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Updated: 15 hours 37 min ago

Uninsured Rate Falls To Record Low Of 8.8%

September 12, 2017

Three years after the Affordable Care Act’s coverage expansion took effect, the number of Americans without health insurance fell to 28.1 million in 2016, down from 29 million in 2015, according to a federal report released Tuesday.

The latest numbers from the U.S. Census Bureau showed the nation’s uninsured rate dropped to 8.8 percent. It had been 9.1 percent in 2015.

Both the overall number of uninsured and the percentage are record lows.

The latest figures from the Census Bureau effectively close the book on President Barack Obama’s record on lowering the number of uninsured. He made that a linchpin of his 2008 campaign, and his administration’s effort to overhaul the nation’s health system through the ACA focused on expanding coverage.

When Obama took office in 2009, during the worst economic recession since the Great Depression, more than 50 million Americans were uninsured, or nearly 17 percent of the population.

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The number of uninsured has fallen from 42 million in 2013 — before the ACA in 2014 allowed states to expand Medicaid, the federal-state program that provides coverage to low-income people, and provided federal subsidies to help lower- and middle-income Americans buy coverage on the insurance marketplaces. The decline also reflected the improving economy, which has put more Americans in jobs that offer health coverage.

The dramatic drop in the uninsured over the past few years played a major role in the congressional debate over the summer about whether to replace the 2010 health law. Advocates pleaded with the Republican-controlled Congress not to take steps to reverse the gains in coverage.

The Census numbers are considered the gold standard for tracking who has insurance because the survey samples are so large.

The uninsured rate has fallen in all 50 states and the District of Columbia since 2013, although the rate has been lower among the 31 states that expanded Medicaid as part of the health law. The lowest uninsured rate last year was 2.5 percent in Massachusetts and the highest was 16.6 percent in Texas, the Census Bureau said. States that expanded Medicaid had an average uninsured rate of 6.5 percent compared with an 11.7 percent average among states that did not expand, the Census Bureau reported.

More than half of Americans — 55.7 percent — get health insurance through their jobs. But government coverage is becoming more common. Medicaid now covers more than 19 percent of the population and Medicare nearly 17 percent.

Guess Who Pays The Price When Hospital Giants Hire Your Private Practitioner?

September 08, 2017

 

MOUNTAIN VIEW, Calif. — When Dr. Sarah Azad followed her mother into the field of obstetrics eight years ago, she thought she’d be in private practice for the rest of her career. At the time, independent practices abounded in Silicon Valley.

“From the time we were young, my mom’s patients loved her. She was a part of their lives. That’s just always how I’ve seen medical care,” she said.

But over the past decade, she’s watched as doctor after doctor sold their practice and went to work for one of the large hospital systems in town. Today, Azad runs one of the last remaining independent OB-GYN practices in Mountain View.

The number of physician practices employed by hospitals increased by 86 percent from 2012 to 2015, according to a study conducted by Avalere Health for the Physicians Advocacy Institute, a health policy-focused nonprofit.

Perhaps nowhere has the trend been more pronounced than in Northern California.

This KHN story also ran in the Los Angeles Times. It can be republished for free (details).

As large hospital systems like Sutter Health, Stanford Medicine and UCSF Medical Center gobble up doctor practices, they gain market muscle that pushes costs upward. It’s a key reason why Northern California is now the most expensive place in the country to have a baby.

A study published this week in Health Affairs found that large doctor practices, many owned by hospitals, exceed federal guidelines for market concentration in more than a fifth of the areas studied. But the mergers are typically far too small for federal antitrust authorities to notice.

“When you have less competition, prices go up,” said Martin Gaynor, a health care economist at Carnegie Mellon University. “If you’re an insurance company and you don’t reach an agreement with Sutter, then you have a hard time offering an attractive insurance product because it’s so big and pervasive. So you don’t have the same negotiating power, and Sutter can extract higher prices.”

In the San Francisco Bay Area, the reimbursement rate for a vaginal delivery is two to four times higher for physicians who work for large hospital systems than for those who are independent, according to a Kaiser Health News analysis. The news organization examined claims data provided by Amino, a health cost transparency company, plus results from medical cost calculators available from certain employers to help workers comparison shop.

The extra money for physician services goes to the hospital system, and doctors, now on salary, might take home no more than before. Although switching from independent practice spares OB-GYNs the considerable hassles of negotiating with insurers and running an office, doctors say the lion’s share of the benefit goes to hospital systems — not to physicians or patients.

