The Zika epidemic puts spotlight on women’s health

Congress left for a seven-week summer recess without approving the $1.9 billion President Barack Obama requested in February to combat the virus. Proposals that have flitted around since then include provisions that target abortion and contraception.

In June, the House passed a $1.1 billion bill that stalled in the Senate after Republicans wanted the bill to cut $50 million to organizations like Planned Parenthood to provide family planning and birth control services, which critics say is badly needed in light of the fact that virus can be sexually transmitted.

Last month, a House appropriations committee proposed a funding bill that would have slashed money to the Title X Family Planning Program. In place for nearly 50 years, the federal program funds a network of 4,200 family planning centers that serve more than 4 million low-income patients a year. The program prevents an estimated 1 million unintended pregnancies a year.

Most recently, Republicans angered Democrats by adding a provision to a $1.1 billion take-it-or-leave-it measure that would have slashed funding for Planned Parenthood clinics in Puerto Rico, where the number of infected pregnant women is skyrocketing.

House Speaker Paul Ryan, writing in USA Today on Thursday, did not mention that provision in blaming Democrats for blocking the legislation. Ryan (R-Wis.) instead said the move is “a blatant ploy in an election year.”

Politics are playing a significant role in the states that might be most vulnerable to the Zika virus.

Florida, where more than 320 cases of infection have been found as of Aug. 3, and which last week reported the first case of locally transmitted infection within the continental U.S., banned state funding to providers that receive private funds to perform abortions. That was seen as a move to defund Planned Parenthood in the state. But the move also affected safety-net providers who offer contraception and prenatal health services to low-income women.

Like Florida, many of the states that are at higher risk for a Zika outbreak have policies in place that limit reproductive health and family planning services.

At least 20 southern states also have failed to adopt policies that the National Women’s Law Center says help women make responsible decisions about pregnancy. They include: allowing Medicaid to cover family planning services and abortions, allowing private insurers to cover abortions, and requiring workplace accommodations for pregnant workers.

Florida’s Republican Gov. Rick Scott also rejected Medicaid expansion under the Affordable Care Act. Many of the 19 states that have refused expansion are in warm, Southern climates perfect for breeding the Aedes aegypti mosquitoes that are the primary carriers of Zika. Studies estimated as many as 3 million low-income women could be eligible for Medicaid through expansion. Nearly half of all births in the U.S. are paid for by Medicaid, and is the primary form of health coverage for approximately 70% of low-income, non-elderly women.

Total public funding for reproductive health services rose by 31% between 1980 and 2010, with Medicaid responsible for the vast majority of the increase. Title X program funding actually fell sharply during the time period, down 71% according to their figures.

Researchers say the virus is quickly evolving and that they’re learning new things about it every day, making it even more important to have a stable infrastructure available for the most vulnerable to stand on.

Florida health officials this week told pregnant women who live near or within the active transmission areas to get tested for Zika and consider getting additional ultrasounds.

But it’s not just this election cycle that’s witnessed cuts to family planning and reproductive health programs.

Coleman said a “battle-ready” public health system would be one that has adequate resources for family planning as well as contraceptive services. But funding for such preventive healthcare has been cut for years within states either on financial or ideological grounds.

In the current public health crisis, such a measure has been viewed by some as antithetical toward efforts to limit the number of pregnant mothers infected with the virus, which would increase the possibility that their unborn children develop microcephaly, a defect that causes a baby to be born with a smaller head than normal size.

But the problem with underfunding reproductive health care services is not exclusive to Medicaid. According to a July report by the National Women’s Law Center, despite the ACA requiring health insurers to cover the 100% of the cost of birth control, some plans still call for women to pay out-of-pocket costs in violation of the law.

Such costs can serve as barriers to access to birth control for some women, said Janel George, director of Federal Reproductive Rights and Health at NWLC, which are only one of a number of efforts over the years that have played a part in restricting reproductive health services.

“I think years of imposing barriers has negatively impacted and limited a lot of women’s access to care,” George said. “This crisis, I think, is highlighting some of those access issues and some of those barriers, but they are barriers that have been present for years.”


Medicare Advantage payment rates for 2017 will rise by 1.35%

Baseline Medicare Advantage payment rates for 2017 will rise by 1.35% on average, an early win for health insurance companies in what is the final Medicare rate battle of the Obama administration.

