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

Health Insurance

Attached a link http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.pdf to a very interesting federal study titled "The Concentration and Persistence in the Level of Health Expenditures over Time: Estimates for the U.S. Population, 2008-2009" published by the Center for Financing, Access, and Cost Trends of the Agency for Healthcare Research and Quality. Using information from the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) for 2008 and 2009, this report provides detailed estimates of the persistence in the level of health care expenditures over time. Studies that examine the persistence of high levels of expenditures over time are essential to help discern the factors most likely to drive health care spending and the characteristics of the individuals who incur them. According to the study in 2008, 1 percent of the population accounted for 20.2 percent of total health care expenditures, and in 2009, the top 1 percent accounted for 21.8 percent of the total expenditures with an annual mean expenditure of $90,061. The lower 50 percent of the population ranked by their expenditures accounted for only 3.1 percent and 2.9 percent of the total for 2008 and 2009 respectively. Of those individuals ranked at the top 1 percent of the health care expenditure distribution in 2008, 20 percent maintained this ranking with respect to their 2009 health care expenditures In both 2008 and 2009, the top 5 percent of the population accounted for nearly 50 percent of health care expenditures. Individuals who were between the ages of 45 and 64 and the elderly (65 and older) were disproportionately represented among the population that remained in the top decile of spenders for both 2008 and 2009. While the elderly represented 13.2 percent of the overall population, they represented 42.9 percent of those individuals who remained in the top decile of spenders. Focusing on the under age 65 population, health insurance coverage status also distinguished individuals who remained in the top decile of spenders from their counterparts in the lower half of the distribution. Individuals who were uninsured for all of calendar year 2009 were disproportionately represented among the population that remained in the lower half of the distribution based on health care spending. While 15.5 percent of the overall population under age 65 was uninsured for all of 2009, the full-year uninsured comprised 25.9 percent of all individuals remaining in the bottom half of spenders (figure 6). Alternatively, only 3.6 percent of those under age 65 who remained in the top decile of spenders were uninsured. What can we learn from the data and how should the data influence public policy? We are spending a disproportionally high percentage of precious healthcare dollars on a very small percentage of sick people.Most of them suffer from preventable chronic diseases which we still cannot manage properly within our existing healthcare system. The overwhelming majority of those "high" spenders were insured and there annual mean expenditure of $90,061 are not covered by the healthcare premiums they pay. The overwhelming majority of healthy "low" spender are uninsured and therefore do not contribute with their health insurance premium payment to cover for their eventuality of their own care needs. Taking all of these facts into consideration we should support an individual mandate that requires health insurance coverage for each and every American to spread the insurance risk. Spreading the risk assures that as the number of people in a given group gets larger, a company or governmental agency can more easily spread the risk (that would be the risk of a payout) among the pool of participants. They can therefore better estimate the average cost (or payout) per person in the event that one or even several of the group are victims of a catastrophic event. In the absence of such a mandate insurance companies can simply not afford to continue paying 50% of health care expenditures on 5% of the population!!! Alternative proposals to create high-risk pools are doomed to fail because the risk to cover "sick" participants is so high that it results in unaffordable health insurance premiums by private insurance companies. If those companies choose to opt out of providing insurances for such a high-risk pool then the government remains the insurer of the last resort, i.e the tax payer. Yours Bernd

