Author: Ann Marie Marciarille

Professor Emily Bazelon tells it like it is to her female students interested in courtroom practice. 

I wonder about how much we doom ourselves to repeat old practices and follow old ways by keeping deeply sexist courtroom practices alive in the re-telling in litigation training or whether the real path of doom is in sending young attorneys into practice without any insight into what may be awaiting them.

And it is not just in litigation land where this plays out, you know.  I recently watched one of the vignettes from the film Certain Women and alternately laughed, groaned, and winced to see Laura Dern play an attorney whose client simply won't believe her best legal opinion on a matter until it is verified by a visit to an older white male colleague, who simply reiterates Laura Dern's position. I love the moment where she watches her client assimilate and accept the bad advice from her colleague's mouth. "That's it?" she says.

"That's it" indeed.

 

 

 

 

 

 

 

 

 

Yes, I was with Brad DeLong when he took those pictures.

He left a few things out: only two of the spots were occupied, none of the reserved spots included any limitations on the "reserved" status.

Why would a fundraiser need 24-7-365 urgent access to the hospital to perform their duties?  Because, if I had to guess,  the big fish will not want or need to  navigate the system without their harbor pilots.

Webster's tells us rebukable means worthy of rebuke. Maine's Gov. LePage certainly seems to fit there.  But he who refuses to be rebuked is what – irrebukable? Or, are you rebuked whether you acknowledge it or not?

The latter might be the better description of where Gov. Paul LePage and the people of Maine are right now.  The Governor simply refuses to implement Maine's Medicaid expansion under the ACA consistent with a referendum passed by Maine voters this past fall.

Now, after vetoing five different Medicaid expansion bills, it is clear that Governor LePage knows how he feels about Medicaid expansion under the ACA  This leads to the fascinating position of a sitting (albeit soon to be termed out) governor refusing to implement while indicating authority to do so but lacking the fiscal and political will.

You have to give it to Governor LePage for giving it to you straight: “We don’t mind helping people get health care, but it should not be free. ‘Free’ is very expensive to somebody.”

There is considerable speculation as to what is going on here ranging from the "not on my watch" theory to complicating bargaining leverage for Medicaid expansion on terms more favorable to the state of Maine.  Governor LePage is no fool.  He is well known, by Maine standards, as quite the savvy and successful businessman. 

Of course, there is no "free" in Medicaid.  But Medicaid expansion under the ACA, for better or for worse, does not need to be free to expansion Medicaid beneficiaries. 

Maybe it is really just the drive to pass that buck back to the legislature, claiming implementation is at hand as soon as the legislature appropriates funding.

 

 

 

 

 

Oh, wait… CVS wants to charge $4.99 for an Rx delivered by the USPS.  No discount for being a high volume user? No discount for ordering products that are high margin for CVS? No discount for also including OTC items in the same order?

Oh, and no problems with HIPAA as the carriers, prominently noted to include the USPS, are on it.  Now, I don't know about your neighborhood, but my use of the USPS' own "inside delivery" function documents that one in ten pieces of "coming to your mailbox soon" mail does not make it through the system from the USPS processing facility to the mail slot in my front door.  Yes, we are talking things like written communication from the IRS and the State Franchise Tax Board.  And, even scarier from the CVS angle, many pieces of mail (sometimes several a day) addressed to others in my neighborhood (and beyond) are left as my mail.

And this has been going on for some time.

What's your business model CVS?  When did the flat $4.99 fee become part of the equation for each delivery?  Forgive me while I contain my enthusiasm.

 

 

 

 

 

 

You may have seen the New York Times Editorial Board  discussing  the discord between agony and arithmetic we all confront when opining on Maria Cramer's tweet about the Boston woman injured by the subway train begging her rescuers not to call an ambulance, because she could not afford the $3,000 charge.

