Sunday, July 27, 2014

Health Care in Danger: Deliberate Attacks on Health Care during Armed Conflict

During the past several years the number of armed conflicts has grown. Following the removal of tyrannical leaders multiple organizations both internally and externally have gained power as a result of the power vacuum and withdrawal of American power as a stabilizing leader.

The number of regugees has skyrocked, and health issues become paramount, infectious disease, social strife, malnutrition, and public health. Dealing with any one of these in a challenge in lesser developed nations. Combining these with instability of a central government, destruction of pre-existing health facilities and organization increases morbidity and mortality rates.

Public LibPLOS (Public Library of Science) is an open source platform of peer reviewed articles. This month PLOS focuses on "Health Care in Danger: Deliberate Attacks on Health Care during Armed Conflict"

Citation: The PLOS Medicine Editors (2014) Health Care in Danger: Deliberate Attacks on Health Care during Armed Conflict. PLoS Med 11(6): e1001668. doi:10.1371/journal.pmed.1001668

Since 2001, June 20th has been the day when the world considers the plight of refugees and internally displaced people by commemorating World Refugee Day [1]. This year's theme is a continuation of the “1” campaign, in which the world is asked to take 1 minute to consider the situation for a family forced to flee, many of whom may have just 1 minute to get ready [2]. Keeping with the time theme, the UN High Commissioner for Refugees (UNHCR) estimates that world-wide, one person is forced to flee to become a refugee or internally displaced person every 4.1 seconds [3].

PLOS Medicine supports the importance of research on practical approaches to prevent such attacks, as well as studies that evaluate interventions to improve health care in conflict settings more broadly. Such research is difficult and fraught with “real world” factors, but, as a recent article published in PLOS Medicine argues, disaster health interventions and decision-making can benefit from an evidence-based approach [13]. In this article, Martin Gerdin and colleagues from the initiative Evidence Aid argued that health care decision-making in disaster preparedness and response needs to move towards a reliable and robust evidence base for all interventions being considered in disaster risk reduction, planning, response, and recovery [13].

Deliberate attacks on patients, hospitals, and clinics are atrocious acts. While of course improved data collection on the number and nature of the attacks is important, practical action is also necessary to help improve the health outcomes of people terrorised, harmed, and displaced by such attacks. The PLOS Medicine editors welcome the research, debate, and discussion on how such practical measures can be implemented. Let's hope that next year's World Refugee Day will have more positive news.

To further add to the destruction and chaos of conflict, the past few years have brought mounting concern over the deliberate attacks on health care facilities and health workers, perpetrated to cause maximum damage to the health of populations. In 2011, the International Committee of the Red Cross (ICRC) published a landmark report that documented attacks on health care in 16 countries affected by conflict [7]. As the ICRC says: “Statistics represent only the tip of the iceberg: they do not capture the compounded cost of violence–health-care staff leaving their posts, hospitals running out of supplies, and vaccination campaigns coming to a halt” [7]. These knock-on effects of attacks dramatically limit access to health care for entire communities. Furthermore, such attacks are an insult to the Geneva Conventions, and the international community has responded with several initiatives and activities. For example, the ICRC launched the Health Care in Danger campaign, with the slogan “Violence against health care must end” [8]. And several organizations worldwide have recently joined forces to form the Safeguarding Health in Conflict Coalition, with the aim of promoting respect for international humanitarian and human rights laws for the safety of health facilities, health workers, ambulances, and patients during conflict [9].

With such concerted activity attempting to tackle the egregious acts of attacks on health care, it is disappointing to note the distinct lack of progress in reducing the number of such attacks. A report by Human Rights Watch and the Safeguarding Health in Conflict Coalition, released to coincide with last month's World Health Assembly, catalogued recent examples of attacks on health workers and facilities [12].

