Federal Health Insurance

Attached a link to an article titled " Most Governors Refuse to Set Up Health Exchanges" reporting that as of Friday, December 14th, more than half the states (including Florida) had rejected the Obama administrations pleas to set up their own health insurance exchanges. The exchanges are online market places where people can shop for private health insurance and obtain federal subsidies to help defray the cost. The Congressional Budget Office has estimated that in 2014 about 25 million people will eventually receive coverage through the exchanges. A total of 32 states that haven't agreed to set up their own insurance exchange could present the biggest challenge to fulfilling the law's requirement. In all, around 197 million people live in states that have chosen not to run their own exchanges. Of those people, about 18.3 million are uninsured and have incomes that could qualify them for subsidies if they bought policies through the exchanges.Federal officials and federal contractors will set up and run the exchange in any state that is unable or unwilling to do so. In my opinion the states refusal to set up their own exchanges will preclude those states to address specific insurance and demographic issues. A federal "off-the shelf" solution may not be sufficient to meet those specific requirements. The losers will be those uninsured who are forced to buy what the federal market place can offer. On the other hand, as a single payer advocate I also foresee that a consolidated federal market place may offer a first step for a national health insurance. So may be I should send a thank you note to Governor Scott. Yours Bernd

Medicaid and Primary Care

Attached a link to an article written by John Dorschner titled "Florida will pay Medicaid docs at new Obamacare rate" highlighting that Governor Scott's administration finally relented and, starting Jan. 1, Florida will begin paying Medicaid primary care doctors at new, higher rates required by the federal Affordable Care Act, a state spokeswoman said. The law requires that for the next two years Medicaid must pay primary care doctors at higher rates. According to a study by the Kaiser Family Foundation, Florida primary care doctors in 2008 were paid 55 percent of Medicare rates, meaning a $50 payment would be increased to $90 under the new system. That's indeed good news for all of us, primary care doctors and patients alike. In my case I re-enrolled as a Medicaid provider because more and more of my patients qualified for Medicaid and wanted to continue their care with me. Now, I can afford treating them without loosing money. A great victory for common sense!! But we also have to start demonstrating that this investment into preventive care and chronic disease management will save precious healthcare dollars by decreasing hospital admissions and emergency room utilization rates. That requires the implementation of new care delivery systems such as Patient Centered Medical Homes. I am confident that we can achieve these goals. Happy Thanksgiving Yours Bernd

Governor Scott and Common Sense: A Contradiction?

Attached a link to an article titled "Rick Scott Signals Willingness To Negotiate On Health Care Law" reporting that Florida Governor Rick Scott, one of the most outspoken critics of President Obama's health care law, signaled Tuesday that he may be ready to drop his longstanding opposition to the Patient Protection and Affordable Care Act. In an interview with the Associated Press, the Republican said that he is willing to negotiate with the federal government on implementing the new program. "The election is over and President Obama won," Scott said. "I'm responsible for the families of Florida. … If I can get to yes, I want to get to yes." "I don't think anyone involved in trying to improve health care should say 'no, no, no,'" Scott continued. "Let's have a conversation." Sounds good BUT talk is cheap. Governor Scott can show his change of heart by informing the U.S. Department of Health and Human Services by the deadline tomorrow whether he will set up a Florida health insurance exchange, partner with the federal government, or leave the task to U.S. authorities. The clock is ticking Governor!!

Tallahassee is not Teheran

Tallahassee is not Teheran: We need a real Governor and not a spiritual (mis)leader Attached a link to John Dorschner's excellent front page article in today's Miami Herald titled “Gov. Rick Scott may shift stance on health reform law” reporting that Florida Governor Rick Scott may be open to discuss the (partial) implementation of the Patient Protection and Affordable Care Act (PPACA). The article correctly points out three important milestones which need to be achieved in order to move ahead with the healthcare law implementation: 1) The statutory deadline for submitting Florida’s blueprint for a new health insurance exchange is November 16. Unfortunately, the stubborn refusal of our political leaders in Tallahassee to even consider the creation of a healthcare exchange will force the federal government to step in to set up such an exchange. 2) According to the final PPACA rule Medicaid payments to primary care physicians will be increased to reach Medicare levels. The final rule requires state governments to take further action prior to 2013 to implement this provision. States, including Florida, will receive an estimated $11 billion in new funds over 2013 and 2014 to bolster their Medicaid primary care delivery systems. More than six in 10 (64 percent) family physicians accept new Medicaid patients, and these beneficiaries comprise 15 percent of the average family physician’s patient panel. Governor Scott has refused to accept additional Medicaid funding to increase the pay for primary care physicians. As a result of the increasingly inadequate Medicaid payments nearly two in 10 family physicians have stopped accepting new Medicaid patients. 3) On Jan. 1, 2014, a major expansion of people covered by Medicaid will go into effect. If Governor Scott decides not to expand Medicaid coverage, Florida will lose $27.9 billion in federal funds over 10 years. That breaks down to a $4.5 billion loss for Miami-Dade during that time, and a $2.3 billion loss for Broward. Under the law, Washington will pay all Medicaid expansion costs for the first three years, but then the states would have to pay up to 10 percent of the costs in following years which will amount to approximately $1.7 billion over 10 years in Florida. The expansion could provide coverage to an additional million-plus Floridians. Florida's political leadership has so far stubbornly refused to participate in or prepare for ANY of the above mentioned changes. Subsequently, billions of federal funds will be appropriated to those states who do participate. Our political leaders should be aware about the adverse consequences of their stubborn refusal to implement this federal law. Florida having the third-highest rate of uninsured residents in the country stands to benefit more than most states from the Medicaid expansion intended to increase preventive care and to reduce unnecessary emergency room visits. Health experts warn that not expanding Medicaid could cost Floridians, because many of the state's 3.8 million uninsured residents will continue to receive care they can't pay for in hospital ERs. Those costs ultimately are passed down in the form of higher insurance premiums for everyone else and will further strain the existing Medicaid budget. Often hospitals end up absorbing large amounts of uncompensated, or "charity" care, which experts say affects Floridians in several ways. To recoup those costs, hospitals either reduce services or charge higher rates to insurance companies, or both. Those costs are often passed down to businesses as a “hidden tax” adding to the insurance costs for their employees. Furthermore, health providers have long complained that Medicaid reimbursements are so low they don't cover the costs of care. And because of low reimbursements, fewer physicians in the state actually accept new Medicaid patients. The increase in Medicaid reimbursement by almost 7 % for primary care physicians will allow family doctors, pediatricians and internists to accept new Medicaid patients and to offer urgently needed preventive medical care. I am convinced that Governor Scott knows all of the above mentioned facts but he still refuses to act. In my opinion this represents an egregious case of political malpractice ! Why is this being overlooked? Maybe, Republican leaders consider Tallahassee as their spiritual Mecca and are sacrificing the health of our citizens on the altar of ideological correctness and purity. But Tallahassee is not Teheran and we definitely do not need a supreme leader to decide our personal fate. Governor Scott should recognize that he is not the Governor of the Republicans of Florida but the Governor of the State of Florida. If he is incapable or unwilling to fulfill his constitutional obligation to implement a federal law then he should step down! Its time to man up Governor or to hit the road! Bernd Wollschlaeger,MD,FAAFP,FASAM

