Every January, new billing rules and rates go into place for physicians’ services as part of the annual update to Medicare’s Physician Fee Schedule. Dominating DC health policy concerns in this arena are the medical community’s efforts with Congress to address Medicare’s cost-of-living adjuster, known as the “sustainable growth rate” (SGR), which would have lowered 2010 fees across-the-board by 21 percent, if not for a last-minute temporary stay through the end of February. Negotiations with Congress are on-going to provide a long term or multi-year solution—a costly “fix” that I believe is well worth the price to keep physicians in the Medicare program, and seems to have widespread support.

Getting much less attention is a unilateral policy pronouncement made by the Centers for Medicare and Medicaid (CMS) that Medicare will no longer pay specialists a higher rate for consultations—services often provided by specialists like cardiologists and neurologists. Instead, all physician visit services, whether defined as “evaluation and management” (E&M) services or consultations, will be reimbursed at the same E&M rates. (more…)

Healthcare (insurance) reform has passed in the Senate and final negotiations are happening before it moves on to the President’s desk for signature. While the legislation is not perfect – in fact some would say far from perfect – it is a piece of legislation that is very much in keeping with our American philosophy, our constant pursuit of progress and change.

As the late Senator Kennedy’s career on Capitol Hill demonstrated, change is usually incremental, usually negotiated and usually compromised. But at the end of the day, change usually amounts to progress.

I see tremendous progress, too, as I look back on a decade’s worth of work to promote access to affordable quality health care using nurse practitioners in the role as primary care providers, thereby alleviating the burden on a strained primary care system.

We’ve come a long way regionally and nationally. The fact that we as a country are always striving to improve our path is what most invigorates me as a relatively new American. Our pursuit of progress is never ending, but it is what sets us apart from most countries in the world. We know our work is never done. As we enter a new year and decade, we always should remember that what makes us different from most people and countries in the world is that we have the freedom to purse progress and make change.

This health insurance reform bill is not the end all or be all, but it will help make affordable health insurance available to more than 30 million Americans who have been without it. Furthermore, the legislation contains many provisions for others who fall through the cracks and will need additional care and support.

That’s progress for individuals, families and America, as Walt Disney would have said. And not until you take a ride on the Magic Kingdom’s The Wheel of Progress will you truly appreciate how important it can be to take even a small step in the right direction.

Happy New Year! And a toast to a New Decade and our new Pursuits of Progress for individuals, families, and our country.

Healthy New Year everyone!

Like many people I’m starting the year with healthy – and preventive care – intentions. How about you?

That put a few items on my holiday ‘to do’ list:

• Get a pap smear,
• Find H1N1 vaccine,
• Wrestle the results of a recent bone density scan (Dexa) out of the hands of the medical center and into the hands of my physician, and
• Confirm with Morris White, my trainer, that I’d continue workouts.

The pap smear was easy – this time. I’d not been able to get one during my late-summer vacation visit to the doctor because the appointment was two weeks prior to the annual date of the prior test. That required another trip. Holiday downtime was a good time to do that. Check that off the list.

In doing so, I finally found an H1N1 vaccine dose! Getting a seasonal flu shot was easy at www.phillyflushots.com, but even after calling several immunization providers and both of my physicians at least twice monthly since H1N1 became available, checking websites and following news reports of shots at pharmacies – well, no success. Luckily, my doctor had just received a few doses of H1N1 that day of the pap smear. Check that off the list.

Results of a bone density scan months ago had still not shown up at my doctor’s office. Holiday time was a good time to badger for the ‘results,’ though it was hardly worth the trouble. Turns out  my physician is not part of that medical center’s ‘network’ and can’t get detailed results. Only a note: ‘normal.’ Sorry, that’s not good enough. Neither my physician nor I know whether there has been any change in bone mass since prior tests. Sure, the test results might be ‘normal,’ but the measures might also be trending in a direction that means I’m losing bone mass, something we both should know about. No check there, still on my list.

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Think you have maternity coverage? Think again.

