Author: Ann Marie Marciarille

A few weeks ago, I received my EM from UMKC Student Affairs discussing an apparent mumps outbreak at M.U.  It was fascinating to parse, an exercise in health promotion without offering a low cost option for participation. Here's the text:

 

Dear UMKC Students, Faculty, and Staff:

Earlier this year, MU reported a number of mumps cases, which have so far been the only reported cases in Missouri.  UMKC has not had any mumps cases reported, but we want to take this opportunity at the beginning of the new semester to review this illness and strategies that each of us can take to maintain a healthy campus.

 

Mumps is a highly contagious viral infection that can cause painful swelling of the salivary glands. The best prevention against mumps is to receive the MMR (measles-mumps-rubella) vaccine.  The MMR vaccine prevents most, but not all, cases of mumps and complications caused by the infection.  The Centers for Disease Control and Prevention highly recommends individuals receive two doses of the MMR vaccine to protect against the spread of infectious diseases.

 

Mumps is spread from person to person by direct contact or through the air from an infected person’s coughing or sneezing.  Symptoms include:  swelling and pain in the jaw (one or both cheeks may look swollen), fever, fatigue, body aches, headache, earache, and sore throat.  It usually takes two to three weeks for symptoms to begin after you have been exposed.  Mumps can be spread from five days before and until five days after the onset of swelling in the salivary glands.  Isolation of mumps patients is recommended for five days after their glands begin to swell.  Although there is no cure for the mumps infection, most people with symptoms typically recover in approximately ten days, though in rare cases serious complications can occur.

 

If an individual develops mumps, they should remain at home and refrain from attending school/work for five days after their glands begin to swell.  Please communicate with your faculty/supervisor about any need to miss classes/work.  UMKC requires all individuals who develop symptoms that look like mumps to contact UMKC Student Health and Wellness at (816) 235-6133 to report any mumps diagnoses and to discuss symptoms and treatment.

 

IMPORTANT TO KNOW:

• All individuals who have not been vaccinated and have never had the mumps infection should receive two doses of the MMR vaccination.  Individuals should have their second MMR dose four weeks (28 days) after the initial vaccination. 
• UMKC Student Health and Wellness offers the MMR vaccination for $71 per dose for students; faculty and staff should contact your primary care provider.
• Anyone who has mumps should avoid contact with others.  The CDC recommends isolating mumps patients for five days after their glands begin to swell.
• If you or anyone else in your household has a weakened immune system or is pregnant and has never had the mumps illness or vaccination, talk with your doctor immediately.
• Contact UMKC Student Health and Wellness at (816) 235-6133 to report any mumps symptoms or diagnoses.

 

Please help prevent infectious disease outbreaks on our campus. The actions of each individual student, faculty, and staff member are the most effective method of prevention against mumps and other infectious diseases.  This responsibility of each individual to receive their MMR and other important vaccinations, such as meningitis and influenza, is what maintains a low number of all infectious disease cases and outbreaks.  Please consider receiving the MMR vaccine to help prevent illness and ensure a healthy UMKC campus. 

 

If you have any further questions or concerns please contact Scott Thompson, UMKC Student Health and Wellness Administrator, at (816) 235-6133 or by e-mail at thompsonsco@umkc.edu.  You may also contact the Kansas City, Missouri Health Department at (816) 513-6152 for additional information.

 

Also visit the links below to learn more about the mumps disease and vaccination. 