US Healthcare Costs

According to the latest edition of "Health at a Glance" http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2011_health_glance-2011-en published by the Organization for Economic Co-operation and Development (OECD) The United States stands out as performing very well in the area of cancer care, achieving higher rates of screening and survival from different types of cancer than most other developed countries. The United States does not do well in preventing costly hospital admissions for chronic conditions, such as asthma or chronic obstructive pulmonary disease, which should normally be managed through proper primary care. Avoidable hospital admissions for asthma complications and chronic obstructive pulmonary disease (COPD) are much greater in the United States than the OECD average. For asthma admissions, the rate in the United States was 121 per 100 000 adults in 2009, more than two times greater than the OECD average of 52. For COPD, hospital admission in the United States was 230 per 100 000 adults, compared with an OECD average of 198. Regarding healthcare expenditures the United States spent 17.4% of GDP on health in 2009, much more than the OECD average of 9.6%. Spending per person is two-and-a-half times higher than the OECD average. Following the United States were the Netherlands, France and Germany, which allocated respectively 12.0%, 11.8% and 11.6% of their GDP to health. Is US health spending higher due to higher prices or higher service provision? (or both?) Facts: 1) US prices for a set of hospital services is over 60% higher than the average of 12 OECD countries, 2) US prices for certain procedures (including appendectomy,coronary angioplasty, coronary artery bypass graft, hip & knee replacement) are much higher than in other OECD countries, 3) Almost DOUBLE the spending on Insurance administration expressed in terms of purchasing power parity. Its also of interest to note that in most countries, health spending is largely financed out of taxes or social security contributions, with private insurance or ‘out-of-pocket’ payments playing a significant but secondary role. This is not the case in the United States which, together with Mexico and Chile, is the only OECD country where the government plays the smallest role in financing health spending. The public share of health expenditure in the United States was 47.7% in 2009, much lower than the OECD average of 71.7%. However, the level of health spending in the United States is so high that public (i.e. government) spending on health per capita is greater than in all other OECD countries, except Norway and the Netherlands. For this amount of public expenditure in the United States, government provided in 2009 insurance coverage only for the elderly and disabled people (through Medicare) and some of the poor (through Medicaid and the State Children’s Health Insurance Program, SCHIP), whereas in most other OECD countries this was enough for government to provide universal health insurance. Public spending on health in the United States has been growing more rapidly than private spending since 1990, largely due to expansions in coverage. Private insurance accounted for 33% of total health spending in the United States in 2009, by far the largest share among OECD countries. Beside the United States, Canada and France are the only two other OECD countries where private insurance represents more than 10% of total health spending. Conclusions: we are spending more for healthcare per person than in any other country in the world utilizing an inefficient private insurance model. But also public (i.e. government) spending on health per capita is greater than in all other OECD countries but fails to provide universal coverage. We must achieve a broad based consensus on how to efficiently allocate our healthcare resource to achieve high quality healthcare for all Americans. Tinkering on the edge will not provide us with a meaningful and sustainable solution. If we do not engage in such a dialogue now we will face rationing and further economic slowdown. Yours Bernd

Medical Errors Awaiting Prevention

Attached a link http://www.nytimes.com/2012/01/06/health/study-of-medicare-patients-finds-most-hospital-errors-unreported.html to an interesting article titled "Report Finds Most Errors at Hospitals Go Unreported" pointing out that according to recent federal study hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized. According to the study, from Daniel R. Levinson, inspector general of the Department of Health and Human Services, some of the most serious problems, including some that caused patients to die, were not reported.The inspector general estimated that more than 130,000 Medicare beneficiaries experienced one or more adverse events in hospitals in a single month. Many hospital administrators acknowledged that their employees were underreporting injuries and infections that occurred in the hospital, he said. More often, Mr. Levinson said, the problem is that hospital employees do not recognize “what constitutes patient harm” or do not realize that particular events harmed patients and should be reported. In some cases, he said, employees assumed someone else would report the episode, or they thought it was so common that it did not need to be reported, or “suspected that the events were isolated incidents unlikely to recur.”The inspector general found that “hospitals made few changes to policies or practices” after employees reported harm to patients. In many cases, hospital executives told federal investigators that the events did not reveal any “systemic quality problems.”Organizations that inspect and accredit hospitals generally “do not scrutinize” how hospitals keep track of medical errors and other adverse events, the study said. The federal investigators did an in-depth review of 293 cases in which patients had been harmed. Forty of those cases were reported to hospital managers, and 28 were investigated by the hospitals, but only five led to changes in policies or practices, the study said. What are possible solutions? 1) Train staff to report medical errors and to automatically flag those patients within an electronic health record for IMMEDIATE quality assurance review 2) Utilize software which automatically triggers alerts for diagnoses and conditions including medication errors, severe bedsores, infections that patients acquire in hospitals, delirium resulting from overuse of painkillers and excessive bleeding linked to improper use of blood thinners. 3) Deploy medical error prevention teams within hospitals to educate staff and to assist in the implementation of lessons learned from a root-cause analysis into the clinical practice. I am confident that we can achieve our goals to reduce medical errors and to save lives. Yours Bernd

