Author: Ann Marie Marciarille

Medicare bundled payment initiatives are in the news again.  Overall, I welcome further experimentation in this regard.

But I also wonder what, if anything, we've learned from ongoing experiments with Medicare bundled (prospective)payments for Medicare beneficiaries with end-state renal failure/dialysis ("ESRD"). It has been more than a few decades now that Medicare has taken on this entire population simply defined by disease state or diagnosis. And it has been at least since 2011 that, under that rubric, Medicare has experimented with bundled payments for this group.

Like Dr. Phil McGraw, I often think the best question to ask is "How's that workin' for ya?"  Working well might mean satisfying the goals of comprehensive coverage to begin with or serving a diverse population equitably or serving this population at a price point that improves upon Medicare's original fee for service approach to dialysis payment.

As far as I  can tell, though Medicare enrollment for this group is up, costs have remained constant. Performance indicators began to improve in 2011.So, why don't we talk about it more? Because it seems so precarious as payment for the ESRD bundle is a perennial reimbursement arguing point? Or, is it that we are uncertain consolidation in dialysis providers is an unambiguously good thing or that that the drive to home-based peritoneal dialysis served many beneficiaries well?

 

I stopped by the Kansas City Public Library this past Wednesday to join the crowd (and crowded it was as I eventually listened from a satellite broadcast venue) turned out to hear Joe Califano talk about President Johnson.  The talk was anecdotal and, not surprisingly, hilarious.

When it came to the Medicare and Medicaid Amendments to the Social Security Act Mr. Califano talked about the signing ceremony at the Truman Library in Independence, Missouri.  He also talked about President Johnson telling President Truman something like  "you are the only person who can understand the satisfaction I feel right now."  That quote resonated but I didn't remember it as a private remark. And, sure enough, here is something like it from President Johnson's public remarks at the signing ceremony, a substantial part of which consists of remarks addressed directly to President Truman:

And just think, Mr. President, because of this document–and the long years of struggle which so many have put into creating it–in this town, and a thousand other towns like it, there are men and women in pain who will now find ease. There are those, alone in suffering who will now hear the sound of some approaching footsteps coming to help. There are those fearing the terrible darkness of despairing poverty–despite their long years of labor and expectation–who will now look up to see the light of hope and realization.

There just can be no satisfaction, nor any act of leadership, that gives greater satisfaction than this.

And perhaps you alone, President Truman, perhaps you alone can fully know just how grateful I am for this day.

If you'd like to read more, you might visit the Truman Library online.

 

 

California SB 277 has been signed into law, removing the personal belief exemption from California's school child vaccination requirements. This moves California from the position of one of the most generously worded exemptions all the way over to one of the most tightly constrained exemption systems.  Of course, some exemptions will still be available, even once SB 277 takes effect on July 1, 2016, so California will not be the strictest state but this is still a big move. California is not alone, Vermont has also recently enacted new legislation removing the philosophical exemption.

Of course, what SB 277 is also interesting for what it does not do.  It does not require the disclosure of school specific vaccination rates, the way Vermont's new statute does, for example. Several other states have pondered various systems of disclosure (vaccination rates, the enrollment of a non-vaccinated student, etc.) without specifying what redress might be available to concerned parents. 

And it is worth noting that there have been attempts in states lacking personal belief exemptions to create them.

We are, as they say, conflicted. What do we owe each other in our communal lives? What do we owe each other's children?

Why would California exclude the non-vaccinated from public school attendance but allow non-vaccinated home school students onto the campus to participate in activities that are not classroom based?  Because less physical contact and fewer points of contagion occur on the contact sports playing field than in the reading circle?  

If SB 277 is the triumph of science it is touted to be, I'd rather hear more about the science behind the exemptions.

 

 

 

 

 

 

Don Lee's article about a Los Angeles area McDonald's cook ends up warning about the downside of raising the minimum wage and losing eligibility for CountyCare, L.A. County-subsidized health insurance. Laurel Lucia questions why the story ends there: shouldn't the article have addressed what the fry cook might have gained by access to either expanded MediCal or purchase of subsidized insurance through Covered California?

I never know what to say when the discussion about subsidized health care never considers all the options for an individual.  Yes, thinking this through will slow you down.  The fact that it takes an expert to analyze and optimize all the different coverage options is a disgrace. But surely Don Lee has heard of the Affordable Care Act and the fact that California has expanded Medicaid under the ACA.

What value is there in discussing low wage workers and health insurance options without discussing the totality of income, subsidies, and state and federal benefits. Could it be that most people won't know enough to call you out on your incomplete analysis?

I visited my doctor for an annual exam in late May of this year.  Since that date, I have received six pieces of snail mail correspondence and multiple ems from that practice. Yes, I am enrolled in that practice's electronic medical records system.

So, we certainly have use — but is any of it meaningful?  Almost all of the correspondence is duplicative and at cross purposes. On the same day, the system produced two different and contradictory reminders of my need for an appointment in several months based on conflicting reports on my last visit, etc. 

It is not that I am surprised that quality control measures like patient appointment reminders ("You are due for a visit by X date") can get messed up, but I was surprised by the admission of everyone involved (because I asked!) at front desk, at lower level provider, and at clinical encounter that they had no knowledge of how to update or correct the system.

And so the flood of correspondence continues unabated: either I had my last well woman visit in August of 2014 or August of 2013, right? And I am either timely for an appointment in August of 2015 or not, right? 

Could someone please stop sending me  highly contradictory advice on when next to visit the practice and completely contradictory statements of what tests or procedures I need on my next visit? I mean, if my doctor and I agree that— all things considered— I accept the risk of moving away from an annual mammogram, shouldn't that be noted in my file? Then, why all the notifications crying out in fear that I am now "late" for my annual mammogram.