When factoring in the risk coding tendencies, the average change in Medicare Advantage insurers’ revenue will climb 3.55% next year, according to a CMS release posted late Friday. The proposal is a major shift from last February, when initial benchmark rates were cut by an average of 0.95% before factoring in risk score trends.

In addition to pay bumps, several major policies are embedded within the CMS’ advance rate notice, including changes that will help insurers with many low-income seniors, known as dual-eligibles because they qualify for Medicare and Medicaid. The CMS included changes to the Medicare Advantage risk-adjustment model and quality ratings system that will, in essence, boost taxpayer funding for plans that enroll higher amounts of poor seniors.

The Affordable Care Act phased in cuts to the program’s benchmark rates over six years, and 2017 will be the last year of those payment reductions. Previously, the government heavily overpaid Medicare Advantage plans, and the ACA sought to bring the capitated payments in line with traditional Medicare spending.

Insurers warned those cuts would drastically lower enrollment, but those concerns never came to pass. More than 18 million people, a third of all Medicare beneficiaries, are enrolled in a Medicare Advantage plan as of this month. That’sa sizable increase from the roughly 11 million seniors who had a Medicare Advantage plan before the ACA took effect.

Yet, despite the final ACA-mandated cuts, average payments will remain positive for 2017, according to the CMS. The amounts will vary for each health plan, but many industry observers believe 2017 is “the best rate environment we’ve seen in years,” said John Gorman, a consultant for Medicare Advantage insurers and a former CMS official.

Medicare Advantage plans received roughly $170 billion in 2015. The CMS pays Medicare Advantage insurers a monthly amount for each member, based partly on risk scores. The median monthly capitated payment in 2014 was $754, or about $9,000 per year for the average beneficiary, according to CMS data. Insurers are salivating over the growing membership and revenue base because even a small margin of 2% to 5% reaps billions of dollars in profit for the industry, assuming plans have high quality marks.

The 2017 proposal again makes changes to the program’s risk-adjustment model. Medicare Advantage insurers document the health status of their members by using risk scores that adjust for different demographics and conditions, known as hierarchical condition categories. A higher risk score indicates a person is sicker or has complicated chronic health conditions, which leads to a higher payment.

Walgreens puts hold on more Theranos centers

Walgreens Boots Alliance has placed a temporary hold on expanding Theranos blood-testing centers after an all-day meeting at the startup company’s headquarters in Palo Alto, Calif., the Wall Street Journal reported late Friday.

In a series of recent articles, the Journal alleged that Theranos, whose founder and CEO Elizabeth Holmes developed a proprietary blood-testing technology that requires minimal blood draws, used standard blood draws and another company’s equipment for most of its blood tests.

The newspaper reported that Walgreens officials who attended Thursday’s meeting were unaware that the Food and Drug Administration had conducted surprise inspections of Theranos facilities in August and September until the paper reported it. Holmes told a conference last week that Theranos, whose proprietary technology doesn’t require FDA approval under the Clinical Laboratory Improvements Act because it does its testing in-house, is now seeking agency approval for its test.

“We have to move, as a company, from the lab framework and quality systems to the FDA framework and quality systems,” Holmes told a Wall Street Journal-sponsored conference in Laguna Beach, Calif., last week.

Medicare two-midnight rule

The two-midnight policy has been on the books since Oct. 1, 2013. Currently, Medicare administrative contractors are allowed to audit 10 to 25 short-stay claims per hospital on a prepayment basis. The CMS is calling this a “probe and educate process,” as MACs are supposed to coach hospitals on how to improve short-stay claims.

The heavily criticized Medicare two-midnight rule involving short inpatient stays has technically been in effect for the past year. But providers, regulators and healthcare observers are not sure the rule will hold up in its current makeshift form.

The two-midnight rule entered the healthcare vernacular last year after it was finalized in Medicare’s fiscal 2014 inpatient rule. But enforcement and details of the rule have been far from concrete since then. “It’s just been a lot of change and a lot of confusion for hospitals,” said Regan Tankersley, a healthcare attorney with Hall, Render, Killian, Heath & Lyman.

