Month: December 2015

I have written previously about Missouri's attempts to create a new category of health care practitioner: assistant physician.  You may recall, Missouri's goal is to re-direct non-matching medical school graduates to work as assistant physicians in medically underserved areas in the state.  

Who's idea is that, you say?  Why, an orthopedic surgeon's, though the bill was supported by the Missouri Medical Association, an organization tilted — as are all classic licensed health care provider organizations — toward non-rural providers.   And there's the rub: the rural provider community does not seem to be in love with the idea. Not surprisingly, the AMA and the licensed Physicians Assistant organization hate it.

It is reported that several other states with significant rural populations and chronically underserved areas are watching Missouri's roll out.  This is where it gets tricky. Gov. Nixon's signing message included warnings about consumer protection. The new legislation will require significant scope of practice, licensing, and regulatory work to even approach implementation. This all might help explain why, at about 18 months out, Missouri has not seen one assistant physician.

The larger issue is whether sidestepping medical residency (a multi-year experience for the typical practicing physician and at least a one year experience under traditional Missouri standards) is the way to ease the shortage of primary care providers in medically underserved areas.  

Why not also expand scope of practice under very restrictive Missouri standards to allow every licensed health care practitioner to work to the limits of their training? Ah, because the fight over collaborative practice requirements for groups like advance practice nurses is a fierce one in Missouri.  The assistant physicians hew to the old collaborative practice standards and break no new Missouri ground on independent practice.  I suspect that is the tail wagging the dog here.

 

 

 

 

Yesterday, Kaiser announced its intention to open a medical school in Southern California.  Fresh from the press release, I mentioned the announcement to a friend. His reaction: "Would they actually  name that school: Kaiser Permanente Medical School?'  

I've been thinking about that question ever since. In the moment, my response was "why not?" or "why not Henry J. Kaiser Medical School?" but, afterwards, I thought he may have been tapping into some reserve over a "branded" medical school, one conspicuously designed to take the Kaiser care model to the source of physician training. But if a particular team primary care based approach is associated with the name, why not use it?  After all, Kaiser Permanente's Allied School of Health Sciences  in Richmond, California is named just that.

What of the idea that a medical school could be too closely aligned with one service delivery model and so tarnish its academic reputation in some way by taking that model as part of its name? Or, does it reek too much of grow your own talent in its explicit anticipation that Kaiser expects many of the students at its medical school to focus on primary care and go on to work with Kaiser?

The tricky part is that I am not certain existing medical school education does not involve the close alignment of a branded medical school with a particular care-delivery  model associated with that school that then brings it back to the source: physician training. Does anyone really imagine that medical school training at, say Stanford Medical School, models health care delivered in a multi-site high-tech care-delivery system like Kaiser or is what is going on there more like the high-tech academic medical center ("AMC") model of care (though some of Stanford's medical students do seem interested in PC)? 

Many have observed that the AMC model is probably not the ideal environment in which to cultivate community based primary care medical practitioners. Now, Kaiser appears poised to take this observation and turn it on its head: what would be the ideal environment in which to cultivate and train community based primary care physicians organized in a team delivery model serving one of the most diverse populations in the entire United States look like?  

I can hardly wait to see what they propose. 

Just in case it crossed your mind while reading my two previous posts, it is probably important to know up front that the incarcerated may not use the exchanges to purchase health insurance. For this purpose, however,"incarcerated" has a fairly narrow meaning: excluding probation, parole, or home confinement. In addition, you are not incarcerated if you are in jail or prison pending disposition of charges. Still, the interpretation of ACA Section 1312's language stating that a prisoner "shall not be treated as a  qualified individual, if at the time of enrollment, the individual is incarcerated, other than incarceration pending disposition of charges" has generated a fair amount of confusion.

Many of the imprisoned, on the county jail level, are essentially transitory in that status. The relatively long fuse on applying for health insurance through the exchanges or Medicaid, for that matter,  and then the wait for actual enrollment, probably made this seem mostly a theoretical concern from the perspective of an entity seeking to lower its own correctional health care costs  Of course, if the emphasis were on preparing the incarcerated individual for re-entry, jails would be a clear point of contact for newly eligible individuals for both exchange purchased and government funded health insurance.

As the National Association of Counties points out,  it might be difficult to identify a population more in need of behavioral health services, for example, than the currently imprisoned. For that reason alone, county jails and all correctional authorities ought to be priority locations for assistance in applying for health insurance coverage, whatever the source.  An estimated fifty percent of prison or jail inmates have a mental health problem. Not surprisingly, an untreated mental health problem marks a prison or jail inmate as more likely to have been involved in a fight inside the facility since incarceration. As one group of authors so poignantly asked: When Did Prisons Become Acceptable Mental Healthcare Facilities?  Or, for that matter, when did prisons become unacceptable mental healthcare facilities?  Are they really healthcare facilities at all?

