state expand Medicaid," says Jennifer Haley, a research associate at the Urban Institute who co-authored the report.

In states that don't expand their programs, veterans whose income falls below 100 percent of the poverty level will generally not qualify for Medicaid, nor for subsidized coverage on the exchanges.

Even though a non-disabled veteran may meet the income threshold for VA health care -- nationally, about $34,000, further adjusted by geographic location -- he or she may not live near VA facilities or know that VA care is available, according to the report.

At a hearing last month before the House Committee on Veterans' Affairs, VA officials said they expect a net increase of 66,000 veterans seeking health care through VA facilities when the mandate to have health insurance kicks in next year.

Some veterans will come into the VA system but others will leave to seek coverage on the exchanges or through Medicaid, they said. Those who are eligible for more than one health program may pick and choose, using one program for cheaper prescription drugs, for example, and another for specialist care.

But more choices may not mean better care, says Kenneth Kizer, director of the Institute for Population Health Improvement at the UC Davis Health System.

In an opinion piece published last year in the Journal of the American Medical Association, Kizer, a former VA official, noted that having access to multiple plans can lead to fragmented care, increasing the chances of errors and other complications.

"Tests get repeated, drugs get prescribed that may not be compatible with each other," he says. "One provider may not realize what the other is doing."

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

Doctors' Diagnostic Errors Are Often Not Mentioned But Can Take A Serious Toll

Sandra G. Boodman — Mon, 06 May 2013 19:33:46 GMT

Until it happened to him, Itzhak Brook, a pediatric infectious disease specialist at Georgetown University School of Medicine, didn't think much about the problem of misdiagnosis.

(Illustration by Jesse Lenz)

That was before doctors at a Maryland hospital repeatedly told Brook his throat pain was the result of acid reflux, not cancer. The correct diagnosis was made by an astute resident who found the tumor -- the size of a peach pit -- using a simple procedure that the experienced head and neck surgeons who regularly examined Brook never tried. Because the cancer had grown undetected for seven months, Brook was forced to undergo surgery to remove his voice box, a procedure that has left him speaking in a whisper. He believes that might not have been necessary had the cancer been found earlier.

"I consider myself lucky to be alive," said Brook, now 72, of the 2006 ordeal, which he described at a recent international conference on diagnostic mistakes held in Baltimore. A physician for 40 years, Brook said he was "really shocked" by his misdiagnosis.

But patient safety experts say Brook's experience is far from rare. Diagnoses that are missed, incorrect or delayed are believed to affect 10 to 20 percent of cases, far exceeding drug errors and surgery on the wrong patient or body part, both of which have received considerably more attention.

Recent studies underscore the extent and potential impact of such errors. A 2009 report funded by the federal Agency for Healthcare Research and Quality found that 28 percent of 583 diagnostic mistakes reported anonymously by doctors were life-threatening or had resulted in death or permanent disability. A meta-analysis published last year in the journal BMJ Quality & Safety found that fatal diagnostic errors in U.S. intensive care units appear to equal the 40,500 deaths that result each year from breast cancer. And a new study of 190 errors at a VA hospital system in Texas found that many errors involved common diseases such as pneumonia and urinary tract infections; 87 percent had the potential for "considerable to severe harm" including "inevitable death."

Misdiagnosis "happens all the time," said David Newman-Toker, who studies diagnostic errors and helped organize the recent international conference. "This is an enormous problem, the hidden part of the iceberg of medical errors that dwarfs" other kinds of mistakes, said Newman-Toker, an associate professor of neurology and otolaryngology at the Johns Hopkins School of Medicine. Studies repeatedly have found that diagnostic errors, which are more common in primary-care settings, typically result from flawed ways of thinking, sometimes coupled with negligence, and not because a disease is rare or exotic.

The problem is not new: In 1991, the Harvard Medical Practice Study found that misdiagnosis accounted for 14 percent of adverse events and that 75 percent of these errors involved negligence, such as a failure by doctors to follow up on test results.