Welcome to the first entry of the book I’ll be publishing in 2010 entitled: You gotta laugh: Life in the trenches of the health insurance business. Because I think Disruptive Women readers will find it useful, each month I’ll post an example of a health insurance problem that is so maddening and frustrating that we just gotta laugh at its absurdity.

My goal, however, is to find a way to improve health insurance for beneficiaries and I have some suggestions at the end of this post.

This month’s question: What do you do when you have it in writing from your insurance company that you have maternity coverage — but when you go to use the benefit, the customer service department tells you otherwise?

The situation: When our client, Ms. R, found out a few years ago that she was having a baby she was thrilled. Immediately, she called the insurance company to confirm her pregnancy benefits. Making the call was merely a formality. When she originally purchased the policy, she was single and didn’t opt for the maternity rider. After she got married, she added maternity coverage because she wanted a family.

Indeed, when she called the insurance company, they confirmed she had the insurance she needed. However, after her first OB check-up she received a letter saying she was, in fact, not covered.

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In the midst of furious showdowns on health care reform at town hall meetings, a moment of peace surfaced in Montana when President Obama drew bipartisan applause after calling a mother heroic.  This mother of two had voiced her concern about the Medicaid program she relied on for her child who has multiple chronic conditions.  The president reassured her and went on to discuss how our disease-care system does not proactively manage chronic conditions.

Children and young adults with chronic medical conditions and disabilities (CMCD) need proactive management now and for their entire lives.  Our health care system fails to serve the young people who need it the most.

Children with CMCD are completely dependent on adults for their health care.  Poor health management negatively affects their growth and development, education, and socialization – and drags the entire family down.  As the mother of a young adult with CMCD and the founder of a non-profit created because of our experiences with poor quality health care, I cannot understand why this population is not a major focus of health care reform.

One path to start on is to build on successful programs to create a comprehensive system of care.  Take a look at the 35% of children with CMCD covered by SCHIP/Medicaid. Medicaid provides a specialized set of comprehensive services known as EPSDT, Early Periodic Screening, Diagnosis, and Treatment Program. The current model of care in favor for chronic conditions is the medical home. First conceptualized by the American Academy of Pediatrics for children with CMCD in the 1960s, the medical home has yet to become the standard of care for children with CMCD in Medicaid.  Pairing EPSDT with the medical home would be a step forward in developing a system of care for children covered by Medicaid.    Another step is to expand EPSDT and medical homes to cover the remaining publicly covered children with CMCD enrolled in SCHIP.

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Should managed care sue patients?

We arrive at the dawn of yet-another health reform effort with laws and regulations already in place to protect patients. These arose in past decades when the healer-patient relationship was eroding, presumably at the hands of uncaring clinicians and for-profit medical enterprises.   

The list of those rights was extensive and today’s debates are adding to the mix – guaranteed coverage despite pre-existing conditions comes to mind. The discussion of patient rights has always been politically attractive and I won’t denigrate any one of them. I’m not just writing from a policy perspective, but a personal one as well. I’m a patient, too.

The discussions of patients’ rights, however, has neglected the flip side of rights—responsibilities on the part of patients, and the support that we all need from our communities to be healthy people. Today’s healers are beset with immense responsibilities, yet with few reciprocal rights of their own in their relationships with patients or communities.

As patients, communities and a nation, we all too frequently fail to follow medical advice or practice healthy behaviors, and yet expect that helath care will ‘make it right’ when we become ill or incapacitated.  We smoke, abuse alcohol and drugs, carry guns, drive fast, forget seatbelts, neglect immunizations, shun prenatal care and spread sexually transmitted diseases. We ignore social problems until they create health care consequences—low birth-weight babies, elderly who lack social acceptability, and teens suffering gun-shot wounds. When these risky behaviors result in chronic or high-cost illnesses and disabilities, health-care providers are expected to assure that we get the care we need, insulating us from the cost of our choices by providing whatever we need within a fixed budget. The time has come to broaden all of our health policy and political discussions to encompass the realities that, with rights come responsibilities.

