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HHS seeks public input on improving care coordination and reducing the regulatory burdens of the HIPAA Rules

HHS Gov News - December 13, 2018

 Today, the U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), issued a Request for Information (RFI) seeking input from the public on how the Health Insurance Portability and Accountability Act (HIPAA) Rules, especially the HIPAA Privacy Rule, could be modified to further the HHS Secretary’s goal of promoting coordinated, value-based healthcare. This RFI is a part of the Regulatory Sprint to Coordinated Care, an initiative led by Deputy Secretary Eric Hargan.

HHS developed the HIPAA Rules to protect individuals’ health information privacy and security interests, while permitting information sharing needed for important purposes. However, in recent years, OCR has heard calls to revisit aspects of the Rules that may limit or discourage information sharing needed for coordinated care or to facilitate the transformation to value-based health care. The RFI requests information on any provisions of the HIPAA Rules that may present obstacles to these goals without meaningfully contributing to the privacy and security of protected health information (PHI) and/or patients’ ability to exercise their rights with respect to their PHI.

“This RFI is another crucial step in our Regulatory Sprint to Coordinated Care, which is taking a close look at how regulations like HIPAA can be fine-tuned to incentivize care coordination and improve patient care, while ensuring that we fulfill HIPAA’s promise to protect privacy and security,” said Deputy Secretary Hargan. “In addressing the opioid crisis, we’ve heard stories about how the Privacy Rule can get in the way of patients and families getting the help they need. We’ve also heard how the Rule may impede other forms of care coordination that can drive value. I look forward to hearing from the public on potential improvements to HIPAA, while maintaining the important safeguards for patients’ health information.”

“We are looking for candid feedback about how the existing HIPAA regulations are working in the real world and how we can improve them,” said OCR Director Roger Severino. “We are committed to pursuing the changes needed to improve quality of care and eliminate undue burdens on covered entities while maintaining robust privacy and security protections for individuals’ health information.”

In addition to requesting broad input on the HIPAA Rules, the RFI also seeks comments on specific areas of the HIPAA Privacy Rule, including:

  • Encouraging information-sharing for treatment and care coordination
  • Facilitating parental involvement in care
  • Addressing the opioid crisis and serious mental illness
  • Accounting for disclosures of PHI for treatment, payment, and health care operations as required by the HITECH Act
  • Changing the current requirement for certain providers to make a good faith effort to obtain an acknowledgment of receipt of the Notice of Privacy Practices

Public comments on the RFI will be due by February 11, 2019.  The RFI may be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/

‘We’re Fighting For Our Lives’: Patients Protest Sky-High Insulin Prices

Kaiser Health News:Marketplace - December 12, 2018

Angela Lautner knew her thirst was unusual, even for someone directing airplanes, outside in the Memphis summer heat.

“We had coolers of Gatorade and water for people to always have access to,” Lautner recalled of her job as a ground services agent. “But the amount of thirst that I felt was just incredible.”

She had no appetite and she lost an unusual amount of weight. Then after a trip to the emergency room, Lautner, who was 22, was diagnosed with Type 1 diabetes. The diagnosis was life-changing.

To start, it meant that for the rest of her life she would require insulin injections every day to stay alive. Unlike Type 2 diabetes, which can sometimes be controlled by diet, people with Type 1 diabetes need daily insulin injections to regulate their blood sugar.

Lautner’s diagnosis also meant she was no longer allowed to become a commercial airline pilot in the U.S. — a lifelong dream that she was training for in flight school at the time.

“I cried harder over losing my dream to fly than I did at the diagnosis of Type 1 diabetes,” Lautner said.

But after 18 years living with diabetes, Lautner now says the hardest thing about the diagnosis is accessing insulin — the expensive drug she needs to keep her alive. She has had to borrow money from her parents to pay for insurance; she has spent hours on the phone with drug companies; she has switched brands of insulin to save costs; and she even moved to a new state, Kentucky, with a more generous Medicaid plan.

Last year, Lautner noticed other people with Type 1 diabetes tweeting similar stories under the hashtag #Insulin4All. She read the stories of Shane Patrick Boyle and Alec Raeshawn Smith, two men who died because they could not afford their insulin. It was an epiphany.

“I thought, ‘My goodness, there’s more people than me. I’m not the only one out here,’ ” she said.

Since then, Lautner has joined a group of consumer activists, people who need insulin to live and are angry about the sky-high prices. They are putting pressure on the three main companies that make insulin: Sanofi of France, Novo Nordisk of Denmark and Eli Lilly and Co. in the U.S.

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Taking On The Drugmakers

The cost of insulin nearly tripled from 2002 to 2013 and has doubled again since then. The list price is over $300 for a single vial of medicine, and most people with Type 1 diabetes need multiple vials every month to live. That cost is typically lower with insurance or with discount programs. Still, for some people the price is unmanageable.

There’s been some action by lawmakers on the issue. In October, Minnesota’s attorney general sued insulin manufacturers alleging price gouging, and a bipartisan caucus in the U.S. Congress issued a report in November urging action to bring insulin prices down.

But prices are still going up, so consumer activists like Lautner are taking things into their own hands.

Nonprofit group T1International, which advocates for Type 1 diabetes around the world, with a particular focus on insulin prices, has started holding rallies outside the Indianapolis headquarters of pharmaceutical giant Eli Lilly and Co.

Lautner joined more than 70 people who came together to demonstrate there in September. They were asking for three things: transparency about how much it costs to make a vial of insulin and how much profit comes from each vial, and a commitment from the company to lower the list price of insulin.

Protesters hailed from at least 12 states, mainly Ohio, Illinois, Indiana and Kentucky, but also from as far away as New York. Lautner, who now lives outside Cincinnati, rented a school bus with a dozen others to make the 112-mile trip.

“Insulin is kind of the face of the drug pricing crisis in America,” said Elizabeth Pfiester, founder of T1International who has Type 1 diabetes herself. “We literally die without it,” she said. “We’re fighting for our lives.”

This was the third time the group had protested at Eli Lilly headquarters. Last fall, when the group held its first protest there, Pfiester said, it was “the first time where people living with Type 1 were able to physically stand and show that people are angry enough to come out.”

Eli Lilly declined a request for an interview, but in statement a spokesperson said, “We understand why people are making their voices heard.”

Protesting is one arm of their advocacy efforts; the group is also lobbying at the state and national level, and conducting online awareness-raising campaigns under the hashtag #Insulin4All.

Advocacy At The State Level

Last spring, the fight got even more personal for Angela Lautner. She got a letter from her insurance company saying they were no longer going to pay for the insulin she was taking. They wanted to switch her to a different brand.

Most people with Type 1 diabetes use two types of insulin: short-acting insulin to counteract the carbohydrates consumed with meals, and long-acting insulin to keep blood sugar stable throughout the day.

Lautner has found that the long-lasting insulin brand Lantus works best with her body; it keeps her blood sugars low, but not so low that she becomes dangerously hypoglycemic, risking death. But her insurer was dropping its coverage of Lantus in favor of a different long-lasting insulin, Basaglar.

“The problem that I immediately saw was that [Basaglar] had not worked for my body,” Lautner said. “So I go into my doctor’s office with this letter and I’m like, ‘What am I going to do?'”

Lautner’s doctor connected her to Sanofi’s drug discount program, where she was able to get a month’s supply of Lantus for a couple of hundred dollars. So she decided to pay for the insulin herself.

“I’m fortunate enough to have an emergency fund,” Lautner said.

But she knows others aren’t so lucky.

This year, Lautner organized her own group of diabetes activists in Kentucky, Ohio and Indiana, called KOI Insulin4All. They’ve met with legislators in all three states about establishing emergency insulin prescription refills and about making the cost of insulin more transparent.

There are similar groups starting up in Oklahoma, Pennsylvania, Minnesota and Illinois. In November, activists protested outside the Cambridge, Mass., office of Sanofi. All of them are pushing for the same thing — to make the voices of people with diabetes heard.

This story is part of a reporting partnership with NPR.

Colorado hospital failed to terminate former employee’s access to electronic protected health information

HHS Gov News - December 12, 2018

Pagosa Springs Medical Center (PSMC) has agreed to pay $111,400 to the Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services and to adopt a substantial corrective action plan to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules.  PSMC is a critical access hospital, that at the time of OCR’s investigation, provided more than 17,000 hospital and clinic visits annually and employs more than 175 individuals.

The settlement resolves a complaint alleging that a former PSMC employee continued to have remote access to PSMC’s web-based scheduling calendar, which contained patients’ electronic protected health information (ePHI), after separation of employment. OCR’s investigation revealed that PSMC impermissibly disclosed the ePHI of 557 individuals to its former employee and to the web-based scheduling calendar vendor without a HIPAA required business associate agreement in place. 

Under the two-year corrective action plan, PSMC has agreed to update its security management and business associate agreement, policies and procedures, and train its workforce members regarding the same.

“It’s common sense that former employees should immediately lose access to protected patient information upon their separation from employment,” said OCR Director Roger Severino.  “This case underscores the need for covered entities to always be aware of who has access to their ePHI and who doesn’t.”

Covered entities that do not have or follow procedures to terminate information access privileges upon employee separation risk a HIPAA enforcement action. Covered entities must also evaluate relationships with vendors to ensure that business associate agreements are in place with all business associates before disclosing protected health information.  The resolution agreement and corrective action plan may be found on the OCR website at http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/pagosasprings.

One Implant, Two Prices. It Depends On Who’s Paying.

Kaiser Health News:Marketplace - December 11, 2018

Kim Daniels didn’t have to pay a penny for her double mastectomy or the reconstructive surgery she had after treatment for breast cancer in June 2018. Her health insurance, PennCare, administered through Independence Blue Cross in Pennsylvania, fully covered both procedures.