In Northern California, Sutter, Stanford and UCSF all mentioned quality as a reason why their physician prices are higher, and it might seem intuitive that integrating care among disparate physicians leads to better care.

“Sutter Health-affiliated doctor groups consistently rank among California’s highest performers,” Dr. Jeffrey Burnich, senior vice president at Sutter Health Medical and Market Networks, wrote in an email. In the long run, “by improving care quality and efficiency, we reduce costs.”

But in general, research suggests bigger is not necessarily better.

Fewer patients of small physician-owned practices, for example, are admitted to the hospital for preventable conditions than those of large hospital-owned practices, according to a 2014 study published in Health Affairs. A report from the National Academy of Social Insurance showed that the integrated delivery networks of large hospital systems have raised physician costs without evidence of higher quality. And a recent paper, also published in Health Affairs, found that high-price physician practices, which cost at least 36 percent above average, had no better quality than low-cost practices.

“All of the evidence that we see shows that the quality in these larger systems is the same or worse,” said Kristof Stremikis, associate director for policy at the Pacific Business Group on Health, which represents employers that provide health insurance.

A Personal Connection

On a sunny day this spring, Azad walked into her patient’s room wearing a colorful headscarf. Just weeks from her due date, Ruby Lin sat on the end of the exam table holding her belly. The two women greeted each other like old friends.

“Hi! You look great,” Lin told Azad.

“Thanks — I’m not where I hoped I’d be,” Azad replied, rolling her eyes and touching her stomach. The doctor gave birth to her fourth child just months earlier and hadn’t lost the “baby weight” she wanted to yet.

Dr. Sarah Azad examines patient Ruby Lin in Mountain View, Calif. Azad’s mother was also an obstetrician. (Jenny Gold/KHN)

This was Lin’s second baby with Azad as her doctor. “I get very nervous about seeing doctors and especially OB-GYNs, and Dr. Azad is the only one I’m comfortable with,” said Lin.

This sort of well-established, personal relationship is Azad’s favorite part of being a doctor, and she considers it a hallmark of independent practice. At the larger practices owned by hospital systems, she said, patients may be more likely to have the doctor on call deliver their baby rather than the obstetrician whom they’ve grown to know over months.

But Azad says running a medical practice in one of the most expensive parts of the country is getting harder. “Rent goes up 3 percent per year. Water and utilities went up 18 percent last year alone. But seven years later, [the insurers] are still paying me the same amount, despite any efforts to negotiate.”

At first, Azad tried reaching out to the insurance companies directly to ask for higher rates. They refused even to meet with her, she said. Then she hired a consultant to negotiate on her behalf. Nothing worked.

“One insurance contract responded saying, ’You don’t even have 2 percent of market share. Basically drop our contract or not — it doesn’t affect us,’” she said. Another insurer told her they couldn’t raise her rates because they had to pay too much to the larger health systems in town, she said.

Independent doctors in the Bay Area are reimbursed, on average, a median $2,408.45 for a routine vaginal delivery, which includes prenatal and postnatal visits, according to the Kaiser Health News analysis of Amino claims data.

That compares with $5,238.13 for the same bundle of services for Stanford physicians and $8,049.84 for doctors employed by University of California-San Francisco.

Health data company Amino provided KHN with median billing amounts for Bay Area obstetricians. KHN used a Medicare provider database to determine where each doctor worked. In cases where the doctor’s employment status was unclear, a reporter retrieved the information by calling the health system or physician directly. KHN then calculated the average median billing amount for a routine vaginal birth for each health system.

The Amino database did not contain many claims from doctors employed by Sutter, so KHN also reviewed OB-GYN charges on several insurers’ online cost estimators. The review found that obstetricians employed by Sutter Health are reimbursed about three times more for the same service than independent doctors, or about $6,452 for a vaginal delivery.

Many doctors are mystified as to why prices vary so dramatically — independent or not.

Same Office, Same Pay

After nearly a quarter-century in independent practice, OB-GYN Ken Weber sold his practice to Stanford, where he now works. His office is in the same place, across the street from Azad. Both physicians admit patients to the same local hospital.

But insurers now pay about twice as much for his services as before.

He still makes the same amount, he said. Stanford’s health system gets the rest.

“It doesn’t make sense to me from the insurance company’s standpoint, because they’re losing all these doctors to the bigger groups and having to pay more. And if they just had negotiated with us fairly, I think we could come to some middle ground,” Weber said.

