Author: Ann Marie Marciarille

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.

 

Harvard Pilgrim Health Care has apparently struck a deal with Amgen for a risk-based contract for Repatha, the new cholesterol-lowering drug.  Amgen provides a discount but also assumes financial risk if the HPHC members who take Repatha do not experience the cholesterol-lowering effects touted in the clinical trials.  It has been observed that this adds a interesting layer of pay for performance to the roll out of this drug. 

HPHC, which moves about 1.2 million lives, is old hat at negotiating discounts on pharmaceutical pricing, known for using the leverage of preferential formulary placement to play competing therapeutically equivalent drugs off of each other.  Repatha and other drugs in the category of PCSK9 are targeted toward  a sub-population of those with high cholesterol but they are spendy.

The real challenge is the prescribing protocol that HPHC will have to implement, reserving Repatha for only those enrollees who meet strict eligibility requirements, most likely including the requirements that step therapy with older cholesterol reducing drugs having failed and the beneficiary's willingness to accept an injectable format.  As intriguing as risk-based pharmaceutical contracting is, it has not been invented by this contract but, rather, has been in use for some time in the U.K. 

Will American-style health care (even tightly managed American-style vertically integrated HMO health care ) be able to constrain use?  That's one risk I am pretty sure Amgen was not willing to bet the farm on, although the contract is reported to contain language accelerating increased rebates to HPHC the larger its enrollee pool using Repatha.

A few days ago, I watched the I'll Be Me documentary about Glen Campbell's life after a diagnosis with Alzheimer's.  The film was in limited release a year ago, but I watched it on CNN.  I had read the reviews: most noting how the anguish would be familiar to those who had acquaintance with Alzheimer's or dementia. 

I don't get it. An estimated 5.3 million Americans have Alzheimers. That makes a diagnosis of Alzheimers or dementia something that is not exactly a rare or freakish occurrence.

How could any of us not have had an encounter with someone with some kind of dementia? Have we hidden those with this diagnosis away so well — in the name of human dignity but in the reality of our own discomfort– that Glen Campbell's tearful acknowledgement in the film that he is sad to know where this diagnosis will take him yet feels powerless to stop it is something we imagine we're trying to protect him from?

After viewing the documentary, I wondered if Glen Campbell is still able to live at home with his remarkable wife Kim, so I googled him.  Sure enough, he has been bouncing in and out of care facilities and home residence as his disease progresses.  And not all of his six children sound all that pleased that, as the disease progresses, he continued to be filmed.  I hope his children and his wife find the strength to be as courageous as Glen.  I think Glen Campbell is right, we can't know our enemy until we look it in the eye.

It is at or near open enrollment season for many health insurance plans.  CalPERS marks the approach of open enrollment by crowing about having dropped 18,000 ineligible dependents from its employer-based health insurance rolls. Interestingly, 5,300 were voluntarily dis-enrolled after the announcement of an amnesty period.

CalPERS tells this as part of a responsible stewardship of the public fisc narrative.  Of course, it might also be told as a pushing 18,000 people into uninsured status narrative.  Perhaps it is both.

We hear more about health plan dependent eligibility audits of late. Indeed, an entire industry has grown up around promoting health plan savings through rigorous dependent eligibility audits. Here's an auditor consultant predicting an 8 percent ineligible dependent enrollment rate. And here's another touting the correct response to various "scenarios" where employees claim valid dependent enrollment but the plan excludes them. My personal favorite among these: never mind the explicit language of your divorce decree, no employer is required to carry a former spouse, it is the plan participant's responsibility to fund this via COBRA."  Of course, the law on Qualified Domestic Relations Orders is notoriously complex, so it would be easy to confuse a court's authority to order coverage for a former spouse with a court's authority to order coverage for a former spouse in a plan that allows former spouse coverage.  I often think this is especially confusing to plan enrollees in a Social Security retirement system that does contemplate all kinds of benefit availability for the former spouse. 

The most interesting part of all this to me is how underplayed the story of beneficiary fraud in employer sponsored insurance is in the press.  My word, 2.5 percent of the CalPERS dependent population of 700,000 was a party to fraud, a number that — apparently — makes the CalPERS numbers seem modest in comparison  to the touted 8 percent fraudulent dependent enrollment in garden variety employer sponsored commercial insurance.  Where's the outrage? Where are the front page articles on how all dependent coverage provisions of commercial insurance ought to be abolished because of this percentage of apparently fraudulent beneficiary  claims? In 2010, the GAO estimated a ten percent fraud rate for government funded health insurance (both beneficiary fraud and provider fraud). Now, that received lots of press. 

Yes, the speck in our neighbor's eye is surely almost always of more interest than the log in our own, but it is also that  the deceits of middle class people are so much less interesting than the deceits of poor people.

I know, I know: health care is full of perverse cross-subsidizations. Economists, for example, will talk to you until you and they are blue in the face
about tax breaks for employer sponsored health insurance (generally available to the higher income) that only take but don't give from those taxpayers whose employers choose not to offer employer sponsored health insurance.