Knowing that, cost wasn’t an issue for Daniels when selecting the type of breast implants. She asked her plastic surgeon at the Hospital of the University of Pennsylvania, “If I were your wife, what would you [choose]?” He went with Mentor MemoryGel implants.

According to Daniels’ hospital bill, those implants came with a price tag of $3,500 apiece, or $7,000 total.

Such a high charge for the exact same item would have been unthinkable if the procedure was cosmetic breast augmentation, which is generally not covered by health insurance. When patients pick up the tab, cosmetic surgery packages for breast augmentation cost about the same — $7,000 — but that includes the doctor’s fee, implants, operating room time and anesthesia.

The radical difference in price demonstrates in stark numerical terms how costs often depend on who is paying the bill.

Dr. Anupam Jena, a health economist at Harvard Medical School, said it’s precisely because cosmetic patients pay out-of-pocket that their costs for implants are far lower than what hospitals charge reconstructive patients.

“Cosmetic surgery providers have to compete with each other,” he said, and “one of the big ways they’re going to compete is to compete on price.”

“Whatever the cost is for the implant, they can’t up-charge too much, or a patient will just go somewhere else.”

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Dr. Alex Sobel, a cosmetic surgeon and president of the American Board of Cosmetic Surgery, said the price he charges cosmetic patients for breast implants is pretty close to the price he pays for the implants from the manufacturer. High-end implants like Daniels’ would be priced at a maximum of $3,000 for a set, he added, if Daniels had been undergoing cosmetic breast augmentation surgery.

Sobel operates a cosmetic surgery practice in Bellevue, Wash., which is in the region of the U.S. with the highest cost range for cosmetic breast surgeries. He said he usually pays around $250 to $700 per implant for saline and $700 to $1,000 per implant for silicone. The most expensive form — stable silicone or “gummy bear” implants — are usually priced around $1,350 each.

Similarly, Dr. Brent Rosen, a cosmetic surgeon with a practice in a northern suburb of Philadelphia, said the silicone implants he buys range from $1,500 to $2,000 per individual implant.

For the entire cosmetic breast augmentation procedure with silicone implants Rosen charges $6,500. That’s $500 less than the charge for just Daniels’ silicone implants at the nearby Hospital of the University of Pennsylvania.

Jena, the Harvard health economist, said the reason behind many of these price markups is that hospitals are like any other business trying to make a profit. They can ask more from a company like an insurer than they can from an individual.

“Why does Apple charge $1,000 for an iPhone? It doesn’t cost that much to make an iPhone. It’s so they can extract surplus money. Same goes for hospitals,” said Jena.

Breast implants are just one example of how medical devices are significantly marked up by hospitals.

A 2017 study published in JAMA found that for knee and hip implants, insurance companies were paying double what the hospitals paid when they purchased the implants from manufacturers.

It is hard to define a reasonable manufacturing cost or wholesale price for a medical-grade bag of silicone. Mentor Worldwide and Allergan, the two biggest manufacturers of breast implants in the U.S., declined to share their products’ wholesale costs or their price negotiation practices with providers. Manufacturers regard their pricing as a trade secret.

Hospitals typically obtain medical devices through health care group purchasing organizations, which are supposed to negotiate with manufacturers to get lower costs for items. Bigger hospitals or providers that offer to use more of a certain product often get steep discounts over wholesale.

In 2016, Medicare, which has huge leverage in negotiations, paid $516.59 for a “silicone or equivalent breast prosthesis.”

So, the hospital markup for patients who pay for the procedure or are commercially insured is even more extraordinary.

A Penn Medicine spokesperson told KHN in an email that they were unable to comment on specific patient cases, but that the hospital receives a single “case rate” or bundled payment for all breast reconstruction surgeries and that reimbursement is not related to the type of breast implant chosen.

Of course, when dealing with powerful insurance companies, hospitals don’t get paid the full asking price conveyed on their bills. The price is often merely the starting point for negotiations with insurers.

“Hospitals are absolutely marking up the prices for medical devices,” said Jeffrey McCullough, a health policy professor at the University of Michigan. But, he added, “you can almost guarantee the list price you see on a hospital bill is not what the hospital is getting paid by insurance companies,” which bargain for discounts.

Even so, not all patients have health insurance coverage as comprehensive as Kim Daniels’. In such cases, all or part of the hospital’s high charge for breast implants could be billed directly to patients.

“If you don’t have an insurance company bargaining on your behalf, the default is to charge the patient,” McCullough said.

KHN’s coverage of women’s health care issues is supported in part by The David and Lucile Packard Foundation.

Need Health Insurance? The Deadline Is Dec. 15

Kaiser Health News:HealthReform - December 10, 2018

The woman arrived at the University of South Florida’s navigator office in Tampa a few weeks ago with a 40-page document describing a short-term health insurance plan she was considering. She was uncomfortable with what the broker had said about the coverage, she told Jodi Ray, a health insurance navigator who helps people enroll in coverage, and she wanted help understanding it.

The document was confusing, according to Ray, who oversees Covering Florida, the state’s navigator program. It was hard to decipher which services would be covered.

“It was like a bunch of puzzle pieces,” she said.

Encouraged by her wife, the woman eventually opted instead for a marketplace plan with comprehensive benefits.

The annual open-enrollment period for people who buy their own insurance on the Affordable Care Act’s marketplaces ends Dec. 15 in most states. Enrollment in states that use the federal healthcare.gov platform has been sluggish this year compared to last. From Nov. 1 through Dec. 1, about 3.2 million people had chosen plans for 2019. Compared with the previous year, that’s about 400,000 fewer, or a drop of just over 11 percent.

The wider availability of short-term plans is one big change that has set this year’s apart from past sign-up periods.

Another is the elimination of the penalty for not having health insurance starting next year. The Congressional Budget Office has estimated that as many as 3 million people who buy their own coverage may give it up when they don’t face a tax penalty.  But experts who have studied health insurance enrollment say that surveys so far indicate that the penalty hasn’t typically been the pivotal factor in people’s decision on whether to buy insurance.

They also caution against reading too much into the preliminary enrollment totals.

“There typically is a surge in enrollment at the end,” said Sabrina Corlette, research professor at Georgetown University’s Center on Health Insurance Reforms. “It’s hard to know whether it will make up for the shortfall.”

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If they don’t pick a new plan, people who are enrolled in a 2018 marketplace plan may be automatically re-enrolled in their current plan or another one that is similar when the open-enrollment period ends. About a quarter of people who have marketplace plans are reassigned in this way.

Another factor that may be affecting enrollment is tighter federal funding for the health insurance navigators, like Jodi Ray in Tampa, who guide consumers through the complicated process. With fewer experts available to answer questions and help fill out the enrollment forms, consumers may fall through the cracks.

Across the country, funding for navigators dropped from $36 million in 2017 to $10 million this year. In Florida, federal funding for the Covering Florida navigator program was slashed to $1.25 million this year from $4.9 million last year, Ray said. The program was the only one to receive federal funding in the state this year.

The Covering Florida program reduced the number of open-enrollment navigators to 59 this year, a nearly 61 percent drop, Ray said. Navigators this year are available in only half of Florida counties; the organization is offering telephone assistance and virtual visits to people in counties where they can’t offer in-person help.

“It’s all we can do,” Ray said. So far, the group’s navigators have enrolled about half the number of people this year as they had last year.

It’s unclear the extent to which the Trump administration’s efforts to reduce health care costs by expanding access to short-term plans is affecting marketplace plan enrollment.

These plans, originally designed to cover people who expected to be out of an insurance plan for a short time, such as when they change jobs, can be less expensive. Unlike marketplace plans, short-term plans don’t have to provide comprehensive benefits or guarantee coverage for people who have preexisting medical conditions.

The Obama administration limited short-term plans to a three-month term. But in August, the federal government issued a rule that allowed their sale with initial terms of up to a year, and the option of renewal for up to three years.

Ten states either ban short-term plans or restrict them to terms of less than three months, said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Many people are seemingly not focused on their options this open-enrollment season, however. According to a recent survey, about half of adults under age 65 who were uninsured or who buy their own coverage said they planned to buy a plan for 2019. But only 24 percent of people in that age group said they knew what the deadline was to enroll in health insurance, according to the Kaiser Family Foundation’s November health tracking poll.

Must-Reads Of The Week On Health Care

Kaiser Health News:HealthReform - December 07, 2018
The Friday Breeze

Want to read the best and most provocative stories from the week? Welcome to the Friday Breeze, where we compile them all — so you’re set with your weekend reading.

Your regular Breeze correspondent, and its creator, Brianna Labuskes, is taking a break, but we didn’t want you to be without some semblance of a report today of things you don’t want to miss in health care.

So I’ll do my best at filling in. Be kind, and check back next week for the really good stuff.

One of the biggest bits of news this week was a coughed-up blot clot from the lung. Not sure why that seemed to fascinate people. We can skip that, but feel free to look.

The Atlantic: Doctors Aren’t Sure How This Even Came Out of a Patient

A more authentic bit of news was the report that health care spending slowed in 2017. It’s still growing, mind you, but growing more slowly. That’s not terribly surprising, because it has been slowing for a number of years. What Dan Diamond over at Politico calls “slowth.” It increased 3.9 percent to $3.5 trillion, while the year before it had grown 4.8 percent. Another way to look at it: Americans spend $10,739 per person on health care. HuffPost had a nice analysis:

HuffPost: America’s Health Care Spending Keeps Rising Really Slowly. Seriously.

Read the full report here.

The New York Times attempts to explain why enrollment in Obamacare is down. Any number of things could factor in, like higher employment at places that offer health insurance, no mandate forcing people to enroll or people signing up for Medicaid. Further study may present an answer.