GOP Lawmakers call for suspension of meaningful use incentives

Its obvious that even the pending presidential election does not prevent the outbreak of a silly season on capitol hill. The letter sent by House Republican leaders to HHS Secretary Kathleen Sebelius is such an example filled with inconsistencies, falsehoods and fear mongering. The authors "believe that the Stage 2 rules are...weaker than the proposed Stage 1 regulations released in 2009. The result will be a less efficient system that squanders taxpayer dollars and does little, if anything, to improve outcomes for Medicare." They specifically point out that the Stage 2 regulation lower the threshold of compliance compared to Stage 1 meaningful use. The authors specifically criticize the fact that Stage 2 regulation "fail to achieve comprehensive interoperability in a timely manner" and claim that Stage 2 rules "eliminate the requirement to exchange information with other providers." They further claim that the alleged absence of interoperability standards represents a waste of $10 billion already spent for this program. To top it off they quote a New York times article claiming that EHR technology contribute to higher Medicare spending because EHRs " making it easier to bill for services, whether or not they [ hospitals and physicians] provide additional care." Based on the above arguments the Republican leaders call for a suspension of the incentive payments, significantly increase requirements for meaningful users, take steps to "eliminate the subsidization of business practices that block the exchange of information between providers." Now lets separate facts from fiction and ideology from reality. The Republican leaders and their staff seem to have omitted the fact that physician organizations asked CMS to lower the threshold of compliance and ease the requirements to achieve Stage 2 MU standards. In a letter sent to CMS by the American College of Surgeons,dated July 9th 2012, which was signed and endorsed by 24 medical specialty organization the authors emphasize that the Stage 2 rules may be too ambitious for small practices and " the significant initial price of implementation remains the greatest barrier to its adoption among small practices. For small practices, the high cost of EHR adoption is not offset by existing financial incentives. To the contrary, practitioners face uncertainty regarding the value they will receive. This is because the initial financial benefits of adoption, if they even exist, are difficult to quantify." Based on this request any further tightening of the compliance requirements will jeopardize the EHR implementation and a delay, or suspension, in incentive payments will make it nearly impossible for small practices to even comply with the Meaningful Use requirements. Until now more than seventy percent of hospitals have registered for the EHR incentive payments, and 55% have received their first-year payments. Healthcare organizations have made plans and are looking for that money to be paid to further invest in EHR technology and provider training. Nearly 294,300 physicians and other “eligible professionals” have enrolled for EHR incentive payments under the Medicare, Medicare Advantage and Medicaid programs and not quite 140,500 have been paid, according to the CMS. These funds represent a significant stimulus and provide desperately needed cash flow for financially strapped medical practices. Any suspension of those funds will especially penalize small business owners who will be forced to lay off staff and curtail purchasing. Is this what we need in our struggling economy? I am concerned that the Republican lawmakers, or their staff, have either not read, or misunderstood, the Stage 2 meaningful use objectives. Those clearly state that the test of “exchange of key clinical information” core objective from Stage 1 is eliminated in favor of a more robust “transitions of care” core objective in Stage 2; and the “Provide patients with an electronic copy of their health information” objective is also eliminated because it was replaced by the “electronic/online access” core objective. The final rule adds “outpatient lab reporting” to the menu for hospitals and “recording clinical notes” as a menu objective for both EPs and hospitals. There will be 20 measures for EPs (17 core and 3 of 6 menu) and 19 measures for eligible hospitals and CAHs (16 core and 3 of 6 menu). The final rule reduces some thresholds for achieving certain measures and modifies criteria for exclusions to respond to difficulties commenters identified in implementing certain objectives in certain situations. For example, for some objectives CMS has added exclusions based on broadband availability that allow providers in rural or underserved areas to achieve meaningful use with fewer hurdles. Initially, CMS also proposed two ambitious measures for the "Electronic Exchange of Summary of Care Documents " objective in Stage 2. The first measure required that a provider send a summary of care record for more than 65 percent of transitions of care and referrals. In the final rule CMS is reducing the first measure to a lower threshold of 50 percent. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals, and that the summary of care be electronically sent to a provider with no organizational or vendor affiliation. The intent of this second measure was to foster electronic exchange outside established vendor and organization networks. CMS is finalizing the 10 percent threshold for electronic transmittal, but eliminating the organizational and vendor limitations. Instead, CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR. Yes, interoperability is important and we should not relent our focus on this essential issue. But Stage 2 builds on the current phase and starts to emphasize data sharing. The main focus areas is the new requirements and enhanced standards for exchanging information. These rules are a true game changer in advancing interoperability between providers and patients. The goal of these rules is to improve patient outcomes by providing right information at the point of care. Highlights of improved/changed interoperability rules include: Provide summary of care document for transitions of care and referrals Provide online access to health information to patients with more than 5% of patients actually accessing the information Transmit structured electronic lab/image results to ambulatory providers Use secure messaging with patients A major one - use of data portability standards. Standards for coding structured data that is sent in the summary of care documents or other documents. Not only these standards will reduce errors but also will accelerate the use of analytics and secondary uses of the data. Transmission of information to cancer registries. Claiming that EHR technology contribute to higher Medicare spending because it easier to bill for services, whether or not they [ hospitals and physicians] provide additional care, is an insult to all decent physicians and other healthcare providers who, until now, had to accept dwindling insurance payments and intrusive insurance audits. EHR technology provides better documentation and coding tools which guarantees that a physician is being paid for what he does and not for what the insurance company decides he is worth receiving. EHR technology empowers physicians to be paid fairly and not arbitrarily. Its obvious whose side those Republican are representing. Its also obvious that insurance company lobbyist have contributed to the content of this letter and are now trying to scuttle any gains physicians made in achieving fair reimbursement. This letter should be rejected as an example of cheap propaganda and physicians bashing. Yours Bernd

Medicaid in Florida

I just returned from Germany where I attended a conference in Berlin. Read the attached excellent article by John Dorschner online in my hotel room and, what a coincidence, that same weekend an article in a German magazine highlighted healthcare cost control measures within the German universal healthcare system. In my opinion the Medicaid reform measures are doomed to fail as long as physician practices are incapable to measure the quality, outcome and costs of care rendered. The fee-for service model rewards volume above value of care and the participating physicians have no other choice but to apply this doomed treatment paradigm to keep their practices afloat. In a recent New England Journal of Medicine article the authors called for reengineering prevention into the U.S. System to accelerate the transition from Sick Care to Health Care. The Patient Centered Medical Home (PCMH) represents the foundation of such a new approach to health care including reconnecting medicine to public health services and integrating prevention into the management and delivery of care. Furthermore, the utilization of information technology tools within a PCMH allows for the value stream mapping for healthcare delivery to determine if what we spent for healthcare translates into cost-efficient, high quality and patient centered care. Eliminating administrative waste, i.e. insurance companies, is part of the value stream mapping process and must be addressed to transform our highly inefficient sick care system into a patient centered health care model. Bernd

Attached a link to a provocative editorial titled "Simple Treatments, Ignored" focusing on the poor outcome of hypertension treatment. The editorial reflects on the findings of a recent federal health analysis which found that nearly one-third of all American adults have high blood pressure and more than half of them don’t have it under control. The new analysis, issued last Tuesday by the Centers for Disease Control and Prevention, found that 67 million Americans had high blood pressure and that 31 million of them were being treated with medicines that reduced their blood pressure to a safe level. The remaining 36 million fell into three groups: people who were not aware of their hypertension, people who were aware but were not taking medication, and those who were aware and were treated with medication but still had hypertension.There are many missed opportunities for people with high blood pressure to gain control. Doctors, nurses and others in health care systems should identify and treat high blood pressure at every visit. The editorial not only points out that this is an abysmal record for a medical condition that is easy to detect and treat but also features solutions. Kaiser Permanente says that in Northern California it increased the percentage of patients whose hypertension was under control from 44 percent in 2001 to 87 percent in 2010. Over approximately the same period, stroke mortality declined by 42 percent, heart attacks by 24 percent and the most serious type of heart attack by 62 percent. The organization created a hypertension registry to track patients and the care they were getting; eased the burden on doctors by using pharmacists to initiate drug therapy and medical assistants to monitor patients’ progress; made it easy for patients to get free blood pressure checks; and showed doctors how their record on controlling blood pressure compared with others in the system. In my opinion our healthcare system is dysfunctional and deeply flawed. The system is still characterized by the separation of functions and tasks delivered by a plethora of healthcare providers who collect mountains of paper, or now Terabyte of data, but fail to share such data efficiently to coordinate care. We must break down these walls of isolation and collaborate in teams. Patient Centered Medical Homes can provide solutions to this problem but we need to accelerate its implementation and deploy community-based healthcare teams comprised of doctors, nurses, social workers, pharmacists, community activists etc. We have to break down the barriers built by professional organizations which protect the interest of its members, but lost their focus on public health. Such a local, regional and national strategy can control healthcare costs, improve quality of care and decrease debilitating morbidity related to chronic diseases. What are we waiting for? Yours Bernd

