I am told it would likely be done administratively and included in the budget without a line item listing, just an appropriation for the service without saying who will do it.  It could very well show up as a footnote in the line items for Medicaid.  To quote one insider, “the farther along it goes in the budgetary process, the more difficult it is to stop.”  So you probably won’t get a separate bill number to reference.  I am told that the Governor would need to be promoting it for this to happen, but I am not sure how far along the process of persuading him has gone.  I also understand that at least one member of the Governor’s Cabinet, the head of a major state agency, has publicly indicated in discussions with Legislative Leadership that “managed care is a done deal— either Medicaid will do it on its own or the Legislature will make it happen”.  

So it is possible that if we don’t make a LOT of noise now, before much more happens, this potentially disastrous change could be made without attracting any attention beforehand and without even most legislators knowing anything about it.  None of them at our recent Madison County Legislative Forum seemed to be aware.  That’s my job and yours—make sure everyone hears about this and watches for it.  The session starts Feb. 9.  We don’t have much time.

Our first priority needs to be the money committees.  In the Senate, that’s the Finance and Taxation General Fund Committee.    On the House side, it’s the Ways and Means General Fund Committee.   Please contact these legislators—they need advance warning and not just from me.   Members of the Legislative Contract Review Committee could delay specific contracts but can’t stop the process.  If you click on these links, you will pull up the committees, and then click the individual names for contact information.

Contact the Governor as well, and contact his Chief of Staff David Perry.   I am told (but cannot verify) that Perry is in favor of the contracts.  As a physician, Dr. Bentley and Medicaid Commissioner Bob Mullins  should have an understanding of how this works—they know that physicians will drop Medicaid under administrative hassles and paperwork, because they had to hire staff to do paperwork himself. But we don’t know the quality of advice the Governor, Commissioner Mullins and Mr. Perry are getting.  If it’s from these companies, it’s likely very misleading.

There is a certain paper by the Lewin group we suspect the companies may be using.  If so, there is a footnote at the beginning specifically stating that they did not address states with Primary Care Case Management (PCCM) programs—and that’s what Alabama has.  The studies they review are comparing completely unregulated fee for service (including programs run by for-profit companies) with capitated managed care.  Obviously a total free-for-all is going to be more expensive!  No one in their right mind would suggest we should abandon cost controls.  Alabama, on the other hand, has many effective managed care tools already in place.   So tell them to toss that Lewin paper.

Emails and phone calls are fine.  Making an appointment and visiting your own senator and representative is important if you have time.  A friend asked if I would provide a template letter or email, but I don’t think that’s a good idea.  When things look too much alike, they get ignored.  Mainly we need to let them know we are firmly against sending our Medicaid money out of state and ruining a program that has been very cost-effective.   A personal story is great.  When you talk to them, remember that they aren’t the bad guys—that would be the companies providing misleading information.

This whole thing reminds me of what happened a couple of weeks ago when I was playing zebra hunter and getting teased at work for allegedly “geeking out”.  I had heard about a couple of kids in our practice having hand-foot and mouth (HFM) infections—these are common in the summer but not winter, so it caught my attention.  Then I was getting my hair cut, and a mom at the beauty salon said her baby had it—what she described sounded much more severe than the usual HFM.  And she said adults had been getting it as well, definitely not normal.  One so badly he couldn’t walk due to the pain in his feet.   Every so often we have an unlucky parent get a childhood illness, but not several at once!  That’s a warning the infection is a strain we don’t usually see here, or a new mutation.

The very next day, I had a family in my office whose teenager and toddler both had the fever and rash.    So I called the Alabama Department of Public Health to see what might be going on and ask if they wanted any samples.  Next thing I knew, I was Skyping with a room full of epidemiologists.  We started collecting swabs and stool samples, and now we’re waiting to hear back from the CDC.

When I talked to my doctor friends around the state, it turns out this virus has probably been around a few months, but no one had called ADPH.  HFM is common, and we have a saying that an uncommon presentation of a common illness is more likely than a common presentation of an uncommon illness.  When you hear hoofbeats, think horses, not zebras.  (Don’t panic—this isn’t like the movie Contagion.  People are getting a painful rash and then getting over it.  When I find out what it is, I’ll let you know!)  But it’s important to keep track of emerging diseases, even minor ones, for many reasons.  Sometimes it really is a zebra. 