The New York Times: Why Is Obamacare Enrollment Down?

The Friday Breeze

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This week, the Annals of Internal Medicine retracted a 2009 paper by Brian Wasinick, the now-discredited Cornell University researcher. The half-baked paper had claimed that the recipes in the more modern editions of the classic “Joy of Cooking” cookbook had more calories than the original. The always enlightening Retraction Watch website, which tracks medical and scientific research that has been undermined, has the whole story of the delightful sleuthing that led to the debunking. (And while you are on the site, peruse all the other Wasinick papers on food research that have been rescinded.)

Retraction Watch: The Joy of Cooking, Vindicated: Journal Retracts Two More Brian Wansink Papers

One of my favorite writers on health care makes an often overlooked point about health insurance: Its goal ought to be the same as other insurance, that is, to safeguard the financial health of beneficiaries. And Aaron Carroll, who is also a professor of pediatrics at Indiana University School of Medicine, says that several studies show it does exactly that.

Read the whole piece for yourself:

JAMA Forum: Medicaid as a Safeguard for Financial Health

As a bonus on this topic, here is an academic paper surfacing this week on the effects of the Affordable Care Act on mortgage delinquencies. Spoiler: The value of fewer evictions and foreclosures is substantial compared to the cost of the ACA subsidies.

The Effect of Health Insurance on Home Payment Delinquency: Evidence from ACA Marketplace Subsidies

The Commonwealth Fund, a foundation that seeks to improve health care,  wanted to know how the Affordable Care Act affected the uninsured and the insured. As its chart that summarizes its findings issued this week shows, there was considerable movement. The main finding was the number of young adults who switched from Medicaid to individual insurance — and the other direction as well.

The Commonwealth Fund: Who Entered and Exited the Individual Health Insurance Market Before and After the Affordable Care Act?

Commonwealth also conducted a forum on “Being Seriously Ill in America,” which dealt with the financial consequences.

Forbes likes to compile those “30 under 30” lists. (I’ve long wished someone would go back and look at one of those lists from 20 or 25 years ago to see how the luminaries are doing now.) Anyway, it put together a list of people in the health care industry. Most are on the cusp of 30, which might tell you something about how hard it is to get a fast start in the industry. But one person on the honor roll is only 18. In case you were wondering, because I was, Elizabeth Holmes, the founder of the ill-fated Theranos, was on a different “40 under 40” Forbes list in 2014. We hope these folks fare better.

Forbes: 30 Under 30 in Healthcare

This article ran a while back, but I got a kick out of it and just had to mention it. It looked at prehistoric health care. Researchers will never know how much Stone Age dwellers bored their hut mates with discussions of a paleo diet, but they are learning how they performed medical procedures that appeared to have worked.

The Atlantic: Neanderthals Suffered a Lot of Traumatic Injuries. So How Did They Live So Long?

May you survive another whirlwind week of health care news, until next Friday’s breezy recap.

More Than Half Of California Nursing Homes Balk At Stricter Staffing Rules

Kaiser Health News:Marketplace - December 07, 2018

More than half of California’s nursing homes are asking to be exempted from new state regulations that would require them to spend more time directly caring for their patients.

The state’s new staffing requirements for nursing homes, quietly passed in last year’s budget bill, seem universally unpopular. Patient advocates say the new regulations don’t go far enough and that residents remain at risk in poorly staffed homes. Nursing home operators say they can’t hire enough staff to comply.

Under the new rules, which took effect in July but haven’t yet been enforced, skilled nursing facilities must provide at least 3.5 hours of direct care per resident per day, up from 3.2 hours of care previously. That care can range from inserting a feeding tube to changing an adult diaper or helping residents with eating and bathing.

The California Department of Public Health, which oversees nursing homes, is expected to announce in late January which — if any — facilities it will exempt from the new regulations. But some patient advocates don’t like the nursing homes’ balking.

Look Up Nursing Homes In California

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“We’re appalled by the waiver system. It’s sending the worst possible message to California nursing homes that it’s OK to staff at levels that endanger residents,” said Mike Connors of California Advocates for Nursing Home Reform, a consumer advocacy group.

(Check to see which California nursing homes have applied for workforce shortage waivers here and here.)

Researchers have strongly linked more nursing staff with better care, with some experts recommending from 3.8 to 4.1 hours of care per patient per day as a bare minimum for quality nursing home care. Having enough staff helps prevent falls, pressure sores and other problems that can land fragile seniors in the hospital.

A recent Kaiser Health News investigation found that for years nursing homes nationwide overstated staffing to the federal government. Now, nursing homes are required to report actual payroll records to remain eligible for Medicare and Medicaid payments.

During the first three months of 2018, 58 percent of California’s skilled nursing facilities averaged at least 3.5 hours of patient care a day, according to a Kaiser Health News analysis of payroll records submitted to the federal government. That rose to 76 percent when including nursing homes where administrators also were counted.

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California is one of only a few states that set their own minimum requirements for nursing home staffing. Most states abide by federal government standards requiring skilled nursing facilities that receive money from Medicare or Medicaid to have enough staff to meet residents’ needs, said Robyn Grant, director of public policy and advocacy for National Consumer Voice for Quality Long-Term Care, an advocacy group.

Illinois requires nursing homes to provide a minimum of 3.8 hours of care per patient a day and the District of Columbia requires 4.1 hours, Grant said. Maine and Oklahoma take a different approach, establishing staff-to-patient ratios, rather than hours of care, for nursing homes.

Nursing home officials and their lobbyists say it’s tough to find qualified nurses and assistants in California’s robust economy, and they bemoan what they describe as inadequate reimbursement from Medicare and Medicaid. They also have criticized a provision of the new requirements that 2.4 of the 3.5 hours of patient care must be provided by a certified nursing assistant, rather than another nursing professional.

Nursing homes need flexibility because “not every patient is the same, not every diagnosis is the same,” said Matt Robinson, legislative affairs director for the California Association of Health Facilities, an industry group. “We’re not opposed to more staff. But we want quality staff. We want to make sure there’s a sustainable workforce to meet that mandate, otherwise it’s just an empty mandate.”

Robinson said facilities are applying for waivers on a “good-faith basis.” If waiver requests aren’t granted, he said, nursing homes may reduce their beds or even shut down.

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In Los Angeles, the 300-bed Kei-Ai Los Angeles Healthcare Center has applied for an exemption citing a “workforce shortage.” But Cynthia Sakaki Sirlin, whose 86-year-old father, a veteran of the Korean War, lives there says, “I think it’s wrong.”

“I don’t know why they’re doing this. They need more nursing staff to improve patient care, not less, the research shows that. So why are they asking for a waiver? Why is the state allowing them? That just rewards owners who are not willing to staff the homes,” Sakaki Sirlin said.

Sakaki Sirlin, a nurse practitioner and a representative of Kei-Ai’s family council, said that since the formerly nonprofit nursing home was purchased by a real estate developer in 2016, she has noticed more staff turnover. She worries that her father, a wheelchair user who can’t feed himself, won’t get the care he needs. Representatives from Kei-Ai did not respond to a request for comment.

There are nearly 100,000 certified nursing assistants in California, according to federal labor data. Patient advocates say many CNAs choose not to work for nursing homes because of the comparatively low pay and tough workload.

“If they paid them better, they’d have plenty of staff,” even in remote parts of California, said Suzi Fregeau, long-term care program manager in Humboldt and Del Norte counties. The mean hourly wage for certified nursing assistants in California was $16.13 in 2017, according to federal labor data.

Some of the California homes seeking exemptions have been repeatedly cited by the state’s Department of Public Health for inadequate staffing that led to patient harm. Among them are homes owned by Shlomo Rechnitz, who reportedly controls 1 in 14 nursing home beds in California. He has faced numerous federal and state probes of understaffing and quality problems at his homes.

The CEO of one of Rechnitz’s nursing home management companies said in a written statement that several homes submitted “patient needs” waiver requests on their own with data provided by the company. “All of these facilities prioritize the needs of their patients above all else and these facilities have a stellar history of complying with applicable staffing requirements,” said David Silver, CEO of Rockport Administrative Services LLC.

“What we’re seeing is that the facilities that already are understaffed — the facilities for which we do get complaints — are the ones asking for waivers,” said Joe Rodrigues, the state’s long-term care ombudsman. “We’re not supportive of those requests.”

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

HHS Announces CHPL Data Challenge Winners

HHS Gov News - December 06, 2018

The U.S. Department of Health and Humans Services’ Office of the National Coordinator for Health Information Technology (ONC) today announced the winners of the Certified Health IT Product List (CHPL) Data Challenge.

Winning submissions to the challenge all showed how the CHPL data could be used and applied across the healthcare industry and could help provide users of the CHPL different ways to use the information.  This information on the CHPL contains information about health information technology (health IT) systems and specifically details data on certified health IT. As of May 2018, the CHPL has more than 300 listings for active 2015 Edition certified health IT products.

“This challenge shows that there is more to the CHPL data than meets the eye. It is great to the see the creativity and ingenuity each participant put into their submissions,” said Steve Posnack, executive director, office of technology, ONC.

The winning submissions provided information about how their analyses were conducted, how their software works, and the application’s impact towards advancing the use of CHPL data. The winning submissions are:

ResearchAE. ResearchAE is a search engine for health and health IT datasets. They produced an application mapping CHPL’s API with meaningful use attestation, the Medicare Provider Enrollment, Chain, and Ownership System (PECOS), and National Plan and Provider Enumeration System (NPPES) data. Users are able to perform cross-sectional searches allowing users to analyze who is using ONC certified health IT and how it’s being used. The award for the winning submission is $20,000.