The report makes depressing reading and provides explicit examples from 18 countries of attacks on health care, some better known than others. For example, in September 2013 the UN-mandated Independent International Commission on the Syrian Arab Republic stated that Syrian health workers and facilities have been deliberately and systematically targeted [12]. And the report states that since December 2013, South Sudan's conflict has led to widespread attacks on civilians, including in hospitals, and massive destruction of dozens of hospitals and clinics [10]. The report notes that the level of attacks has escalated recently and calls on the global community to recognize attacks targeted against health care as a critical human rights issue [12]. The report also adds to the Bellagio call for action and stresses that more action is urgently needed, including expanding and coordinating research on attacks and on the interference with health care, through in-depth qualitative studies [12].

Citation: The PLOS Medicine Editors (2014) Health Care in Danger: Deliberate Attacks on Health Care during Armed Conflict. PLoS Med 11(6): e1001668. doi:10.1371/journal.pmed.1001668

Tuesday, July 22, 2014

Affordable Care Act---F.U.B.A.R. Supreme Court Throws out Subsidies for Federal Health Benefit Exchanges

Court Deals Setback to Health Care Law

WASHINGTON — A federal appeals court ruled Tuesday that the government could not subsidize health care premiums for people in three dozen states that use the federal insurance exchange, a ruling that could upend President Obama’s health care law.

The 2-to-1 ruling could potentially cut off financial assistance for more than 4.5 million people who were found eligible for subsidized insurance in the federal exchange, or marketplace.

Under the Affordable Care Act, the court said, subsidies are available only to people who obtained insurance through exchanges established by states.

The law “does not authorize the Internal Revenue Service to provide tax credits for insurance purchased on federal exchanges,” said the ruling, by a three-judge panel of the United States Court of Appeals for the District of Columbia Circuit. The law, it said, “plainly makes subsidies available only on exchanges established by states.”

For many people, their share of premiums could increase sharply, making insurance unaffordable

Share Your Experience With the Affordable Care Act

By THE NEW YORK TIMES JULY 9, 2014

Friday, July 18, 2014

Health Care Reform......Do the Number of Enrollees really Matter?

The first five months of this year haven't brought more patients into doctors' offices, despite a large increase in sign-ups during the open enrollment for health insurance exchanges, according to a new report from the Robert Wood Johnson Foundation (RWJF) and athenahealth.

In fact, there was a slight drop in percentage of total visits with new patients compared to the same period last year.

This early finding on the effect of the Affordable Care Act may be misleading. The reasons may be multiple. The argument that ACA will reduce costs by sending more patients to primary (and, in theory, preventative) care may not hold water, either, contends a post on a New York Times' blog post. .0

The RWJF report said the lack of change in patient volume might be caused by newly insured patients who are still unfamiliar with the healthcare system.

Many may have continued to seek care in emergency rooms instead of physician offices, for example, which could be because consumers don't understand how insurance works. A study published in the Journal of Health Economics found that only 14 percent correctly understood four basic insurance concepts--deductibles, copays, co-insurance and out-of-pocket maximums, FierceHealthPayer previously reported.

The Times post makes another point about patients who seek emergency care: "It is true that some people use the emergency room for minor problems. But that lack of access isn't all about insurance. Even for the insured, one of the major reasons people use the emergency room is that it's more convenient. That doesn't change with the ACA."

Another barrier to access:, it's likely taking some consumers with new exchange plans more time to shop for doctors, schedule appointments and see their new doctor, particularly if they have plans with narrow networks that limit provider choices, according to the JWJF report."

There has been an uptick in states with Medicaid expansion plans, although there is no indication that patients with chronic disease are seeing more providers. The rate limiting factor in primary care may be that it is already at capacity and there is no ability, or little to see more patients. In fact many patients often see a specialist who will offer primary care. Networks an managed care attempt to limit this by blocking access to specialists, requiring primary care referrals. In fact insurers often deny a payment if their is no primary care referral. Prmary care doctors may also be 'maxed out' in processing referrals to specialists.