So some questions:

• If managed care has a responsibility to meet all the patients’ needs, do patients have the responsibility to practice healthy lifestyles?
• If patients have the right to sue health-care providers for the failures to meet the patient’s expectations, do health-care providers have a similar right—to sue patients for the costs incurred from their failures to follow medical advice?
• At what point do patients who have rights also become citizens who have responsibilities, particularly as we all—collectively—pay for each other’s health care?
• If the community has a right to call on health-care providers to keep us all productively at work and at school, do communities have a responsibility to do their share as well?
• As the population ages and more health-care costs are attributable to lifestyle, can we afford not to hold patients and communities more responsible for their own health-damaging, cost-increasing behaviors?

What will it take?  Will clinicians, payers and managed care groups be forced to sue patients and communities to get the debates going?

Consider hypertension. (more…)

The following guest post is written by Melinna Giannini, President, CEO, and Founder of ABC Coding Solutions (formerly Alternative Link), who has worked in the health insurance industry since the 1980s. She is one of the nation’s leading experts on contracting, billing, and practice management for nursing and other forms of integrative healthcare. Melinna designed ABC codes to fill gaps in national code sets used for managing healthcare reimbursement and outcomes analysis.

The U.S. healthcare system can no longer rely on medicine as its primary form of healthcare. Our U.S. medical schools cannot increase the physician workforce fast enough to keep pace with population growth and the needs of baby boomers.

The physician workforce decreased from 772,000 doctors to 633,000 doctors since 2000. Significantly, the U.S. population grew by 50 million people since 2000. Care shortages, dramatic cost escalations and more people without insurance require immediate action.

Our nation can immediately increase care and reduce costs by maximizing direct patient access to the 2+ million healthcare professionals who are authorized and available to manage non-acute patient care. Rather than routing patients to physicians for non-acute care, we can route them to non-physicians who are legally authorized to manage care without oversight. This minor change in policy will free physicians to better manage acute care, provide patients with timely care and reduce physician oversight charges.

To make this change in our healthcare delivery model, certain government healthcare policies must be modified. For example, Medicare should eliminate its policy of disallowing direct reimbursement to advance practice nurses.

Non-physicians also need an infrastructure to bill public and private insurers for their services in order to:

• Reduce paperwork burdens and costs for both parties
• Increase the accuracy and speed of communications
• Protect providers and payers from fraudulent billing practices
• Identify effective options to more expensive medical care
• Help create more effective federal and state healthcare policies

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I wanted to let you all know about an excellent opportunity that has been presented to the National Hispanic Medical Association. NHMA has been invited to participate in the development of health care reform legislation for Senators Kennedy and Baucus, Congressmen Waxman, Rangel, and Miller and the Congressional Hispanic Caucus.

Their respective staff will be introducing and distributing their bills starting in June for public comment. We have been asked to submit our recommendations on reforming the system for inclusion into these bills by June 1st; this gives us a narrow window of three weeks or less to prepare a document for submission to congressional staff.

The magnitude of the debate is broad; Congress is asking us for specific strategies that respond to four topics: 1) the expansion of affordable insurance coverage that impacts favorably on Latinos; 2) the expansion of primary care services, integration of preventive medicine and recommended incentives to be responsive to the Latino patient; 3) how do we improve quality via the creation of culturally competent, CLAS, and Patient-Centered Medical Home primary care services; 4) how de we reform medical education to ensure the appropriate future workforce for achieving health care reform?

I invite you and your colleagues to join the NHMA Hispanic Provider Community Forum on Health Care Reform on our portal: www.hispanichealth.info to share your insights and recommendations for health care reform today.

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Nearly 20 years ago, I had the opportunity to spend a summer working with the Congressional Caucus for Women’s Issues. Of course, I was absolutely thrilled when they asked me to support the introduction of the Women’s Health Equity Act. However, as I began to research the subject to prepare the fact sheets and advocacy materials to support the legislation, that excitement quickly turned to dismay.