Shiro Labs. Shiro Labs created a web-based application that combines Medicare Quality Payment Program (QPP) data with CHPL data, allowing providers to better understand how ONC certified health IT complements their QPP reporting requirements. The runner up submission is awarded $10,000.

Darena Solutions. Darena Solutions, developers of MyMipsScore (https://www.mymipsscore.com/), created a mobile application, called CheckEHR. The interactive program allows users to view where certified health IT modules have the certification criteria to meet several healthcare delivery and quality goals, such as care coordination and patient engagement. The runner up submission is awarded $10,000.

One honorable mention was also awarded to Tom Nguyen who designed a search engine tool embedded in the Google Chrome systems he calls the CHPL Chrome Extension. This enhancement provides users with on screen notifications for ONC certified health IT, features to recommend new site searches, and allows them to quickly navigate to the CHPL’s listings.

View the winner presentations and demonstrations at Certified Health IT Product List (CHPL) Data Challenge.

Secretary Azar Announces Senior Advisor for Drug Pricing Reform

HHS Gov News - December 06, 2018

On Thursday, Health and Human Services Secretary Alex Azar announced that John O’Brien, will serve as Senior Advisor to the Secretary for Drug Pricing Reform. Previously, O’Brien had served as Advisor to the Secretary for health reform and drug pricing, as well as Deputy Assistant Secretary for Health Policy within the Office of the Assistant Secretary for Planning and Evaluation.

“John O’Brien has already been an integral leader in HHS’s efforts to bring down the high price of prescription drugs,” said Secretary Azar. “As a senior advisor, he will carry forward the legacy of our departed colleague Dan Best and build on the substantial progress that has already been made. John will continue to play an important role in our overall efforts to deliver Americans better, more affordable healthcare.”

Prior to his time at HHS, O’Brien, a pharmacist, was Vice President of Public Policy for CareFirst BlueCross BlueShield. He has also worked at the Centers for Medicare & Medicaid Services, the Notre Dame of Maryland University College of Pharmacy, and various pharmacy and pharmaceutical organizations.

O’Brien has a master’s degree in public health from the Johns Hopkins Bloomberg School of Public Health, a doctor of pharmacy degree from Nova Southeastern University, and studied pharmacy and public policy at the University of Florida.

Podcast: KHN’s ‘What The Health?’ Is Health Spending The Next Big Political Issue?

Kaiser Health News:HealthReform - December 06, 2018
Julie Rovner

Kaiser Health News

@jrovner

Read Julie's Stories Rebecca Adams

CQ Roll Call

@RebeccaAdamsDC

Read Rebecca's Stories Joanne Kenen

Politico

@JoanneKenen

Read Joanne's Stories Margot Sanger-Katz

The New York Times

@sangerkatz

Read Margot's Stories

The Republican-led Congress was unable to repeal the Affordable Care Act in 2017, but the Trump administration continues to implement elements of the failed GOP bill using executive authority. The latest change would make it easier for states to waive some major parts of the health law, including allowing subsidies for people to buy insurance plans that don’t meet all the law’s requirements.

Meanwhile, in states that are transitioning from Republican governors to Democrats, GOP legislators are using lame-duck sessions to try to scale back executive power and lock in some key health changes, such as work requirements for Medicaid enrollees.

And there is growing evidence that even with health insurance, patients who use significant amounts of medical care are increasingly unable to afford their share.

This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Joanne Kenen of Politico and Rebecca Adams of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Trump administration outlined last week what type of waivers it is willing to consider for states’ ACA markets. Options include changes in who gets premium subsidies and how much they receive, and making short-term insurance plans that are not as comprehensive as current marketplace plans eligible for subsidies.
  • Any changes are likely to end up in court, as have most of the revisions that the Trump administration has proposed.
  • In Wisconsin and Michigan, Republican legislatures are seeking to restrict what the new Democratic governors can do to change GOP policies on Medicaid and challenges to the ACA.
  • A recent study has highlighted that health problems can create financial hardships well beyond the illness. For example, loss of income from a debilitating illness can make paying other bills very difficult and sometimes other family members must give up their jobs to be caregivers.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: NBC News.com’s “FDA Approves Drug for Dogs Scared by Noise,” by Maggie Fox

Margot Sanger-Katz: The Washington Post’s “An Experiment Requiring Work for Food Stamps Is a Trump Administration Model,” by Amy Goldstein

Joanne Kenen: The Atlantic’s “The CRISPR Baby Scandal Gets Worse by the Day,” by Ed Yong

Rebecca Adams: The New York Times’ “Why Hospitals Should Let You Sleep,” by Austin Frakt

Also mentioned in this episode:

The New York Times: “1,495 Americans Describe the Financial Reality of Being Really Sick,” by Margot Sanger Katz

Kaiser Health News: “No Cash, No Heart. Transplant Centers Require Proof of Payment,” by JoNel Aleccia

CBS News: “High Cost Has Many Diabetics Cutting Back on Insulin,” by Serena Gordon

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcher or Google Play.

Seniors Steamed Over Cuts To SilverSneakers Fitness Program

Kaiser Health News:Insurance - December 06, 2018
Navigating Aging

Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.

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John Garland Graves was taken aback when he walked into his McKinleyville, Calif., gym in October and learned that his SilverSneakers membership was being canceled.

Since 2014, Graves, 69, has enjoyed free access to the gym through SilverSneakers, the nation’s best-known fitness program for seniors. He was disturbed by the news, as are many other people who have recently learned they’re losing this benefit.

A controversial business decision by UnitedHealthcare, the nation’s largest health insurance carrier, is causing the disruption. As of Jan. 1, the company is dropping SilverSneakers — an optional benefit — for 1.2 million customers with Medicare Advantage plans in 11 states (California, Connecticut, Illinois, Indiana, Iowa, Kansas, Missouri, Nebraska, Nevada, North Carolina and Utah) as well as 1.3 million customers with Medicare supplemental (Medigap) insurance in nine states (Arizona, California, Connecticut, Illinois, Indiana, North Carolina, Ohio, Utah and Wisconsin).

Graves, who works out four to five days a week and has a UnitedHealthcare Medigap policy, decided to seek coverage elsewhere after the company raised his policy’s rates and eliminated SilverSneakers in California. He has signed up for a new policy with Blue Shield of California.

Starting next year, UnitedHealthcare will offer members a package of fitness and wellness benefits instead of paying to use SilverSneakers — a move that will give the company more control over its benefits and may save it money.

Seniors with UnitedHealthcare Medicare supplemental policies will get 50 percent off memberships at thousands of gyms across the country, telephone access to wellness coaches and access to various online communities and health-related resources. Those with Medicare Advantage policies can join Renew Active, UnitedHealthcare’s fitness program, with a network of more than 7,000 sites, at no cost, and qualify for an evaluation from a personal trainer and an online brain-training program, among other services.

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Steve Warner, who leads UnitedHealthcare’s Medicare Advantage product team, explained the company’s move by noting that over 90 percent of policyholders who are eligible for SilverSneakers “never step foot in a gym” or use this benefit.

UnitedHealthcare wants to reach “a broader portion of our membership” with a “wider variety of fitness resources,” he said, noting that the company’s shift away from SilverSneakers began last year and has accelerated this year. (Altogether, more than 5 million customers have been affected. But the company is making market-by-market decisions, and nearly 675,000 UnitedHealthcare Medigap policyholders and 1.9 million UnitedHealthcare Medicare Advantage plan members will retain access to SilverSneakers in 2019.)

“I think it’s a smart move,” said Connie Holt, an independent broker with Goldsum Insurance Solutions of Pleasant Hill, Calif.

But many of the company’s customers aren’t happy that SilverSneakers, which offers group classes tailored to seniors in addition to gym access at 15,000 sites, is disappearing. And confusion about alternatives is widespread.

It’s one of the “top topics” that seniors have been raising over the past few months when they call Ohio’s Senior Health Insurance Information Program, said Chris Reeg, the OSHIIP program director.
This story also ran on NPR. This story can be republished for free (details).
Michael Chanak Jr., 69, of Wadsworth, Ohio, had problems getting through to UnitedHealthcare’s customer relations department several times when he called with questions — a common complaint. “The way this is being implemented is a train wreck,” said Chanak, who has a UnitedHealthcare Medicare supplemental policy and spends an hour every day exercising at his gym.

People are “extremely upset,” wrote Margaret Lee of Arroyo Grande, Calif., in an email. “That’s about the only topic of conversation at my water exercise class!”

AARP has also become a target of anger because it endorses UnitedHealthcare’s Medigap and Medicare Advantage insurance policies — an arrangement that yields substantial royalties for the organization.

In an email, Mark Bagley, a spokesman for the organization, said, “UHC [UnitedHealthcare], not AARP, operates these plans and determines the benefits.”

“I will be dropping my AARP membership when it is time to renew,” wrote Shelley Holbrook, 67, of Yorba Linda, Calif., a UnitedHealthcare Medigap policyholder, in an email exchange about the loss of SilverSneakers. “I am a Parkinson’s patient who has been prescribed this type of exercise program,” she explained. “This program is under the guidance of certified instructors that make sure the exercise routines are performed correctly. … An ordinary gym membership provides no instruction on how to use the equipment safely for seniors.”

“A health coach is not what I need,” Holbrook continued. “I have used the health coaches before, and have found them to be totally worthless.”

For policyholders like Holbrook, the situation is complicated by another factor: Federal laws don’t ensure that seniors can switch Medicare supplemental insurance plans without undergoing new medical evaluations after an initial “guarantee issue” period. (This period occurs six months following a person’s enrollment in Medicare. Changes are allowed under a few specific circumstances and by laws in a few states.)