Based on my own experience primary care doctors may spend 10-20% of their day processing referrals, learning new network providers and deleting former providers due to narrow networks, which in turn will increase the patient load on select specialist increasing wait times for appointments. Patients are well advised to learn the specialists in their network to avoid delays and call for direct appointments after the referral is made. Patients are creative, innovative and specialists will 'work around' the system as they have done for many years, leaving te insurers to play with their meaningless paper work

Direct payment and concierge medicine is growing rapidly, and a quick cost comparison between what is called conventional medicine and direct payment reveals suprising and significant cost savings for most patients. Insurers now are relatively safe following rules, and regulations imposed by state insurance commissioins who strictly set standards and scope of care in the na me of cost containment. They would do far better by rejecting state and federal rules.

For the first time providers, patients and insurers are closer together in opposing what has been forced upon us all, by our congress, which passed the affordable care act. In our democracy the people do have power to vote them out of office. President Obama is not the problem although he catalyzed events leading to passage of the ACA.

"These findings indicate that the implementation of the ACA is widening the gap of the total share of Medicaid patients that doctors in expansion vs. non-expansion states are caring for," the report said.

RWJF and athenahealth also determined that there hasn't been a rise in chronic conditions being diagnosed, meaning that so far new consumers aren't sicker than people who have had coverage.

To learn more:
- here's the RWJF/athenahealth statement and report
- read the New York Times post

Study: Consumers don't understand insurance basics
The challenge of keeping exchange members enrolled
Cities to see insured rate, economy grow under Medicaid expansion.

Tuesday, July 15, 2014

SEX, LIES, CMS, HHS AND MEDI-CAL

Number of Medi-Cal Providers Down by 25% in Spring 2014

Tuesday, July 15, 2014

Paul Krugman

Recently Paul Krugman a well known op-editorialist for the New York Times said,

"Obamacare Fails to Fail"

How many Americans know how health reform is going? For that matter, how many people in the news media are following the positive developments?

Nearly 25% fewer doctors participated in Medi-Cal during spring of this year than in the spring of 2013, HealthyCal reports. Medi-Cal is California's Medicaid program.

The drop comes amid a significant increase in Medi-Cal beneficiaries.

Background

Since Medi-Cal was expanded under the Affordable Care Act, more than two million individuals have enrolled in the program, bringing total enrollment to 10.6 million.

Meanwhile, about 600,000 Medi-Cal applications still are pending.

Details of Provider Participation

According to the state Department of Health Care Services, 82,605 doctors were enrolled in Medi-Cal in spring of this year, compared with about 109,000 in spring 2013.

Of participating doctors in May 2014:

43,760 were specialists; and
38,845 were primary care providers (Guzik, HealthyCal, 7/14).

Reasons for Decrease

Providers have noted that Medi-Cal reimbursement rates are among the lowest Medicaid payment rates in the country, and that low rates could cause doctors to stop treating Medi-Cal patients because their overhead costs outstrip reimbursements (California Healthline, 6/23).

However, DHCS spokesperson Anthony Cava said the drop in participating physicians is the result of the agency's efforts to remove providers from the program who have not:

Complied with the program's updated application requirements; or
Billed the program in 12 months or more.

Cava added that the updated application rules "have strengthened the department's ability to deny or terminate providers who do not comply."

Implications for Access to Care

Cava said that the drop in participating physicians "has not resulted in a decrease in access to care."

Further, he said the agency's provider lists do not specify whether physicians are accepting new patients or how many they are accepting. For example, Cava said that while some physicians on the list have treated about 2,000 Medi-Cal patients, others may only treat a couple or none (HealthyCal, 7/14).

Mr Krugman is an authority on economics and a Nobel Prize winner. No one should question his theories or opinions . The problem is that he and others have never had responsibility for individual patients, nor that the health system may sign up all these new consumers, and will fail to deliver...

Empty promises, reassurances, and like Sex, Lies and Videotapes leaves only disappointment and justified anger.

