S.T.

Nov 11 2022

This commentary is by Patrick Flood, former commissioner of the Department of Mental Health and the Department of Disabilities, Aging and Independent Living, and former deputy secretary of the Agency of Human Services. He is now retired and lives in Woodbury. This is one of three commentaries about health care; one was published Nov. 4 and the last will be published Nov. 18.


In her recent commentary, Julie Wasserman described in detail how health care reform efforts in Vermont have failed over the past six years. They have failed chiefly because they have not focused on the right issues and solutions.

Health reform has been a thinly veiled effort to maintain the status quo while tinkering around the edges. Our state’s reform effort has been an initiative led by the hospitals, primarily the UVM Health Network, to protect the hospitals’ funding 💰 and 🦀 dominance of the health care system.

The reality is that Vermont will never achieve rational cost control, universal access and better health for its population until our reform efforts shift dramatically to focus on primary care, prevention and other health-related community services.

It is a well-established fact that most health care systems in Europe guarantee universal access to health care as a right and achieve better health outcomes for much lower cost. What explains the latter? For starters, these health care systems dedicate more resources to primary care and to addressing social issues (like mental health, hunger and homelessness) that create or worsen health problems.

In this country, including Vermont, we do just the opposite. Most of our health care dollars are directed to hospital care and high-cost services, much of which can be avoided with more medical and social intervention at the community level. As Ms. Wasserman pointed out in her commentary, a significant percentage of hospital services in Vermont is avoidable.

There are four things we can do immediately to avoid unnecessary hospital treatment and, thus, bring down the cost of health care.

First, expand and strengthen primary care services and remove financial barriers, like high deductibles, which prevent people from accessing it. Everyone in health care knows that primary care is foundational to a high-quality, affordable and equitable health care system and we have known it for a long time. Yet, primary care capacity in Vermont is grossly inadequate.

Statewide, we urgently need more primary care doctors, physician assistants and nurse practitioners, and nurses. Reimbursement rates for primary care need to be increased, working conditions improved, and more medical students incentivized to choose primary care as a profession. None of this is a mystery or complicated.

Second, expand and improve mental health services. Mental health problems like anxiety and depression, left untreated, cause or worsen many physical health problems and drive-up costs. Yet, our mental health system is also in crisis. More hospital treatment beds are not the answer. A more preventive approach, including more crisis response, community support and counseling, is the answer. It is far cheaper and cost -effective to fund prevention and community-based intervention than to increase and fill more beds.

Third, expand and strengthen home health services. Home health caregivers regularly care for chronically ill people in their homes and reduce the number of unnecessary hospital stays. Home health also offers hospice services, which keep terminally ill people out of hospitals for expensive end-of-life care that they may not want.

Yet, home health agencies struggle to maintain the staff they need due to funding cuts at the federal level and inadequate funding at the state level. So, instead, many people needlessly spend time, including their final days, in hospitals.

Fourth, we must effectively address what are called the “social determinants of health,” such as hunger, homelessness and abuse. These issues have huge impacts on people’s health, yet we treat them as if they are separate from the health care system. We underfund them, then wait until people have severe and untreated medical conditions and end up in the hospital.

How would Vermont fund such improvements?

First, the state should stop funding the failed accountable care organization, OneCare Vermont, and reassign that funding to these initiatives. Seventy-eight percent of OneCare’s operating costs are paid with publicly funded Medicaid funds and could be redirected to better use.

If properly implemented, these four initiatives would result in lower hospital and emergency room admissions by reducing avoidable care. That alone would not suffice. However, savings from those reductions could be redistributed to further expand the initiatives above.

This redistribution would continue until Vermont reached the best balance between funding for hospitals and funding for community services and achieved a well-balanced, affordable health care system.

There is no magic to designing a high-quality, affordable and fair health care system. We know what needs to be done, and we’ve known it for a long time. We need to restructure our hospital system to limit its cost (remember how much of the care is avoidable) and, instead, reallocate funding poorly spent in that system to support the prevention-oriented services and programs described above.

Of course, we need and want an adequately financed, high-quality hospital system, and we certainly can have one with all the money we are spending on it today. But a lot of that money is being spent unwisely and ineffectively. As a result, many Vermonters can’t get or afford the care they need. We can do better, and we need to begin now.