If seniors can meet medical standards, they’ll find SilverSneakers available from other insurance operators. In 2019, Tivity Health is offering the program through more than 65 health plans covering more than 15 million older adults and introducing a new digital platform that emphasizes its social benefits: SilverSneakers Connect.

“There are people we’ve learned who are alone but don’t want to go to the gym,” and the new platform can help them connect with each other as well as activities in their communities, said Donato Tramuto, Tivity Health’s CEO. Recent research suggests that SilverSneakers may help reduce isolation and loneliness in seniors who go to classes and form new relationships, he noted.

Whether UnitedHealthcare’s health plans will be less appealing because of the shift away from SilverSneakers is yet to be determined. Several years ago, Humana, another giant insurer, also began reducing the number of plans that offered SilverSneakers, but it faced a backlash from members and sales representatives. “The membership perceives [SilverSneakers] as a valuable benefit despite the fact that not everyone uses it,” said George Renaudin, Humana’s senior vice president of Medicare.

Humana subsequently reversed course and is now making SilverSneakers broadly available to about 3.5 million Medicare Advantage and Medigap policyholders.

Ray Liss, who retired seven years ago, just changed over from UnitedHealthcare to a Humana Medicare supplemental policy with his wife. The loss of SilverSneakers precipitated the switch, which has an unexpected benefit: The couple will save almost $60 a month next year on their new policy.

In an email, Liss, who declined to say where he lives, was philosophical about the value of exploring his options, writing, “I was pretty mad at the time, but it worked out for the best.”

We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

No Cash, No Heart. Transplant Centers Require Proof Of Payment.

Kaiser Health News:Marketplace - December 05, 2018

When Patrick Mannion heard about the Michigan woman denied a heart transplant because she couldn’t afford the anti-rejection drugs, he knew what she was up against.

On social media posts of a letter that went viral last month, Hedda Martin, 60, of Grand Rapids, was informed that she was not a candidate for a heart transplant because of her finances. It recommended “a fundraising effort of $10,000.”

Patrick Mannion received a double-lung transplant in May 2017 after being diagnosed with idiopathic pulmonary fibrosis, a progressive, life-threatening lung disease. Through a transplant fundraising organization, HelpHopeLive, he has raised nearly $115,000, twice the original goal to help pay expenses that insurance didn’t cover, including copays for costly anti-rejection drugs. (Courtesy of Patrick Mannion)

Two years ago, Mannion, of Oxford, Conn., learned he needed a double-lung transplant after contracting idiopathic pulmonary fibrosis, a progressive, fatal disease. From the start, hospital officials told him to set aside $30,000 in a separate bank account to cover the costs.

Mannion, 59, who received his new lungs in May 2017, reflected: “Here you are, you need a heart — that’s a tough road for any person,” he said. “And then for that person to have to be a fundraiser?”

Martin’s case sparked outrage over a transplant system that links access to a lifesaving treatment to finances. But requiring proof of payment for organ transplants and post-operative care is common, transplant experts say.

“It happens every day,” said Arthur Caplan, a bioethicist at the New York University Langone Medical Center. “You get what I call a ‘wallet biopsy.’”

Virtually all of the nation’s more than 250 transplant centers, which refer patients to a single national registry, require patients to verify how they will cover bills that can total $400,000 for a kidney transplant or $1.3 million for a heart, plus monthly costs that average $2,500 for anti-rejection drugs that must be taken for life, Caplan said. Coverage for the drugs is more scattershot than for the operation itself, even though transplanted organs will not last without the medicine.

For Martin, the social media attention helped. Within days, she had raised more than $30,000 through a GoFundMe account, and officials at Spectrum Health confirmed she was added to the transplant waiting list.

In a statement, officials there defended their position, saying that financial resources, along with physical health and social well-being, are among crucial factors to consider.

“The ability to pay for post-transplant care and life-long immunosuppression medications is essential to increase the likelihood of a successful transplant and longevity of the transplant recipient,” officials wrote.

In the most pragmatic light, that makes sense. More than 114,000 people are waiting for organs in the U.S. and fewer than 35,000 organs were transplanted last year, according to the United Network for Organ Sharing, or UNOS. Transplant centers want to make sure donated organs aren’t wasted.

(Story continues below.)

“If you’re receiving a lifesaving organ, you have to be able to afford it,” said Kelly Green, executive director of HelpHopeLive, the Pennsylvania organization that has helped Mannion.

His friends and family have rallied, flocking to fundraisers that ranged from hair salon cut-a-thons to golf tournaments, raising nearly $115,000 so far for transplant-related care.

Allowing financial factors to determine who gets a spot on the waiting list strikes many as unfair, Caplan said.

“It may be a source of anger, because when we’re looking for organs, we don’t like to think that they go to the rich,” he said. “In reality, it’s largely true.”

Nearly half of the patients waiting for organs in the U.S. have private health insurance, UNOS data show. The rest are largely covered by the government, including Medicaid, the federal program for the disabled and poor, and Medicare.

Medicare also covers kidney transplants for all patients with end-stage renal disease. But, there’s a catch. While the cost of a kidney transplant is covered for people younger than 65, the program halts payment for anti-rejection drugs after 36 months. That leaves many patients facing sudden bills, said Tonya Saffer, vice president of health policy for the National Kidney Foundation.

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Legislation that would extend Medicare coverage for those drugs has been stalled for years.

For Alex Reed, 28, of Pittsburgh, who received a kidney transplant three years ago, coverage for the dozen medications he takes ended Nov. 30. His mother, Bobbie Reed, 62, has been scrambling for a solution.

“We can’t pick up those costs,” said Reed, whose family runs an independent insurance firm. “It would be at least $3,000 or $4,000 a month.”

Prices for the drugs, which include powerful medications that prevent the body from rejecting the organs, have been falling in recent years as more generic versions have come to market, Saffer said.

But “the cost can still be hard on the budget,” she added.

It’s been a struggle for decades to get transplants and associated expenses covered by insurance, said Dr. Maryl Johnson, a heart failure and transplant cardiologist at the University of Wisconsin School of Medicine and Public Health.

“It’s unusual that there’s 100 percent coverage for everything,” said Johnson, a leader in the field for 30 years.

GoFundMe efforts have become a popular way for sick people to raise money. About a third of the campaigns on the site target medical needs, the company said.

But when patients need to raise money, they should use fundraising organizations specifically aimed at those costs, transplant experts say, including HelpHopeLive, the National Foundation for Transplants and the American Transplant Foundation.

There’s no guarantee funds generated through such general sites such as GoFundMe will be used for the intended purpose. In addition, the money likely will be regarded as taxable income that could jeopardize other resources, said Michelle Gilchrist, president and chief executive for the National Foundation for Transplants.

Her group, which helps about 4,000 patients a year, has raised $82 million for transplant costs since 1983, she said. Such efforts usually involve a huge public-relations push. Still, 20 percent of the patients who turn to NFT each year fail to raise the needed funds, Gilchrist said.

In those cases, the patients don’t get the organs they need. “My concern is that health care should be accessible for everyone,” she said, adding: “Ten thousand dollars is a lot to someone who doesn’t have it.”

Every transplant center in the U.S. has a team of social workers and financial coordinators who help patients negotiate the gaps in their care. Lara Tushla, a licensed clinical social worker with the Rush University transplant program in Chicago, monitors about 2,000 transplant patients. She urges potential patients to think realistically about the costs they’ll face.

“The pharmacy will not hand over a bag full of pills without a bag full of money,” she said. “They will not bill you. They want the copays before they give you the medication.”

KHN’s coverage of prescription drug development, costs and pricing is supported in part by the Laura and John Arnold Foundation.

Without Obamacare Penalty, Think It’ll Be Nice To Drop Your Plan? Better Think Twice

Kaiser Health News:HealthReform - December 05, 2018

Dana Farrell’s car insurance is due. So is her homeowner’s insurance — plus her property taxes.

It’s also time to re-up her health coverage. But that’s where Farrell, a 54-year-old former social worker, is drawing the line.

“I’ve been retired two years and my savings is gone. I’m at my wit’s end,” says the Murrieta, Calif., resident.

So Farrell plans — reluctantly — to drop her health coverage next year because the Affordable Care Act tax penalty for not having insurance is going away.

That penalty — which can reach thousands of dollars annually — was a key reason that Farrell, who considers herself healthy, kept her coverage.

Now, “why do it?” she wonders. “I don’t have any major health issues and I’ve got a lot of bills that just popped up. I can’t afford to pay it anymore.”

Farrell is among millions of people likely to dump their health insurance because of a provision in last year’s Republican tax bill that repeals the Obamacare tax penalty, starting in 2019, by zeroing out the fines.

The Congressional Budget Office estimated that the repeal of the penalty would move 4 million people to drop their health insurance next year — or not buy it in the first place — and 13 million in 2027.

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Some people who hated Obamacare from the start will drop their coverage as a political statement. For people like Farrell, it’s simply an issue of affordability.

Since Farrell started buying her own insurance through the open market in 2016, her monthly premium has swelled by about $200, she says, and she bears the entire cost of her premium because she doesn’t qualify for federal ACA tax credits. Next year, she says, her premium would have jumped to about $600 a month.

Instead, she plans to pay cash for her doctor visits at about $80 a pop, and for any medications she might use — all the while praying that she doesn’t get into a car accident or have a medical emergency.

“It’s a situation that a lot of people find themselves in,” says Miranda Dietz, lead author of a new study that projects how ending the penalty will affect California.

Dana Farrell

People like Farrell whose incomes are too high to qualify for tax credits are especially vulnerable, says Dietz, a research and policy associate at the University of California-Berkeley Center for Labor Research and Education. They must pay the entire premium themselves.