Attribution: NY Times, California Health Care Foundation

Commentary:

Saturday, July 12, 2014

Patient Satisfaction....What is it ? What it is Not

3 Reasons Patient Satisfaction is More Important Than Ever

Social media, insurance coverage and patient experience are main drivers

How to balance patient satisfaction and quality care

"In essence, we want physicians to care about satisfaction, but not too much," Joshua J. Fenton, M.D., MPH, of the University of California, Davis, recently toldMedscape in an interview following up on his team's 2012 widely cited studyindicating that highly satisfied patients had higher hospital admissions, higher drug expenditures and were even 26 percent more likely to die.

The study has garnered both support and criticism during the two years since its publication in the Archives of Internal Medicine. With the opportunity to clear up misunderstandings in how the findings have been interpreted and offer current insights, Fenton made the following points:

In most settings, technical quality of healthcare is invisible to patients, and therefore has a weak relationship with patient satisfaction. "For example, in preventive healthcare, there might be an unadjusted relationship between patient satisfaction and receiving an appropriate cancer screening test," Fenton said, "but when you adjust for patient characteristics and other confounding factors, that relationship is no longer present."
Any incentive, if weighed too heavily, can become perverse, so "excellent" satisfaction at every encounter may not be an effective goal. "When difficult issues are raised, such as a patient's ability to drive, a possible substance abuse issue, or perhaps poor exercise habits, patients may have an affective response that leads to lower satisfaction," he said. "Yet compensation schemes that unduly award maximum satisfaction would discourage these important conversations."
Physicians in the bottom 20^th percentile of satisfaction scores may need communication training. Physicians scoring well below their peers may likely be making "simple communication missteps" that can be easily corrected with the help of a trusted supervisor, colleague or consultant, Fenton said. "On the other hand, if a physician's satisfaction scores are in the middle of the bell curve for his or her peers and this physician is doing his or her best to communicate with respect, empathy, and care, then we have no compelling evidence to force that physician to change," he concluded.

Satisfied patients more likely to die, incur higher costs

In a surprising new study published in the Archives of Internal Medicine, patients who rated themselves as most satisfied with their doctors not only incurred 8.8 percent higher health expenses in a two-year period but were also 26 percent more likely to die shortly thereafter than those who rated themselves as less satisfied. In addition, the analysis of 51,946 patients' surveys revealed that although satisfied patients were less likely to visit emergency departments, they had more inpatient admissions.

More immediately, the takeaway for physicians may be that despite the benefits of patient satisfaction in keeping patients loyal and engaged, it's important that servicenot be confused with medical decision-making. In other words, there is probably no downside to offering convenient hours or streamlining a practice's phone systems, for example, but when it comes to deciding medical treatments, the "customer" is not always right.

"Practicing physicians have learned--from reimbursement systems, the medical liability environment, and clinical performance scorekeepers--that they will be rewarded for excess and penalized if they risk not doing enough," wrote Brenda Sirovich from the Department of Veterans Affairs Medical Center in White River Junction, Vt., in an accompanying invited commentary. "It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."

Tuesday, July 8, 2014

The New Era in Health Care

Californians report roadblocks in new era of health care

By Christopher Cadelago
ccadelago@sacbee.com

Inaccurate provider lists are among the challenges facing customers as many transition from the ranks of the uninsured under the federal health care overhaul. Covered California, the nation’s leading state exchange, alone has signed up 1.4 million people through the Affordable Care Act.

“Health plans often use intentionally vague or confusing contracting practices, which result in consumer confusion and frustration, as physicians often do not know that they are listed as participating in certain network.

Read more here: http://www.sacbee.com/2014/07/08/6539580/californians-report-roadblocks.html#mi_rss=Latest%20News#storylink=cpMore than 1,800 complaints about the process were submitted to state regulators through June 8. Customers have complained that they haven’t received their identification cards and enrollment packets. They’ve said they had trouble navigating narrow networks to find a doctor who will take their coverage.