Medicaid Pilot Program in Florida

Letter to the Editor published in Miami Herald, December 23rd, 2011 Patients protected The Dec. 16 article State can expand Medicaid pilot program incorrectly stated that the federal government approved the expansion of the Medicaid pilot project. Actually, the extension of the five-county Medicaid pilot project was approved until 2014, but with significant improvements to the program. They include the denial of the medical-loss-ratio waiver requiring the participating private health plans to spend 85 percent of the funds on patient care and the denial of capping benefit levels for Medicaid beneficiaries, which prevents the termination of Medicaid services because recipients have already met their maximum. These requirements will protect patients from arbitrary insurance denials and will force private health insurance plans to manage the taxpayers’ dollars more efficiently and responsibly. We should continue to oppose any expansion of the pilot project unless the state of Florida can provide solid data that it improves access and enhances the quality of healthcare for all Medicaid enrollees. Bernd Wollschlaeger, MD,

ER, Dental Care and Medicaid

I recommend reading an article published in today's Sun Sentinel titled "More patients turning to ERs for dental care" summarizing the findings of a study by the Florida Oral Health Coalition which found that more than 115,000 people went to the hospital last year for dental care that could have been prevented or done at a much lower cost in a dentist's office. That's up 9 percent since 2008. More than 15,500 of them were children. ERs charged $88 million for that dental care last year — $30 million to Florida's state-federal Medicaid program , the study found. Hospitals not reimbursed for the care likely pass on the cost to other patients through higher charges. The reliance on ERs for tooth care was even heavier in South Florida, with the number of ER visits up 32 percent in Broward County since 2008. To tackle the problem, the group suggests expanding services that can be offered by dental hygienists, raising Medicaid payments to attract more dentists, having Medicaid cover adult dental care, and expanding county health department dental clinics. But the recommendations would require more tax money at a time when state officials are trying to shrink the Medicaid budget.

Florida Medicaid Pilot

On Thursday the federal officials agreed to extend Florida's five-county Medicaid managed-care experiment to 2014 but required the state to make significant improvements to the program. They include the denial of the medical-loss-ratio waiver requiring the participating private health plans to spend 85 percent of funds on patient care and the denial to cap benefit levels for Medicaid beneficiaries preventing the termination of Medicaid services because recipients had already met their $500,000 maximum for the year. These requirements will protect patients from arbitrary insurance service denials and will force private health insurance plans to manage taxpayers dollars efficiently and responsibly. Meanwhile, we should continue to oppose any expansion of the pilot project UNLESS the State of Florida can provide solid and indisputable data that the pilot project improves access and enhances the quality of care for all  Medicaid enrollees. So far I have not found any evidence to substantiate Governor Scott's claim that "we've seen higher quality in administration of care, produced cost savings and consumers in the pilot have found improved access for Medicaid recipients." Looking forward to your feedback. Yours Bernd For more information see: http://htpolitics.com/2011/12/15/feds-make-key-decisions-on-medicaid-and-health-insurance-for-floridians http://blogs.orlandosentinel.com/news_politics/2011/12/what-is-changing-in-florida-medicaid-maybe.html

The Sick Business of Medicine

Attached a link http://www.miamiherald.com/2011/11/12/2499995/finances-strain-the-marriage-between.html to an interesting article by John Dorschner published in the Miami Herald titled "Finances strain the marriage between Jackson and the University of Miami" which details the increasingly strained relationship between Jackson Memorial Hospital and the University of Miami. At the center of the dispute are insured patients seeking medical care at Jackson Memorial hospital. UM critics claim that UM physician direct these patients to the UM hospital across the street, and that Jackson Memorial hospital is left with treating the uninsured patients. Miami-Dade taxpayers pay Jackson Memorial $330 million a year to treat uninsured people who seek treatment in the county-owned Jackson system. As part of the system that has evolved over the years, Jackson also pays UM when its doctors treat the uninsured at Jackson. UM critics also claim that once an uninsured patient gets insurance UM doctors are shifting their care to the UM hospital, which then receives the Medicare reimbursement money. UM calls that patient choice. Jackson counters that its paying patients shouldn’t be siphoned off to UM facilities. What troubles me is that patients are being considered as milkable cash cows and once they are loosing their production value they are being pushed back into Jackson Memorial Hospital. Its a sick system which encourages overutilization of medical services and drives up healthcare costs even further. Yours Bernd