Premiums, even for a bronze plan with a deductible of more than $6,000, are enormous in some cases, she says. “The state’s done a great job of implementing the ACA,” she says, “but there are still Californians who just find insurance out of reach.”

Up to 450,000 more Californians may be uninsured in 2020 as a result of the penalty ending, and up to 790,000 more by 2023, boosting the state’s uninsurance rate for residents under 65 to 12.9 percent, according to the study. The individual market would suffer the biggest losses.

Covered California, the state health insurance exchange, predicts that enrollment in the individual market — both on and off the exchange — could drop by 12 percent next year, says agency spokesman James Scullary.

Exchange officials also blame the end of the penalty for a 3.5 percent average increase in premiums, because the departure of some healthy people from the market will lead to a sicker and costlier insurance pool.

Health insurance can be difficult to afford, but going without it is a “bad gamble,” Scullary says. Keep in mind: More than 22,000 Covered California enrollees broke, dislocated or sprained arms or shoulders in 2017, and 50,000 enrollees were either diagnosed with — or treated for — cancer, he explains.

“We know that none of those people began the year thinking, ‘This is when I’m going to break my arm,’ or ‘This is the year I get cancer,’” he says.

If you’re considering dropping your plan and risking the devastating financial consequences of an unexpected medical expense, check first to see if you can lower your premium.

“A big mistake for people is to look at the notice they get for their current health insurance and see it’s going up a lot and then throw up their hands and decide they’re going to go without,” says Donna Rosato, a New York-based editor at Consumer Reports who covers health care cost issues.

“Before you do that, look at other options.”

The most important thing to do is seek free help from a certified insurance agent or enrollment “navigator.” You can find local options by clicking on the “Find Help” tab on Covered California’s website, http://www.CoveredCA.com.

Next, see if you can qualify for more financial aid. For instance, if your income is close to the threshold to qualify for tax credits through Covered California or another Obamacare insurance exchange — about $48,500 for an individual or $100,000 for a family of four this year — check with a financial professional about adjusting it, Rosato suggests. You might be able to contribute to an IRA, 401(k) or health savings account to lower the total, she says.

Beyond that, be flexible and willing to switch plans, she advises. Consider different coverage levels, both on and off health insurance exchanges. If you’re in a silver-level plan (the second-lowest tier), you might save money by purchasing a less expensive bronze-level plan that has higher out-of-pocket costs but would protect you in case of a medical emergency.

This year, Farrell got a clean bill of health from her doctor after a round of tests. She’s nervous about being without coverage next year, but feels she doesn’t have a choice.

“It’s going to be the first time in my life I’m not going to have insurance,” she says.

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

New HHS Checklist Helps First Responders Ensure Language Access and Effective Communication During Emergencies

HHS Gov News - December 04, 2018

The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR) has unveiled a plain language checklist to help first responders provide services to individuals with limited English proficiency and individuals with disabilities during emergency response and recovery efforts. 

According to the U.S. Census Bureau, at least 350 languages are spoken across the country.  In addition, approximately 15 percent of adults report some trouble hearing, 8.1 million people are visually impaired, and 32 million adults are illiterate.  Federal civil rights laws, including Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973 mandate that federally funded emergency response and recovery services must be accessible to people with limited English proficiency and people with disabilities. 

“Recent natural disasters have demonstrated the importance of ensuring accessibility to health and human services for everyone living in the United States, including people who are limited English proficient or with disabilities in need of interpretation and translation services,” said Director of the HHS Office for Civil Rights and Chair of the HHS Language Access Steering Committee, Roger Severino. “I commend our first responders for keeping Americans safe, and hope that this tool will assist them and the diverse communities they serve in emergency situations.”

The checklist resulted from efforts of the HHS Language Access Steering Committee, led by the HHS Office for Civil Rights.  It includes recommendations, specific action steps, and resources to assist first responders in providing on-the-ground language assistance and communicating effectively in disasters.  It complements an emergency preparedness checklist HHS released in 2016, and is an additional tool for responders and local partners who serve community members limited English proficiency or disabilities.  Practical tips range from how to identify language needs in a disaster-impacted community to effectively utilizing interpreters. 

In a recent blog, experts in the HHS Office of the Assistant Secretary for Preparedness and Response and OCR explore how public health, healthcare, and emergency response organizations can use the new checklist to enhance language access and create disaster health communications to better assist impacted communities. 

Visit the OCR website to view the checklist and read essential information on how federal civil rights laws and HIPAA laws apply in emergencies.

Florida contractor physicians’ group shares protected health information with unknown vendor without a business associate agreement

HHS Gov News - December 04, 2018

Advanced Care Hospitalists PL (ACH) has agreed to pay $500,000 to the Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (HHS) and to adopt a substantial corrective action plan to settle potential violations of the Health Insurance Portability and Accountability Act (HIPAA) Privacy and Security Rules. ACH provides contracted internal medicine physicians to hospitals and nursing homes in west central Florida.  ACH provided services to more than 20,000 patients annually and employed between 39 and 46 individuals during the relevant timeframe.

Between November 2011 and June 2012, ACH engaged the services of an individual that represented himself to be a representative of a Florida-based company named Doctor’s First Choice Billings, Inc. (First Choice). The individual provided medical billing services to ACH using First Choice’s name and website, but allegedly without any knowledge or permission of First Choice’s owner. 

On February 11, 2014, a local hospital notified ACH that patient information was viewable on the First Choice website, including name, date of birth and social security number.  In response, ACH was able to identify at least 400 affected individuals and asked First Choice to remove the protected health information from its website.  ACH filed a breach notification report with OCR on April 11, 2014, stating that 400 individuals were affected; however, after further investigation, ACH filed a supplemental breach report stating that an additional 8,855 patients could have been affected.

OCR’s investigation revealed that ACH never entered into a business associate agreement with the individual providing medical billing services to ACH, as required by HIPAA and failed to adopt any policy requiring business associate agreements until April 2014.  Although ACH had been in operation since 2005, it had not conducted a risk analysis or implemented security measures or any other written HIPAA policies or procedures before 2014.  The HIPAA Rules require entities to perform an accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity, and availability of an entity’s electronic protected health information.

“This case is especially troubling because the practice allowed the names and social security numbers of thousands of its patients to be exposed on the internet after it failed to follow basic security requirements under HIPAA,” said OCR Director Roger Severino.

In addition to the monetary settlement, ACH will undertake a robust corrective action plan that includes the adoption of business associate agreements, a complete enterprise-wide risk analysis, and comprehensive policies and procedures to comply with the HIPAA Rules. 

The resolution agreement and corrective action plan may be found on the OCR website at http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/agreements/ACH/index.html

HHS Secretary Azar Declares Public Health Emergency in Alaska Due to Earthquake Damage

HHS Gov News - December 04, 2018

Following President Trump’s lead in declaring an emergency in Alaska after the Nov. 30 earthquake, Health and Human Services (HHS) Secretary Alex Azar today declared a public health emergency in Alaska. The declaration triggers other legal authorities that give the HHS Centers for Medicare & Medicaid Services (CMS) beneficiaries, their healthcare providers and suppliers greater flexibility in meeting emergency health needs in the aftermath of the earthquake.

“HHS is working closely with state health authorities and monitoring the needs of healthcare facilities,” Secretary Azar said. “This declaration will help ensure that Americans who were affected by the earthquake and rely on Medicare, Medicaid, and the Children’s Health Insurance Program have continuous access to the care as the area recovers.”

With the declaration in place, CMS can use legal authority provided under the Social Security Act section 1135 to grant waivers that will aid healthcare facilities in providing uninterrupted care and services for the elderly and people with disabilities living in long-term care facilities. The waivers also support the Alaska Medicaid Agency’s administrative processes, ensuring that Medicaid funds continue to flow despite the temporary closure of the agency’s offices.

As part of the federal response to the earthquake, the Substance Abuse and Mental Health Services Administration’s Disaster Distress Helpline is available to assist residents in the impacted areas in coping with the stress of the disaster. The Disaster Distress Helpline provides immediate 24/7, 365-days-a-year crisis counseling and support to people experiencing emotional distress related to natural or human-caused disasters. This toll-free, multilingual, and confidential crisis support service is available to all residents in the United States and its territories. Stress, anxiety, and other depression-like symptoms are common reactions in disasters. Call 1-800-985-5990 toll free or text TalkWithUs to 66746 to connect with a trained crisis counselor.

Additionally, the HHS Office for Civil Rights (OCR) has guidance available for territory agencies and community organizations to help ensure equal access to emergency services and the appropriate sharing of medical information during emergencies, including how federal civil rights laws apply in an emergency and how HIPAA laws apply in an emergency. OCR also provides a HIPAA Disclosures for Emergency Preparedness Decision Tool.

In declaring the public health emergency in Alaska and authorizing flexibilities for CMS beneficiaries, Secretary Azar acted under his authority in the Public Health Service Act and Social Security Act. These actions and flexibilities are retroactive to Nov. 30, 2018.

Reforming America’s Healthcare System Through Choice and Competition

HHS Gov News - December 04, 2018

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

U.S. DEPARTMENT OF THE TREASURY

U.S. DEPARTMENT OF LABOR

The President
The White House
Washington, DC 20500

Dear Mr. President:

On October 12, 2017, through Executive Order 13813, you directed the Administration, to the extent consistent with the law, to facilitate the development and operation of a health care system that provides high-quality care at affordable prices for the American people by promoting choice and competition.  We are pleased to provide you with this report, prepared by the Department of Health and Human Services (HHS) in collaboration with the Departments of the Treasury and Labor, the Federal Trade Commission, and several offices within the White House.  This report describes the influence of state and federal laws, regulations, guidance, and polices on choice and competition in health care markets and identifies actions that states or the Federal Government could take to develop a better functioning health care market.