The Role of Safety Net Providers

Attached a link to an article published in the recent edition of Health Affairs titled " Safety-Net Providers In Some US Communities Have Increasingly Embraced Coordinated Care Models." The findings of this study were also the focus of an article by John Dorschner published in the Miami Herald titled " Jackson Memorial Hospital too weak, county too divided to provide good safety net, study says." Here are some background information, facts and study findings excerpted from the article: FACTS: Safety-net providers play a crucial role in providing health services to uninsured and low-income people. Although the Affordable Care Act is expected to expand coverage to more than thirty million uninsured people, it is generally recognized that the safety net will still be needed to provide services to an estimated twenty million people who will remain uninsured. In addition, in all likelihood, many existing Medicaid and newly insured patients will continue to use safety-net providers rather than private mainstream providers because the safety net can better meet low-income people’s specialized needs related to language, culture, and transportation PROBLEM: Delivery of health services through the safety net historically has been fragmented. Usually hospitals, community health centers, and private physicians providing charity care have operated independently of each other, with little or no coordination of the care of a patient. Such fragmentation can result in severe gaps in the availability of services, reduce quality, lead to redundant use, and increase the costs to providers who typically operate with limited resources and thin margins. SOLUTIONS: During the past decade, however, a variety of community efforts to better coordinate care for the uninsured that reduce the use of emergency departments and increase the use of primary care providers have been documented. Most community initiatives focus on providers’ efforts to better manage care for their uninsured patients; stretch limited public and private funds; and address serious gaps in services, particularly the lack of access to specialty care. Often these programs improve access to care for the uninsured at a much lower cost than either private insurance or local Medicaid programs. STUDY DESIGN: The Community Tracking Study, conducted by the Center for Studying Health System Change, consists of in-depth tracking of health system changes in twelve randomly selected metropolitan areas from 1996 to 2010. Representative of US metropolitan areas, the communities are Boston, Massachusetts; Miami, Florida; Orange County, California; northern New Jersey; Cleveland, Ohio; Indianapolis, Indiana; Phoenix, Arizona; Seattle, Washington; Lansing, Michigan; Syracuse, New York; Greenville/Spartanburg, South Carolina; and Little Rock, Arkansas. The article describes safety-net coordination efforts in twelve randomly selected communities and illustrates how these efforts evolved during the past decade. In particular, we focus on initiatives that attempted to coordinate care across multiple providers and were often communitywide in scope. These initiatives were better able to manage the care of uninsured patients than a more fragmented system of care (for example, the initiatives used more outpatient primary care to reduce inpatient and emergency department use). Some evidence obtained from the twelve communities indicates that initiatives to coordinate care across providers reduce high levels of emergency department use and reduce the cost of providing care to the uninsured, but barriers to coordination remain. SELECTED KEY ASPECTS & FINDINGS OF THE STUDY : Nine of the twelve communities studied had some type of organized safety-net program in 2010, compared to only three communities in 2000 Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. Five of the six programs explicitly require patients to have a medical home that they use for all primary care needs. A primary care physician practice that serves as a medical home is generally responsible for authorizing referrals for specialty care. Generally, a single primary care physician serves as the medical home for program participants. An exception is HealthNet in Boston, which is organized around the fifteen participating federally qualified health centers that serve as medical homes for the patients who are referred to Boston Medical Center (the safety-net hospital that administers HealthNet) for specialty and inpatient care. Centralized referral networks are the most common type of community initiative and have grown most quickly during the past decade. They focus primarily on providing a centralized location where patients can receive referrals to physicians and schedule appointments with private practice physicians (mostly specialists) who agree to treat uninsured patients for free or at reduced costs. A few of the (MEDICAL HOME) programs use provider incentives, such as capitation or enhanced fees, to encourage appropriate utilization of services for patients. For instance, the Medical Services Initiative in Orange County offers financial incentives for physicians to join the network. The program also includes extra payments for medical homes to provide at least one visit for each patient per year (two for people with chronic conditions), pay-for-performance incentives for medical homes to improve utilization of preventive services, and incentives for providers to reduce emergency department utilization. Health Advantage in Indianapolis pays capitated rates to primary care physicians to motivate physicians to encourage appropriate use of services and build relationships with their patients. It is unknown, however, whether these incentives are inadvertently discouraging the use of appropriate or necessary services. Formal evaluations of the six coordinated care programs have not been conducted or are not publicly available. One reason may be a lack of staff availability or other resources. However, available data show that Health Advantage in Indianapolis has been successful in decreasing inpatient use and emergency department use. In the first eighteen months after the program began, inpatient days for uninsured people decreased by 50 percent, and emergency department use decreased by 30 percent. In addition, in collaboration with researchers from the University of California, Los Angeles, the Medical Services Initiative in Orange County found that the ER Connect program reduced emergency department visits and increased the number of visits to primary care providers.Recent research on similar programs not included in the Community Tracking Study found that their patient costs were 25–50 percent lower than for patients enrolled in local Medicaid programs or through private insurance. What are the challenges and problems safety-net providers face? Many of the programs lack the capacity to serve all of the eligible uninsured. Providers’ practices are often full, and they have limited availability to see new patients, especially uninsured patients for whom they provide care for free or for reduced fees. Publicly subsidized programs are vulnerable to cuts in funding, especially given the strained local and state budgets of recent years. A major concern is the potential loss of funding for programs that have relied on Medicaid’s disproportionate-share hospital payments, extra payments to hospitals that serve a large number of Medicaid and uninsured patients, which are to be reduced under the Affordable Care Act. Health insurance coverage expansions in the Affordable Care Act may create the perception that the uninsured problem has been solved and these safety-net programs are no longer needed, potentially bringing an end to such efforts. Despite efforts at greater community collaboration, fragmentation and competition among safety-net providers remains. Competition among safety-net providers for Medicaid patients can inhibit closer cooperation. Most safety-net hospitals and federally qualified health centers depend on Medicaid patients for their financial viability both because reimbursements are based on the cost of care (and therefore are considerably higher than reimbursement rates to private physicians) and because grant revenue often doesn’t cover the full cost of care to the uninsured. Community health centers may be reluctant to participate in collaborative arrangements if they think that such cooperation could result in a loss of Medicaid patients. For example, interview respondents from Miami noted that some federally qualified health centers in the community were concerned that efforts by Jackson Health System (the main public hospital) to convert some of its primary care clinics to federally qualified health centers would increase competition for Medicaid patients, given the higher Medicaid rate that the hospital-based clinics receive. Safety-net hospitals are often the natural leaders for community integration efforts given their size and broad service area, not all safety-net hospitals are willing or able to assume that role. For example, Jackson Health System is the primary safety-net hospital for Miami-Dade County but generally does not provide a leadership role in coordinating care and services with other safety-net providers in the community. Part of this reflects Jackson’s financial troubles at the time of the site visit (Jackson lost about $240 million in 2009 and $100 million in 2010), which forced it to cut back on some services. But it also reflects the fragmented nature of Miami’s safety net, which respondents characterize as having more competition than coordination and collaboration among providers to provide care to low-income Medicaid and uninsured patients. Outlook & Opportunities: Safety-net providers—including health centers and hospitals—can form accountable care organizations to participate in Medicare’s Shared Savings Program, in which networks of providers that jointly take responsibility for the cost and quality of care provided to their patients can share in Medicare savings. New demonstration projects to test new payment and care delivery models have a potential impact on safety-net coordination.15 For instance, the bundled payment model involves a single payment to multiple providers for an episode of care, which motivates providers to coordinate and deliver care more efficiently. Safety-net coordination initiatives are also well poised to facilitate the insurance coverage expansions and health insurance exchanges created in the Affordable Care Act because of their established centralized enrollment systems that screen for eligibility for other public insurance. A MUST read article! Yours Bernd

Medicaid Expansion in the News

I case you missed those articles. Carol Gentry's great article titled Medicaid expansion could save over 5,000 lives was published in yesterdays Miami Herald " Other Views" section. In the article she referred to a recent New England Journal article titled Mortality and Access to Care among Adults after State Medicaid Expansions which concludes that State Medicaid expansions to cover low-income adults were significantly associated with reduced mortality as well as improved coverage, access to care, and self-reported health. Carol Gentry correctly argues that " If Medicaid expansion prevents 2,840 deaths/year for every 500,000, then Florida’s looking at 2,840 times 2, or about 5,680 a year. These are early deaths that are preventable. So when the debate begins about Medicaid expansion, remind those who control the state that they aren’t just talking about money. They’re talking about lives." She provided a factual contrast to Rick Scott's position whose "arguments" can be boiled down to a simple dogma: We need to help people get the skills and education they need to get a job, and help the private sector succeed so they have jobs to offer. Then you’ll have fewer people dependent on government programs because they’ll be pulling themselves out of poverty and financial distress. There is ONLY one problem! Even higher education and more skills won't get you better paid jobs anymore and no more unions are available to fight for workers rights, benefits and fair pay! Therefore, people need to work in two or three jobs to make ends meet which almost always is not enough to pay for expensive health insurance premiums. Rick Scott's line of argument reminds me of the statements made by communist party officials I encountered many years ago when I spent some time in communist East Germany and had to endure the ideological communism babble. Its almost the same tune: we need more .... ism to make people happy. Well, extreme right and left do meet each other at the fringes of extreme "thinking." But as of today at least I know that our rights come from nature and God, not from government. Guess, I have to do a bit more praying to get access to those rights fast because my health insurance premiums keep on rising. Yours Bernd

Back to the Future?

Attached a link http://online.wsj.com/article/SB10000872396390444840104577552823507551472.html to an article titled " Remember Managed Care? It's Quietly Coming Back" and video clip to the same topic http://live.wsj.com/video/health-insurers-erect-more-patient-hurdles/00207EE1-AEBD-4631-A6B8-78616EA417C1.html#!00207EE1-AEBD-4631-A6B8-78616EA417C1 highlighting the emergence of a new (old) policy by some of the U.S.'s biggest health insurers requiring doctors to get prior authorization before patients can get certain care. Managed care companies tried this in the 90's and quickly backed off responding to political pressure and the fact that employers switched away from restrictive health-maintenance organizations. So what will be different now? Health insurers say today's versions of 1990s strategies use new technology to focus closely on improving care as well as reining in expenses. UnitedHealth, for one, said it is using prior authorization "surgically" to counter "extreme variations in quality and cost." But doctors aren't sure how much things have changed. We must carefully monitor this new(old) development because it certainly will increase the workload in primary care practices WITHOUT receiving additional reimbursement. Yours Bernd

Healthcare in Israel

As a licensed Israeli physician and Israeli citizen I am grateful that Governor Romney praised the achievements of the Israeli healthcare system. He was quoted saying at a fundraiser in Jerusalem, “When our healthcare costs are completely out of control. Do you realize what healthcare spending is as a percentage of the GDP in Israel? 8 percent. You spend 8 percent of GDP on healthcare. And you’re a pretty healthy nation.” Yes, Israelis are enjoying superb healthcare because Israel requires all residents to carry insurance (mandatory insurance coverage) and puts caps on parts of the healthcare system (rationing of healthcare services). Israel created a national government controlled healthcare system in 1995 with compulsory participation. The system is funded through payroll and tax revenue and the government provides all citizens with health insurance.Health care coverage is administered by a small number of organizations, with funding from the government. People get to choose between four nonprofit plans, which have to accept all applicants including those with pre-existing conditions. All Israeli citizens are entitled to the same Uniform Benefits Package, regardless of which organization they are a member of, and treatment under this package is funded for all citizens regardless of their financial means. There are no life-time caps and nobody can be dumped off the insurance plan, The plans also must provide a list of government-mandated benefits. In the U.S. certain political groups call such a system a "socialist model" and any country that embraces such model a " socialist society." In Israel we call it a human right and cherish the accomplishment of our democratic society. Thank you Governor Romney for supporting Israels efforts to provide healthcare for all. I hope that Governor Romney will allow us to learn from Israel and to adopt their system. Yours Bernd