Health Care Cost Control

"Unfortunately, few people really understand how much we spend on health care,how much we need to spend to provide quality care, and the difference between the two." The New York Times published three articles by Ezekiel Jonathan Emanuel,MD PhD focusing on how to control the escalating health care costs in the United States. I highly recommend reading the articles published so far and have attached the links to each article below. The following bullet points represent an excerpt of the arguments made in his articles: How much do we spent on health care in the United States? In 2010, the United States spent $2.6 trillion on health care, over $8,000 per American.The United States spends on health care alone what the 65 million people of France spend on everything: education, defense, the environment, scientific research, vacations, food, housing, cars, clothes and health care. In other words, our health care spending is the fifth largest economy in the world. For more than 30 years, health care costs have been growing 2 percent faster than the overall economy. That means every year we spend ever more on health care and therefore have to spend less on other things — or borrow money to pay for the extra health care. If we continue at this rate of growth, health care will be roughly one-third of the entire economy by 2035 — one of every three dollars will go to health care — and nearly half by 2080. This level of spending on health care is high, but is it worth it? Does it make us healthier? The United States spends around 20-30 percent more per person than the next highest-spending countries, Switzerland and Norway BUT the United States is not getting 20 or 30 percent better health care or results than other countries! As a country we are actually doing worse than a number of countries, like France and Germany, that spend considerably less! How do we spent our health care dollars and how can we start saving? In health care, you have to be talking about tens of billions of dollars before you are talking about real money. A useful threshold for savings is 1 percent of costs, which comes to $26 billion a year. Anything less is simply not meaningful. Cutting health insurance companies profits? Last year, health insurance companies did rack up big profits, but it turns out that the combined profits of the country’s five largest for-profit health insurance companies — United, WellPoint, Aetna, Humana and Cigna — were $11.7 billion, only 0.5 percent of total health care spending. Even confiscating every penny of those profits would add up to less than half of the cost-saving threshold. Cutting drug companies profits? Between 2004 and 2009, generic drug use rose from 57 to nearly 75 percent of all prescriptions. Paradoxically, over those same years, the total amount Americans spent on drugs actually increased by 31 percent — the same rate as overall health care expenditures. Even the best estimates suggest that savings from expanding generics’ use even further are, according to the Department of Health and Human Services, “likely to be small relative to total spending on drugs.” Pharmaceutical costs account for roughly 10 percent of total health care spending, some $260 billion in 2010. Importing brand name drugs from abroad would cut about 2 percent from that — $5 billion per year. Another cost control disappointment. Malpractice reform is the solution? In 2009, the Congressional Budget Office did a comprehensive assessment of the potential cost savings from medical malpractice reforms. Its conclusions: A package that included a $250,000 cap on noneconomic damages, a $500,000 cap on punitive damages and a one-year statute of limitations for claims by adults would save about $11 billion a year — 40 percent from reduced malpractice premiums and the rest in the form of fewer defensive procedures like M.R.I.’s. Frankly, $11 billion is not insignificant BUT at less than half the $26 billion threshold, malpractice reform is certainly not a cost savings magic bullet either. Restrict health care spending on exorbitantly expensive patients? An unpublished analysis of nearly 20 million commercially insured patients(provided to the author of the article) showed that there were only 255 patients who consumed over $1 million in 2010. Together they spent 0.5 percent of all costs — a very large number for so few patients, but just half the 1 percent threshold for cost-saving that matters. And not all of those costs could be saved. Are administrative services one of the biggest money wasters in our health care system? Administration accounts for roughly 14 percent of what the United States spends on health care, or about $360 billion per year. About half of all administrative costs — $163 billion in 2009 — are borne by Medicare, Medicaid and insurance companies. The other half pays for the legions employed by doctors and hospitals to fill out billing forms, keep records, apply for credentials and perform the myriad other administrative functions associated with health care. The range of expert opinions on how much of this could be saved goes as high as $180 billion, or half of current expenditures. But a more conservative and reasonable estimate comes from David Cutler, an economist at Harvard, who calculates that for the whole system — for insurers as well as doctors and hospitals — electronic billing and credentialing could save $32 billion a year. And United Health comes to a similar estimate, with 20 percent of savings going to the government, 50 percent to physicians and hospitals and 30 percent to insurers. For health care cuts to matter, they have to be above 1 percent of total costs, or $26 billion a year, and this conservative estimate certainly meets that threshold!!! How do we get to these savings? First, electronic health records would eliminate the need to fill out the same forms over and over. An electronic credentialing system shared by all hospitals, insurance companies, Medicare, Medicaid, state licensing boards and other government agencies, like the Drug Enforcement Administration, could reduce much of the paperwork doctors are responsible for that patients never see. Requiring all parties to use electronic health records and an online system for physician credentialing would reduce frustration and save billions. But the real savings is in billing. There are at least six steps in the process: 1) determining a patient’s eligibility for services; 2) obtaining prior authorization for specialist visits, tests and treatments; 3) submitting claims by doctors and hospitals to insurers; 4) verifying whether a claim was received and where in the process it is; 5) adjudicating denials of claims; and 6) receiving payment. Substantial costs arise from the fact that doctors, hospitals and other care providers must bill multiple insurance companies. Instead of having a unified electronic billing system in which a patient could simply swipe an A.T.M.-like card for automatic verification of eligibility, claims processing and payment, we have a complicated system with lots of expensive manual data entry that produces costly mistakes. The Affordable Care Act requires the Department of Health and Human Services to develop operating standards for electronic eligibility determination and payment — steps one and six — in the next few years, but we need to go further. We need the standard operating rules to encompass authorizing tests and treatments, submitting claims, verifying where in the process a claim is and the real-time adjudication of denials. And we must accelerate the process, covering all steps by 2015. Finally, the government needs to require that all parties — doctors, hospitals, insurers, government agencies — use the electronic systems. This platform of electronic eligibility, claims and payment would — in addition to saving billions of dollars in paperwork — facilitate anti-fraud measures like those used by credit card companies. It would ease the administrative burden on doctors, letting them do the work that really matters — treating patients. Finally, it could improve care through built-in guidelines; if a doctor tried to schedule a stent implantation for a patient with stable heart disease, the system could tell him to try medication first; if he tried to order an M.R.I for a patient with normal back pain, it could tell him to prescribe physical therapy first. We have to realize that there are no " magic bullets" to solve our health care cost crisis.Any solutions offered so far to provide universal health care coverage will fail UNLESS they are being combined with meaningful and sustained cost control measures. This requires a total reform of our reimbursement system transforming it from a quantity to a quality focused service industry utilizing state-of-the-art information technology tools. Unless we are not willing to change, we are going to be forced to further ration medical services. What do we prefer? Yours Bernd Links: Spending More Doesn’t Make Us Healthier, http://opinionator.blogs.nytimes.com/2011/10/27/spending-more-doesnt-make-us-healthier/ Less Than $26 Billion? Don’t Bother., http://opinionator.blogs.nytimes.com/2011/11/03/less-than-26-billion-dont-bother/ Billions Wasted on Billing, http://opinionator.blogs.nytimes.com/2011/11/12/billions-wasted-on-billing/#more-112339