Despite their prevalence and impact, such mistakes have been largely ignored, Newman-Toker and others say. They were mentioned only twice in the Institute of Medicine's landmark 1999 report on medical errors, an omission some patient safety experts attribute to difficulties measuring such mistakes, the lack of obvious solutions and generalized resistance to addressing the problem.

"You need data to start doing anything," said internist Mark L. Graber, founding president of the Society to Improve Diagnosis in Medicine and a leading errors researcher. Despite dozens of quality measures, Graber said, he is unaware of "a single hospital in this country trying to count diagnostic errors."

In the past few years, a confluence of factors has elevated the long-overlooked issue. In his 2007 bestseller, "How Doctors Think," Boston hematologist-oncologist Jerome Groopman vividly deconstructed the flawed thought processes that underlie many diagnostic errors, including several he made during his long career.

More recently, an influential cadre of medical leaders has been pushing for greater attention to the problem. They cite concerns about the growing complexity of medicine and increasing fragmentation of the health-care system, as well as relentless time pressures squeezing doctors and the overuse of expensive, high-tech tests that have supplanted traditional hands-on skills of physical diagnosis.

Publicity about the death last year of 12-year-old Rory Staunton, sent home from an emergency room in New York after doctors missed the raging systemic infection that quickly killed him, have put a human face on the problem. At the same time, new digital databases such as IBM's Watson and Isabel promise to boost doctors' accuracy, although their usefulness remains a matter of debate.

"One of the reasons it's time to begin looking at it is that so many of the quality measures we use now assume that the diagnosis is the right one in the first place," said Christine Cassel. A member of the panel that wrote the 1999 IOM report, she is now president and chief executive officer of the American Board of Internal Medicine.

But what if it's not?

In a much-cited essay, Robert Wachter, associate chair of the Department of Medicine at the University of California at San Francisco, wrote that a hospital could earn "performance incentives for giving all of its patients diagnosed with heart failure, pneumonia and heart attack the correct, evidence-based and prompt care -- even if every one of the diagnoses was wrong."

Discovered Late -- Or Never

Unlike drug errors and wrong-site surgery -- mistakes that patient safety experts consider to be "low-hanging fruit" amenable to solutions such as color-coded labels and preoperative timeouts by the surgical team -- there is no easy or obvious fix for diagnostic errors. Many are complex and multifaceted, and may not be discovered for years if ever, said Graber, a senior fellow at RTI International, a research firm based in Research Triangle Park, N.C.

"There is probably nothing more cognitively complicated" than a diagnosis, he said, "and the fact that we get it right as often as we do is amazing."

But doctors often don't know when they've gotten it wrong. Some patients affected by misdiagnosis simply find a new doctor. Unless the mistake results in a lawsuit, the original physician is unlikely to learn that he blew it -- particularly if the discovery is delayed. While diagnostic errors are a leading cause of malpractice litigation, the vast majority do not result in legal action.

Some environments are more susceptible to error than others. Graber calls the emergency room "a petri dish" for diagnostic mistakes: The doctor doesn't know the patient, the patient doesn't trust the doctor, and time pressures and frequent interruptions are the rule.

Misdiagnosis is not limited to hospitals; a recent commentary on the Texas VA study by Newman-Toker and Martin Makary estimates that "with more than half a billion primary care visits annually in the United States . . . at least 500,000 missed diagnostic opportunities occur each year at U.S. primary care visits, most resulting in considerable harm."

There is another reason such mistakes have been long ignored: They are regarded as an unusually personal failure in a profession where diagnostic acumen is considered the gold standard.

"This really gets to who we are as clinicians," said internist Robert Trowbridge, who directs the medicine clerkship program for Tufts University medical students at Maine Medical Center in Portland.

"Overconfidence in our abilities is a major part of the problem," said Graber, who believes doctors have gotten a pass for too long when it comes to diagnostic accuracy. "Physicians don't know how error-prone they are."

Many, he noted, wrongly believe that the problem is "the other guy" and that they don't make mistakes. A 2011 survey of more than 6,000 physicians found that 96 percent felt that diagnostic errors are preventable; nearly half said they encountered them at least once a month.