Medicaid Expansion in Florida

Attached a link to an editorial published in today's Miami Herald titled "Not so fast, Gov. Scott" focusing on Governor's Scott refusal to expand Medicaid. The editorial emphasizes that " for Floridians desperate to get basic healthcare the consequences could be dire. Train wreck, perfect storm, falling off the cliff — all of these phrases have been used to describe the impact of Mr. Scott’s decision unless the Legislature takes a more thoughtful approach. ....If Florida continues to ignore the “working poor” who can’t afford health insurance, these patients will have no recourse except to continue relying on public hospitals for unreimbursed care. But they will do so without the increased funding that the new law guarantees as compensation for the states, placing the burden on local taxpayers." The costs of uncompensated care will be passed down as a "hidden tax" to business that provide insurance for their employees, or to individual insurance policy holders. In 2008 this added an extra $1,017 to annual family health insurance premiums, and an additional $368 in individual premiums. The National Association of Public Hospitals estimates that about 4 million people who would have been eligible for Medicaid could go uninsured in states that have decided against expansion. In Florida, the move would expand coverage to an estimated one million more adults and children. Rejecting expansion will worsen the problem of uncompensated care in Florida, which already has the third highest percentage of uninsured patients in the country. But wait, it gets worse! Officials at the Jackson Health System are wary. They get $350 million in a special Medicaid appropriation from the Low Income Pool, far more than any other hospital in the state. They worry that if those funds are redistributed by Congress to cover Medicaid expansion nationwide, they could lose more than they gain in federal funds for new Medicaid patients. Without those funds Jackson Memorial Hospital and other hospitals in South Florida will be in dire financial straits. Lets remind ourselves why that is happening: Because the political leadership in this state is dominated by ideological "thinkers" who are refusing to acknowledge reality. Therefore, its of crucial importance that we act now using all available social networking tools at our disposal to educate and mobilize Floridians. Yours Bernd

Docs vs Glocks

I have some good news to share with you. In the case Wollschlaeger vs. Farmer the federal judge today decided in our favor permanently baring the State of Florida to enforce the gag law preventing physicians to discuss firearm safety issues with their patients.Now we can continue educating our patients about the safe handling and storage of firearms, thereby preventing the accidental injury and death of children. I am very grateful for the opportunity to represent the Florida Academy of Family Physicians which supported our case all the way to victory. Wollschlaeger vs Farmer "The State is permanently enjoined from enforcing § 790.338(1), (2), (5), and (6). The State is also permanently enjoined from enforcing § 790.338(8), to the extent that it provides that violations of § 790.338(1) and (2) constitute grounds for disciplinary action. The State is further permanently enjoined from enforcing § 456.072(1)(mm), to the extent that it provides that violations of § 790.338(1), (2), (5), and (6) shall constitute grounds for which disciplinary actions specified under § 456.072(2) may be taken. A separate judgment will be issued forthwith pursuant to Rule 58 of the Federal Rules of Civil Procedure." Yours Bernd

The Supreme Court Decision

Personally, I am very pleased about the Supreme Court decision upholding the Patient Protection and Affordable Care Act because it represents a step forward in creating a better and more equitable health care system for all Americans. I find it ironic that the two leading presidential candidates from both parties support(ed) an individual mandate. Unfortunately,during the election campaign the facts about health care will be drowned by ideologically driven rhetoric . Now should be the time to explain to the American people how we can create a sustainable high quality and efficient health care system. I do not give up the hope that this is possible. Yours Bernd

Waiting For The Supreme Court

Attached some of my thoughts and comments regarding the pending decision by the US Supreme Court. The court will have to answer four distinct legal questions raised by the challenge to the Patient Protection and Affordable Care Act (PPACA) Threshold Question: The threshold question is whether the court may decide the case now, or whether it must wait until 2015, when all of its provisions — including the individual mandate — have gone into effect. The judges, the plaintiffs and the defendant (US Department of Health and Human Services) during the hearing were uniformly inclined to decide the case now. Individual Mandate Question: Is the provision requiring virtually all Americans to have health insurance constitutional? The Supreme Court will have to determine whether Congress exceeded its powers to regulate commerce by creating a mandate that would force most Americans who aren't otherwise insured to buy coverage. The Commerce Clause, Article I Section 8 Clause 3 of the Constitution of the United States, grants the federal government specified powers, reserving the rest to the states and to the people. The two powers at issue in the case, set out in Article I, Section 8, concern the regulation of interstate commerce and the imposition of taxes. The administration’s primary argument is that the law is authorized by the commerce clause, which gives Congress the power to regulate commerce “among the several states.” The decision under review, from the United States Court of Appeals for the 11th Circuit, in Atlanta, said the health care law overstepped the limits imposed by the commerce clause by regulating inactivity and forcing people into the marketplace. Solicitor General Donald B. Verrilli Jr. argued that Uninsured Americans each year use $43 billion of health care they cannot pay for. Thereby, the effectively transfer those costs to other American families to the tune of about $1,000 per year, which constitutes a commercial activity. There is no question that f the court decides to strike down the individual mandate, then insurance companies cannot recoup the costs for those they have to enroll with preexisting conditions. Therefore, the health insurance premiums will substantially increase effective 2013, or even earlier! Medicaid Expansion Question: This expansion adds 17 million more people to the rolls. The states challenging the overhaul law have argued that even though the federal government will pay almost all of the cost, it is still impermissibly coercive. In my opinion Medicaid is a (poor) substitute for a failed Public Option for those who qualify: The expansion of Medicaid broadens that coverage to include all individuals and families with an income at or below 133% of the Federal Poverty Level (FPL) ($14,483.70) for an individual, and $29,725.50 for a family of 4. Additionally, applicants will no longer be required to complete an asset or resource test. Legislation also maintains eligibility limits (e.g., Medicaid limits as of March 23, 2010) through 2014 for adults and 2019 for children and provides states with the option for covering patients above 133% of the FPL. For individuals and families with an income ranging from 133% to 400% of the FPL, the expansion of insurance coverage will be in the form of state based health insurance exchanges where certain qualified patients will be eligible for premium or cost sharing assistance for private insurance. National guidelines will also govern a standard profile of benefits that will include among other things access to prescription drugs. The uniform coverage for Medicaid will also mirror the basic coverage package available to those purchasing coverage through the exchange. In an effort to empower patients, Enrollment information will be accessible on-line. States will be required to create a website for patients by January 1, 2014 where they can apply or renew Medicaid/CHIP or the State run insurance exchange. The problem with this approach is that it will create a class of Americans above 400 % FPL who CANNOT afford the expensive private health insurance premiums ( often > $20,000 per year) and therefore will have to stay uninsured WITH or WITHOUT penalty. This is already happening in Germany where the individual mandate without a viable public option has created a growing class of self-employed uninsured who do NOT qualify for the national health insurance plan for the poor. Separability Question: The Supreme Court will decide whether, if any part of the law is unconstitutional, it can be separated out, or whether the entire law has to be invalidated. Its important to understand that striking down a small component of the PPACA could have numerous consequences --both intended and unintended.For example, what will happen with the rule, already in place, that allows adult children to remain on their parents' insurance plans until age 26? Even though some of the biggest insurance companies have vowed to keep this provision in place, but if the court invalidates the law, those additional benefits might be taxable. The law waived a key tax provision to ensure that health insurance benefits are not taxed as income. But without the law, parents may have to pay income taxes on those benefits and employers could face higher payroll taxes. Personally, I consider the PPACA as leap forward in creating a better healthcare system for most Americans BUT it falls short to insure ALL Americans and to control the spiraling healthcare costs. As noted by President Obama, “Unless you have what’s called a single payer system in which everybody is automatically covered, then you’re probably not going to reach every single individual.” In other words, single payer is the only way to actually achieve universal coverage (White House press conference, July 22, 2009). In contrast to the PPACA, an improved Medicare for all would provide truly universal, comprehensive coverage; health security for our patients and their families; and cost control. It would do so by replacing our wasteful private health insurance industry with a single, nonprofit agency like Medicare that pays all medical bills, streamlines administration, and reins in costs for medications and other supplies through its bargaining clout. Research shows the savings in administrative costs alone would amount to $400 billion annually, enough to provide quality coverage to everyone with no overall increase in U.S. health spending. The most rapid way to achieve universal coverage would be to improve upon the existing Medicare program by excluding private insurance participation (through so-called Medicare Advantage plans) and eliminating co-pays and deductibles, and then to expand the program to cover people of all ages. For more information see http://www.pnhp.org/ Yours Bernd