Personhood Amendment

On November 8th Mississippi voters will be asked to decide on a proposed amendment to the state constitution, which would define as a person “every human being from the moment of fertilization, cloning, or the functional equivalent thereof.” For most voters it sounds like a good idea and it will most probably pass. Therefore, several other states, including Florida http://personhoodfl.com/, are preparing similar constitutional amendments. Florida Senate Majority Leader and former US Senate Candidate Mike Haridopolos recently signed the FL Personhood Amendment!! The ambiguous language in the Florida and Mississippi 'personhood' amendment are intentionally not being represented properly by the proponents of this ballot initiative. A recent New York Times article http://www.nytimes.com/2011/10/31/opinion/mississippis-ambiguous-personhood-amendment.html correctly points out the following problems: "First, what does “fertilization” mean? As embryologists recognize, fertilization is a process, a continuum, rather than a fixed point. The term “fertilization” — which is sometimes considered synonymous with “conception” — could mean at least four different things: penetration of the egg by a sperm, assembly of the new embryonic genome, successful activation of that genome, and implantation of the embryo in the uterus. The first occurs immediately; the last occurs approximately two weeks after insemination (or, in the case of embryos created through in vitro fertilization that do not get implanted, never). Thus, on some reasonable readings of the amendment, certain forms of birth control, stem cell derivation and the destruction of embryos created through in vitro fertilization would seem impermissible, while on other equally reasonable readings they are not." Following the "logic" of the "personhood" advocates doctors can be charged with manslaughter or even murder by prescribing morning after pills, because it can irritate the lining of the uterus (endometrium) so as to inhibit implantation of a fertilized egg, i.e. "killing a person." A doctor could also be criminally charged by inserting an IUD because it adversely affects a new embryo as it enters the uterus, thus preventing it from implanting in the uterine lining . Again, according to the "personhood" advocates this constitutes the "killing of a person." Even though, abortions are still being protected by federal law women may still face criminal charges according to state law. Other unintended consequences include the question if the treatment of an ectopic or a molar pregnancy requires first a court order to overrule a "personhood" amendment in the respective state constitution. Needless to mention that any delay of these time-sensitive treatment decisions may harm the mother and even jeopardize the life and well-being of a women. I urge all of you to speak up against any such ballot initiatives, to protect the physician-patient relationship and to guard against further state intrusion into our lives. Yours Bernd