This Medicaid situation is kind of like that—an early infection without many warning signs, but one we need to nip in the bud right away, before it makes us really suffer.  The way I found out was similar too—instead of being in the salon, I was in various committee meetings.  Which means another way to participate in democracy is to join groups, even non-political ones, and pay attention to what you hear.  Then don’t just shrug and keep it to yourself—tell somebody.

I know I have whined frequently to my friends about hating committee meetings, and I admit to fidgeting like a high school kid when they run over an hour.  But it matters—we can’t do democracy by staying home and watching TV, whether it’s MSNBC or Fox.

Please get busy, and email me with results of your conversations.  Thanks to all of you who have helped so far!  We might just win this one.

Here it is, short and sweet:

SEC. 104. PROHIBITION AGAINST DUPLICATING COVERAGE.

 (a) IN GENERAL.—It is unlawful for a private health

 insurer to sell health insurance coverage that duplicates

 the benefits provided under this Act.

 (b) CONSTRUCTION.—Nothing in this Act shall be

construed as prohibiting the sale of health insurance coverage for

any additional benefits not covered by this Act,

 such as for cosmetic surgery or other services and items

 that are not medically necessary.

First, notice the very specific wording that only a private insurer can’t duplicate benefits.  Does it leave room for a different form of public insurance?  For instance, could a state get a waiver and offer its own insurance plan? And if so, would that option appeal to folks in regions that love the 10^th Amendment?  Although I prefer a national program for cost-saving reasons, we don’t need to marry that idea if it would prevent moving forward.  I am watching the progress in Vermont and California toward state single payer with great interest.

Sometimes progressives don’t see the good side of states’ rights.  It isn’t only about limiting centralized power—it also allows for simultaneous trials of 50 variations on a theme.  This is a much more efficient way to test options than one at a time for all of us, and we can learn from each other.  For instance, I can use Connecticut’s experience with corporate managed care Medicaid to help Alabama see it would be a mistake. 

What about the allowed sale of private insurance for non-covered services?  I think that’s a great example of an area where the market is the most appropriate venue.  These are luxury services—cosmetic surgery, cosmetic orthodontics, etc—not things necessary for life and basic health.  The kicker is that more conventionally attractive people do have an edge when it comes to jobs and status.  But trying to flatten the playing field completely is a total waste of time—rich folks will always find a way to get ahead.  I just don’t think we should let them do it by denying ordinary medical care to us and tanking our economy in the process.

So let the insurers get into business there.  They can offer group negotiated discounts for face lifts.  It might actually bring the price down, because people can afford to take time for shopping around on luxuries.  As opposed to doing so in the middle of a heart attack.

This section will be the one opponents will argue against the hardest.  I can imagine it as the target of legal challenges when the bill is eventually passed.  Like the universal mandate with the ACA, without this section the rest of the plan will fail.  There is no reason that a government program will work any better than what we have now, unless we all have a dog in the fight.  If any substantial percent of us doesn’t have to use our national health plan, we will not be able to generate enough political pressure to force it to run well.

Is there any workable way around that?  Probably not.  The only one I think is worth at least discussing is to consider allowing private insurance for doctors, hospitals and patients who agree to opt out of the public system 100%.  They would still have to pay taxes on the public system, just as people do who use public schools, but upon purchase of private insurance, they would forgo the right to use public services.

Doctors would have to choose which system to participate in. Anyone who receives public money in any form (obviously legislators) or contracts with a public agency would not be able to participate in private plans for themselves or their employees.  And there would be “prison rules” for those insurances, because we should not have to waste public money on regulation and oversight.

In my book, I suggested the option of patients using either system, since they had paid taxes.  But a similar set-up hasn’t worked well for England.  The difference with my idea would be that politicians and anyone who gets any form of public funds couldn’t be allowed to go private and would have to experience what they set up.   Would that be enough to make it safe for the rest of us?

Germany did a mandated choice between public and private, and the problem is that people find out they can’t afford their private plans but then can’t switch to the public system.  This would create preventable suffering and hurt the economy (sick people can’t work well).

So what if we said patients could make one switch back to public insurance when private plans failed them?  Kind of like Dirty Santa?  And after that, I guess they’d have to emigrate to another developed country without national insurance—oh, wait, there aren’t any. 

I’m going to borrow her phrase today.  We have a situation indeed:   hungry, out-of-state corporate vultures are circling Alabama’s already limited Medicaid money, and we need your help to fend them off.