As a bright-eyed college intern, I was shocked to learn about the underlying race and gender disparities within clinical trials and health research. I felt that same sense of disappointment when I started examining the race and ethnic disparities that remain in our health care delivery system today.

Kaiser Permanente recently ran a series of advertisements that highlighted the fact that despite the fact that our nation spends $2.5 trillion on health care, we leave more than 47 million uninsured (not to mention the 20+ million who are underinsured). Without the type of universal coverage that every other industrialized nation provides, our nation is forcing millions to forego care and get sicker.

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Today, April 28th, is Blog for Fair Pay Day. In recognition of this important day, our guest post by Lisa Codispoti, Senior Counsel for Health and Reproductive Rights, National Women’s Law Center, relates to health care and equal pay.

Between 2000 and 2006, health insurance premiums increased 87.5 percent—4 times more than wages. In addition to the burden of inflated health care costs, women are still paid only 78 cents for every dollar earned by men—with women of color earning even less. In a world where women are earning significantly less than men for comparable work, how can they also afford health care?

Pay inequity for women compounds the issues that already exist with our broken health care system. This is a system that makes unfair practices by insurance companies flourish, such as allowing health to be more expensive for women. For example, women pay higher premiums than men when they try to buy health insurance directly from an insurance company through the individual health insurance market (a practice known as gender rating.) Even worse is that many of these health plans do not cover maternity care or expect women to pay an additional fee (what is called a rider) to gain maternity coverage. Women are then left trying to stretch their already smaller paycheck for a much larger health care bill.

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On April 2, Julie Connelly reported that “Doctors Are Opting Out of Medicare.¹” The article focuses initially on specialists but quickly turns to primary care clinicians as well, noting that 29% of Medicare patients surveyed last year were looking for primary care physicians.

Note to my health reform buddies working towards universal coverage… apparently having insurance coverage is not enough.

It’s a surprise to me that it took so long for this problem to hit the presses. About five years ago I had the opportunity to travel across the country with a small group of medical and employer leaders, facilitating discussions between physician groups and local employers collaborating to improve access, quality and cost dynamics in their local areas. To prepare, I called local physicians to “take their pulse and find out where it hurt.” They hurt plenty.

When we started on the East Coast, physicians said they were worried that “one day they would not be able to take Medicare patients.” Moving westward, by the time we reached Dallas later that year they “no longer accepted Medicare patients.” By the end of the year, in the Pacific Northwest, they did not take new patients aged 60 because “in five years they would be on Medicare.”

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Note: While Disruptive Women in Healthcare is designed as a platform for women to present their ideas and concerns on today’s health issues, we occasionally allow posts from men who we feel will add to the discussion.  This guest post is from Peter Pitts, the President of the Center for Medicine in the Public Interest:

“President Bush leaves office with a health care legacy in bricks and mortar: he has doubled federal financing for community health centers, enabling the creation or expansion of 1,297 clinics in medically underserved areas.”

Says who? The New York Times. (Ergo, it must be true.) The article, “Expansion of Clinics Shapes a Bush Legacy.” All the news that’s fit to print? Well almost. It’s pretty amazing that the Gray Lady opted to leave out any mention of Part D in the President’s legacy. But maybe that article’s on the way.

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The New York Times recently reported on Health Reform Private House Parties. At this particular party, the participants easily sided with the angels: health care is a right, insurance should cover everything and coverage should be available from government and businesses. There, that was easy. Bet they had a nice time.

Partygoers were not asked for solutions and the devil is always in the details, so let’s use my favorite – flu shots.

First, the New York Times reported that party participants quickly agreed that “…health care was a right…” It makes me wonder; if health care is a “right,” what of “responsibility”?

- If I have a “right” to flu shots to help prevent flu disease, do I have a “responsibility” to get them to protect myself, reduce my medical care costs, improve economic productivity and protect others around me?
- If I don’t get the shot, infect others and cause them to be ill, am I responsible for the cost of their care?
- If others I infect miss work, am I responsible for the cost of temporary workers or losses incurred by their employer? Am I responsible to the government for the loss in taxable productivity?
- What if they die as a result of the flu I transmit to them? Am I culpable?