Drug Treatment Instead Of Prison

Attached a link http://www.sun-sentinel.com/news/opinion/editorials/fl-prison-bill-editorial-dl-20111030,0,3676874.story to an interesting editorial published in today's Sun Sentinel titled " State prisons need drug treatment alternative." The Sun Sentinel Editorial Board supports legislation — CS/HB 177 and SB 448 — which intends to establish a re-entry program for nonviolent offenders that offers intensive substance abuse treatment, adult education courses and vocational training as alternatives to long prison sentences. The idea is to reduce recidivism, which is essential if state officials want to get a handle on the costs of incarceration. The bills are sponsored by State Sen. Ellyn Bogdanoff, R-Fort Lauderdale, and State Rep. Ari Porth, D-Coral Springs. The two lawmakers are trying to pass needed, positive legislation to help the state of Florida reduce the costs of operating its prisons. In my opinion we should support this legislation and begin lobbying members of the Florida House and Senate. E-mail, twitter, mail or call your representative because " Unlike prison privatization and the more controversial ideas to cut state prison costs, the re-entry program is a simple solution that promises both savings and a much-needed reduction in the state's ongoing recidivism problem." Yours Bernd

Substance Abuse Counseling and Preventive Health Care

Attached a link http://www.ama-assn.org/amednews/2011/10/17/bica1017.htm to an interesting article titled "Counseling on alcohol helps patients and is billable" published in AMA News and posted on October 17th, 2011. Several highlights:

* Since early 2011, many commercially insured patients have been able to receive alcohol counseling paid at 100% with no co-pay or deductible, and the same is expected to be true for Medicare beneficiaries as of Jan. 1, 2012.
* Just asking about alcohol abuse will not necessarily lead to reimbursable payment, but treating those who screen positive most probably will. In addition to the usual fee-for-service, other incentives on the table should further make dealing with the issue more financially feasible for practices and make it more likely that patients will enter treatment.
* Tracking the percentage of adolescents and adults with new episodes of alcohol or other drug dependence who initiate treatment is on the list of eligible professional measure specifications from the Centers for Medicare & Medicaid Services.
* Information should be noted in the patient's chart, along with the time spent on this task. Counseling sessions longer than 15 minutes are billable, but shorter ones are not.
* On July 19, CMS issued a proposed decision memo stating that, as of Jan. 1, 2012, Medicare will cover annual alcohol misuse screening. (A final decision has not yet been made.) Under the proposal, Medicare would pay for four brief, face-to-face behavioral counseling interventions a year. The American Medical Association and other medical societies support his move.
* In addition, alcohol misuse screening and counseling is on the list of preventive services that non-grandfathered health plans must cover at 100% with no deductible or co-pay, according to the Patient Protection and Affordable Care Act. Grandfathered health insurance plans are those that have not changed since the health system reform law was enacted. Non-grandfathered ones are new policies issued after Sept. 23, 2010, and must cover a recommended list of preventive services with no cost-sharing with patients.
* When billing private insurers, the CPT codes are 99408 for an intervention lasting 15 to 30 minutes. An intervention longer than 30 minutes should be coded 99409. H0049 is the code for alcohol and drug screening of Medicaid beneficiaries. H0050 can be used for every 15 minutes of intervention. The services can be provided by a nurse practitioner or physician assistant as well as a physician.

Yours
Bernd