• http://www.cdc.gov/vaccines/vpd-vac/mumps/default.htm
• http://www.cdc.gov/vaccines/hcp/vis/vis-statements/mmr.pdf

 

Sincerely,

 

Mel Tyler

Vice Chancellor for Student Affairs and Enrollment Management

 What the Important Health Message doesn't say:

1. KCMO had quite a measles outbreak in 2014 (actually a significantly more dangerous disease, for some populations, than mumps) and if mumps is in wide circulation, measles (also highly contagious) may be again as well because the MMRV vaccination is a multi-disease combined shot.
2. All nine or so confirmed cases of mumps to date at M.U. have reportedly been among students able to individually confirm receipt of the CDC-recommended two doses of MMRV (which M.U., apparently, makes a condition of enrollment and UMKC, apparently, does not). Since 5-10% of vaccines don’t take for various reasons, this is not entirely unusual as much as it tells us how much those who ARE vaccinated are at risk. Why? Because Missouri’s  school entry vaccination rate has dropped below 90%, the failure of herd immunity danger zone.

Missouri school entry vaccination entry requirements allow for religious as well as medical exemptions. This problem is not going away any time soon.

 

 

 

The Second Circuit, in N.Y. State Psychiatric Ass'n v. UnitedHealth Group, recently reversed a federal trial's court dismissal of a Mental Health Parity and Addiction Act of 2008 ("Parity Act") suit brought on behalf of its members (NYSPA) against UnitedHealth Group as a plan administrator for alleged violation of the Parity Act by refusing to treat mental health benefits on par with medical and surgical benefits when applying treatment limitations.

As this was a reversal of a ruling on a Motion to Dismiss and  resulting in remand, we still don't know if NYSPA's opportunity to pursue their claim of standing to bring this litigation will ultimately prevail.  It will require NYSPA's proving its assertion that advancing the Parity Act claims does not require individualized proof.

Even the possibility that Parity Act claims might be proven at the global level and might be amenable to systemic analysis is a heady one.

 

When Jonathan Kozol tells us how his father, Dr.Harry Kozol, diagnosed himself with cognitive decline, we know we have met in his father a formidable intellect and a remarkable  spirit. What Jonathan Kozol was not ready for was how the wider community of family, friends, and health care practitioners  would so quickly adopt a practice of "talking across" his father rather than to him, once the Alzheimer's diagnosis was official.   This particularly offends him, I think, because it was not the way his father treated those with diminished capacity or cognitive impairment, whatever its source.  I do have to wonder, though,  if his father's determination to seek a  much delayed confirmation of his self-diagnosis tapped into  his father's  understanding of this aspect of human behavior.

The author is 87 pages into his book  The Theft of Memory before he can say it: "I never felt they [his father's clinicians] gave him back in full, or even in small part, what he had given once unstintingly to people who had placed their trust in him."

And what was that thing? Dignity.

"My father had always liked the word 'clinician' better than 'physician' because it held the connotation of direct, unmediated, never arm's-length service to the people he had been asked to care for." We meet Jonathan Kozol's father through his eyes, including his memories of tagging along on after-hours calls to patients in mental health facilities who, no matter their distress, his father unfailingly attempted to connect with as people.

What a gift, in the pre-HIPPA era of course, for Jonathan Kozol to watch his father search for humanity first and patient second.

Shortly after the Affordable Care Act's arrival on the scene, I began to hear rumblings of various groups wanting to enter health insurance markets, in particular the insurance cooperative market fostered by the Act. Cooperatives are designed to launch new products to enhance competition in the exchanges. Consumer board governed, they attracted many  in the not for profit world.   My first face-to-face meeting with an interested party was sobering.  They, in fact, either seemed or wanted to seem pretty ignorant of the state solvency requirements, for example, such an entity might face. I was concerned.

When I learned recently that 22 of the 23 extant coops lost money last year, I can't say I was surprised. Entry into health insurance markets is notoriously difficult.  Although start-up funding from the government can be useful, building enrollment in an industry with powerful brands is a challenging time consuming project.  Oh, and did I mention that entry into highly concentrated markets may leave very little room in which to play the maverick market entrant? And the reinsurance payments, though generous at the start, are going away.

The brightest star of all is Maine's Community Health Options, which has achieved a surplus while insuring some 71,000 covered lives in Maine and New Hampshire.  Interestingly, size matters but a proprietary network of providers may matter more. The largest Coop, Health Republic Insurance in New York, is losing money, after all.