Medicare and Cuba

Attached a link to an article published in today's Miami Herald titled "Feds in Miami: Millions stolen from Medicare wound up in Cuban banking system" which should belong in the world of fiction but instead represents the sad reality of healthcare in South Florida. According to the article federal prosecutors have charged a Miami man, Oscar Sanchez, 46, with engaging in a massive money-laundering scheme and identified him as a key leader in a group that funneled at least $31 million in stolen Medicare dollars into Cuban banks in Havana. While Sanchez was a target of the ongoing investigation, prosecutors say dozens of crooked Medicare providers — who offered HIV and medical equipment services — all took part in the laundering scheme set up for one reason: To hide the money.In all, 70 medical company owners in South Florida submitted more than $374 million in claims to Medicare, and were reimbursed about $70 million. Most of the money was laundered through foreign banks, including Cuba, and the Castro government also extorted Medicare bounty from criminals who are allowed to go travel freely between here and the island nation. I have asked my self the same questions over and over again: how could such a criminal enterprise fed with Medicare money flourish and thrive? Why do Medicare contractors only smell the rat when the rat already left the sinking ship? Why can we not utilize a similar approach applied successfully in Taiwan where all healthcare providers are connected to the Bureau of National Health Insurance through (BNHI) a Virtual Private Network (VPN) for e-claim purposes. Any suspicious claims could be detected in real-time and their payment stopped. Instead, in the US we are acting after the criminals already laundered the money and left the country. This case should serve as (another) example that we have to strengthen the accountability and increase the transparency of the Medicare payment process. Yours Bernd

Wellcare's Response

Attached a link to a letter to the editor by Wellcare's vice president of corporate communications published in today's Miami Herald. It contains Wellcare's official response to the ongoing criticism of their efforts to bid for the lucrative Medicaid contracts. The letter emphasizes that WellCare today represents a transformed company "sensitive to the concerns of those advocacy groups that share our mission of service – a mission to provide quality healthcare solutions to the most vulnerable and fragile populations in Florida" Well, I believe that individuals can change and turn their lives around. Nevertheless, they still have to do time for the crimes they committed. Why does a different standard apply to a corporation which engaged in truly despicable actions? Those include ending coverage for sick people and as a result, the company saved $20,000 for every one of the 425 prematurely delivered babies that were dropped from their plan. Employees were also removing certain patients from coverage because they cost too much money.When the goal was reached, the company hosted a celebratory dinner. Such egregious behavior should not be rewarded by allowing the fox back in the henhouse. Wellcare should operate instead under public oversight with an ombudsman (or woman) representing the interests of the public by investigating and addressing complaints reported by individuals. The ombudsman(or woman) should investigate constituent complaints and attempt to resolve them, usually through recommendations (binding or not) or mediation. Is that too much to ask for? Yours Bernd

Floridians Deserve Protection

Attached a link to a great letter by Laura Goodhue, Executive Director Florida Community Health Action Information Network, which was published in today's Miami Herald. The letter was a response to Florida Insurance Commissioner Kevin McCarty's Other View article titled "Whoa — Don’t cash those rebate checks yet" in which he claims that the Medical Loss ration (MLR) requirements adversely affect the healthcare marketplace and are already creating unintended consequences that could lead to less competition, fewer products, and fewer opportunities for consumer choice. Laura Goodhue correctly points out that "the law says that insurers must limit the amount they spend on profit and overhead and spend a set minimum of premium dollars on direct medical expenses. If health insurers fail to meet that standard, they have to issue rebates for the difference. The Kaiser Family Foundation reported that Floridians would see $148 million in rebates that will be issued as refund checks or credited toward the portion of the premium that employees pay. Going forward, the MLR rule means that consumers will get a better deal from their health insurance company. These sound consumer protections must be embraced by our state — not dismissed.Ironically, Florida’s Office of Insurance Regulation has refused to accept funding to increase the agency’s ability to review proposed health insurer rate increases — a move that would help control the premiums faced by Floridians. To make matters worse, there’s no process for the public to weigh in on these same proposed rate increases. It doesn’t stop there: In the last year, the state also insisted that Florida get a partial exemption from the MLR requirements because, it claimed, it would lead to a mass exodus of insurers from our market. This request was rejected, and insurers didn’t flee after all." I absolutely agree that Floridian's deserve protection against corporate greed. Health insurance companies continue to enjoy " healthy" profit margins and will not leave Florida just because the Affordable Care Act requires adherence to the Medical Loss Ratio. There is still too much money to made from denying healthcare. Its irresponsible that the Florida Office of Insurance Regulation blocks all efforts to protect our fellow citizens but continues to shelter insurance companies. It makes me sick to my stomach!! Yours Bernd

Healthcare Fraud: The Ultimate Chutzpah

In his book, The Joys of Yiddish, the Jewish humorist Leo Rosten defines chutzpah as "gall, brazen nerve, effrontery, incredible 'guts,' presumption plus arrogance such as no other word and no other language can do justice to." In the same book, Rosten also defined the term as "that quality enshrined in a man who, having killed his mother and father, throws himself on the mercy of the court because he is an orphan." Chutzpah is not only restricted to individual misbehavior but includes corporate malfeasance, too. A great example of such behavior is being displayed by Wellcare, a Tampa-based health insurer with a checkered past, which is preparing to bid on billions of dollars in state government contracts to serve Florida's poor and disabled. But why does Chutzpah apply to this company? Well, lets review their checkered past. WellCare administers Medicaid benefits in Florida, Georgia, Hawaii, Illinois, Missouri, New York and Ohio and Medicare Advantage plans in 12 states. The company learned it was under federal investigation in 2008. Law enforcement agencies alleged that the company defrauded Florida's Health Kids program out of $40 million and subsequently made misleading earnings statements based on the ill-gotten gains. The company entered into a deferred prosecution agreement with the U.S. Attorney General's Office and the Florida Attorney General's Office in May 2009, agreeing to pay back $40 million in addition to a $40 million fine. It settled a class-action lawsuit with shareholders for $200 million in December 2010. On April 26, the Tampa, Fla.-based company signed a final settlement with the Civil Division of the U.S. Dept. of Justice, the Office of Inspector General of the U.S. Dept. of Health and Human Services, nine states and five whistle-blowers. The settlement terms were announced as a preliminary agreement in June 2010 and require the company to pay the Justice Dept. a $137.5 million fine. On the same date, WellCare signed a corporate integrity agreement with the HHS Office of the Inspector General. As part of the agreement, the company will hire a third-party observer to monitor its compliance with state and federal regulations, train its employees on compliance with those rules, retain a chief compliance officer and introduce an internal monitoring program. No further fine was required as part of the agreement. As part of various settlements with state and federal law enforcement, WellCare agreed it would neither admit nor deny the allegations against it. Critics also slam the federal settlement, finalized in April, which requires the company to repay less than half of the alleged $400 million to $600 million it siphoned from taxpayers.Five former executives — including CEO Todd Farha, CFO Paul Behrens and general counsel Thaddeus Bereday — were indicted in March 2011 and are awaiting trial. Evidence against them includes taped conversations between executives discussing how they could duplicate their bills to the state. The executives also discussed plans to save money by terminating coverage for neonatal babies and terminally ill patients, and throwing parties to reward employees who ousted expensive enrollees, according to whistle-blower documents. And what does Wellcare representatives have to say? "Most importantly, the corporate integrity agreement ends concern about our eligibility to participate in Medicare, Medicaid and other federal and state health care programs," WellCare General Counsel Tim Susanin triumphantly declared during the company's first-quarter earnings call May 6. That's chutzpah because it is apparent that two different standards of law seem to apply: one for companies and one for ALL others who dare to defraud the federal health program(s). For us mortals the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), takes a tough position regarding suspension or exclusion from the Medicare Program or revocation of Medicare provider numbers. There are some situations in which the law requires that the OIG to issue a mandatory exclusion from the Medicare Program, such as loss of the professional's license or conviction of health care fraud. There are other situations in which exclusion from the Medicare Program will only result in a possible "permissive exclusion," such as conviction of a nonhealth care related felony or discipline of a health professional's license. This gives leeway to the OIG to determine whether or not it will ultimately exclude or suspend the provider from the Medicare Program. Regardless, the consequences are long-lasting and much more devastating to a health provider than might be imagined until it is experienced. A person, organization or facility excluded from the Medicare Program will be placed on the List of Excluded Individuals and Entities (LIEE) maintained by HHS. All Medicare or Medicaid providers or contractors are required by law to check this before contracting with a health provider or employing a health provider. The law prohibits any Medicare, Medicaid or Federal Health Program from contracting with or employing in any way a person or organization that has been excluded. This even extends to any officer, director or shareholder of an organization that has been excluded. Lesser known is the fact that if a person or organization is excluded or suspended from the Medicare Program, then they are automatically placed on the Excluded Parties List System (EPLS) maintained by the government Services Administration (GSA) and they are also "debarred" or excluded form being able to contract with the federal government (or any contractor of the federal government) for anything. This even extends to any officer, director or shareholder of an organization that has been excluded or debarred.States have been required to become more aggressive in recovering fraudulent payments and overpayments in Medicaid cases, as well. A portion of the money they recover must be returned to the federal government since the federal government provides 55% of Medicaid funding. Many states have passed laws that require exclusion from the state's Medicaid Program if the health provider has been found to have committed Medicaid fraud. Exclusion form a state's Medicaid Program is also grounds for exclusion from the federal Medicare Program. Many state's have also passed laws that require revocation of the professional license of an individual who has been excluded from the state's Medicaid Program. For example, in 2009, the Florida Legislature passed SB 1986 which became effective July 1, 2009. It amended Chapter 456 of Florida Statutes. It prohibits the Florida Department of Health from issuing a license to or renewing a license of anyone excluded from the state's Medicaid Program until that person has been reinstated back into the Medicaid Program and has been delivering services in it for at least five (5) years. This would be difficult for any health provider to do. But all of the above mentioned facts do not apply for Wellcare because it has found a guaranteed absolution of all past sins: hire a former U.S. senator , who serves as a paid director on the company's board and chairs a committee to ensure the company is ethical and complies with regulations, and contribute lots of money to state political campaigns ( at least $2 million since 1997) What can we do faced with such ultimate Chutzpah? Don't give up fighting the corrupt political system. Start investigations, blow the whistle, file lawsuits and support a free and unbiased media. Otherwise, if left unchallenged, this system will metastasize and destroy us. Yours Bernd