It appears no ambulance was called, though the injured woman (with twisted, bloodied, skinned leg) has been reported to have been hospitalized. Her rescuers and bystanders may have recognized the wisdom in her fear. 

Yes, she apparently wanted help.  It is reported that bystanders organized to rock the subway car to free her leg as it was trapped between the train and platform. But, she couldn't afford ambulance transport to follow up care. Surely, bystanders wondered if she was insured but some of them, even then, probably knew that ambulance transport is often only modestly covered for the commercially insured.

Ambulance services are confusing because our health care system is confusing.  A Medicaid beneficiary would likely have first dollar coverage for that ambulance ride in Massachusetts. A commercially insured individual would likely not. A Medicare  beneficiary would have limited coverage at a negotiated rate.

In Boston, Boston Emergency Medical Services is a public safety agency, one of the oldest ambulance services in the nation. This is an increasingly antiquated system. A number of municipalities and counties have moved to no public ambulance service. Even in Boston, however, public does not mean free to the recipient of the services.

If there is a better example of the patchwork nature of our health care system than ambulance services, I don't know it.  There are about 14,000 ambulance services across the country, run by governments, volunteers, hospitals and private companies.  It can be hard to know what kind of ambulance service you have called, your friends or family have called, or a stranger concerned about you may have called. Whoever called the ambulance, if you accept the services (even if you don't accept the actual transport, in some cases), you will be billed and not the individual who summoned the ambulance. You  are, in short, at the mercy of others. 

The woman injured on the T? She, then, was begging for the mercy of others to ,first, release her foot and, second, not saddle her with a $3,000 medical transport bill she could not afford. Could she use Uber or Lyft, both  eager to enter the market for non-emergency medical transport? Would an Uber or Lyft driver have been willing to pick up a passenger apparently unable to stand fully on her own, bloody,  and in visible pain?  What if she somehow masked her circumstances until the ride was underway? Uber drivers are facing this with some regularity, apparently, and do not like the liability risk.

The story of how ambulance charges ended up so sky high is also a story of medical innovation, inconsistency, and patch work development. More could be done pre-hospitalization, so more expensive gear was added to the ambulance and more expensive training for the ambulance attendants.  Your ambulance is chosen for you by the ambulance dispatcher and, in many places, charges may vary depending upon the complexity of the training and equipment sent to attend you.

I could go on and on.  But I did have to wonder if the "don't call an ambulance" fear was even bigger than the $3,000 possible  ambulance bill.  You see, your ambulance attendants choose your hospital and the one they choose may well be out of network.  Then, you could be looking at a lot more than a $3,000 charge.

I recently had the pleasure of hearing Barak Richman talk about the costs of medical billing, you know the extraordinarily byzantine world of insurance reimbursement, for providers. When you consider how much it costs a health care provider to get a bill paid, you gain some insight into why provider  reimbursement rates are so high. Bottom line: at the academic medical center studied, it costs $20 to get a primary care visit billed and paid, considerably more for a specialty visit. Interestingly, this was not as easily attributable to the complexity of dealing with multiple payers with non-standardized contracts as you might guess.

More later on the causes of the expensive billing costs but it is worth noting that other health care systems based on private insurance have much lower administrative costs though they also have far more standardized or streamlined contracts and/or fee schedules.

 

John Carryeyrou's Bad Blood (a/k/a The Theranos Story) is an interesting read.  Even if you've been following Carreyrou's articles in the Wall Street Journal on this topic, it is useful to have the whole narrative in one place.  And, today, the narrative advances with word of Elizabeth Holmes' criminal indictment.

What a story: how the vaporware ethos of Silicon Valley enabled Holmes; how the FOMO (fear of missing out) paranoia fueled the deception; how Walgreen's and Safeway became true believers through the willing suspension of disbelief; and how George and Charlotte Schultz chose fealty to the Theranos story line over belief in their own grandson.

This will make a great movie. And people will have trouble believing it really happened.

