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It has been a few years since AHRQ has begun to use stimulus money to promote targeted academic detailing projects in the United States. Pfizer's CEO is just recently on record that this kind of conflict-of-interest behavior — where trained clinician consultants visit physicians, pharmacists, nurses, other clinicians, and health care system decisionmakers nationwide to share unbiased, noncommercial information about medications and other therapeutic options with the goal of improving paitent care — must be stopped.  Academic detailing, he insists, is directly analogous to commercial  pharmaceutical company funded detailing and if the latter is increasingly subject to sunshine and disclosure requirements, so should the former be.

Now, why would Pfizer want to track the path of academic detailing done by the government or at the government's direction? Would shadowing the government-sponsored academic detailiers to counter-detail with commercially prepared or selected materials be the next logical step?  And then would the government counter counter academic detail? And Pfizer renew its commercial detailing efforts in the wake of every government sponsored academic detailing visit?

Would any health care provider or decision maker have any time in the day to do anything other than meet and greet prescription drug educators/detailers?  Is that the best and highest use of the scarce clinical time of primary care providers, for instance?

Of course the fight for the hearts and minds of those clinicians and decisionmakers who control our nation's total drug spend is no joke.

About a week ago, I blogged about state governments struggling to comply with or evade the ACA's employer pay or play requirements for health insurance. A few days ago, the Wall Street Journal chimed in documenting a further effort on behalf of private employers to alter the ACA requirement of employer pay or play for all employees at 30 hours a week and up. Those of you who kow anything about the demographics of part time work will not be surprised to see the National Restaurant Association as part of the leadership in opposition to the statutory requirement.

And no lesser lights than the folks at NPR and Sarah Kliff are busy documenting the move to part time workers. But will this necessarily last?  Or, will employer-sponsored health insurance benefits be used — as they have been from their WWII wage freeze origins — as a way to tie quality employees to the employer, offered by quality service emphasizing employers as a way to skim the best employees  for themselves?  If not, will enforcing the employer pay or play mandate not free those highest quality service sector employees from job lock and free the market to reward them more appropriately for what they bring to the table?

I suppose how you feel about freeing employees in labor markets all depends upon whether you're a buyer or seller in those labor markets.

The funny thing about Medicaid expansion is that it is like endless soup — that recipe where tomorrow you take on yesterday's leftovers, build in a few new ingredients, and serve it up. Don't like today's soup? You could always hold out for tomorrow's.   By this, I mean that optional Medicaid expansion under the ACA is never a yes or no thing, only a "not now" or "not on those terms" thing.  And so it has always been with Medicaid state buy-in since its very inception and so it is, I would argue, with American-style health care reform.  We are rarely all in or all out.

That's what I say when people ask me about the Missouri legislature's apparent failure to address ACA optional Medicaid expansion this session.

Anybody for yesterday's soup?

Earlier this month, President Obama submitted a budget proposal offering to delay the implementation of DSH cuts by twelve months. I have dished on the significance of DSH before and will merely note here that this is a proposal — a bargaining chip if you will — and that twelve months is not an extraordinarily long time in the acute care hospital budget cycle.

DSH's re-invention is inevitable, it seems to me. Forestalling the 75%  DSH cuts that bind while states move toward Medicaid expansion makes sense so long as progress is being made. Otherwise, it is hard to rationalize the continuation of such a troubled federal subsidy system.

The battle over DSH or Medicaid expansion highlights the irony, of course, that it is federal dollars that keep some acute care hospitals alive — whether those dollars come to the hospital through the back door (DSH) or through the front door (through expanded Medicaid enrolled patients). Ironically — given the gaming of DSH payments — significant numbers of rural low income facilitites would do better under the federal dollars through the front door model than the current gamed-DSH through the back door system, where the majority of dollars go to suburban hospitals in only a few regions of the country.

I tell my students there are always cross-subsidizations in health care, some of them perverse. I also tell them we can learn a great deal about health care payors and players by looking at how the cross subsidization works.  And then I talk about DSH.