It is pretty clear that, to continue to pursue this experiment, more and longer term subsidy will be required.  In a country with a rapidly consolidating health insurance sector, it will be interesting to see how interested we are in attempts to foster market entrants.

This past Tuesday, it was my pleasure to speak at the Ethics Committee Brown Bag Workshop at Children's Mercy Hospital in Kansas City.  This is a wonderful facility, perched right near the border between Missouri and Kansas.  As Children's Mercy's own website notes: 

 

Medicaid covers 32 million children nationwide. 163,000 children are covered by Medicaid in Kansas and 414,000 children are cover by Medicaid in Missouri. The Medicaid program is extremely important to Children’s Mercy as approximately 50% of our patient population is covered by Medicaid.

 

In that context it was probably inevitable that any discussion of health care reform was going to eventually get around to questions about Medicaid in general and Medicaid for children, in particular.

Children are historically a favored Medicaid population.  Single adults without children are historically a disfavored Medicaid population. And there we have it, those deemed among the most sympathetic combined in an expansion program with those deemed among the least sympathetic. One of the boldest strokes in the ACA is this push to expand Medicaid away from categorical as well as financial and medical eligibility.

But the decisions by the states whether or not embrace this potentially radical transformation of Medicaid are, of course, ongoing.  And, it is no accident that waiver negotiations — to the limited extent they are made public — have been circling around the desire to re-introduce categorical eligibility for the ACA Medicaid expansion population, albeit under a different name.

Consider, for instance, Arizona's soon to be filed waiver request to set a five year life-time cap on the receipt of Medicaid for "able-bodied" adults. Categorical eligibility redux? 

The whistleblower under a Federal (and some state) False Claims Act case is called the relator.  Relators, quite often, have intimate knowledge of the particular False Claims Act violations alleged because they played some role in conceiving or implementing the false claims. Nobody said this was going to be pretty.

The Kane v. Healthfirst and U.S. v. Continuum cases caught my eye, however, because the relator was the very employee in Healthfirst's Revenue Cycle Department who was tasked with investigating a 2010 claim by the New York Office of the State Comptroller that a number of claims had been improperly billed, using New York's Medicaid program as a secondary biller to a managed care program involving Healthfirst.  After identifying as many as 900 claims (at a value of over a million dollars), Robert Kane wrote a memo outlining what he had discovered and estimating outside exposure.

And then his employment was terminated.

These very recent cases are important for the light they shed on the "reverse false claims" standard requiring speedy repayment of claims identified as false under something often referred to as "the sixty day rule."  Part of the take away from these cases is that a potentially false claim identified as such — even though not definitively identified as such — is  apparently enough to trigger the sixty day repayment rule. The defendants here took over two years and one set of civil investigative demands to complete their re-payment.  

The recent ruling in these cases is also a wake up call to health care employers who think an adversarial relationship with an employee fulfilling an assignment to scope out the problem and estimate potential liability makes a defense of good faith error and good faith effort to re-pay more credible.

Puerto Rico's economy has problems. Given the state-federal funding nature of Medicaid ("Mi Salud" is Puerto Rico's Medicaid program), this almost inevitably would mean Medicaid woes as well. And this is almost certainly exacerbated by a Congressionally imposed per capita Medicaid funding cap that is far below that of the states. So, with an estimated 45 percent of Puerto Rico's population enrolled in Medicaid, the recipe for disaster is complete.

How does the disaster manifest itself? One predictable way is by the wholesale movement of Puerto Rico's doctors from the island to the mainland. The New York Times reports that "[m]ost medical school graduates do not even bother looking for jobs here [in PR]." The villains?  Lower pay, a practice system still oriented around solo and small practitioners, reduced Medicare Advantage reimbursement rates, and a Medicaid funding cap. Oh, and add to that the fact that Puerto Rican's are not eligible for subsidies for health insurance exchange purchases and you might just have the perfect storm.