As health care spending continues to rise, Americans are not receiving the commensurate benefit of living longer, healthier lives.  Health care bills are too complex, choices are too restrained, and insurance premiums and out-of-pocket costs are climbing faster than wages and tax revenue.  Health care markets could work more efficiently and Americans could receive more effective, high-value care if we remove and revise certain federal and state regulations and policies that inhibit choice and competition.

The Administration has already taken significant steps to improve health care markets by addressing government rules and programs that limit choice and competition and produce higher prices for the American people.  Among the most significant actions:

  • In October 2018, the Departments of HHS, the Treasury, and Labor proposed a rule that would provide employers with significant new flexibility in how they fund health coverage through Health Reimbursement Arrangements (HRAs).  If finalized, this flexibility would empower individuals to take greater control over what health insurance benefits they receive.  The Treasury estimates that more than 10 million employees would benefit from this change within the next decade.
  • In August 2018, the Departments of HHS, the Treasury, and Labor finalized a rule to expand Americans’ ability to purchase short-term, limited-duration insurance—coverage for which premiums are generally much more affordable than Affordable Care Act (ACA) plans.  Millions of Americans, including middle-class families who cannot afford ACA plans, will benefit from the additional choice and competition resulting from this reform.
  • In June 2018, the Labor Department finalized a rule to expand the ability of employers, including sole proprietors without common law employees, to join together and offer health coverage through Association Health Plans.  For many employers, employees, and their families, these employee benefit plans will offer greater flexibility and more affordable benefits.
  • In May 2018, HHS released “American Patients First,” a historic blueprint for actions to bring down the high price of drugs and reduce out-of-pocket costs. HHS has taken a number of actions that were laid out in the blueprint to empower consumers and promote competition, building on accomplishments such as the Food and Drug Administration’s record pace of generic drug approvals.
  • In December 2017, you signed the Tax Cuts and Jobs Act, which eliminated the onerous and regressive individual mandate tax penalty.  This freed Americans to finance their health care needs in the way that works best for them.
  • The Administration has enacted reforms to deliver better value through choice and competition in the Medicare program, including payment changes that establish site-neutral payment policies for a number of Medicare services, a simplification of how physicians are paid for evaluation and management visits, new consumer-transparency measures, and flexibility for insurers to offer more options and benefits in Medicare Advantage.
  • HHS and the Treasury have issued revised guidance under section 1332 of the ACA that significantly expands the ability of states to reform their individual insurance markets while ensuring that people with pre-existing conditions are protected.

While the Administration has made much progress in reforming the American health care system significant obstacles remain.  This report identifies four areas where federal and state rules inhibit adequate choice and competition and offers recommendations for improving public policy in each of these four areas.

Health Care Workforce and Labor Markets:  Reduced competition among clinicians leads to higher prices for health care services, reduces choice, and negatively impacts overall health care quality and the efficient allocation of resources.  Government policies have suppressed competition by reducing the available supply of providers and restricting the range of services that they can offer.  This report recommends policies that will broaden providers’ scope of practice while improving workforce mobility, including telehealth, to encourage innovation and to allow providers more easily to meet patients’ needs.  The report also recommends that the Federal Government streamline funding for graduate medical education to allocate taxpayer dollars efficiently and to address physician supply shortages.

Health Care Provider Markets:  State policies that restrict entry into provider markets can stifle innovative and more cost-effective ways to provide care while limiting choice and competition.  These policies have resulted in higher health care prices and fewer incentives for providers to improve quality.  This report makes several recommendations to promote choice and competition in provider markets, including state action to repeal or scale back Certificate of Need laws and encourage the development of value-based payment models that offer flexibility and risk-based incentives for providers, especially without unduly burdening small or rural practices.

Health Care Insurance Markets:  Government mandates often reduce choice and competition in insurance markets and increase overall premiums.  In the individual and small group markets, many consumers face limited coverage options that cover services they do not want or need and that drive up premiums, while others have been completely priced out of the market.  Regulations that limit coverage choices should be changed so that states have more flexibility to develop policies that account for diverse consumer preferences.  This report recommends scaling back government mandates, eliminating barriers to competition, and allowing consumers maximum opportunity to purchase health insurance that meets their needs.

Consumer-Driven Health Care:  Our health care system’s excessive reliance on third-party payment insulates consumers from the true price of health care and offers them little incentive to search for low-cost, high-quality care.  When federal and state health policies give consumers more control over their health care dollars, they can use that power to demand greater value.  For example, promoting and expanding Health Saving Accounts (HSAs) and HRAs would expand personal control and introduce more consumer power into the health care market.  The report recommends expanding access to HSAs, implementing reference pricing where appropriate, and developing price and quality transparency initiatives to ensure that newly empowered health care consumers can make well-informed decisions about their care.

We know the United States health care system too often fails to deliver the value it should.  This report identifies barriers on the federal and state levels to market competition that stifle innovation, lead to higher prices, and do not incentivize improvements in quality.  It recommends policies that will foster a health care system that delivers high-quality care at affordable prices through greater choice, competition, and consumer-directed health care spending.  While American consumers and many providers would significantly benefit from the reforms laid out in this report, there are entrenched and powerful special interest groups that reap large profits from the status quo.  It will take bold leadership to confront these incumbents and implement reforms, but under your direction, we are convinced we can significantly improve the American health care system.

We look forward to working with you as we create a more effective and efficient health care market that provides information for consumers as they make health care decisions for their families, rewards quality, encourages innovation, and delivers care at prices the American people can afford.

Sincerely,

Alex M. Azar II
Secretary
U.S. Department of Health and Human Services

Steven T. Mnuchin
Secretary
U.S. Department of the Treasury

Alexander Acosta
Secretary
U.S. Department of Labor

Download the report

People using assistive technology may not be able to fully access information in this file. For assistance, contact Roman Burleson at digital@hhs.gov.

Medicare Cuts Payments To Nursing Homes Whose Patients Keep Ending Up In Hospital

Kaiser Health News:Marketplace - December 03, 2018

The federal government has taken a new step to reduce avoidable hospital readmissions of nursing home patients by lowering a year’s worth of payments to nearly 11,000 nursing homes. It gave bonuses to nearly 4,000 others.

These financial incentives, determined by each home’s readmission rates, significantly expand Medicare’s effort to pay medical providers based on the quality of care instead of just the number or condition of their patients. Until now, Medicare limited these kinds of incentives mostly to hospitals, which have gotten used to facing financial repercussions if too many of their patients are readmitted, suffer infections or other injuries, or die.

Bonuses And Penalties For Nursing Homes


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“To some nursing homes, it could mean a significant amount of money,” said Thomas Martin, director of post-acute care analytics at CarePort Health, which works for both hospitals and nursing homes. “A lot are operating on very small margins.”

The new Medicare program is altering a year’s worth of payments to 14,959 skilled nursing facilities based on how often their residents ended up back in hospitals within 30 days of leaving. Hospitalizations of nursing home residents, while decreasing in recent years, remain a problem, with nearly 11 percent of patients in 2016 being sent to hospitals for conditions that might have been averted with better medical oversight.

These bonuses and penalties are also intended to discourage nursing homes from discharging patients too quickly — something that is financially tempting as Medicare fully covers only the first 20 days of a stay and generally stops paying anything after 100 days.

Over this fiscal year, which began Oct. 1 and goes through the end of September 2019, the best-performing homes will receive 1.6 percent more for each Medicare patient than they would have otherwise. The worst-performing homes will lose nearly 2 percent of each payment. The others will fall in between. (You can see the scores for individual nursing facilities here.)

For-profit nursing homes, which make up two-thirds of the nation’s facilities, face deeper cuts on average than do nonprofit and government-owned homes, a Kaiser Health News analysis of the data found.

In Arkansas, Louisiana and Mississippi, 85 percent of homes will lose money, the analysis found. More than half in Alaska, Hawaii and Washington state will get bonuses.

Overall, 10,976 nursing homes will be penalized, 3,983 will get bonuses, and the remainder will not experience any change in payment, the KHN analysis found.

(Story continues below.)

Medicare is lowering payments to 12 of the 15 nursing homes run by Otterbein SeniorLife, an Ohio faith-based nonprofit. Pamela Richmond, Otterbein’s chief strategy officer, said most of its readmissions occurred with patients after they went home, not while they were in the facilities. Otterbein anticipates losing $99,000 over the year.

“We’re super disappointed,” Richmond said about the penalties. She said Otterbein is starting to follow up with former patients or the home health agencies that send nurses and aides to their houses to care for them. If there are signs of trouble, Otterbein will try to arrange care or bring patients back to the nursing home if necessary.

“This really puts the emphasis on us to go out and coordinate better care after they leave,” Richmond said.

Congress created the Skilled Nursing Facility Value-Based Purchasing Program incentives in the 2014 Protecting Access to Medicare Act. In assigning bonuses and penalties, Medicare judged each facility’s performances in two ways: how its hospitalization rates in calendar year 2017 compared with other facilities and how much those rates changed from calendar year 2015.

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Facilities received scores of 0 to 100 for their performances and 0 to 90 for their improvements, and the higher of the two scores was used to determine their overall score. Facilities were then ranked highest to lowest.

Medicare is not measuring readmission rates of patients who are insured through private Medicare Advantage plans, even though in some regions the majority of Medicare beneficiaries rely on those to afford their care.

Through the incentives, Medicare will redistribute $316 million from poorer-performing to better-performing nursing homes. Medicare expects it will keep another $211 million that it would have otherwise paid to nursing homes if the program did not exist.

The new payments augment other pressures nursing homes face from Medicare and state Medicaid programs to lower readmissions to hospitals.