The AP is reporting that Washington state is considering a proposal to move part time state government employees eligible for employer sponsored health insurance out of state health coverage and into Exchange health insurance purchases.  This latest proposal focuses on Washington state government employees who work 20-30 hours per week only. Washington, unusually generous in this regard, has historically extended state health coverage to those who work for state government for as few as 20 hours a week.

Many other states are not so generous, but they also struggle with the budgetary significance of the ACA's requirement that those who work a minimum of 30 hours a week be offered employer sponsored health insurance. Virginia  is reportedly requiring that all part-time state employees work less than 30 hours a week, to dodge the ACA coverage requirement. This move parallels reports of similar conduct in the private sector.

Washington state's circumstances are distinguishable, of course.  These matters are a subject of collective bargaining in Washington state.  A revised collective bargaining agreement sweetening the deal for individual state workers in the 20-30 hours per week category to move to the Exchnage is reportedly under discussion.

But, as far as I can tell, noone is offering to sweeten the deal for Virginia's part time state employees.  Florida, taking another tack, is moving to extend state coverage to its 30-39 hours per week employees, a group that has traditionally not been offered health insurance in that state.

Where you end up, on this, depends on where you started, of course.  Each state has its own state employee insurance coverage and state government employment system. Each state starts with its own profile of coverage and non-coverage in the state employee population and must determine for itself how generous it chooses to be to less than full time state employees. I will note that, in some states, part time state employees are the majority of employees in some state agencies.  You may, for example, read about the predominance of part-time state employees in Virginia's ABCD here http://www.timesdispatch.com/news/state-regional/virginia-politics/general-assembly/state-grapples-with-insurance-rules-for-part-time-workers/article_03136cab-9eab-5295-9359-89a19fae4a15.html.

Tradeoffs will have to be made.  Just as commercial employers must struggle with employer sponsored health insurance for part time employees, so must state and local governments. State and local governments, in fact, are the largest single employees in some places in the United States. State government employee wages have long been discussed as a fraction of total state employee compensation.  In tax parlance, compensation includes wages and benefits.  And anyone who has ever been involved in payroll knows that the tail can wag the dog in this regard.

Is it a good or a bad thing that state government employees below 40 hours or 30 hours a week employment status are moved to the Exchanges?  The answer to that will depend on what sweeteners, if any, these state employees bring to their Exchange purchases and to the prices of the plans in the Exchanges — particularly the prices of those plans that most closely mimic the scope and depth of the state health insurance offered to 30 hour a week or 40 hour a week state employees. The biggest sweetener for low wage workers — whether employed by the state government or in the private sector — is the potential expansion of Medicaid, of course.

It will come as no surprise to some that Arizona — several decades late to the party on original Medicaid — worked hard for approval of a plan to extend Arizona Medicaid to all Arizona state employees. This plan fell short of implementation.  But everyone should know that this idea is not new.

 

Here I am on KCUR talking to the razor-sharp health care reporter Elana Gordon about health care POAs — not always as straightforward as they might seem:

 

http://www.kcur.org/post/role-power-attorney-health-care-setting

 

 

 

People find me. I don't always know how they do it, but they find me. And they persist until they catch me between classes or other commitments and fire their ACA-related questions at me. For my part, I look for what the questions tell me about the zeitgeist here in Kansas City and beyond.  What is it about the ACA that confuses my fellow citizens?  What is it about the ACA that scares them?  What are the biggest urban legends about the ACA?

In the past few days, I have been asked several times about the ACA's ban on cancer treatment for Medicare patients.  You mean you haven't heard of it? Could that be because it does not exist in the ACA?

The first time I was asked about this, I wondered if it might be the product of lingering anxiety over the proposed-but-dropped Medicare benefit to fund a beneficary's doctor-patient conversation about end-of-life planning. Sometimes, anxieties can have a long fuse. And "death panels" certainly did get a fair amount of airplay.