In the Texas VA study, more than 80 percent of cases lacked a differential diagnosis, in which a doctor not only declares what he believes is ailing the patient but also lists other potential causes of the problem based on symptoms, test results and a physical exam.

"A differential helps people to cognitively focus," said Hardeep Singh, director of the Houston VA Patient Safety Center of Inquiry. Failure to ask "What else could this be?" can cause premature fixation on the incorrect diagnosis, said Singh, the study's lead author.

At Maine Medical Center, Trowbridge spearheaded a pilot program launched in 2010 to persuade doctors to anonymously report diagnostic errors, which would then undergo comprehensive analysis. He said he had to "hound" his colleagues to report mistakes. During the first six months, 36 errors that would otherwise have gone unreported were identified; most were deemed to have caused moderate to severe harm.

Trowbridge said the program has changed how he practices. "I'm much more reflective, much more attuned to the errors I'm prone to make. I work with checklists more."

It Wasn't Fibromyalgia

While second opinions are one strategy believed to reduce misdiagnosis, the original error may be the basis of a cascade of mistakes.

For nearly three years, beginning in February 2008, financial executive Karen Holliman logged more than 50 visits with various doctors in Durham, N.C., trying to get help for the increasingly severe fatigue that had plagued her for several years as well as back pain so excruciating that she wound up in a wheelchair.

Doctors variously told her she had fibromyalgia, chronic fatigue syndrome or a psychiatric problem. The real reason for her symptoms was metastatic breast cancer, which had riddled her spine, fracturing her back. Signs of cancer had been found on an MRI scan performed in February 2008. But a bone scan performed a few weeks later did not indicate cancer; her internist told her she did not have cancer, and doctors repeatedly failed to investigate the discrepancy.

To make matters worse, Holliman was taking hormone replacement pills prescribed by her internist to combat hot flashes; the drug fed her breast cancer.

"I'm terminal," she said. In December 2010, when she was told she had Stage IV breast cancer, an oncologist estimated her life expectancy at about three years. "I could have been diagnosed in 2008," she said, adding that she believes timely diagnosis and treatment might have extended her life expectancy to 10 years.

Holliman has regrets: that she never got a second opinion from an internist or orthopedist, that she didn't question the radiologists who performed her scans and that she failed to obtain her medical records earlier.

During meetings last year attended by her family, including a relative who is a prominent physician, as well as by her doctors and the hospital system for which they worked, Holliman said, a hospital lawyer called her case "a series of unfortunate events" but denied that the hospital was liable for the delayed diagnosis.

"I spent a lot of time being angry," said Holliman, who is 52. She said she has not filed a malpractice suit because she was advised she was unlikely to win. "Now I'm just trying to live a really great life in the time I have left."

State Spending On Consumer Assistance Could Have ‘Huge Impact’ On Marketplace Enrollment

Phil Galewitz — Sun, 05 May 2013 12:12:00 GMT

Florida is on course to spend $6 million to reach out to nearly 4 million uninsured people and help them sign up for coverage in the federal health law’s online marketplace this fall.

Maryland will spend more than four times as much, or about $24.8 million, to help about 730,000 uninsured. The District of Columbia expects to spend about $9 million assisting 42,000 uninsured.

The wide variation in spending to hire and train people to provide consumer assistance in the first year of the new marketplaces could have a major impact on how many people actually get coverage under Obamacare, experts say.

Yet states with some of the nation’s highest uninsured rates, such as Florida and Texas, are getting far less federal money per uninsured resident than states with low rates, such as Maryland, Vermont and Rhode Island, according to a Kaiser Health News analysis.

That’s because states relying on the federal government to run their marketplaces are getting far less money than states setting them up themselves because of how the health law was written. In addition, some states such as Maryland that are running their own operations are supplementing the federal dollars with states funds. That’s widening the gap.

“The spending difference could have a huge impact,” said Jon Kingsdale, a consultant who helped launch the Massachusetts health insurance exchange in 2006.