But, my mind is on Medicare today and the astonishing admission that the likely Medicare premium increases for 2016 could be borne exclusively by the roughly thirty percent of  beneficiaries who either do not pay their Medicare premiums by automatic deduction from their Social Security checks, who are new Medicare enrollees, whose annual income exceeds $85,000, or who are dual eligibles.  Overwhelmingly, the highest income individuals and the lowest income individuals enrolled in Medicare  fall into these groups. And, as of now, they appear to be destined to pay full freight for all Medicare beneficiaries' premium increases, as the automatic deduction folks are statutorily protected from the increase so long as there is no COLA for Social Security. Seen from this perspective, we have been on tenterhooks about two announcements: Social Security's COLA (now officially ruled out for 2016) and Medicare premium increases.

Does any of this make sense?  The New York Times discusses this bizarre outcome as part of a legislative quirk, but it is not as simple as that. There are strong financial reasons to encourage Medicare beneficiaries to pay their Medicare premiums by automatic deduction from Social Security benefits, a practice now involving seventy percent of Medicare beneficiaries.  Further, few are willing to attack Medicare's modest nibbling-at-the-edges approach to means testing for the household income over $85,000 group. Even those who don't love it accept it as a fait accompli and debate, instead, the merits of possible  expansion of Medicare premium  means testing.

As with so much about our incredibly complex health insurance and social insurance systems, we can see that those with resources and knowledge are already figuring out how to get out of the about to be  dunned group.  Yes, those file and suspend folks are working on this. But what about the low income low health insurance and low health insurance literacy Medicare beneficiaries? 

UMKC Schools of Law and Pharmacy  student volunteers  host their annual free Medicare Part D Fair this Saturday, October 24, 2015 from 9:00AM-1:00PM in Pierson Auditorium on the Volker Campus at UMKC (free parking).  Explaining this one to that crowd ought to be a great experience for my Health Law Society members.

In KCMO or KCK and would like to attend?  Here we are in the Kansas City Star with all the particulars.  

 

Last night, I was able to attend an American Public Square conversation on Medicaid held at UMKC.  The panelists included Kathleen Sebelius, Daniel Landon, Tarren Bragdon, and Michael Cannon. American Public Square is an organization dedicated to promoting civil civic discourse on the important issues of our day. The emphasis throughout is on civility and open discourse (no clapping, no jeering, opportunities to call time outs for neutral fact checking, etc).

This was my first American Public Square Event so I don’t know if they always try to gin up extremes or whether the issue of Medicaid is particularly polarizing. It does mean that Medicaid was both demonized (forget expansion Medicaid, I’m talking original Medicaid) and extolled in somewhat inaccurate and unfair terms throughout the evening. Michael Cannon, for example, explained the very early results from the Oregon Medicaid Lottery to mean that Medicaid produced no better health outcomes, but when "fact checked" on this adopted a fallback position and began to argue that the studies interpreting the early results were methodologically flawed. Because it was all done in an earnest and calm manner, it apparently passed the American Public Square definition of civil discourse. 

Maybe it is just that I have a different idea of civility.  After all, the conduct of the members of the House of Commons has many of the characteristics American Public Square apparently considers uncivil. Yet, robust and even rowdy debate in the House of Commons seems to me to be exceedingly civil. Maybe true civility is not in the surface adornment of the event (no clapping, etc.) but in respecting the forum and the audience enough to not misrepresent, to not overstate, and — most of all — to concede that it is possible you could be wrong.

I'd say that is what was missing last night, a healthy respect for one's own fallibility and a generosity of spirit toward the fallibility of others.

The rare Medicaid expansion/original Medicaid discussion would be one where the parties had genuinely thoughtful and strong opinions yet admitted, “but, hey, I could be wrong.”  Who there had read Kathryn Schulz’s Being Wrong and taken it, even a little bit,  to heart?

 

Steven Tharratt, the California Prison Health Care Services' CMO, was brave to take this topic on at McGeorge SOL's recent conference on Ethical Pricing Decisions in Healthcare. California's prison system is staggering under the burden of next generation pharmaceuticals such as Gilead's Hep C pill Sovaldi.  Of course the problem is writ large in California's state prison system for a few reasons including  the prevalence of Hep C in our prison population and the lengthier time of incarceration in the "three strikes" era.

What frames this issue so nicely is that Sovaldi — sometimes called the $1,000 a pill medication — is a cure  for Hep C, though you may acquire Hep C again after you are cured. It does not confer immunity.

By any estimation, Sovaldi is an amazing development probably priced against the cost of treating an individual with end stage liver failure. Not surprisingly, the U.K.'s NICE has compared its Sovaldi acquisition cost (call it the $700 a pill medication in the U.K.) as compared with its end stage liver failure treatment cost and declared it a good value.

But is it a good value for the California Correctional System, who may not acquire at the U.K. acquisition cost or even our own Medicaid acquisition cost (both estimated at about $700 a  pill)? Given the movement of Sovaldi to mainstream Hep C treatment therapy in California, is this a question that can even be asked?

Like others of you, I read about developments in global public health and sometimes think about their domestic application. This challenge to "enable self-testing for cervical cancer" in the developing world really caught my eye.

We are a country steeped in the clinical medicine approach to cervical cancer screening. The biggest problem with that, is that a public health approach is what appears to lift screening levels in the riskiest population and lower mortality.  

Some of this testing, at least at the level of using self-HPV testing as a proxy for self-testing for cervical cancer, is already being tried in China.  

Here, social and cultural barriers to the Pap Test are not insignificant in some settings, particularly among Asian women in the U.S.

When you look at the cervical cancer death rates in the U.S. under the screens of race, ethnicity, and age you know we have our own "Grand Challenge."