But the second and third time I was asked about this made it clear that this concern is something different.  There is evidence circulating that, since April 1, 2013,  the sequester's cut to Medicare has had an unforseen effect on doctor-administered chemotherapy treatments under Medicare Part B.  The across-the-board two percent cut, when applied to certain kinds of cancer treatments, cuts so deeply into the physician chemotherapy drug acquistion price plus 6% overhead payment that some have determined to turn patients away. Press reports indicate that oncologists refusing treatment on these grounds are urging patients to contact federal elected officials to complain.

This may explain the "connection" to the ACA. I have noticed, among the public, an increasing propensity to attribute every hiccup in health care markets and health care finance to the ACA.  In this case, they are attributing every defect in our governing process to the ACA. That's why I'm thinking of putting together an essay on the ten biggest myths surrounding the ACA. (Please post your derby entries in the comments.)

That said, how do I respond now?  I could explain that the ACA is very modest health care reform, quite incrementalist really and that  it does not place extraordinary amounts of power in the Executive Branch to determine the scope of Medicare benefits.  The Independent Payment Advisory Board, for example,  is specifically precluded from addressing rationing. The "R" word is anathema to the drafters of the ACA.

I could also explain that some oncologists are in a better position to serve their patients at a loss for the sequestration period. It is not as if all Medicare chemotherapy patients are being turned away at the door by oncologists. This is further evidence — as if any more were needed — of how geography and income status are destiny in health care.

Finally, I could also explain that there are bills pending (including H.R. 1416) to terminate the application of sequestration to payment for certain physician-adminisered drugs under Part B of Medicare.

But I am not certain that truth is the antidote to an urban legend.

The possible sale of North Kansas City Hospital has been in the local news for some time now.  The more than 50 year old not-for-profit hospital was first rumored to be heading toward sale this past summer when the North Kansas City Council hired a New York investment bank to advise on the possible sale of the city-owned hospital. 

The press resports NKCH was built with property tax revenue and city bonds though it has neither received funding from nor provided revenue to city coffers in decades.  At present, the city's involvement with NKCH appears to be limited to appointing the board of trustees. Of course, that is a very powerful appointment power to retain — as witnessed by the current dispute over the City's attempts to add new members to the board of trustees while litigation over the authority to sell the facility is pending. A Clay County Court judge has approved the ongoing appointments while simultaneously entering an injunction to prevent the actual sale of the facility while the authority to sell litigation is pending.

This litigation is a brilliant example of all the issues exposed in hospital sales — and particularly raised in the sale of public hospitals and in the potential sale of not-for-profit facilities to for-profit entities.

Who owns this not-for-profit hospital?  Who owns any not-for-profit hospital? Those who conceived of it, built it, and nurtured it in its early years?  Those who took on its operation when the city cut the financial chord?  Those who operate it now, consistent with its mission statement on public service? The residents of North Kansas City who granted tax exempt status to shelter the founding and continued operation of the facility? What does this not-for-profit hospital owe, if anything, the community of North Kansas City?

The North Kansas City Attorney claims that the hospital is owned by the City –hence the board of trustees appointment power.  Seen from this perspective, current members of the NKCH Board are suing themselves: one part of the City attempting to sue another "like a dog chasing its own tail," to quote their legal counsel.

The analogy is apt, though perhaps not in the way the NKC Attorney meant it.  NKC is conflicted over its future plans for the hospital and over its own obligations to the citizenry who raised the hospital up. Maybe the situation is less like a dog chasing its own tail than two mother dogs squabbling over a puppy each believes is hers.

This concern with trying to track the ownership – but not necessarily legal ownership — of not-for-profit health care facilities is manifest all over our country as publicly funded hospitals decline in number. Who "owns" the return on that initial investment?  Has it been recompensed many times over by decades of service?

Maybe some of the answer to this conundrum in North Kansas City will depend on how good and generous a neighbor NKCH has been, how closely it has honored its mission statement, how carefully it can document what it has already given back to the community in exchange for a good start in life and ongoing tax exempt status.