The two-midnight rule attempts to define a medically necessary Medicare inpatient admission. The rule says when an admitting physician reasonably expects a patient will need a hospital stay that spans at least two midnights, the hospital is eligible for Part A reimbursement. But if a patient stays in a hospital for fewer than two nights, hospitals have to list the encounter as observation and bill Medicare for the lower Part B payment, which also imposes higher cost-sharing on patients. Further, patients under observation care are not eligible for Medicare-covered nursing and rehabilitation services, which require three nights as a hospital inpatient.

Although Medicare’s recovery audit contractors can’t review hospital claims for compliance with the rule until April 2015, the policy appears to be changing behaviors. Community Health Systems, Franklin, Tenn., said it recorded 5,000 fewer admissions in its first quarter this year because of the two-midnight rule. Minneapolis-based Allina Health and the Cleveland Clinic also said in their second-quarter financial statements that the two-midnight rule was partially responsible for lower admissions and increased observations. Observation stays already have been on the rise as hospitals try to avoid preventable readmissions and their associated penalties.

At the very least, the two-midnight policy is forcing hospital systems to closely evaluate how they are treating patients who only need a couple of days in the hospital. “Right now we’re not sure it’s had a systemwide dramatic impact on the bottom line,” said Lydia Jumonville, chief financial officer of SCL Health System in Denver. “But it’s continuing to cause everyone to appropriately manage observation and inpatient stays.”

In light of the rule’s unpopularity, the CMS in Mayasked for public comment on how to improve payments for short stays and create a less rigid structure. It received lots of ideas, but there was no consensus on a new policy, CMS spokesman Alper Ozinal said.

Experts mostly agree the two-midnight rule is unlikely to be scrapped but that it may take a new form with more flexibility. Ted Doolittle, who worked as deputy director of the CMS’ fraud and abuse unit from 2011 to early 2014, said the agency has to find a happy medium from its current “all-or-nothing” payment approach. “Let’s turn it to a ski slope instead of a cliff,” said Doolittle, who now works as an attorney for LeClairRyan.

Congress passes bill to stop cut to Medicare Physicians

WASHINGTON (AP) — With just hours to spare, Congress stepped Monday to finalize legislation to prevent doctors who treat Medicare patients from being hit with a 24 percent cut in their payments from the government.

The Senate’s 64-35 vote sends a measure to delay the cuts for a year to President Barack Obama, who’s expected to quickly sign it. The House passed the measure last week.

The $21 billion measure would stave off a 24 percent cut in Medicare reimbursements to doctors for a year and extend dozens of other expiring health care provisions such as higher payment rates for rural hospitals. The legislation is paid for by cuts to health care providers, but fully half of the cuts won’t kick in for 10 years.

It’s the seventeenth temporary “patch” to a broken payment formula that dates to 1997 and comes after lawmakers failed to reach a deal on financing a permanent fix.

The measure passed the House on Thursday, but only after top leaders in both parties engineered a voice vote when it became clear they were having difficulty mustering the two-thirds vote required to advance it under expedited procedures. Several top Democrats opposed the bill, saying it would take momentum away from the drive to permanently solve the payment formula problem.

There’s widespread agreement on bipartisan legislation to redesign the payment formula that would give doctors 0.5 percent annual fee increases and implement reforms aimed at giving doctors incentives to provide less costly care. But there’s no agreement on how to pay the approximately $140 billion cost of scrapping the old formula.

Senate Finance Committee Chairman Ron Wyden, D-Ore., promised to keep pressing ahead with a long-term solution, proposing to use savings from the troop drawdown in Afghanistan to pay the cost. Republicans and most budget experts say such savings are phony and are demanding at least some of the money to come from cuts to Obama’s Affordable Care Act.

“Paying for this through (war savings) is the mother of all gimmicks,” said Sen. Jeff Sessions, R-Ala.

Groups representing doctors, including the powerful American Medical Association, opposed the legislation because it sets back the effort for a permanent solution.

Six Democrats opposed the measure, including Wyden, while 16 Republicans voted in favor of it.

“We just don’t have the votes right now to fix this problem for good,” said Majority leader Harry Reid, D-Nev., who negotiated the measure with House Speaker John Boehner, R-Ohio. “For the millions of elderly Americans and their doctors this fix is good news. It means the promise of accessible, quality health care to our nation’s seniors is being honored for another year.”