On Nov 18, in the third and final installment of these commentaries, Mark Hage will describe systemic steps that can be taken to restructure hospital funding to make it more equitable, affordable and understandable.
https://vtdigger.org/2022/11/11/patrick-flood-an-affordable-health-care-system-for-a-healthier-vermont/

Feb 27 2023 Wendell Potter


Analysis of the 2022 financial statements of UnitedHealth Group, CVS/Aetna, Cigna, Elevance, Humana, Centene, and Molina
SNIPPET:

A few other facts and figures to keep in mind as Big Insurance thrives:

🤦‍♂️ 27.5 million people remain uninsured in the United States. Up to 14 million more will lose their Medicaid coverage once the pandemic emergency period ends later this year.

🤦‍♂️ 100 million of us – almost one of every three people in this country – now have medical debt.

😠 In 2023, U.S. families can be on the hook for up to $18,200 in out-of-pocket requirements before their coverage kicks in, up 43% since 2014 when it was $12,700.

Read ALL OF IT:
https://wendellpotter.substack.com/p/big-insurance-2022-revenues-reached

June 8, 2023 by Rosa Mino, PhD, and Amanda Masino, PhD
Rosa Mino, PhD, and Amanda Masino, PhD, are biology professors.



SNIPPET:

*Patient's name has been changed

Magda* was 70 years old when she suffered a mild stroke. She was taken to a hospital, where the emergency department and critical care unit ran the appropriate tests and sent her home with medicine and a monitor for irregular heartbeats.

Practice guidelines for stroke follow-up advise providers to evaluate stroke cause, which includes, for patients like Magda, noninvasive cervical carotid imaging to evaluate any stenosis. If present, cervical artery stenosis must be addressed. This would include revascularization when appropriate, or medication and lifestyle modification. Magda was not told this. If not for a knowledgeable family member who categorically requested the necessary imaging, she may have gone untreated.

The oversight was almost catastrophic. She had severe stenosis. It could have taken her life.

There are many possible reasons why the attending physician decided not to proceed with imaging tests. Perhaps they felt it was clinically unnecessary. But then why, once it was requested, did they perform the test without any objections? Magda suspects it happened because of her insurance: she is covered by Medicare.

Unfortunately, Magda's experience is not unique. Private insurance generally pays healthcare providers more than federally funded programs like Medicare or Medicaid. Public insurance beneficiaries report they feel that they don't have the same level of access to high-quality care as privately insured patients. This apprehension is not imaginary.

Patients must be able to determine not only whether a provider accepts Medicaid/Medicare, but also if that provider treats patients who have publicly funded insurance with the same level of care. One part of the solution could be transparent and easily accessible information about patient demographics (information that includes data by patient insurance type).

A Medicare or Medicaid patient's first challenge is in finding a healthcare provider that will take their insurance. Many providers do not accept federally funded insurance coverage, although some get certified because, despite the lower revenue, they expect more consistency in payments. (Unfortunately, claim denials and billing problems often stymie these expectations.)

Full article with info on the most Socially Responsible Hospitals:
https://www.medpagetoday.com/opinion/second-opinions/104912

An estimated 795,000 Americans die or become permanently disabled every year due to misdiagnosed diseases, according to a study in BMJ Quality & Safety.



July 16, 2023


SNIPPET: 👀

Results 👉 Annual US incidence was 6.0 M vascular events, 6.2 M infections and 1.5 M cancers 🤦‍♂️. Per ‘Big Three’ dangerous disease case, weighted mean error and serious harm rates were 11.1% and 4.4%, respectively. Extrapolating to all diseases (including non-‘Big Three’ dangerous disease categories), we estimated total serious harms annually in the USA to be 795 000 (plausible range 598 000–1 023 000). Sensitivity analyses using more conservative assumptions estimated 549 000 serious harms. Results were compatible with setting-specific serious harm estimates from inpatient, emergency department and ambulatory care. The 15 dangerous diseases accounted for 50.7% of total ☠️ serious harms and the top 5 (stroke, sepsis, pneumonia, venous thromboembolism and lung cancer) accounted for ☠️ 38.7%.

Conclusion 👉 An estimated 795 000 Americans become permanently disabled or die annually across care settings because dangerous diseases are misdiagnosed. Just 15 diseases account for about half of all serious harms, so the problem may be more tractable than previously imagined.

Read more:
https://qualitysafety.bmj.com/content/early/2023/07/16/bmjqs-2021-014130

August 10, 2023 by Nikesh Patel, PT

Patel is a physical therapist.