Consumer assistance is considered key to enrolling the uninsured for several reasons. Polls show most people are unfamiliar with the law’s benefits, including new government subsidies that take effect next year. For example, those subsidies will apply to a family of four with an income as high as $94,000.

The online marketplaces, which open for enrollment Oct. 1, were envisioned to be as easy to use as travel websites like Expedia, but experts say that many people will need help figuring out which plan is best for them and what information they might need to sign up for coverage.

Some have never applied for health insurance coverage before and may need assistance even to navigate the website, said Sonya Schwartz, program director of the National Academy for State Health Policy, and project director of State Refor(u)m, a discussion forum about implementation.

The marketplaces, also known as exchanges, are the key way the law expands health coverage to about 27 million people by 2016. That’s where people will shop for and enroll in private coverage and determine if they are eligible for premium discounts, or for Medicaid, the state-federal health insurance program for the poor. While many customers will be uninsured, others with coverage will use them to take advantage of government subsidies.

“It’s a shame that we see states with lower rates of uninsured putting more money into education and outreach than states with higher rates of uninsured,” said Deborah Bachrach, a former New York State Medicaid director who is special counsel at the law firm Manatt Phelps & Phillips.

To be sure, consumer assistance is only one way that potential enrollees may learn of new insurance options and how to sign up for them. Additional federal dollars will go to advertising on radio, television and billboards. And insurers, hospitals and nonprofit groups may supplement public education efforts in many states.

The biggest reason for the uneven spending on consumer assistance is that when Congress passed the health law in 2010, it assumed most states would run the online marketplaces, and it authorized broad funding for that. As it turned out, only 16 states and the District of Columbia agreed to do so.

The law did not set aside money for the federal government to operate the marketplaces, either alone or in partnership with the states, as it is doing in at least 34 states. To remedy that, the Obama administration recently moved $54 million from the law’s prevention fund to provide money to hire and train people to assist consumers in those states, based on their number of uninsured.

That money will be awarded directly to organizations that agree to hire and train people to assist consumers. Those eligible include church groups, local health agencies, community health centers, chambers of commerce.

“This is a huge challenge,” said Laura Goodhue, executive director of Florida CHAIN, a consumer advocacy group. “As community based groups start to really plan and get ready for October, they are realizing just how difficult a job they will have and how the funding will only go so far.”

She estimates about 1.7 million people in Florida could benefit from subsidized coverage in the marketplace run by the federal government, but few know it will exist.

“We are equally concerned about a lack of consumer assistance or any type of consumer advocacy at the state level to help resolve issues related to enrollment and eligibility,” she said.

Texas, with the nation’s highest uninsured rate of about 24 percent, will get as much as $8 million to enroll about 5 million uninsured in a federally run marketplace. That’s less than $2 per uninsured resident— compared to about $31 per person in Maryland.

Virginia, with 845,000 uninsured, is getting $1.4 million for consumer assistance to help people sign up for its federally run marketplace.

Several states with high rates of uninsured are running their own marketplaces, and as a result, have more money for consumer assistance. New York, for instance, expects to spend up to $32 million on consumer assistance. Washington state has budgeted $6 million; Nevada, $2.3 million through 2014; California has budgeted $49 million through 2014.

Small states running their own marketplaces also have relatively big budgets to hire and train people to assist consumers. Rhode Island, which has 116,000 uninsured residents, plans to spend nearly $2 million over 18 months.

A handful of states, including Maryland and Vermont, are also spending state taxpayer money to supplement their federal grants. Maryland has put up $8.6 million on top of $16 million it got from the federal government. Vermont, which has about 55,000 uninsured, has put up $400,000, for a total of $2 million.

Genevieve Kenney, senior fellow at The Urban Institute, said that while the amount of money channeled toward consumer assistance is important, other factors also will have an impact. For example, states can streamline enrollment in Medicaid and make other efforts to make the process as consumer friendly as possible.

A number of states are also counting on help from private organizations. The California Endowment, a large health foundation has offered about $29 million to help California’s already well-financed outreach effort—mostly to help find and enroll people in Medicaid.