Second, participants also agreed “…that insurance should cover ‘everything,’ not just some services….”
- If a flu shot is covered and I choose not to get one, should I be required to pay for any doctor visits and medicines I need?
- Should my employer have the right to charge me for the temporary help that might need to be hired to replace me on the job?
- Should Uncle Sam have the right to tax me for earnings I would have made if I had been on the job?
- Should the cost of something so reasonably priced be covered for everyone? Really, I mean everyone? Even the wealthy who can well afford the cost?

Third, participants agreed that “…coverage should be readily available from the government, as well as from employers….” They agreed that individuals and businesses should have to pay a “small health care tax” to fund care.
- Who are they kidding, “small health care tax?” Have they looked at cost projections lately?
- And what about non-coverage barriers? Coverage is only one barrier to care. Ask those in rural areas, anyone not fluent in English or medically literate.

And yes, I’m still harping on flu shots. The season is not nearly over and there are plenty of doses left to protect the nation from the $87.1 billion – or more – that flu could cost us this winter.¹

1. Molinari NA, Ortega-Sanchez IR, Messonnier ML. The annual impact of seasonal influenza in the US: Measuring disease burden and costs. Vaccine 2007;25:5086-5087.

Two reports recently released by the Congressional Budget Office, Key Issues in Analyzing Major Health Insurance Proposals, and Budget Options, Volume 1: Health Care, have dominated discussions this week.

Jane Zhang of the WSJ reported:

The Congressional Budget Office analyzed 115 options to change health care, some costly and others that would save the government and consumers some money.
…
Among the findings:

- If no changes occur, CBO says health care spending will rise to 25% of GDP by 2025 from 16% last year.

- If the federal government required all employers with more than 50 workers to provide insurance or pay a penalty, federal revenue would increase by $13 billion in four years and $47 billion over nine years.

- Allowing non-federal workers and companies to buy into the Federal Employees Health Benefits Program would cost the federal government about $2 billion over four years and $6.2 billion over nine years.

Ezra Klein explained the importance of these reports and the impact they could have on healthcare reform plans:

How do we decide how much a government program costs? It’s an essential question. Programs need prices, because the government has to produce a budget. But pricing legislation in advance is impossible… But you still need a number. So Washington operates amidst a tacitly agreed-upon imprecision. What the CBO says, goes. “In this town,” says Henry Aaron, a senior economics fellow at the Brookings Institution, “it’s not infrequent to hear people say it doesn’t make any difference what it really costs. It only matters what CBO says it costs.”

The books that the CBO released this week are essentially a guide to the CBO’s scoring process. They tell congressmen, in advance, how the Number will be built. The Wonk Room and The New York Times are focusing on the equations. But they’re not what’s changed. Rather, the difference is that Congress knows what they’ll be in advance. The scoring process will still be a minefield, but now legislators will have a map. There won’t be a situation analogous to 1994, when the White House was shocked by an unwelcome assumption and their legislation was mortally wounded by a staggering price point. Obama and his allies in Congress, along with Orszag’s help, will be able to build a bill able to survive the scoring process. They can, effectively, decide their own Number.

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Having received the diagnosis of stage 4 pancreatic cancer dad decided that his remaining days should be oriented toward providing him comfort rather than treatment. I had not heard the term (actively dying) before dad was admitted into inpatient hospice. It was a brief stay following his collapse at home. It seemed that he would have preferred and felt safer and more secure to stay longer; perhaps it was the supportive listening and personal care and attention they provided. Or the three meals a day he could have (if only he had an appetite). Or the audiences who came into his room and listened to him conversing fluently in various languages.

But the staff said that he was not yet “actively dying” and there was little (no?) need for him to remain on the inpatient hospice. Yet seeing the sad and fearful look in his eyes, the physician quietly mentioned that perhaps he could remain on the unit one more night. So he stayed another night and then we finalized the plans and arrangements for him to go home with round the clock home health aides.

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