Weber said he hung on to his independent practice as long as possible, but he grew increasingly frustrated. “It’s hard to know that you’re doing the same work someone else does at Sutter or Stanford or wherever,” yet insurers are paying more for patients to see the other person, he said.

Nonetheless, there have been some real benefits to selling his practice, he added: He no longer has to worry about dealing with billing or maintaining compliance with the new electronic health record regulations.

For their part, the big Bay Area hospital systems caution against oversimplifying the many factors that go into paying for obstetrical care. A Stanford spokeswoman, Samantha Dorman, said the health system incurred significant costs when it integrated new provider groups. For instance, many were not yet on electronic health records and needed updated equipment. Dorman added that Stanford reduced physician charges a few years ago to be more in line with other practices.

A UCSF spokeswoman said that just looking at physician reimbursement rates was misleading because while the system charges more for physician services, it charges less for other hospital services. Overall, she said, their costs are competitive.

For its part, Sutter suggested it was not accurate or fair to judge physician price discrepancies on online cost calculators. According to Burnich of its Medical and Market Networks service, the rates provided are inconsistent and often out-of-date.

The agreements between hospitals and insurers have “gag clauses” barring either party from divulging rates. The bottom line, for many patients, is that it’s almost impossible to determine either the cost or the value of the various health care providers available to them. This is particularly problematic for patients with high-deductible plans, who may be on the hook for a significant portion of those costs.

Meanwhile, the type of consolidation that Azad has witnessed in Northern California is spreading quickly throughout the country, and it is extremely difficult to reverse.

The most consolidated places like Northern California, Pittsburgh and Boston have become a “poster child of what not to do,” said economist Gaynor of Carnegie Mellon. “We should look at places that have consolidated and think about how to avoid that.”

Kaiser Health News correspondent Sydney Lupkin contributed to this report.

Move To End DACA Leaves Some Young Immigrants Fearing For Their Health

September 06, 2017

LOS ANGELES — For 26-year-old Paulina Ruiz, having legal immigration status is about more than going to school or holding a job. It’s about staying healthy.

The University of California-Los Angeles graduate, whose parents brought her from Mexico to the U.S. illegally two decades ago, has cerebral palsy, a neurological condition diagnosed shortly after birth.

In the past, Ruiz said, she relied on emergency rooms for her health care and rarely could see specialists. She developed kidney and back problems after years of inconsistent medical care and using an inappropriate wheelchair.

Paulina Ruiz, who has cerebral palsy, said losing her legal immigration status could mean losing her health coverage and access to doctors. Ruiz is on Medi-Cal, which helps cover some of the costs of her medical care. (Courtesy of Paulina Ruiz)

But in 2012, she qualified for the federal Deferred Action for Childhood Arrivals (DACA) program, which temporarily protected her from deportation. In California, that meant she could get Medi-Cal, California’s version of the Medicaid insurance program for low-income Americans, and regularly see a doctor.

The Trump administration’s controversial decision on Tuesday to scrap the DACA program does more than put nearly 800,000 “Dreamers” in fear of deportation and losing their jobs. It threatens the health care of thousands of young adults like Ruiz, who either have job-based insurance or whose incomes qualify them for Medicaid in California and several other states.

“I am very upset,” said Ruiz, who organizes for the Coalition for Humane Immigrant Rights of Los Angeles and lives near the city. “I don’t know what’s going to happen to my health.”

The decision is set to take effect in six months, unless Congress comes up with an alternative plan. Trump has said the program, started under President Obama in 2012, rewards lawbreakers who hurt Americans by taking their jobs and depressing wages, a claim some economists dispute. Attorney General Jeff Sessions said Tuesday that the program was unconstitutional because it was a unilateral executive action on a proposal that had been repeatedly rejected by Congress.

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Trump, who has suggested he has conflicting sentiments about the program, left open the door for Congress to change it. “I have a love for these people, and hopefully now Congress will be able to help them and do it properly,” he said, according to The New York Times. But the newspaper noted that he did not call for bipartisan legislation to restore its protections.

The program allows immigrants between the ages of 16 and 31 who were brought to the United States illegally as children to receive work permits and temporary protection from deportation. Those who qualified were explicitly barred from receiving federal health benefits through Medicaid, Obamacare exchanges or other programs.