Propping up Medicare Advantage can hardly be the solution as the subsidization of Medicare Advantage comes at the price of raised costs in fee for service Medicare, though the providers interviewed in the New York Times seemed focused on this medical reimbursement rate focused fix. Raising the cap on federal Medicaid contribution to the level of comparable states might be a more coherent start. Recognizing the special problems of an island economy and offering particular assistance to those providers eager to stay on the island after having completed (government-subsidized) medical school education and training would be a good second step.  

Sadly, the crisis in health care in Puerto Rico is not really news, the Medicaid contribution cap has been in place since 1968, after all, at least in its first iteration.  The larger economic woes of Puerto Rico have brought the health care crisis into sharper focus, though. 

The story of aviation's re-invention of itself along the lines of strict quality control, sophisticated quality metrics, and dedicated use of checklists is one that is often told in health care circles. It is an object lesson, of course, in how health care might be or a study in contrasts, if you will. 

And now we see the beginnings of even more aviation style performance rigor possible in Boeing's direct contracting with health systems. Boeing has moved — first in Seattle and now in Charleston, South Carolina and St. Louis, Missouri — to direct contracting. 

Why do this?  Have Intel's first direct contracts in New Mexico and Lowe's and Wal-Mart's limited direct contracts for certain specialties (orthopedic and cardiac surgeries) yielded such great returns that it has become a no brainer?

Actually, little  public data is out there, though the cost savings must be substantial for Boeing to be able to reward employees who select health plans operating under the new direct contracts with free primary care, free generic prescriptions, reduced premiums, and more substantial health savings account contributions — an offer some 30 percent of eligible employees in Puget Sound accepted last year.

Boeing seems persuaded direct contracting can lower cost and improve quality.  As Modern Healthcare so diplomatically quotes a Providence-Swedish Health Alliance executive: "Employers set demands for services that exceed typical expectations in the healthcare industry."

Missouri's unique take on health insurance rate disclosure has made it to the Kansas City Star. Missouri is the only state that does not require health insurers to disclose in advance proposed insurance rates for products to be sold through the exchange. 

Why not? Is it that we love a surprise? Or, don't ask don't tell is a more comfortable perch from which to defend Missouri's other omission: failing to bargain for better rates for its citizens who will purchase through the exchange? Indeed, the latter is arguably the greater failing.

All of this does not stop the rumor mill from operating.  With a very limited range of choices available through Missouri's exchange and not even the disinfectant of sunshine available to  state rate reviewers, residents can only wait in dread for the rumored nineteen percent premium increase in exchange purchased health insurance.  

Just whose interests are served by a refusal to require advance notice of health insurance premium hikes?

Good thing we love surprises.

 

 

 

 

 

 

 

 

 

 

I sometimes encounter a cynicism about the health care regulatory process completely disproportionate to actual knowledge of the health care regulatory process.  I can be plenty cynical about some aspects of the health care regulatory process myself but I can't pretend that health care regulation has been for nought. Indeed, I sometimes think about starting a list of great moments in health care regulation.

Today, I offer an entry on the parallel list of great heroes of health care regulation, remembering the work of Frances Kelsey, the FDA officer who blocked the full introduction of thalidomide in the American market. She died only recently at the age of 101.  

One of the things most striking about her willingness to stand up for safety was her relative youth and newness to the FDA.  Her legacy: the 1962 enactment of the Kefauver-Harris Drug Amendments that mandated “substantial evidence” of a drug’s effectiveness as developed by “experts qualified by scientific training,” in addition to evidence of a drug’s safety, and provided for greater oversight of drug investigations. 

As thalidomide's legacy fades, with an estimated 5,000 thalidomide survivors remaining worldwide, my students most often have never heard of thalidomide and certainly never met a survivor. But we discuss thalidomide in Health Law.  Its role in the history of pharmaceutical regulation should not be forgotten, nor should Frances Kelsey.