“Skilled facilities have been working toward this and knew it was coming,” said Nicole Fallon, vice president of health policy and integrated services at LeadingAge, an association of nonprofit providers of aging services.

The American Health Care Association, a trade group of nursing homes, said in a statement that it had supported the program and was gratified to see that more than a quarter of facilities received bonuses.

While most researchers believe that readmissions can be reduced, some consumer advocates fear that nursing homes will be reluctant to admit very infirm residents or to re-hospitalize patients even when they need medical care.

“It may end up causing great pain to residents who actually need to be hospitalized,” said Patricia McGinnis, executive director of California Advocates for Nursing Home Reform, which is based in San Francisco.

Fallon said Medicare eventually may penalize homes that have done all they can to prevent return trips to the hospital. But because of the program’s design by Congress, Medicare still will need to punish large numbers of homes.

“There’s always going to be winners and losers, even if you make good progress,” Fallon said. “At what point have we achieved all we can achieve?”

Meanwhile, Medicare is looking to expand financial incentives to other kinds of providers. Since 2016, it has been testing quality bonuses and penalties for home health agencies in nine states. Richmond, the nursing home executive, applauded that kind of expansion.

‘There’s a whole bunch of people in this chain” of institutions caring for patients at different stages, she said, “and we all need to be working in a common direction.”

KHN data editor Elizabeth Lucas contributed to this report.

KHN’s coverage related to aging and improving care of older adults is supported in part by The John A. Hartford Foundation.

Readers And Tweeters Demand Action On Gun Violence, Mental Health Care Options

Kaiser Health News:Insurance - December 03, 2018

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.

Behind The Bloodshed

In 2018 alone, there have been more than 300 mass shootings in the United States (“Gun Control Vs. Mental Health Care: Debate After Mass Shootings Obscures Murky Reality,” Nov. 19). That’s almost equivalent to the number of days in the year. When so many shootings occur in such a short period of time, it’s clear there’s at least one common reason behind them. But many people assume there’s only one reason and are divided over what that reason is. Some people say the underlying problem is gun control. Others say the underlying problem is mental health. Statistics prove that mental health is definitely one of the problems. In that case, why are the people, including the people in power, who blame mental health as the issue so hesitant to make reforms to the health care system and the way mental health is handled? They could at least attempt to fix the problem. Gun violence is becoming a prevalent issue in American society, one that simply can’t keep being ignored. We need to stop debating and start doing something to protect the lives of innocent civilians. How many more deaths will it take before people in power take action?

— Srija Ponna, San Jose, Calif.

An Untenable Solution On Mental Health Care?

So the family becomes the untrained caregiver (“With Hospitalization Losing Favor, Judges Order Outpatient Mental Health Treatment,” Nov. 13). From experience, it’s impossible to find good, timely assistance for a person with bipolar disorder. The patient can just disappear for days, wreak havoc in the community, hurt themselves or others. By the time the patient has reached the point of mandatory outpatient treatment, a lot of damage has probably already occurred and both the patient and family are desperate. How can they be certain a person with bipolar disorder is properly taking medicine? Such patients often shun their medicine, especially when experiencing mania. This is an unrealistic option for treatment of some mental health disorders. I think it places the patient, family and community in danger of further damage.

— Glenn McGahee, Fort Lauderdale, Fla.

More research couldn’t hurt, tweeted Daphne Chakurian of California:

Interesting concept. This needs research to evaluate cost to benefit for patients vs. some other model of care that is desperately needed.

— Daphne Chakurian (@DaphneChakurian) November 14, 2018

— Daphne Chakurian, Roseville, Calif.

Lofty Praise

Excellent piece about air quality (“Smoke-Filled Snapshot: California Wildfire Generates Dangerous Air Quality For Millions,” Nov. 21). Once auto emissions plummeted, I never thought about any planetary forces except earthquakes. This raises awareness exactly as everything you do should. ;-) Thanks.

Lucy Johns MPH, San Francisco

Casting A Wide Net On Fish Oil Study

NPR and ABC covered these studies, and included positive results at the end of the articles. KHN didn’t even mention benefits (“Fish Oil And Vitamin D Pills No Guard Against Cancer Or Serious Heart Trouble,” Nov. 10). UPI reported an “overwhelming benefit of fish oil supplements for black participants, who had a 77 percent reduction in their risk of heart attack.” I think this shows a lack of thorough reporting on KHN’s part.

— Joy Thomas, Foster City, Calif.

Mixed messages about the study were prevalent online, one tweeter noted:

Everything is conflicting these days. Earlier today I heard the opposite

— Matt Jade (@matthewhochstra) November 12, 2018

— Matt Jade, New York City

Echoing an expert in the KHN story, that’s what happens when researchers slice data into smaller segments, with fewer patients in each group. The results can prove unreliable when zeroing in on specific outcomes such as heart attacks among blacks.

Have A Whole Look At Medical Records, Holes And All

Not likely to be revealed in a medical record: any complication from treatment that results in harm or death to a patient and is not owned up to by the physician/surgeon or hospital (“In Days Of Data Galore, Patients Have Trouble Getting Own Medical Records,” Oct. 25). Thus, a medical record can be used as documentary evidence of not reporting an adverse medical or surgical event that should have been reported to the Centers for Medicare & Medicaid or other patient safety organizations. In my opinion, that is the primary reason for providers’ reluctance to furnish medical records related to a harmed/killed patient.

— Lars Aanning, Yankton, S.D.

Quality not quantity is what matters when collecting health data, one tweeter observed:

Large part of the failure of EHRs to improve care is “data galore”. Too much clinically irrelevant data for reimbursement not care. Ten pages of documentation from ER visit often contain little or no clinically important data. Need good data not galore.

— Edward T Chory (@DrEdMDBFD) October 25, 2018

— Dr. Edward Chory, Lancaster, Pa.

It’s not as if solutions don’t exist; the challenge is executing them, reader Michael Millenson suggested on Twitter.

"In Days Of Data Galore, Patients Have Trouble Getting Own Medical Records." All true, but CMS proposals to make it easier drew little support, except those of us @S4PM. industry opposed. https://t.co/vxF7yMIeII @khnews @judith_graham

— Michael Millenson (@MLMillenson) October 26, 2018

— Michael Millenson, Chicago

Monster Bills Only Scratch The Surface

This is the tip of the iceberg (Bill of the Month’s “That’s A Lot Of Scratch: The $48,329 Allergy Test,” Oct. 29). Medicine has become a medical-Industrial complex ever as powerful as the military-industrial complex that President Dwight Eisenhower warned us about. Hospitals all over the country use this same “scam” to maximize their profits. Recent schemes by private individuals involve the billing for medical laboratory studies done by private labs, but billed through rural hospitals such that a drug screen urine test costs $2,500. Other hospitals bill insurance companies up to $10,000 for an outpatient sleep study, for which Medicare allows $180.

Two hospitals here in San Antonio bill $8,000-$10,000 for inpatient sleep studies for which Medicare allows $950. A local, private cardiac catheterization laboratory bills $99,999 as a facility fee for a cardiac pacemaker change that literally takes 30-45 minutes — and they manage to collect $75,000.

Most private emergency room facilities bill out-of-network for thousands of dollars for routine visits. Medicare patients who go to these facilities are billed outside of Medicare and held responsible for all charges. Almost all ER facilities “upcode” to a higher level of care to maximize profit. Emergency rooms historically have been operated at a loss. They are now among the most profitable centers for hospitals.

This is a national scandal and costs the insurance companies and American patients hundreds of millions of dollars a year. No one does this to Medicare, because they might go to jail. But outside of Medicare, it is a civil matter.

— Dr. Michael Wooley, San Antonio

Exorbitant bills could be avoided altogether if prices for medical treatment were standardized and publicized, David Vuk argued on Twitter.

STOP STOP STOP letting insurance companies be the middle man!! Standard prices for just about everything can and should be posted nationwide. Doctors should not have to charge insurance companies $400 to accept $150!

— David Vuk (@doesnotcompute0) October 29, 2018

— David Vuk, Eastsound, Wash.

And some aspects of the convoluted health care system may simply be above a patient’s pay grade.

Why is a dermatologist or allergist in a hospital outpatient clinic? Stanford is absolutely 100% aware that this is not patient-friendly. Patients should not be expected to understand provider-based regulations for an encounter like this one.

— Ben Carver (@bencarverclt) October 29, 2018

— Ben Carver, Charlotte, N.C.

Statement from HHS Secretary Alex Azar ahead of World AIDS Day

HHS Gov News - December 01, 2018

HHS Secretary Alex Azar issued the following statement ahead of the 30th anniversary of World AIDS Day:

“The observance of World AIDS Day is an annual reminder of the need to remain vigilant in our efforts to combat the HIV/AIDS pandemic, and also of the potential we have for further progress. Advances in HIV prevention, treatment, and care services have enabled us to significantly reduce the rate of HIV infections and improve the health of those living with HIV. We have seen progress both at home, through initiatives such as the Ryan White HIV/AIDS Program, and abroad, through the success of the U.S. President’s Emergency Plan for AIDS Relief, which marks its 15th anniversary this year. We must also continue our work to remove the stigma that surrounds HIV so that no one is afraid to learn their HIV status, and receive treatment or take steps to prevent infection.

“Bringing federal resources to the battle against infectious diseases such as HIV has been a special focus of my public career, and the Trump administration is strongly committed to achieving the goals of our National HIV/AIDS Strategy. By ensuring access to and the availability of the effective tools we have today, such as pre-exposure prophylaxis (PrEP) and daily antiretrovirals, and strong support for new methods of HIV prevention and treatment that are in the research pipeline, we are optimistic that we can continue our advances toward ending the HIV/AIDS pandemic.”

For more information on HIV, go to HIV.gov

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