Many DACA recipients now have jobs with health insurance. In addition, California, New York, Massachusetts, Minnesota and the District of Columbia have used their own money to cover low-income Dreamers through Medicaid, according to Tanya Broder, a Berkeley, Calif.-based senior staff attorney for the National Immigration Law Center.

Maria Garcia, 22, said she was able to get a job as a receptionist at a Los Angeles hotel because of the DACA program. The job also came with health insurance, which helped cover physical therapy from a knee injury. She fears getting fired and being unable to pay for her own health insurance and medical care. (Anna Gorman/KHN)

An estimated 367,000 people qualify for DACA in California. There are an estimated 220,000 DACA recipients in California, the largest number in the country. Those who meet income requirements — 138 percent of the federal poverty level or $33,534 for a family of four — can qualify for coverage under the state’s “Permanently Residing in the United States under Color of Law” eligibility category.

That coverage is now in question. In California, those at risk of losing Medicaid are 19 and older, because the state under a separate law decided to cover all low-income children, regardless of immigration status, through age 18. That decision was not connected to the DACA program.

With the federal government’s action, “nobody will lose coverage in the Medi-Cal program immediately,” said Ronald Coleman, director of government affairs for the California Immigrant Policy Center, an immigrant advocacy group. But Coleman worries about what happens after March 5, when DACA’s protections will end — unless Congress takes action to protect the program.

The Department of Health Care Services, which oversees Medi-Cal, could not provide a comment on Tuesday, a spokeswoman said.

Marielena Hincapié, executive director of the National Immigration Law Center, told reporters in a conference call on Tuesday that she expects DACA recipients to start losing their job-based health insurance. Hincapié said she is particularly concerned about the effect of the president’s decision on the mental health of DACA recipients.

“The need for mental health services will only be greater,” she said.

Jocelin Reyes, 19, said having protection from deportation relieved her fears and anxieties. But now, the University of California-Santa Barbara student said, “the fear has tripled.” (Anna Gorman/KHN)

At a protest in downtown Los Angeles Tuesday against the Trump administration’s decision, Jocelin Reyes made a similar point. She said DACA’s protections had helped put some young immigrants’ fears to rest, as they were able to get jobs, attend college or graduate school and come out of hiding.

“A lot of people don’t understand how much fear we had” about being deported, said Reyes, 19, who is about to start school at the University of California-Santa Barbara. “Now that fear has tripled.”

Another demonstrator, DACA recipient Maria Garcia, 22, said that losing her job as a hotel receptionist would mean the end of her job-based health insurance — coverage she relies on for physical therapy for a knee injury and any time she gets sick.

“If they take away my DACA, I’ll get fired,” she said. “And then what will I do for health insurance?”

State Sen. Ricardo Lara (D-Bell Gardens) said ending DACA would only hurt “the well-being of these American children who have played by the rules.” And they could end up having to go to costly emergency rooms for medical care.

Lara, who led the charge to get all undocumented children covered by Medi-Cal, said one possible solution in California would be to increase the age limit for Medi-Cal coverage for kids from 18 to 26.

“We have to answer this call to ensure that our DACA students and workers are not pushed aside,” he said.

The California Medical Association said that terminating DACA could indeed hurt the health care workforce.

“Our nation’s health care system has the largest percentage of foreign-born and foreign-trained workers of any industry in the country. Already facing a national shortage of physicians and other health care professionals, revoking DACA could also undermine patient care and disrupt medical schools and hospitals for decades to come,” said California Medical Association President Ruth E. Haskins in a statement.

Ana B. Ibarra contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Mayo Pain Expert: Holistic Approach Helps Patients Ditch Opioids

August 29, 2017

Each year, more than 300 patients with chronic pain take part in a three-week program at the Pain Rehabilitation Center at Mayo Clinic in Rochester, Minn. Their complaints range widely, from specific problems such as intractable lower-back pain to systemic issues such as fibromyalgia. By the time patients enroll, many have tried just about everything to get their chronic pain under control. Half are taking opioids.

In this 40-year-old program, that’s a deal breaker. Participants must agree to taper off pain medications during their time at Mayo.

More than 80 percent of the patients who enroll stay for the entire program, said Wesley Gilliam, the center’s clinical director, and many previous opioid users who finish the treatment report six months later that they have been able to stay off opioids. Just as important, he added, they have learned strategies to deal with their pain.

Insuring Your Health

KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.

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But such a program is not for everyone. Insurers might disagree that the intensive, interdisciplinary approach is medically necessary for some patients or simply not cover the program’s billing codes, he said. Mayo’s insurance team sometimes advocates on patients’ behalf if they’re good candidates for treatment, but success isn’t assured.