Cutting physical therapy reimbursement is bad for patients and bad for spending

Falls among seniors pose a significant public health challenge, leading to 3 million emergency room visits and more than 36,000 deaths 😞 each year. By prioritizing physical therapy as a preventive measure, we can address this issue proactively and promote healthier aging for our senior population.

Helping seniors build strength and balance is not only good for patients, but also, it is cost-effective and helps save the Medicare system money. So, it is alarming that Medicare has proposed yet another round of cuts to physical, occupational, and speech therapy. These cuts, if implemented, would have severe consequences for seniors' access to vital care and threaten the effectiveness and affordability of treatment.

Congress must take immediate action to prevent these cuts and protect the well-being of our aging population as we tackle the immense problem of senior falls.

Over the years, the Centers for Medicare & Medicaid Services (CMS) has consistently announced plans for deep cuts to specialty services, including physical therapy . Planned 😈 cuts to physical therapy services have compounded on top of one another , reaching 9% between 2020 and 2024. The Medicare Physician Fee Schedule Proposed Rule for CY2024, released on July 13, continues this trend by proposing to cut payments for these services by at least 3.36% -- and even higher in some parts of the country due to the highly technical 😉😈 formula CMS uses to determine reimbursement. If allowed to go into effect next year, these cuts will place an extraordinary burden on providers and undermine their ability to deliver quality care to older Americans. Even more worrying, the cuts will endanger the ability of seniors to access the community-based therapy services that are essential for their well-being.

The continuous cuts to reimbursement rates jeopardize the stability of all specialty sectors, including physical therapy, and raise concerns about the potential closure of practices and restricted access for Medicare beneficiaries. If Congress does not act, this would profoundly impact seniors who rely on physical therapy to maintain their health, independence, and quality of life.

If cost savings are the most important factor, let's point to the runaway financial burden if the senior falls epidemic is left unaddressed. By CDC estimates, about $50 billion is spent on medical costs related to nonfatal fall injuries each year, and $754 million is spent connected to fatal falls. According to a report by the American Journal of Lifestyle Medicine, the annual cost will skyrocket to $100 billion spent on fall treatment care by 2030.
https://www.medpagetoday.com/opinion/second-opinions/105834

September 6, 2023 by by Cheryl Clark, ProPublica This story was originally published by ProPublica.


Dozens of experts said building a tool for navigating  insurance appeals would be impossible

Health insurers reject millions of claims for treatment every year in America. Corporate insiders, recordings, and internal emails expose the system and its harm.

Have you ever had a health care claim denied by your insurer? Ever tried to appeal it? Did you wind up confused, frustrated, exhausted, defeated?

I've been a healthcare reporter for more than 40 years. And when I tried to figure out how to appeal insurance denials, I wound up the same way. And I didn't even try to file an actual appeal.

ProPublica came to me earlier this year with what might have seemed like a simple proposition. They wanted me to create an interactive appeals guide that would help readers navigate their insurers' maze. (A team of reporters at ProPublica and The Capitol Forum has been investigating all the ways that insurers deny payments for healthcare. If you've got a story to share, let them know hereopens in a new tab or window.)

Over the next several weeks, I spoke with more than 50 insurance experts, patients, lawyers, physicians, and consumer advocates. Nearly everyone said the same thing: Great idea. But almost impossible to do. The insurance industry and its regulators have made it so complicated to file an appeal that only a tiny percentage of patients ever do. For example, less than two-tenths of 1% of patients in Obamacare plans bothered to appealopens in a new tab or window claims denied in 2021.

The central problem: There are many kinds of insurance in the U.S., and they have different processes for appealing a denial. And no lawmakers or regulators in state and federal governments have forced all insurers to follow one simple standard.

I tried to create a spreadsheet that would guide readers through the appeals process for all the different types of insurance and circumstances. When a patient needs care urgently, for instance, an appeal follows a different track. But with each day of reporting, with each expert interviewed, it got more and more confusing. There was a point when I thought I was drowning in exceptions and caveats. Some nights were filled with a sense that I was trapped in an impossible labyrinth, with signs pointing to pathways that just kept getting me further lost.

Here are some of the issues that make it so confusing:

First, people have to know exactly what kind of insurance they have. You may think that UnitedHealthcare is your insurer because that's the name on your insurance card, but that card doesn't tell you what kind of plan you have. Your real insurer may be your employer. Some 65% of workers who get their coverage through their employers are in what's known as "self-funded plans," according to KFF (formerly Kaiser Family Foundation). That means the employer pays for medical costs, though it may hire an insurance company like UnitedHealthcare to administer claims.