Oregon's Medicaid Experiment

A story on NPR titled "Oregon's Medicaid Experiment Represents A Defining Moment" summarized an ambitious efforts to efficiently manage health care costs. Gov. John Kitzhaber, a Democrat and a former emergency room doctor, has convinced the federal government that he has a way to make Medicaid treatment better, and cheaper, by completely changing the way the sickest people in Oregon get health care. Under this new system each city will have its own umbrella group for caring for the Medicaid population, known as a "coordinated care organization." These umbrellas will include hospitals, doctors, mental health providers and dentists. Kitzhaber's vision is that all those health care businesses will stop competing so directly and will be linked electronically so that the systems can talk to each other — and patients can go wherever they need to get the most cost effective and high quality care. The goal of creating local coordinated care organizations is to improve care and reduce costs so deeper reductions won’t be necessary. Providers would have more flexibility in treating their members. Metrics would allow for providers and CCO to be paid based on member outcomes, instead of by just the number of services provided. For example, by keeping members at their healthiest and out of high-cost emergency rooms, providers would be paid more than if their members’ health did not improve. There are opportunities for shared savings when members are healthy and not in need of high-cost care such as emergency room visits Under the current system, hospitals and doctors don't have a financial incentive to make people better. Quite the opposite: If a patient keeps coming back, they keep getting paid. But under the new system, the quicker a patient gets better, the more money the coordinated care organization can keep. Kitzhaber believes that over the next five years, Oregon will be able to save the feds every penny of the $2 billion the state's been promised. "We estimated that if every state Medicaid program in the country were to adopt this model, the net savings would be about $1.5 trillion over 10 years," he said The question remains why Florida legislators stubbornly pursue a failed experiment to privatize Medicaid and refuse to examine other options? In my opinion, Oregon has taken a bold step forward in challenging all participating healthcare providers to collaborate to manage the scarce healthcare resources for the benefit of the patients and our community. Yours Bernd Addendum: What are "coordinated care organizations" and what is being proposed? House Bill 3650 proposes organizations in Oregon that would administer the health care coverage for OHP (Oregon Health Plan) members through a collaborative network of service providers. The vision is that CCOs would be a community-based network of patient-centered care, driven by local need. The idea is to take the best thinking in Oregon and creating local organizations focused on one thing: reducing the barriers that stand between members and good health. Because each community is different, there may be different models for CCOs. The criteria for how CCOs would operate are being developed with input from members, providers, stakeholders and the public. Today more than 80 percent of Oregon Health Plan members receive physical and mental health through a type of managed care organization that receives a set rate per patient for health care. Under the CCO model, a couple of key things would change. First of all, a CCO in a community would be responsible for coordinating all of the mental, physical and dental care for OHP members through collaborative relationships. Under the proposal, a CCO also would be paid differently than MCOs are today. There would be a global budget for all care, rather than a set rate or a “capitated rate” for each different type of care. At the same time, the CCO would have more flexibility to manage dollars in a way that pays for improved health rather than having to rely on approved billed services. Performance measurements for CCOs would provide incentives for better care. And CCOs would be accountable for addressing avoidable population differences in health care outcomes. Under the proposal, local providers would have the means and incentive to work together for the population they serve. There would be more flexibility for preventive care, chronic disease management and culturally competent care. The CCO would manage a global budget and if performance standards were met, providers could share in the savings. Source: Coordinated Care Organizations

Hospitals and Patient Safety

A new report card from healthcare watchdog the Leapfrog Group ranks hospitals for patient safety – A through F. A blue ribbon panel of the nation’s top patient safety experts provided guidance to the Leapfrog Group, an independent national nonprofit run by employers and other large purchasers of health benefits, to develop the Hospital Safety Score. The Hospital Safety Score is calculated using publicly available data on patient injuries, medical and medication errors, and infections. For the first time, the Hospital Safety Score will highlight the country’s best hospitals and warn against the worst to save lives and bring attention to the nation’s silent safety epidemic. According to recent studies, one in four Medicare patients will leave a hospital with a potentially fatal issue they didn’t have prior to hospitalization. On average, one medication error per day occurs for each hospitalized patient, and more than 180,000 Americans die every year from hospital accidents, errors, and infections. The Hospital Safety Score website allows visitors to search hospital scores for free, and also provides information on how the public can protect themselves and loved ones during a hospital stay. In South Florida 25 of 49 hospitals scored an "A." The news for South Florida hospitals wasn't all good, though. Eight rated a mediocre "C," including Mount Sinai Medical Center in Miami beach, Delray Medical Center, Plantation General Hospital and Wellington Regional Medical Center. Worse, six Miami-Dade County hospitals, including Jackson Memorial and the University of Miami Hospital, would have scored a "D" or an "F" but got a "score pending" reprieve in this go-round. They'll have a chance to improve their grades before the next ranking comes out in the fall, according to a public relations executive working with Leapfrog. Ashish Jha, MD, of Harvard, a member of the blue ribbon expert panel was quoted in the press release stating that "Even hospitals with excellent programs for surgical and medical care, state-of-the-art diagnostic equipment, and dedicated physicians may still need this score as a reminder that patient safety should be a top priority."

Healthcare Costs Analysis

Attached a link to an interesting article titled “Database to shed light on healthcare costs” reporting that researchers from the nonprofit, nonpartisan Health Care Cost Institute gained access to a database of 3 billion medical claims for more than 33 million individuals. The previously confidential information, scrubbed of identifying details, is being provided by three of the nation’s largest insurance companies: Aetna, Humana and United Healthcare, whose combined customers account for about 20 percent of Americans under age 65 who are insured through an employer. Until now, researchers have had to extrapolate from far smaller surveys of employers, or rely on government claims statistics from Medicare, which are almost exclusively limited to Americans over 65. The institute offered a first look at its findings, in a report that largely confirmed previously identified trends, but added intriguing details. The published results shed light on questions such as why healthcare costs are still rising faster than the inflation rate and why people seek less care. Attached a summary of the findings: Decline in healthcare utilization: According to the report, from 2009 to 2010 people with employer-sponsored insurance had 3.3 percent fewer admissions to hospitals and other medical facilities, 3.1 percent fewer “outpatient” visits to such facilities, and virtually no change in the number of procedures performed at doctor’s offices. In 2010, the average out-of-pocket payment for an admission to a hospital or other facility went up by more than 10 percent, to $700. The total charge for an outpatient visit including an emergency room visit or surgery that does not require an overnight stay also rose 10 percent, reaching $162. Reason: Cost-shifting to consumers of healthcare services. Many employers push more of the cost of care onto workers in the form of higher deductibles, co-pays and co-insurance. Prices grew at faster rates than the intensity of services: Increased spending by not just patients but employers was primarily caused by increases in the prices that hospitals, doctors and other providers charged for every category of service in 2010. The total price per outpatient visit, including the insurer and the out-of-pocket share, rose 10 percent, to $2,224. The increase was also significant for inpatient admissions, which went up 5.1 percent, to $14,662. Higher healthcare spending for younger patients: The growth in spending per patient in 2010 was as much as twice as high for those 18 and under than for any other age group. Does this mean that younger patients will have higher costs through their lives, which raises implications about bending the long-term cost curve? In my opinion we need more of those data to learn more about healthcare spending and how to contain rising healthcare costs.