Mayo’s program isn’t the only one to address the emotional, social and psychological aspects of pain, and other programs also focus on reducing patients’ reliance on addictive medications to manage their pain. But as the nation weathers an opioid epidemic, there are too few programs like these around the country to address the need, Gilliam said.

Gilliam, a clinical psychologist with a specialty in behavioral pain management, talked with me about the program.

The transcript has been condensed and edited for clarity.

Q: How do pain medications work? By blunting the pain?

Wesley Gilliam, the clinical director of the Mayo Clinic’s pain rehabilitation center, says the use of medication and relaxation exercises can help relieve pain. (Courtesy of the Mayo Clinic)

They blunt some of the pain. Opioids are very effective for acute problems, but they were never designed to be used chronically. They’re not effective in the long term.

Opioids are central nervous system depressants. They soothe people who are in distress. Many people aren’t demonstrating improved functioning when they take opioids; it’s calming their nerves. It’s chemical coping.

Q: In treating pain, does it matter what’s causing it or how severe it is?

Pain is pain. The fundamental approach to self-managing it doesn’t change based on the cause or severity of the pain. 

Q: How does someone wind up at a program like yours?

Virtually all of our patients have tried and exhausted primary and secondary treatment options for pain.

[In] primary care, a patient comes in with a complaint, and a treatment plan is developed. It generally involves encouraging the patient to be active, to stretch, maybe the doctor initiates a non-opioid medication like a non-steroidal anti-inflammatory (NSAID) or an antidepressant.

If the patient continues to complain of chronic pain, the primary care provider will step up to level two and refer someone to a neurologist or maybe a pain psychologist or pain anesthesiologist.

If patients don’t respond, they start to think about step three, which is a pain program like Mayo.

Q: How does the Mayo program work?

People come to us every weekday from 8 a.m. to 4 p.m. for three weeks.

We don’t take a medical approach. It’s a biopsychosocial approach, [which] acknowledges not only the biological aspect of pain, but also recognizes that psychological and social variables contribute to how people experience pain.

That is not to say that pain is imagined, but rather how people experience pain is influenced by mood, anxiety and how that person’s environment responds to the person’s symptoms.

A more medical approach tends to focus on targeting and eliminating symptoms at the expense of the recognition of individual differences.

Q: What does that mean for the patient who’s in pain?

People need to accept that they have pain and focus on their quality of life. Some approaches reinforce in patients that the only way you can function is if you reduce your pain, as measured on a pain scale from zero to 10.

We focus on how to get you back into your life by focusing on function instead of eliminating symptoms and pain. When I refer to functioning, I mean getting back into important areas of your life such as work, social activities and recreation. If you’re waiting for pain to go away, you’re never going to get back into your life. When that happens, people get despondent, they get depressed.

Q: So how do you help people manage it?

When you’re in chronic pain and it’s poorly managed, the nervous system can get out of whack. Your body behaves as if it’s under stress all the time, even when it’s not. Your muscles may be tense and your heart and breathing rates elevated, among other things.

With meditation and relaxation exercises, we’re trying to teach people to learn to relax their bodies and hopefully kick in a relaxation response.

If I have low-back pain, for example, during periods of stress muscular tension is going to exacerbate the pain in my back. We focus on helping people to disengage from their symptoms.

By learning to relax in response to stress, muscular tension can be diminished and the experience of pain eased. This doesn’t require a medication or a procedure, just insight and implementation of a relaxation skill.

Relaxation/meditation training is one component of a much broader treatment package. All aspects of our treatment — cognitive techniques for managing mood, anxiety and anger, physical therapy, occupational therapy — are all designed to settle the nervous system.

Q: Does insurance typically cover the program? 

Insurance companies may want to see patients complete more conservative treatment approaches before approving an interdisciplinary pain rehabilitation program like ours.

There are patients whose policies don’t cover our billing codes. If we deem a patient a good candidate, we’ll write letters saying they should be accepted.

There are a very select few who have paid out-of-pocket for our program. This is a significant minority, however. The program can cost up to $40,000 for someone with other complicated medical problems in addition to chronic pain.

There are studies that show these programs do save money over the long term in health care costs and reduced health care utilization.

If we’re going to manage this chronic pain problem, we have to look at it for what it is: multifaceted. You can’t just treat the symptom, you have to treat the whole person.

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