For more than a decade the federal government have been making inquiry into these matters as they concern federal tax exempt status.   Most recently, proposed regulations under the Affordable Care Act propose to beef up the charitable care reporting requirements of not-for-profit hospitals. You may see changes the IRS has already made to 501(c)(3) entity reporting requirements here:http://www.irs.gov/Charities-&-Non-Profits/Charitable-Organizations/New-Requirements-for-501(c)(3)-Hospitals-Under-the-Affordable-Care-Act   And you may see further proposed regulations relevant to the assessment of community needs here: http://www.healthreformgps.org/resources/irs-issues-nprm-for-charitable-hospital-organizations/

On a parallel track, some states have become quite agressive in considering what it takes to justify the public sacrifice of tax dollars for a non-profit health care facility and what, if anything, is owed to the public when and if the entity changes hands. The Provena Hospital loss of tax exempt status in the State of Illinois, which you can read about here:http://www.fiercehealthcare.com/story/il-hospital-loses-high-profile-tax-case/2006-10-03, illustrates how searching the inquiry into public return on tax exempt status can be.

We are in a state of flux in defining what we expect from not-for-profit hospitals.  And those same hospitals are struggling to find a place in increasingly concentrated hospital networks, concentration that may be increased by the implementation of the ACA.

Maybe the dispute over the ownership of NKCH is so complex because both senses of "ownership" are in play — legal ownership and principled ownership of and responsibility for the mission statement of a not-for-profit hospital.

 

The Kansas City Star is reporting that Prime Healthcare has completed its purchase of hospitals in Kansas City and Leavenworth Kansas. Buying at both ends of the hospital-size continuum, Prime has closed the deals to purchase the 400-bed Providence Medical Center and the 80-bed St. John's Hospital. These appear to be the first Prime acquisitions in Kansas.

Prime is a for-profit entity that specializes in the purchase of financially-distressed properties to add to its California-based 23 acute care hospital chain. These acquisitions were no exception to the Prime business model. It is reported that the $54.3 million sale price came nowhere near the $121 million in debt the Sisters of Charity of Leavenworth Health System was carrying on the facilities.

Prime has quite a high profile in California.  You could read about their legal battles with Kaiser Permanente Health Plan over billing and transfer practices here: http://www.modernhealthcare.com/article/20120918/NEWS/309189959.   And you could read about Prime's kwashiorkor cases here:http://www.sfgate.com/health/article/Hospital-eases-billing-for-rare-malady-4141154.php. Or, you could read about Prime's patient data breach issue here: http://www.californiahealthline.org/articles/2013/1/18/prime-sued-over-alleged-patient-confidentiality-breach.aspx.  

The closing of a hospital can best be understood as the death of a civilization.  Many communities, particularly rural communities, build much of their civic life around hospitals. The pressure to find a buyer — any buyer — can be intense when a hospital is on the apparent brink of closure. 

 

CMS has just released a proposed rule on the role and place of ACA navigators or consumer aides who will help uninsured Americans apply for insurance through the Exchanges. As Missouri will not operate its own Exchange, I am particularly interested in who is going to help consumers navigate the federally facilitated Exchange here. And I would like to understand the difference between navigators and "non-navigator assistance personnel."

I suppose some of this is self-interested. I like to think I put myself out there to be helpful  but I can tell you I am utterly overwhelmed with questions about the ACA, usually along the lines of "What will the ACA mean for me?" No surprise that the answer requires a certain amount of knowledge of the ACA and a certain amount of training and experience in insurance counseling.

I sometimes joke that the first assignment of a health law professor is to explain the university's health insurance program to the faculty and staff and then to be a teacher and scholar. If my faculty and staff peers cannot get a handle on this stuff,  how will the average American, particularly in a state uninterested in explaining the law to the broader population?

So far, all of the focus has been on who a navigator or non-navigator assistance personnel may not be. By this, I mean the big quarrels have been over excluding insurance brokers from eligibility and CMS's requiring that state requirements for licensing or certifying navigators may not conflict with the ACA. Yes, the revenge of the disintermediated is a fearsome thing.

I can't help but wish, though, that more thought were being given to what would make a good navigator or non-navigator assistance personnel. Many moderate income Americans will need assistance from these people.  I would like to know who they are.  Enrollment begins in October, you know. Or, did you not know that?