The heavily lobbied measure blends $16 billion to address Medicare physicians’ payments with about $5 billion more for a variety of other expiring health care provisions, like higher Medicare payments to rural hospitals and for ambulance rides in rural areas. Manufacturers of certain drugs to treat kidney disease catch a break, as do dialysis providers and the state of California, which receives increases in Medicare physician fees in 14 counties such as San Diego and Sacramento that are designated as rural and whose doctors therefore receive lower payments than their urban counterparts.

The bill increases spending by $17 billion over the next three years, offsetting the cost with cuts to health care providers. The authors of the bill employed considerable gimmickry to amass the cuts, however, and fully half of them don’t appear for 10 years. For instance, the bill claims $5 billion in savings through a timing shift in Medicare cuts in 2024.

Sen. Tom Coburn, R-Okla., cited the gimmicks as he criticized the legislation in a lacerating floor speech. He said the so-called offsets were phony and that the measure delays a long-sought overhaul of Medicare’s fee-for-service system, which pays doctors according to the number of tests and treatments they perform.

“We are going to put off until tomorrow what we should be doing today,” Coburn said. “It’s a sham. … It’s nothing but gimmicks.”

Other savings come from curbs on payments to hospitals that care for a large share of indigent patients. But those hospitals first get a one-year reprieve from cuts scheduled in 2016.

The measure would give Medicare doctors a 0.5 percent fee increase through the end of the year. It also creates two new mental health grant programs, including $1.1 billion over four years for improvements to community health centers and $60 million over four years for outpatient treatment for people with serious mental illness.

The measure solves the fee schedule problem through next March.

Because of a flawed formula dating to 1997, Medicare doctors are threatened with big fee cuts almost every year. After allowing a 4.8 percent Medicare fee cut to take effect in 2002, Congress has since stepped in 16 times to prevent the cuts.

Obama’s $2 trillion reality by Dr. Barry Chaiken

Dr. Barry P. Chaiken’s article on Obama’s $2 trillion reality as originally published in Wisconsin Technology Network, March 16, 2009.

On March 12th in an OpEd piece for the Wall Street Journal titled “Obama’s $80 Billion Exaggeration”, respected physicians and authors Jerome Groopman, MD and Pamela Hartzband, MD questioned President Obama’s claim that electronic medical records would save $80 billion annually in healthcare costs while improving quality of care. They based their conclusion on the work done by the respected Rand Corporation published in 2005 showing questionable benefits from the implementation of electronic records. Well, I agree with Drs. Groopman and Hartzband questioning the assertions made by the President but not their ultimate conclusion. What my colleagues fail to take into consideration is Obama’s $2 trillion reality – a failing healthcare system that delivers questionable quality of care and inconsistent access while costing our country a significantly higher percentage of GDP than any other developed country in the world.

My focus on this OpEd piece was generated by a colleague from New York, a successful dermatologist, who is using an EMR (electronic medical record) in his clinic and is trying to understand what value such systems provide. In his mind, as similarly presented in the OpEd piece, these EMRs just generate voluminous documentation geared to optimize reimbursement rather than better patient care. In addition, there is no real data supporting the notion that these systems actually improve patient care. My responses to my colleague follow:

How sad this statement is about documentation. Yes, these systems were designed to do the administrative part of medicine, billing, better, with little effort applied by vendors to understand how to obtain better clinical and financial outcomes out of these systems. I sometimes despair that we will never be able to get great benefit from these systems until we solve the reimbursement issue. If the major reason we use these systems is to document care for billing purposes, rather document for care delivery purposes, how can we expect to save money and improve quality? The processes and workflow have to be redesigned with a deep understanding of the capabilities of the systems. The systems are just tools to achieve a particular outcome. For now, it seems that outcome is better billing. We cannot expect to achieve better, less costly clinical outcomes until we set that as a goal for these systems. Right now the driving factor for purchasers is optimizing reimbursement, for without that focus, these systems may generate better outcomes for the patient while failing to deliver an accurate reimbursement to the physician. While working on an implementation of an EMR in a hospital owned clinic in upstate New York I noticed that the problems physicians had using the system were related to getting the documentation right for billing not for patient care. Documenting patient care for patient care sake is relatively easy.