“While some private foundations and consumer groups will try to help, ultimately it’s what states invest in education and outreach that’s going to matter the most,” said former Medicaid director Bachrach.

Health advocacy groups in Maryland, meanwhile, are giddy at the $24 million that state is putting toward getting people signed up for insurance. The money will pay for 300 consumer assistance jobs created by six groups, including county health agencies and nonprofits.

The Baltimore area is getting $7.9 million of that to help find and enroll about 220,000 uninsured. That will be coordinated by HealthCare Access Maryland (HCAM), a nonprofit group that helps people get coverage, which will work closely with local hospitals, the YMCA, homeless shelters, community health centers and religious groups.

Asked about how Baltimore will have more money for consumer assistance than the entire state of Florida, HCAM CEO Kathleen Westcoat laughed.

“Maryland is putting its money where its mouth is,” she said.

Florida Legislative Session Ends Without Deal On Medicaid Expansion

Lynn Hatter, WFSU — Fri, 03 May 2013 22:52:56 GMT

The question of whether Florida would expand its Medicaid program to cover more low-income people has been answered, and it’s a “no” — at least for now. The state Legislature closed its regular session Friday without reaching an agreement to expand access to the program under the Affordable Care Act.

To be revived in the near term, Gov. Rick Scott would have to call a special session of the Legislature. There has been no indication that he is willing to do that – or that he is close to a deal with state House Republicans that would warrant such a session.

Scott, a Republican, stunned supporters and critics alike in February when he flipped from being a staunch opponent of the federal health law to endorsing its Medicaid expansion.

The health care overhaul gives states the option to expand their existing Medicaid programs with the federal government footing the full cost of the expansion in the first three years and paying 90-percent thereafter. In Florida, the raw numbers were persuasive to Scott, who is a former executive with hospital giant, HCA. Medicaid expansion would bring $50 billion in federal money to the state over the next ten years and cost Florida $3.5 billion in the same time frame.

State Sen. Joe Negron, a Republican, was the architect of a bill that passed the Senate. He laid out the differences between members of the two chambers within his own party.

“I have a view that when it comes to providing health care to people who get up and go to work every day, there is a role for government to provide assistance for their premiums,” Negron said. “And in the House, there’s a concern that we’re becoming too reliant on federal funds and [that] we could be setting up a program that’s too expensive for us to afford.”

Negron’s proposal, which is similar to a plan that has passed in Arkansas, would use the federal money to help eligible Floridians purchase private plans. That was a non-starter for House Republicans. Instead House lawmakers pitched a separate plan to insure far fewer people using state funds. The back and forth between the two sides got heated, culminating in a protest by House Democrats that required every single bill to be read aloud before the chamber, line-by-line, and in full. That prompted Republicans to employ “Mary” the House’s auto reader, stalling all House business for two days as "she" read.

At one point, there were talks of a compromise between the two chambers. But Senate President Don Gaetz said, “It appears the shot-clock has run out on the health care issue for this session. But that doesn’t mean we’re going to stop working.”

Nearly 4 million people, or about one in five Floridians, are uninsured. An expansion of the Medicaid program, or some kind of alternative, could cover up to a million of the uninsured. Florida Hospital Association President Bruce Reuben says accepting the federal money would reduce the costs of treating the rest of the uninsured.

“Even if we did nothing, we’d still be paying for the cost of care for these people,” Reuben said. “We’d simply be paying for it through a hidden tax, a cost shift onto people’s private health insurance premiums.”

U.S. Rep. Debbie Wasserman Schultz, who is Chairwoman of the Democratic National Committee and who represents the Fort Lauderdale area, criticized Scott for his inaction.

“It seems to me he’s sitting on the sidelines trying to have his cake and eat it too,” said Wasserman Schultz. “You can’t have it both ways. You’re either for it or you’re against it, and in Tallahassee you have to take a stand.”

For states that have taken action, the Medicaid expansion goes into effect in January. If Florida waits until next year to expand the program, it would lose some of the federal money it would otherwise have received. States do not have a deadline when they have to accept or permanently reject the expansion.