 

 

 

 

If you've ever presented a prescription at the pharmacy only to be told that additional pre-authorization information is required by your insurer, you know that what usually follows is the pharmacy's offer to notify your provider of the need to contact the insurer.  And when you go back and you still are not able to purchase the prescription with insurance coverage, you will likely again have the pharmacy offer to contact your physician. 

If you follow up with your physician independently or your insurance company independently, you will get the distinct impression that — even though you are the person in need of the prescription and carrying the relevant health insurance — this is a conversation ordinarily meant to exclude you.  You may persevere anyway trying to interject yourself into a conversation designed to exclude you or you may rely on the representations of the pharmacy that messages are being sent and the representations of your provider's answering service that your messages are being received.  If you choose the latter, you may be surprised to learn you do so at your own risk. The legal message has been that the pharmacy owes you no duty to try to advance your claim or to help you document medical necessity within the terms of your plan.

And then, just a few weeks ago, along came Correa v. Schoeck out of the Massachusetts Supreme Judicial Court.  There, the court held that parents of a young woman with a seizure disorder who relied on the representations of the pharmacy could in fact sue Walgreen's for apparent failure to reach out to the provider's office and to follow up as was promised on several repeated visits. Noting that "[t]he skill and knowledge of pharmacists today involve more than the dispensing of pills," the court refused to dismiss the case.

Now we'll see what happens on the merits. What we do know already is that Marushka Rivera was a young woman with significant health care needs and that the last year of her life was very difficult indeed.

 

 

 

 

San Francisco's flavored tobacco ban appears to have passed.   Somewhat less discussed, San Francisco's ban includes mentholated tobacco products as part of the ban.

The complicated history of specialty marketing of mentholated tobacco products to African-Americans is reviewed here. It is also significant that an estimated 85 percent of all African American smokers use mentholated  tobacco products. 

The long history of how African-Americans became marketing magnets for the cooler smoke and then, disproportionately, heavy users of mentholated tobacco products raises important questions about freedom.  Big Tobacco's big San Francisco  gamble to argue that the freedom to smoke and the freedom to use mentholated products that enable deeper inhalation and, quite possibly, more addictive tobacco use appears to have moved relatively few in San Francisco.

 How Kool.

 

We have some 500 freestanding ERs in the United States. One hundred and eighty of them are in Texas, predominantly in urban areas. Originally touted as a panacea for hospital-poor rural areas, recent proposals to rein freestanding ERS in tell us that is not where the growth has been.

Freestanding ERS come in two flavors: hospital-affiliated and non-hospital affiliated. The latter are not bound by federal EMTALA obligations, though some states have added access obligations of their own. 

MedPAC is poised to propose to alter Medicare reimbursement for freestanding hospital-affiliated ERS in close proximity to hospital based ERS, acknowledging that these facilities cherry pick less complex patients at what has been the same reimbursement rates (where the facilities fee component for ERs matters).

Why have a hospital-affiliated  freestanding ER in such close proximity to a hospital based ER?  Customers like the easier access.  Less complexity dials down the chaos a bit, apparently. You can bill at the hospital facility rate for services performed at the satellite that may have directed elsewhere in the health care system. 

Why not have a freestanding  hospital-affiliated ER in such close proximity to a hospital based ER?  Customers will prefer the easier access of the satellite ER and, eventually, sort themselves by severity between the two ERs, leaving a distorted severity mix and payor mix.  And hospital affiliated ERS will not like being left only with the more demanding, though not necessarily more richly reimbursed, cases. The satellite allows the hospital mother ship to reach more patients of lower acuity at higher facility based reimbursement rates. 

By all accounts, MedPAC is still not loving non-hospital affiliated ERs, as they  remain unable to participate in Medicare. Will the MedPAC proposal slow the growth of hospital-affiliated freestanding ERs? It seems likely.  Will the MedPAC proposal slow the growth of non-hospital affiliated ERs? Not one bit.