This is not a new problem, it has been an issue for many years, and the Affordable Care Act has made it much worse. Why? The launch of the Health Benefit Exchanges was premature, contracting with providers was incom0plete. The new ACA policies were unique and require providers to sign new contracts to participate. Among these changes are significant differences in reimbursement rate. Many providers and insurers refused to sign on for Health Benefit Exchanges, waiting to see if the system would function.

The Humboldt-Del Norte County Medical Society reviewed one insurer’s provider lists and reported late last month that just one-third of area doctors were accurately reflected. Many were not seeing patients with that insurance coverage, had moved from the area, or had retired, according to the California Medical Association, of which the society is a subsidiary.

The countywide review came after the medical association surveyed physicians and determined that 80 percent were confused about their participation status. It followed up with a one-page letter to members.

All or some of these issues present challenges to patienits..Caveat Emptor.

Attribution: FierceHealtlhCare

Read more here: http://www.sacbee.com/2014/07/08/6539580/californians-report-roadblocks.html#mi_rss=Latest%20News#storylink=cpy

Thursday, July 3, 2014

Hospital CEOs--Not Doctors--among Medicine's top earners

NYT finds healthcare exec pay eclipses salaries of surgeons and general physicians

By Ilene MacDonald

Healthcare and insurance executives' base pay outstrips physician salaries, according to an analysis for The New York Times by Compdata Surveys.

Hospital CEOs on average earn a base pay of $386,000 and hospital administrators make an average of $237,000, the analysis found. But even though physicians are the most highly trained professionals in the healthcare industry, surgeons earn an average of $306,000 and general doctors make $185,000, according to the Times.

But those salaries don't take into account that top hospital executives earn most of their income from non-salary compensation, according to the article. For example, in 2012, the year he retired, Ronald J. Del Mauro, former president of Barnabas Health in New Jersey, earned a salary of $28,000 but had a total compensation package of $21.7 million.

But the highest earners are top health insurance execs. Aetna CEO Mark T. Bertolini, for instance, earned a salary of $977,000 in 2012 but his total compensation package was more than $36 million.

One of the highest paid execs is Trevor Fetter, CEO of Tenet Healthcare, who earned $22.7 million last year.

"The pay for the top five or 10 executives at insurers is pretty astounding--way more than a highly trained surgeon," Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, told the Times.

Yet research indicates the more CEOs are paid, the worse their performance. "For the high-pay CEOs, with high overconfidence and high tenure, the effects are just crazy," Michael Cooper of the University of Utah's David Eccles School of Business, one of the study authors, told Forbes, noting they return 22 percent worse in shareholder value over three years as compared to their peers.

It's not just the CEOs who oversee the business of healthcare that are on the receiving end of these generous packages. Senior leaders frequently earn high salaries too. "At large hospitals there are senior VPs, VPs of this, that and the other," Cathy Schoen, senior vice president for policy, research and evaluation at the Commonwealth Fund, a New York-based foundation that focuses on healthcare, told the Times. "Each one of them is paid more than before, and more than in any other country."

Doctors aren't pleased about the widening gap, especially given that the administrative costs result in inflated charges for medical services, according to the article. "Most doctors want to do well by their patients," said Abeel A. Mangi, M.D., a cardiothoracic surgeon at the Yale School of Medicine, in the article. "Other constituents, such as device manufacturers, pharmaceutical companies and even hospital administrators, may not necessarily have that perspective."

Last month Hans Rechsteiner, M.D., a surgeon in Wisconsin led a backlash against the prices after he discovered a brief outpatient appendectomy he performed for $1,700 generated a $12,000 hospital bill for the patient.

Although the healthcare industry boasts some of the highest paid professionals in any business, it also has staff that earn the lowest salaries, the Times noted. An emergency medical technician typically earns an annual salary of $27,000, the analysis found, while the average staff nurse receives $61,000 a year.

I don't think many will disagree that overseeing a healthcare institution is an extremely challenging job given the current industry climate. But is it worth $22 million year? That is approximately $60,000 a day.