The other main type of insurance that companies provide for their workers is known as a "fully insured plan." The employer hires an insurer to take all the risk and pay the claims. With that kind of plan, the name on your card really is your insurer. Why does this difference matter? Because the route you follow to challenge an insurance denial can differ based on whether it's a fully insured plan or a self-funded one.

But all too often people don't know what kind of plan they have and aren't really sure how to find out. I'm told that some employers' human resources departments don't know either -- although they should.

"It is a little scary, because people honestly don't really know what they have," said Karen Pollitz, a senior fellow at KFF who specializes in health insurance research. "I'm just going to warn you that if you set up the decision tree with an A: yes, B: no, or C: not sure, you'll find a lot of people clicking not sure."

Government insurance is its own tangle. I am a Medicare beneficiary with a supplemental plan and a Part D plan for drug coverage. The appeals process for drug denials is different from the one for the rest of my healthcare. And that's different from the process that people with Medicare Advantage plans have to follow.

A spokesperson for the Centers for Medicare & Medicaid Services, the federal agency that oversees Medicare, wrote in an email that the agency "has been actively engaged in identifying ways to simplify and streamline the appeals process and has worked with stakeholders and focus groups to identify ways to better communicate information related to the appeals process with the beneficiaries we serve."

And we can't forget about Medicaid and the Children's Health Insurance Programs, which together covered 94 million enrollees as of Aprilopens in a new tab or window, more than a quarter of the U.S. population. The federal government sets minimum standards that each state Medicaid program has to follow, but states can make things more complicated by requiring different appeal pathways for different types of healthcare. So the process can be different depending on the type of care that was denied, and that can vary state to state.

And don't even get me started on how baffling it can be if you're one of the 12.5 million people covered by both Medicare and Medicaid. As far as which appeals path you have to take, Abbi Coursolle, a senior attorney with the National Health Law Program, explains: "It's Medicare for some things and Medicaid for others."

I sought help from Jack Dailey, a San Diego attorney and coordinator for the California Health Consumer Alliance, which works with legal-aid programs across the state. On a Zoom call, he looked at an Excel spreadsheet I'd put together for Medi-Cal, California's Medicaid program, based on what I had already learned. Then he shook his head. A few days later, he came back with a new guide, having pulled an all-nighter correcting what I had put together and adding tons of caveats.

It was seven single-spaced pages long. It detailed five layers of the Medi-Cal appeals process, with some cases winding up in state Superior Court. There were so many abbreviations and acronyms that I needed to create a glossary. (Who knew that DMC-ODS stands for Drug Medi-Cal Organized Delivery Systemopens in a new tab or window?) And this was for just one state!

Christianne Heck, MD, a neurologist specializing in epilepsy with Keck Medicine of the University of Southern California, said her health system has a team of professionals dedicated to appealing denials and making prior-authorization requests -- where you have to call the insurer and get approval for a procedure beforehand.

"It's a huge problem," Heck said. "It usually takes multiple attempts. We have to play this horrible, horrible game, and the patients are in the middle."

It's especially complicated in oncology, said Barbara McAneny, MD, a former president of the American Medical Association who runs a 6,000-patient oncology practice in Albuquerque, New Mexico.

"My practice is built on the theory that all the patients should have to do is show up and we should manage everything else ... because people who are sick just cannot deal with insurance companies. This is not possible," she said.

McAneny told me she spends $350,000 a year on a designated team of denial fighters whose sole job is to request prior authorization for cancer care -- an average 67 requests per day -- and then appeal the denials.

For starters, she said bluntly, "we know everything is going to get denied." It's almost a given, she said, that the insurer will lose the first batch of records. "We often have to send records two or three times before they finally admit they actually received them. ... They play all of these kinds of delaying games."

McAneny thinks that for 😈 insurance companies, it's really all about the money.

Her theory is that insurance companies save money by delaying spending as long as possible, especially if the patient or the doctor gives up on the appeal, or the patient's condition rapidly declines in the absence of treatment.

For an insurance company, she said, "you know, ☠️ death is cheaper than chemotherapy."

I asked James Swann, a spokesperson for AHIP, the trade group formerly known as America's Health Insurance Plans, what his organization thought of comments like that. He declined to address that directly, nor did he answer my question about why the industry has made appealing denials so complex. In a written statement, Swann said that doctors and insurers "need to work together to deliver evidence-based care and avoid treatments that are inappropriate, unnecessary, and more costly. Most often, a claim that is not immediately approved just requires the provider to submit additional information to appropriately document the request, such as the diagnosis or other details. If a claim is not approved after correct and complete information is submitted, there are several levels of appeal available to the patient and their provider."