At some point, the electronic medical record has to be my electronic medical record, documenting my negotiated decisions with my practitioners and not just a barrage of notices from somebody's best practices checklists. What's that you say? None of the meaningful use protocols stress EMR accuracy?

So, if the electronic medical record I have is almost completely detached from memorializing my clinical encounters, is it still meaningful use for which my provider ought to be rewarded by my insurer?  Or, is it more like meaningful abuse?

I was aware, in an up close and personal kind of way, that environmental concerns drove the exit of CFC-propelled Albuterol inhalers from the market. I remember my doctor raising the issue with me and discussing training me on a new kind of inhaler. I went home and looked it up and found something like this. I can't say I gave it too much thought.  But now that I've read this and have to wonder just what that game was about.  

I have to say I love the conclusion: large cost increases in out of pocket spending for commercially insured, relatively small drop in utilization for commercially insured, and insufficient data to track the end result for the uninsured. We can speculate, though.

 

 

 

 

The Daily Californian's lead editorial today decries the announced termination of dependent coverage in Berkeley's Student Health Insurance Plan (SHIP) effective this fall. The rationale is simply that even voluntary dependent coverage is expensive and that the University would rather these families seek dependent coverage through California's Healthy Families Program, Medi-Cal, or the California Exchange.

So, just what is it about the 200 of the 23,000 enrollees in SHIP that makes these dependents such a cost-savings bonanza to eliminate? Here's what The Daily Californian reports:

        But for those whose incomes disqualify them from Medi-Cal or whose families need specific health         care packages that cover expensive and up-to-date treatments, the change can be frustrating.

How frustrating? Try too rich for Medi-Cal and unable to buy through California's Exchange with subsidies, frustrated. Or, try undocumented and a stranger to the Affordable Care Act, frustrated. Or, try, guessing most of those excess expenses went for maternity care, frustrated.

Now, Berkeley is the jewel in the system's crown. And other UC locations continue to offer dependent coverage in SHIP. Is it worse that the most exclusive of the campuses makes it incrementally harder for those with dependents to move forward economically?  Or, would it be even worse if all the UC campuses decided that students with dependents — overwhelmingly lower income students — were expendable as well? Oh, and it is women who are overwhelmingly more likely to be balancing their roles as parents and students.

Now, the relationship between the Berkeley campus and the system wide SHIP program has been fraught, but leading the way to screening student mothers out of Berkeley's student body is hardly a beacon of light.

What would a genuine student-parent success initiative look like? Not like this.

Western Dental is one of the largest Denti-Cal providers in the state of California. How big, you say? Western Dental is reported to serve between 650,000 and 700,000 patients annually with a higher Medi-Cal payer mix since the implementation of Medicaid expansion California.

Typically, new patients are a good thing. But it is possible to have too much of a good thing when it comes to payer mix, particularly when Denti-Cal's reimbursement rates actually decreased by 10 percent in 2013? That came on the heels of no payment rate increases since 2000-2001.

I don't think the timing on this is any accident. When you twin the recent Supreme Court decision in Armstrong (holding that Medicaid providers do not have standing to challenge the adequacy of a state's Medicaid reimbursement rates) with prior decisions like Douglas (holding that Medicaid beneficiaries also lack standing to challenge a state law that sets the low reimbursement system in place), you see that market exit or partial market exit is pretty much Western Dental's only immediate option.  And so Western Dental has announced its decision to stop accepting new patients under Denti-Cal.

Lots of hand wringing has ensued. Yet the "crisis" was predictable. What is unpredictable is whether this will force California to get serious about licensing dental therapists.

 

With the growth in high deductible health plan enrollment, it was inevitable that hospitals might have to think harder about collection practices.  A whole industry has grown up to help them think about it. See, for instance, an article about CarePayment's relationship with Memorial Hospital of South Bend, Indiana. Of course, there has also sprung up a counter industry designed to help patients deal with being on the receiving end of health care collection practices. You can visit, for example, a firm called Claim Jockey and learn more about how this business model has been applied to long term care insurance billing.

But I want to note that, whatever the enticement of higher accounts receivable, much of this effort  is to put a more humane face on hospital collection practices.  This is because those very practices have attracted negative attention from the tax authorities that consider tax exempt status for hospitals.

Over the past week,  I have attended a few legislative roundup presentations discussing health care wins and losses in the recently ended Missouri and Kansas legislative sessions. Each time, the presenter would discuss a (different) relatively non-controversial bill that failed even to get out of committee, musing that the state hospital associations were behind the bill and how that might have been the problem.

It is official, Pennsylvania has given notice that it may choose to switch to a state operated exchange, should that be necessary to preserve subsidies after a potential ruling adverse to these subsidies through the federally facilitated exchanges under King v. Burwell.

The letter leaves open whether or not this is something Pennsylvania will do as well as the terms of a potential jointly operated exchange. Of course, all exchanges (federal or state) are jointly operated in the functional sense, since the back of the house operations have to merge state-specific Medicaid enrollment standards with nationalized standardized federally operated exchange applications and subsidies.

On one level, I just don't get it. Every exchange, to a certain extent, is state operated and federally operated. Yes, even Missouri's (as of this date Missouri has not withdrawn from original Medicaid, though it has declined to expand Medicaid under the ACA, having seen fit to have expanded it under earlier expansions, however).

One possible post-Burwell anti-subsidies through the FFE possibility could be that other states announce and then implement hybrid exchanges.  But isn't that what they already are functionally?