FierceHealthcare ran a story about CEO compensation trends in 2014, which indicate execs will receive modest pay raises and boards will work to make sure bonuses will be attached to performances measures.

Parkland Health & Hospital System in Dallas announced it will raise the minimum wage from $8.78 to $10.25 an hour next month for approximately 230 lowest-level employees. I suspect those employees are grateful for the extra $1.47 an hour or $58 a week to help pay for a tank of gas, a few groceries or coinsurance for a doctor's visit.

But don't weep for the 60 vice presidents and top executives at Parkland who have $350,000 less for bonuses. The pool of money left in that account is $3 million to $5 million. More than enough to hand out to the C-suite. -

Read additional comments at The View From Here

Wednesday, July 2, 2014

Veterans Administration Debacle.....New or a Chronic Problem

No one should be pleased with the recent publcity regarding the VA hospital situation.

VA officials, Democrats work to offset scandal damage

As Department of Veterans Affairs (VA) hospitals work toward solutions to delayed care, vulnerable Democrats want to mitigate damage from the revelations surrounding the scandal.

The VA administration has taken several steps to fix departmental problems, So far, various agencies conducted several reviews and investigations, including a report from the VA's independent office of inspector general, an internal audit and a broad review of the VA network pointing to a "corrosive culture" in which management retaliated against whistleblowers,

In addition, the VA banned executive bonuses and made several leadership changes; VA head Eric Shinseki resigned in June, and President Barack Obama this week nominated former Proctor & Gamble CEO Bob McDonald to replace him. In the meantime, interim VA Secretary Sloan Gibson reached out to more than 100,000 wait listed veterans to schedule appointments and discuss their healthcare needs, according to the Washington Post. Furthermore, the VA removed seeing patients within 14 days of appointment requests as a goal, a target White House advisor Rob Nabors called said was unrealistic, overly vague and had potentially "incentivized inappropriate actions."

The director of Richard L. Roudebush Veterans Affairs Medical Center in Indianapolis is touting the results of steps the facility took to fix problems, telling visiting members of Congress that patient wait times are down two-thirds,according to the Indianapolis Star. Director Tom Mattice said the 229-bed facility reduced average wait times from 42 days to less than two weeks.

Obama to name former Proctor Gamble CEO as new VA head

Bob McDonald tapped to replace Shinseki as Secretary of Veterans Affairs

The choice of a successor to Gen Sinsheki is a bit out of the 'box' Typically the head of the VA is chosen from a list of military generals with a large amount of experience in military and government organization. Although Bob McDonald graduated from West Point and had a relatively brief career in the military, his most recent success was as head of Proctor and Gamble. His position at P&G (80 billion dollar business) gives him a strong consumer oriented approach to a product.

The VA administrative organization is heavy with ex-military personnel who have a direct path to civil service positions when they retire from their military activity. Their strength may be in organizational and hierarchal decision making, but lacks a patient oriented attitude unless they were in a health care related positon in the military.

The rigidity of the VA does not readily adapt to patient needs, and the prevailng attitude is to squeeze the patient into the system, instead of designing a system to fit the patient.

The change in leadership in this direction indicates that a 'patient centric' approach will mimic the change in other areas of health care.

Long COVID

Long COVID Experts and Advocates Say the Government Is Ignoring 'the Greatest Mass-Disabling Event in Human History' Video of Patient with Long Covid Many of the symptoms are identical to "chronic fatigue syndrome: which was a "wastebasket" term used to identify a constellation of signs and symptoms present in patients with 'Long Covid'. Long Covid is still a constellation of signs and symptoms that scientists are studying. There is strong evidence that it is linked to the immune system and there may be a genetic link for those who develop 'Long Covid" Some think it is related to the activation of the Epstein-Barr virus, once thought to result in "chronic fatigue syndrome". Both Chronic Fatigue Syndrome and Long Covid are enigmatic. However modern science is showing that Long Covid is a real entity proven by tests that were not available at the time of Chronic Fatigue