Medicare Fraud and "Obamacare"

Attached an interesting article by Jay Weaver titled "Feds arrest more than 100 Medicare fraud suspects in South Florida, nationwide" reporting that several days ago, the feds charged 107 suspects with submitting $452 million in false bills to Medicare in seven U.S. cities. In the Miami area, 59 of those defendants were accused of trying to steal $137 million from the taxpayer-funded healthcare program.As a result of stepped-up law enforcement Medicare’s expenditures for a variety of medical services in South Florida decreased by a half-billion dollars over the past year alone! Its also important to emphasize that these successful efforts to curb Medicare fraud are part and parcel of the Patient Protection and Affordable Care Act (PPACA). The President has made a commitment to reduce Medicare fraud 50% by 2012. Therefore, the Affordable Care Act provides an additional $350 million over the next ten years to help fight fraud through the Health Care Fraud and Abuse Control Account (HCFAC) from FY 2011 through 2020. The Act also allows these funds to support the hiring of new officials and agents that can help prevent and identify fraud. Furthermore, the Affordable Care Act directs the Sentencing Commission to increase the Federal sentencing guidelines for health care fraud offenses by 20-50% for crimes that involve more than $1,000,000 in losses. The law makes obstructing a fraud investigation a crime and makes it easier for the government to recapture any funds acquired through fraudulent practices. And the law makes it easier for the Department of Justice (DOJ) to investigate potential fraud or wrongdoing at facilities like nursing homes. Those "Obamacare" opponents who rail against the law should be reminded that they have failed to provide an alternative option on how to save half-billion dollars over the past year! Yours Bernd

Choose Wisely

Wednesday, April 18, 12 To The Editor of the Miami Herald RE: “Better health, fewer tests”, April 16th, 2012 As a board-certified family physician and addiction specialist I endorse the initiative, Choosing Wisely, of the ABIM Foundation supporting evidence-based recommendations that should be discussed to help make wise decisions about the most appropriate care based on a patients’ individual situation. We must understand that health care costs are finite! We reached a tipping point that leaves only two options: health care rationing, or the efficient utilization of treatment resources. This requires a new health care delivery paradigm based on expanded primary care access, care coordination, utilization of information technology to measure quality and outcome of care, and the involvement of the patient as a partner and not the object of care. Such a Patient Centered Medical Home (PCMH) will not only contain and manage health care costs but, most importantly, will improve care. We also must shift from a volume to a value based payment system rewarding those health care providers who demonstrate accountable, efficient and safe quality medical care. We spent more than two-third of our health care resources on chronic disease management. We could stop the waste! Our patients need to understand that they have to share responsibility for their wellness care and treatment. Joint accountability implies that physicians and patients are partners in the healthcare delivery process. I am optimistic that we can succeed improving our country's health care system.

Healthcare and the Supreme Court

Attached a link to an interesting article "Is public option the last one?" emphasizing that IF the Supreme Court decides to strike down the entire health care law it might create a predicament for our legislators to resolve the healthcare quandary: Congress wouldn't be able to rely on the private market, because that would require a mechanism to force healthy people into the risk pool. And it would have trouble relying on a federal-state partnership, because that might be considered coercive. Ironically, striking down the individual mandate, or the entire law, would create an inevitable choice:a federal insurance program that would clearly pass constitutional muster. Medicare represents such a model, which currently covers the elderly and is run entirely by the federal government. Medicare gives no role to the states and therefore does not coerce them into anything. An expansion of this program to all Americans funded by a payroll tax would be a workable solution. In my opinion it would be fiscally and morally irresponsible to continue the status quo. Happy Passover and Happy Easter Yours Bernd

Jackson Memorial Hospital in Crisis

Jackson Memorial Hospital, one of our finest teaching hospitals in the U.S., is stuck in a perpetual financial crisis caused, among other reason, by poor management. The proposed solutions do not follow surgical precision thinking but can only be compared with brute amputations threatening to destroy this great institution. The current management lacks strategic vision and obviously does not understand that the rapidly changing health care market demands flexibility and quick adaptation to evolving concepts of care delivery and reimbursement. This requires the development of team based care harvesting the creativity and experience of the highly skilled workforce. Therefore, it's counter-intuitive to reduce the number of experienced health care workers who are needed to develop and sustain new care delivery systems such as the Patient Centered Medical Home (PCMH). The Patient Centered Medical Home is a model of care where each patient has an ongoing relationship with a personal clinician who leads a team that, together, takes responsibility for patient care. The clinician-led care team is responsible for providing all the patient's health care needs and when needed, coordinating care across the health care system. The comprehensive care provided by the medical home leads to better health, longer lives, higher patient satisfaction and less expensive care. Other hospital systems in the U.S. are successfully pursuing such concepts and are being rewarded financially. For example, all 11 hospitals and six large community health centers of the New York City Health and Hospitals Corporation have received medical home designation for delivering accessible, comprehensive and family-centered primary care to New Yorkers that aims to reduce avoidable healthcare costs over time. The special designation was granted by the National Committee for Quality Assurance (NCQA) to 616 primary care physicians who collectively care for nearly 100 percent of HHC's primary care population of more than 477,000 adult and pediatric patients. All of the HHC facilities received "Level 3" designation, the highest ranking, which will qualify HHC for more than $15 million in Medicaid reimbursement rate increases every year. Jackson Memorial Hospital can lead the field in health care innovation and its not too late to implement changes. But we need a management team that can translate vision into reality. Yours Bernd

Supreme Court and Health Care

On Monday morning the Supreme Court will begin hearing arguments about whether the Individual Mandate is constitutional. On what case law the Supreme Court can base its decision? Lets look at the facts. In a recent New York Times article titled " At Heart of Health Law Clash, a 1942 Case of a Farmer’s Wheat" the author points out that a 1942 decision, Wickard v. Filburn, is the basis for the Supreme Court’s modern understanding of the scope of federal power. What was the core issue? The U.S. government had established limits on wheat production based on acreage owned by a farmer, in order to drive up wheat prices during the Great Depression, and one farmer, Roscoe Filburn, was growing more than the limits permitted. Filburn was ordered to destroy his crops and pay a fine, even though he was producing the excess wheat for his own use and had no intention of selling it. The Supreme Court interpreted the United States Constitution's Commerce Clause under Article 1 Section 8, which permits the United States Congress "To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes". The Court decided that Filburn's wheat growing activities reduced the amount of wheat he would buy for chicken feed on the open market, and because wheat was traded nationally, Filburn's production of more wheat than he was allotted was affecting interstate commerce. Thus, Filburn's production could be regulated by the federal government. The Supreme Court issued a decision which included the following statement: "The power to regulate interstate commerce includes the power to regulate the prices at which commodities in that commerce are dealt in and practices affecting such prices." ( P. 128) And this is the issue we are dealing with today! The Filburn decision illustrates just how much leeway the federal government has under the Constitution’s commerce clause to regulate the choices individuals make in matters affecting the national economy. If the government can make farmers choose between growing crops on their own land and paying a penalty, the administration’s lawyers have said, it can surely tell people that they must obtain health insurance or pay a penalty. Now, if the Supreme Court decides that the individual mandates violates the commerce clause then insurance companies will face a quandary: on the one hand they have to offer health insurance coverage to each and every applicant regardless of his/her health status, but on the other hand they cannot sell enough insurance policies to healthy individuals to cover for those expenses because the individual mandate was declared unconstitutional. The health care law will still be valid BUT the financing will be on shaky grounds. Therefore, insurance companies already began to develop alternatives which will include steep premium increases for individual policies! Economists believe that the mandate, as envisioned by the law, will make a significant difference in reform’s impact. Some suggest that removing the mandate from the law would diminish the number of newly insured by nearly two-thirds and raise premiums overall by 30 percent. The Rand Institute researchers predict that eliminating the mandate would have little effect on premiums for individuals. But they, too, believe that health insurance coverage would fall dramatically — from 27 million additional people insured to just 15 million. Those are just projections, but the experts note that one state has managed to impose insurance reforms without weakening its insurance market. It’s Massachusetts, which happens to be the one state that also imposed an individual mandate. More than 98 percent of the state’s residents now have insurance, by far the highest percentage in the country. Premiums in the non-group market have fallen by 50 percent, relative to national trends, while premiums in the group market aren’t rising any faster than they were before the reforms began. Lets hope for the best and I predict the Supreme Court will uphold the individual mandate. Yours Bernd

Medical Practice in Crisis

Attached a link to an article "Why America's Doctors Are Struggling to Make Ends Meet" highlighting the dire economic straits of a medical clinic in Denver Colorado which followed all the recommendations to improve its care: electronic health record implementation, medical home project participation, quality improvement initiatives and care coordination. Nevertheless, the practice struggles to stay financially viable! I have embraced all of the above principles, too, and invested money and time in improving my practice and just obtained PCMH recognition. When will insurance companies follow to support those of us who work hard to improve care and to reduce healthcare costs? Will the savings be pocketed by insurance companies, or be shared with us? I think that we deserve an answer! Yours Bernd

Overseas Patients

Attached a link New push to bring overseas patients to South Florida to an interesting article reporting that Broward and Palm Beach counties are becoming more common destinations for seriously ill patients from overseas who need sophisticated treatment that is unavailable or very expensive in their homelands. Its ironic that according to Deloitte consulting services, in 2010 875,000 Americans traveling outside U.S. borders to receive health care: dental work, elective hip replacements, even bypass surgery. Why? Because the astronomic costs and often substandard quality of health care services in the U.S. force many middle-class workers to seek medical care abroad. Such care is being rendered by board certified medical doctors at Joint Commission International certified health care facilities. Lured by more affordable medical care and modern facilities, places like Malaysia, India and Turkey, have also become hot-spots for patients seeking procedures abroad, according to experts.Medscape News web site has forecast medical tourism in Asia could generate $4.4billion by 2012.According to the Korea Health Industry Development Institute, the number of tourists coming to South Korea ballooned last year to nearly 82,000, generating about $700million in revenues. By next year, Singapore aims to treat a million foreign patients a year, generating about $3billion for the economy, the Singapore Straits Times has reported; while neighbouring Malaysia, attracted nearly 400,000 medical tourists last year, and aims to increase that number to 1.9million by 2020. The Philippines also sees itself as a cut-price destination, and is projecting the number of medical tourists to hit one million by 2015, generating at least $1billion in revenue. Why should U.S. citizens be forced to travel abroad!! They deserve affordable and excellent care right here at home, too!! I guess we have to continue dreaming and save money for our next flight!