There is precedent for states jumping in late to government health programs. Florida adopted the main Medicaid program in 1970, four years after it began.

This story is part of a reporting partnership that includes WFSU, NPR and Kaiser Health News.

Medicare Seeks To Limit Number Of Seniors Placed In Hospital Observation Care

Susan Jaffe — Fri, 03 May 2013 10:26:00 GMT

Medicare officials have proposed changes in hospital admission rules that they say will curb the rising number of beneficiaries who are placed in observation care but are not admitted, making them ineligible for nursing home coverage.

"This trend concerns us because of the potential financial impact on Medicare beneficiaries," officials wrote in an announcement April 26. Patients must spend three consecutive inpatient days in the hospital before Medicare will cover nursing home care ordered by a doctor.

Observation patients don't qualify, even if they have been in the hospital for three days because they are outpatients and have not been admitted. They also have higher out-of-pocket costs than admitted patients while in the hospital, including higher copayments and sometimes paying exorbitant charges for non-covered drugs.

Under the proposed changes, with some exceptions, if a physician expects a senior will stay in the hospital for less than two days (or through two midnights), the patient would be considered an outpatient receiving observation care. If the physician thinks the patient will stay longer, the patient would be admitted. Setting deadlines for observation stays would also limit the growing length of time of observation visits, another trend officials said was troubling.

The reaction from patient advocates, doctors and hospitals has been swift and surprisingly unanimous: it’s a bad idea.

The number of observation patients has jumped 69 percent in the past five years, to 1.6 million in 2011, according to federal records. They also are staying in the hospital longer, even though Medicare suggests that hospitals admit or discharge them within 24 to 48 hours. Observation visits exceeding 24 hours has nearly doubled to 744,748.

Officials said the longer observation stays occur because hospitals are not sure Medicare will pay them if patients are admitted. The proposed changes are intended to address these questions.

The proposed admission changes are part of a 1,400-page annual hospital payment update released Friday. If adopted, the new admission rules would apply to more than 3,400 acute care hospitals, and Medicare estimates it will result in 40,000 more inpatient hospital stays. In order to offset the expected additional cost of $220 million, Medicare would cut hospital payments by 0.2 percent.

Joanna Kim, vice president for payment policy at the American Hospital Association, called the time factor "somewhat arbitrary." The association also objects to the pay cut, arguing that the projected inpatient increase is not certain.

"I can't imagine anyone is going to like this proposed rule because it makes time the determining factor in whether the services are provided on an inpatient or observation basis," said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy. "It is not about what the hospital is actually doing for you, what kinds of care you need and are receiving."

Edelman said the proposal does nothing to help observation patients because it keeps the three-inpatient-days requirement in place, doesn't require hospitals to tell patients when they are held for observation and doesn't give patients a right to appeal their observation status. The center is representing 14 seniors who have filed a lawsuit against the government to eliminate the observation care designation.

A federal judge is holding the lawsuit's first hearing Friday in Hartford, Conn., to consider the government's request to throw out the case because the seniors should have followed Medicare's lengthy appeals process before going to court. Three days ago, government lawyers submitted the proposed rule change to the judge to bolster its argument for dismissal, claiming that it clarifies "when we believe hospital inpatient admissions are reasonable and necessary, based on how long beneficiaries have spent or are reasonably expected to spend, in the hospital."

The American Medical Association is still reviewing the proposed changes, which don't include steps it asked Medicare to take last year: either drop the three-day policy or count observation days toward the requirement.

"This policy is of great concern to the physician community because it has created significant confusion and tremendous, unanticipated financial burden for Medicare patients," James Madara, the AMA's executive vice president, wrote to Medicare. He also criticized hospital's ability to overrule the physician’s decision to admit a patient, which creates more confusion when the physician bills Medicare for inpatient services and the hospital bills for observation services.

Contact Susan Jaffe at Jaffe.KHN@gmail.com

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Kaiser Health News - Stories (Full text)

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