Post-incarceration, the same individuals may be eligible for subsidized exchange purchase. The recently released have a sixty day special enrollment period. After that, it is necessary to wait for the next exchange open enrollment. 

Originally, Medicaid was interpreted to mean a loss of eligibility status upon imprisonment. Section 1905(a)(A) of the Social Security Act prohibits Federal Financial Participation in funding medical care provided to inmates of a public institution, unless the inmate is a patient in a medical institution. As far back as December 12, 1997, DHS clarified that an inmate may not  be funded by FFP unless the inmate becomes a patient in a medical institution on an inpatient basis (now defined as an inpatient stay of at least 24 hours).  This exception was also extended to those on probation, parole, or home detention. The thinking was that the Eighth Amendment obligation of the correctional facility to provide care should not be shifted to other funding sources under ordinary circumstances. From this perspective, each state or county or other political unit would bear the Constitutional cost of its incarceration policies as well as its Medicaid plan design. 

All of this did not excite too much attention until the passage of the ACA.  Once the dust settled on theNFIB v. Sebelius  reinterpretation of Medicaid expansion under the ACA, it became apparent that now-optional Medicaid expansion states had opened Medicaid eligibility to populations beyond infants, children, pregnant women, people with disabilities, and some seniors.  Many of the incarcerated were, in fact,  newly eligible under expansion Medicaid. The fact that expansion Medicaid offers a FMAP of 100 percent through 2017, probably also helped to catch the attention of some states. The enhanced Medicaid match rules found in the ACA were, after all, meant to be attention getting.

Delaware, Louisiana, and Oklahoma were reported to be the first states to access Medicaid dollars for inmate hospitalization.  Other states have been slower to adapt or slower to broker the necessary cooperation between corrections, Medicaid, and the local social services agency.

Even non-Medicaid expansion states, like North Carolina, appear to have become motivated to identify their Medicaid eligible inmates receiving Medicaid eligible services.  In 2013, for example, roughly three percent of North Carolina's inmates had recorded inpatient stays but only one percent of these were Medicaid allowable inpatient stays. Similarly, in 2013, roughly six percent of California's inmates had inpatient stays with just over two percent of those stays deemed allowable inpatient stays. This means that, in 2013, California drew down $38.5 million dollars for these allowable inpatient services for inmates and North Carolina $2.5 million dollars.

Interestingly, North Carolina found these federal funds so attractive, the state reported hiring or training state prison staff to assist in enrolling inmates — this in a a non-expansion state not historically terribly focused on assisting the rest of its citizens in applying for Medicaid. You can now apply for Medicaid in North Carolina online, however, and this may partly account for the post-ACA North Carolina Medicaid enrollment surge.  North Carolina, instead, has decided to focus on turning Medicaid toward Medicaid managed care, reforming but not expanding Medicaid. But, if you're a hospitalized inmate, apparently they might want to really help you.

Your ability to timely apply for Medicaid as you approach release depends upon your ability to navigate the Medicaid application alone or, if you require assistance,  the quality of the negotiated agreement between your correctional facility and the and the local social services agency. Then, in a sense, you're just like everyone else in North Carolina.

Does all of this make sense?  Ought California be able to shift some of the financial cost of its Three Strikes Sentencing  Law approach to incarceration to the federal fisc —  really other states? Is it defensible as part of a grand bargain to expand Medicaid to much larger populations under the ACA?  And what's North Carolina's narrative? 

I have been thinking about Michelle Alexander's The New Jim Crow since reading it last spring. I usually think of it when I notice some wrinkle in the legal system either with the design or defect of extracting further punishment from the previously incarcerated.

I have been thinking about Medicare and Medicaid eligibility for the previously incarcerated in particular as well as eligibility to purchase health insurance through the exchanges.  This post will discuss Medicare eligibility for the incarcerated and the post-incarcerated. My next post will look at Medicaid and the incarcerated and post-incarcerated. Finally, I hope to look at the exchanges and access for the incarcerated and post-incarcerated. 

Medicare, as a general rule,  does not pay for services rendered to incarcerated beneficiaries.  But if state or local laws require inmate reimbursement for correctional health services, an exception code applies and such services may be Medicare reimbursable.  In 2011, HHS identified 135,805 Medicare beneficiaries who were either then incarcerated or previously incarcerated during the 2009-2011 look back period.  And the exception coding procedures were a mess, with inconsistent approaches on how to code both Medicare reimbursable and Medicare non-reimbursable services provided to the incarcerated.  

This confusion is amplified by the definition of those in custody under a penal authority relevant for these reimbursement  rules.  The relevant definition of prisoner, in short,  includes those living in a half way house or a pre-release center as well as those under home confinement.  The Bureau of Prisons, however, typically does not provide any health care to individuals imprisoned in this manner, leaving those eligible for these step-down systems of re-entry in a position  where they must choose between preparing for community re-entry or choosing to stay in prison where correctional health care will remain available to them. Of course, the higher the level of the incarceration, the higher the cost to the taxpayer as well, so the latter choice has implications — on many levels — for us all.   