My colleague went on to ask whether these systems would be effective in delivering less expensive, better quality care if the focus of the implementation of the systems was on patient care rather than reimbursement. I responded:

For EMRs to be effective in reducing costs, they need to be implemented so that the focus is on both reducing costs and improving quality, Therefore, the workflows and processes must be modified BEFORE implementation of the systems rather than afterwards. Unfortunately, most organizations try to change processes after implementation and find the task very difficult. Both organizations and vendors have incentives to implement first and reengineer later. Organizations find the task of process and workflow redesign both politically (i.e., impact on physician relations) and organizationally (i.e., need for expertise) demanding. Vendors, particularly those driven by quarterly earnings, cannot book revenue until the install is completed. Therefore, both stakeholders see non-reengineered implementations of EMRs the most acceptable approach. And let’s not forget the entire medical team including the physicians and nurses. For EMRs to be effective, clinicians must consider a role and responsibility change to impact care. Using EMRs to provide care the same way clinicians do using paper records, fails to take advantage of the capabilities of EMRs and delivers little benefit. This is what the Rand studies are measuring, digitization of an inefficient paper process.

My colleague expressed both enthusiasm and concern for the clinical database these EHRs would create. The exciting research benefits allowed for the expansion of personalized medicine as analysis of the collected data could identify specialized treatments for subsets of patients. The concern about these databases reflected their use to identify effective and ineffective treatments. Such discoveries might increase the probability the government or insurers would implement restrictions on the use of these newly identified questionable treatments. Similar concerns are associated with the United Kingdom’s National Institute for Health and Clinical Excellence (NICE), an organization that determines whether the National Health Service covers the costs of a particular treatment, procedure, or drug. NICE was established in 1999 to advise the government, through objective clinical analysis, what care was clinically and cost effective. Although the NICE was established to remove politics from the healthcare funding debate, this has not been totally effective as some treatments were added to the approved list after considerable public pressure on the government. My response:

Although there is concern in the medical establishment that the Obama administration will form an organization similar to NICE that removes patient and physician choice, this fear is unfounded since such organizations already exists. Payors use their own criteria to decide what care is covered and what care is denied payment. The Center for Medicare and Medicaid Services (CMS), already pays for certain care and not others. Formation of a NICE type body will just work to standardize what is covered and what is not across the government and payors. In addition, the criteria will be based on transparent medical knowledge rather than secret guidelines developed by payors. And let us not forget the strong incentives some physicians and institutions have in providing certain types of care irrespective of their value to the patient. The most egregious of these incentives come in the form of royalty payments to research institutions based upon the frequency of use of particular equipment and drugs. This is a continuing problem in healthcare research.

I concluded my comments to my colleague as follows:

My take on what Obama is doing is that he is forcing the issue politically as he knows that pushing it from a purely scientific position would take too long to achieve any change and therefore end in failed healthcare reform. The iron is hot and the time to strike for healthcare reform is now. Obama thinks if we can get EMRs in place now, we can later take the necessary step to change how the EMRs are used to truly deliver quality care and reduce costs. He, as I, expect a tipping point. To reach that tipping point is needed a complete revision of what physicians and other healthcare providers do. But that will take a long time to happen as there are powerful interests in every quarter. Those who will lose if things change will fight that change (i.e., the AMA fighting Medicare and Medicaid in the 1960s) and those who will win are not organized to fight for their share (e.g., primary care physicians, patients). But in the end, there will be change and winners and losers. It is the natural order of things. And with technology, these changes will be disruptive and happen quicker than we expect. So for these reasons and several more, I support the deployment of EMRs.

 

Barry P. Chaiken, MD, MPH, FHIMSS is the chief medical officer of DocsNetwork, Ltd., Conference Chair of the Digital Healthcare Conference and a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare. With more than 20 years of experience in medical research, epidemiology, clinical information technology, and patient safety, Chaiken is board certified in general preventive medicine and public health and is a Fellow and Board Member of HIMSS. As founder of DocsNetwork, Ltd. (EIS Inc.), he has worked on quality improvement studies and clinical investigations for the National Institutes of Health, Framingham Heart Study, and Boston University Medical School. Chaiken also serves as an adjunct assistant professor in the Department of Public Health and Family Medicine at Tufts University School of Medicine. He may be contacted at bchaiken@docsnetwork.com.