Deep Cuts for Mental Health and Substance Abuse Treatment Programs

Attached a link State Senate proposes $87 million cut in mental health, substance-abuse programs to an article titled " State Senate proposes $87 million cut in mental health, substance-abuse programs" reporting that a Florida Senate proposal would make deep cuts in funding for adult mental health and substance-abuse programs, and entirely eliminate support for some of them.The proposal would slash overall state spending on adult mental health and substance-abuse treatment by about 40 percent, or $87 million.The cuts would include eliminating state support for some programs — including, potentially, the Miami Behavioral Health Center and the Northside Mental Health Center in Tampa. Sen. Joe Negron, the Stuart Republican in charge of the Senate’s healthcare budget, stated that “When it comes to funding, an 85-year-old woman in a nursing home matters more to me than a 45-year-old guy with a substance-abuse problem,” he said. “It’s all about priorities.” Unfortunately, his statement reveals that most politicians have yet to understand that mental health and substance abuse treatment represents cost-effective care! The benefits of treatment far outweigh the costs. Even beyond the enormous physical and psychological costs, treatment can save money by diminishing the huge financial consequences imposed on employers and taxpayers. Comparing the direct cost of treatment to monetary benefits to society determined that on average, costs were $1,583 compared to a benefit of $11,487 (a benefit-cost ratio of 7:1)! In comparing cost offsets in Washington State of people in treatment to non-treated, the authors noted lower medical costs ($311/month); lower state hospital expenses ($48/month); lower community psychiatric hospital costs ($16/month); reduced likelihood of arrest by 16%; and reduced likelihood of felony convictions by 34%! It is a penny wise and pound foolish approach to CUT finding for mental health and substance abuse treatment because in the long run we as tax payers have to pay the higher price for short term political decisions. For more information see Cost Offset Substance Abuse. I urge you to e-mail, call or write Senator Negron! Yours Bernd

Immaculate Conception

The uproar about birth control coverage by insurance companies not only points out the friction between freedom to choose birth control and religious liberties but also the fallacy of our employer-based healthcare system. Yes, I defend religious freedom but I question the authority of religious institutions to impose their morality on others. I understand that bishops and priest do not have to worry about the impact of contraception on their families but I do. Maybe I should not speak up because I am a Jew but I vigorously defend the right of catholic women (and men) to choose the most suitable form of birth control. According to a study by the Guttmacher Institute three quarter of sexually active women of modest means, ages 18-34, said that they could NOT afford a baby BUT thirty percent had put off a gynecological or family planning visit to save money. For those still using an oral contraceptive, one quarter skipped their daily pill to safe money. The cost of birth control is one reason why poor women are more than three times as likely to have unintended pregnancies. We all pay for this failed approach to family planning! Every dollar the U.S. government spends on family planning reduces Medicaid expenditures by $3.74!! If each employer (such as the catholic church and other affiliated institutions, can reserve the right to raise "moral objections" to almost each and every aspect of a broad-based healthcare coverage then we are in real trouble! Whats next? Infertility treatment, already covered only by a quarter of health insurance companies, may be next. Whats about erectile dysfunction treatment for seniors? Treatment for gender identity problems in teenagers? Maybe some orthodox Islamic or Jewish employers will not pay for treatment in clinics that do not provide sex-segregated waiting rooms, or only male gynecologists. Maybe some employers object to gay doctors on moral grounds? In these times of a religiously and ideologically based culture war anything is possible! When will it stop? Well, there is one solution! A single-payer system funded by the tax payer in which each recipient receives a benefit card to CHOOSE healthcare coverage from any doctor, clinic, hospital, emergency room of their choice! Wow, free choice! What an outrageous thought! I hope that more will speak up against the Ayatollization of our society. Yes, I am for religious freedom but priest, rabbis and imans should confine their morality to their respective church, temple or mosque and leave it up to us to make moral choices! Yours Bernd

United Healthcare and Payment reform

Attached a link http://online.wsj.com/article/SB10001424052970203315804577211660010608608.html to an interesting article published in the Wall Street Journal titled " New Way to Pay Doctors: UnitedHealth, Nation's Largest Insurer, Is Latest to Announce Fee Overhaul." According to the article " Under the new plan the carrier is rolling out, part of medical providers' compensation could be tied to goals such as avoiding hospital readmissions and ensuring patients get recommended screenings. UnitedHealth has been trying such efforts on a more limited scale, but now the company says it plans to roll out new contracts nationwide that could include financial rewards for care the company considers high-quality and efficient, and in some cases potentially withhold expected increases if certain standards aren't met." Under an aggressive projection, costs could amount to as much as $3.27 per member a month by 2015, with savings as high as $7.80, the documents said. Using a less-aggressive scenario, the company said, the costs could amount to 46 cents, and the savings to $1.35, per member a month. Much of the cost under both projections wouldn't be locked in, since it would be tied to bonuses that providers would get only if they hit certain goals; indeed, those payments may be calculated as a share of the overall savings achieved. According to the released information pieces of the new payments may be in lieu of increases to traditional fees. Driving the payment reform is the growing realization that the current health-care payment system, with its fees for each service, is flawed. The current system entices quantity but no quality and a value-based reimbursement system would stire healthcare towards prevention, quality and outcome oriented care. Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services, said the initiative "looks promising," but it would be important for the incentives to be strongly enough tied to quality and patient-satisfaction measures, in addition to efficiency goals, to "ensure there's no skimping" on care. In a description of some of its pilot programs, the carrier mentioned potential bonuses of $1 to $3 per member a month for primary-care physicians. For a different provider setup, called accountable care organizations, the document said the bonuses could amount to $1 to $5 per member a month. Accountable care organizations can be built around hospitals or doctor groups, and they generally involve a provider taking overall responsibility for a group of patients. UnitedHealth also said it could offer "clinical integration" fees for providers that make changes aimed at better tracking patients' conditions and coordinating their care. This would include the model known as "patient-centered medical homes," which are typically set up by primary-care doctors, but the fees could also be available to other providers making similar efforts. In my opinion physicians can and should play a proactive role in the payment reform initiative. We have to reorganize our practices , implement efficiency measurements and form groups organized along the Patient-Centered Medical Home concept. We cannot expect that insurance companies will provide us with the panacea for our economic woes. Now is the time to act! Yours Bernd

The Business of Medicine

Attached a link http://www.miamiherald.com/2012/01/22/2601913_p3/hospitals-hiring-doctors-to-get.html to an interesting article written by John Dorschner titled "Hospitals hiring doctors to get ready for reform" highlighting the growing trend of hospitals purchasing physicians practices. Its of interest to note that executives at Baptist and Holy Cross say " the physicians’ practices on their own do not break even after being purchased, but ancillary income from such measures as diagnostic tests boost the bottom line." But more diagnostic tests and procedures also means more health care expenditures! At Jackson Health System, Miami-Dade’s public hospitals, the unaudited financial statements for fiscal 2011 show that the doctors’ practices lost $4.4 million! One employed physician argues that he likes this arrangement because he doesn’t have to spend time dealing with all the business aspects of a private practice. But understanding the business of medicine is exactly what we need to prevail in the rapidly changing health care environment. We cannot pretend that we can practice medicine in splendid isolation and to leave the "dirty" business to others. That's a prescription for certain marginalization and disempowerment. We must acquire knowledge and skills to master the business of medicine in order to practice medicine more efficiently. What do you think? Yours Bernd

Why We Need The Individual Mandate

Attached a link http://www.rwjf.org/files/research/20120112qs70onepager.pdf to an interesting study by the Urban Institute of the Robert Wood Johnson Foundation titled "Eliminating the Individual Mandate: Effects on Premiums, Coverage, and Uncompensated Care," analyzing the different scenarios resulting from the elimination of the individual mandate. Under the Patient Protection and Affordable Care Act (ACA) passed by Congress, most Americans will be required to be covered by health insurance or pay a penalty—the so-called individual mandate. The legality of this feature is being debated in the courts. These Urban Institute authors estimate the effects of the ACA and the individual mandate, as well as various levels of exchange participation, using a model that simulates decisions of individuals and businesses in response to policy changes. Exchange enrollment is viewed as necessary to reduce adverse selection, or the likelihood of only the sickest choosing to be insured. The researchers found that without the individual mandate: Between 40 and 42 million would remain uninsured as opposed to 26 million with the mandate; Private coverage would fall 11 million, covering 4 million fewer people than it would have without reform; Uncompensated care spending would be much higher due to the increased number of uninsured; Individual premiums in the health benefit exchanges would increase by 10 percent in a scenario assuming high exchange participation and by 25 percent with a low participation scenario. Removing the mandate from the ACA while expanding Medicaid eligibility would decrease the number of people with private coverage by 3.6 million. Uncompensated care would increase by $20 billion. I strongly recommend reading this study which provides clear and convincing arguments in favor of the individual mandate. Yours Bernd