In addition, if you were incarcerated while you aged into Medicare eligibility, you likely missed your enrollment window.  Had you attempted to enroll from inside of prison, you would have had to have achieved eligibility (eligibility plus suspension) arranged to pay your Part B Premium directly, as Social Security payments are not made to the imprisoned,  even while not able to use it ($121.80 per month in 2016)  in order to prevent the additional penalty of 10% per annual premium for every twelve months you are dis-enrolled.  It also means that you must wait for the next open enrollment period when you do enroll  and then the start of your Medicare coverage, typically several months after that. 

Are the newly released from incarceration particularly unworthy of Medicare at all?  If so, would it not be more honest to proclaim this loudly and clearly rather than to price some formerly incarcerated individuals out of their Part B premiums and to require all those released from incarceration to rely on possible state Medicaid eligibility at a time of re-entry when health care needs and mental health needs, in particular, may be particularly acute?

There is more of a story here for those who may be eligible for a state Medicaid buy-in program in their state. i will discuss this in my next post.

I commend to you a great and difficult read in this recent study from a group at UC Davis. We have a bigger data set here, though still not all-payer data, confirming that California has poorer survival and higher proportions of late state at diagnosis among Medicaid recipients across several cancer types.

Some of the little pieces of sub-data are just fascinating. For example, those insured by the DOD seem to incur the longest wait time between diagnosis and the start of treatment, though that group's outcomes are still superior to outcomes from some insureds diagnosed sooner but given lower quality care.  

Careful not to draw any conclusions about why, the study concludes that Medi-Cal beneficiaries fare no better than California's uninsured for certain kinds of cancer care.  Does this mean Medi-Cal funding on cancer care is for nought? Or, does it mean any of a number of other things: that Medi-Cal beneficiaries are relatively late diagnosed with certain kinds of cancer because of access problems? Or, is the lower quality care because the Medi-Cal reimbursement accepting oncology universe is less likely to follow current treatment protocols? Or, is it something else? 

There are so many questions to ask the data, I can only hope Ken Kizer et al mean this as a first paper in a series. You see, we have a number of studies like this but few that drill down to ask the subsidiary questions, however even more uncomfortable they might make us. 

The New York Times website has been featuring an embedded link to a kind of video report on a look back at the life and death of David Vetter –– the young man who died at the age of 12 in 1984 who was sometimes known as "the boy in the bubble."  Of course, he was no young boy by the time he died and, in fact, his maturation to a very young man with intelligence, insight, and crippling depression and anxiety because of his life circumstances is what makes the story of his life, suffering,  and death so poignant.

The NYT clip is interesting but the PBS American Experience documentary from 2006 is even more interesting, if you care to learn more. The latter is, as critics have noted, pretty heavy handed in its bio-ethics overlay on the unfolding of David Vetter's life. These are questions of style. The bio-ethics of every moment of David's parents' lives — before he was even conceived — are in your face almost immediately. His mother, in restrospect, acknowledges that a few weeks after the death of David's older brother from SCID, she borrowed from the certainty of the medical team to satisfy her desire to have as many children as God would give her. The telling, in retrospect, of the  uncertainty of the medical team that they could do any more than keep David Vetter alive for some period of time when he might be matched with a perfect donor (as was medically necessary at the time) for his  transplant is what David Vetter's mother was in fact drawing on. And that uncertainty, however unexplored before David's conception and birth, was fully exposed by the time he had lived in complete isolation from all direct human contact for close to twelve years, displaying increasingly disturbing signs of mental illness.

David's life and death presented a natural experiment for the study of Severe Combined Immunodeficiency (SCID), the realization that cancer could be transmitted as a virus (the ultimate cause of his death from the latent unidentified cancer causing virus found in his donor sister's cells), and the impetus to begin to screen for SCID at birth when it became clear that genetic knowledge had advanced to the point that perfect donor matches might no longer be strictly necessary but that any procedure  needed to happen either in utero or within the first three months of life in order to make a difference.

Of course, this made me curious to look into the status of newborn screening for SCID.  The CDC reports:

    Although each state decides which disorders are included in the [NEWBORN] screening, the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC)     recommends  states test for a core panel of 31 congenital disorders. SCID was added to the core Recommended Uniform Screening Panel (RUSP) in 2010.

Illustrating that we often don't find what we don't look for, the 72% of U.S. newborns currently screened for SCID have shown us that SCID's incidence is considerably higher than previously thought and that the disease burden is not evenly distributed in the population (beyond what has long been known about this as a disease of males) and is testing at a particularly higher rate of incidence in Hispanic populations and in some Native American populations.

Now, newborn screening is surprisingly controversial in some states, particularly proposals to expand screening to diseases or disorders that are genetically linked and that may require gene-related therapies to be overcome. "Don't ask, don't tell" may come to have a whole new meaning in this context.