Swann outlined some of the appeals steps available, including a review by a doctor who wasn't involved in denying the claim initially, the chance to submit additional clinical rationale, and a review by an entity that's independent of the insurer. He also noted that Medicare Advantage and Part D programs have multiple levels of appeals before winding up in court, including a step that requires a review by an outside, independent organization.

Domna Antoniadis is a healthcare attorney in New York who co-runs the Access to Care nonprofit, which educates patients and providers on their health insurance rights. She spent hours helping me navigate various appeal systems.

She offered up one important tip for people who use commercial insurance: Get the full plan document for your policy and read it. It'll be around 100 pages and will tell you what medical services are covered and detail all the steps needed to appeal a denial. Don't rely on the four-page summary, she said. It probably won't help.

Likewise, Medicare, Medicare Advantage, and Medicaid denial letters should explain the steps to appeal the decision.

When you can, enlist the help of your medical provider. Sometimes an insurer says no to a claim because a doctor's office submitted it under the wrong code, and that can be fixed quickly.

Antoniadis acknowledged the challenges but believes that consumers have a lot more power than they realize. They can push back to advocate for themselves.

"The appeals process is not always handled properly by the plans, which is why consumers need to report and complain to their relevant government regulators when they believe they've been unfairly denied," she said. "That's integral to changing the system."
https://www.medpagetoday.com/special-reports/features/106199

Commentaries are opinion pieces contributed by readers and newsmakers. VTDigger strives to publish a variety of views from a broad range of Vermonters. Commentaries give voice to community members and do not represent VTDigger’s views.

September 14,2023 This commentary is by Walter Carpenter of Montpelier, who works in Vermont’s tourism business and is a writer and a health care activist. In 2006, he nearly died at the hands of the health care system. He is on the advisory committee of the Geen Mountain Care Board.

September 21, 2023 by by Emily Hutto, Associate Video Producer

In this interview, Jane Zhu, MD, MPP, MSHP, associate professor of medicine at Oregon Health & Science University in Portland, discusses a recent article she co-authored on the corporatization of healthcare in the New England Journal of Medicine: "A Doctrine in Name Only -- Strengthening Prohibitions Against the Corporate Practice of Medicine."


Reality based COMMENT:

Laser_Doc
I remember when Hillary Clinton organized a conference to band insurance companies together, forming what became known as managed care. As smart as physicians are and were, they saw only the overt advantages of what was perceived as increased reimbursements, increased referrals, less interaction and fighting with insurance companies, less impact on patients, etc. So "everyone" ultimately joined managed care.

Only after a threshold of essentially universal physician membership was achieved, did the landscape shift. Decreased reimbursement, only certain referrals allowed, pre-authorization for procedures and surgeries and medications, and care tailored to algorithms as opposed to individual patient needs.

It also became true that computerization, rather than simply enhancing medicine, became a tool of control, that electronic patient records became laborious and required obtuse proof of service rendered, that corporate control became lack of autonomy and assembly line-like induced productivity measured by RVUs.

As just one example, all my patients were referred by other physicians, with office visits in the past summarized by short 3-line notes that captured the essence of the patient, their medical problem, and the physician insight. As time went by, these short but very meaningful notes were generally replaced, by multiple pages of computerized gibberish that simply served proof that the physician did all required for the level of reimbursement that was billed.

But the greatest fear should be of AI, establishing that algorithms can not only be used by less committed paraprofessionals, but now also by microchips capable of churning out their standardization, no less than by using our own professionally created and approved standardsof care. This apparently will be not just for some fields, but even including, e.g., psychiatry, as well as extending to personal relationships. Microchips are not trained to think out of the box, except when they hallucinate for truth.

Search engines have become increasingly monetized, as have been and will be physician acceptance of all of these evolving transitions.

I was among those who incorporated technology early, computerizing my practice some 40 years earlier than others. But as much as I and my patients have benefitted, if I had a choice between no technology and how it has been and is about to be used, I would choose none. Hopefully, we will not just build guard rails, but rather expand the empowerment of physicians through control of technology without its use being mandated, without overseers monitoring, and without further destruction of what remains of physician and patient privacy.

https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/106430