Alabama’s legislators are being heavily lobbied to contract our state Medicaid program to for-profit managed care corporations. I’m told by reputable sources that it may be a “done deal.”  You may know about the projected shortfall to Alabama’s general fund, the part of our budget that pays for prisons, courts, Medicaid and other non-education expenses.   Several corporations have taken advantage of states in similar distress by offering to take over all their Medicaid services for a set fee.  The state gets relief from a budget headache, and the corporations get a windfall. 

What do poor children get?  Less healthcare for our money.

Let’s break it down.  Currently, Alabama Medicaid covers 465,504 children, at an average annual cost of $2,378 per child.  Even including children with chronic illnesses like congenital heart disease or cancer, children are a pretty inexpensive group.  Only 3% of Medicaid money goes to overhead, leaving $2306 to be spent on actual medical services.

If that same pot of money goes to a managed care corporation, do you think they will use 97% of it for medical care?  Losing only 3% to profit and overhead combined?   The Affordable Care Act says that the Medical Loss Ratio (MLR), the money spent on actual medical care, has to be at least 85% for large group policies.  That leaves $2021 per child for medical care, instead of $2306.

The managed care corporations say they are worth it—they can take our supposedly inefficient system and make it run better.  They say we don’t need that extra $300 or so per child for medical care.  They can find a better use for $140 million dollars.

They say patients are over-using resources.   I doubt if that is true, from personal experience.  Sure, sometimes parents think their children have a dangerous illness and they are wrong.  Contrary to propaganda, they don’t want to lose their minimum wage jobs by taking off time to go to the doctor, and they hate sitting in a crowded ER all night as much as we do.

They say doctors waste money by providing unneeded services.  Again, personal experience tells me otherwise.  As a group, pediatricians are fairly frugal.  We notoriously undercharge, despite repeated efforts by coding professionals to convince us our work is worth more.  What services will they decide are not needed—developmental screening?  Autism testing?  Dental care?  They will have a nurse reviewer who has never seen our patients decide whether what we do is medically necessary.

They love to say care is fragmented and they can coordinate it better, thereby saving money.  Maybe in some states, but not in Alabama.  We already have a very well-designed Patient First Network in which children have a personal pediatrician to coordinate care.  There’s always room for improvement. We are already in the process of addressing that through a pilot program of Patient Care Networks.  If there’s a way to save money while preserving quality of care, we will find it ourselves.

One of the corporations salivating over Alabama money is Amerigroup, a multi-state corporation based in Virginia.   They specialize in preying on struggling state Medicaid programs and reaping the profit.  They’re good scavengers—their current revenue is 6.2 billion with an EBITDA of 460 million.  After their cut in overhead (check out these salaries), another 7.4% of state Medicaid money is withheld from medical care of children.  They boast over $4 per share annual profit for shareholders.

The experience of other states in the claws of such programs has been dismal.  A whistleblower lawsuit was filed in Florida, because care to children became so limited.  We should pay attention and not jump over the cliff after them.

How do they limit care?  There are federal rules about minimum services state Medicaid programs must provide, so first they cut out any health-improving service over the minimum, no matter how helpful it is.  They limit panels of specialist providers, creating bottlenecks and waiting lists.  Then they pile on reams of paperwork every time a doctor wants to make a referral or do a test.  Even if they know they’ll eventually have to allow it, they like to keep those funds as long as possible. 

This costs physician offices so much in extra staff time and creates so much aggravation that many of them reluctantly drop out of the Medicaid program.  Then children have a wonderful shiny Medicaid card but can’t find a doctor to help them.  Their desperate parents take them to the emergency room.  Now we have truly fragmented care and dangerously clogged up emergency services.  The corporations won’t mind, because hospital money in Alabama comes from a different pile.  Plus they can always deny payment to the ER docs by saying it wasn’t a real emergency.

Pediatricians in Alabama have worked hard for many years to improve the health of our state’s children.  We volunteer on multiple committees, constantly developing new quality improvement initiatives.  Under corporate managed care, the damage to our system could be so severe it will take us decades to repair. 

Whenever my nurse comes to me with a “situation”, so far I’ve been able to manage.  I even got that little snake out of the office by myself.  But pediatricians can’t fight these powerful vultures alone. We need your help.

I’m posting this as a special column on Martin Luther King Day.  The great man once said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”  If managed “care” like this isn’t an injustice, I don’t know what is.  

Here’s your call to action.  Call (or even better, visit) your state legislators this week.  We don’t have much time before they go back into session—see them while they are in their home offices.  Tell them to get those corporate vultures away from our children and find another way to manage our Medicaid funds.  Don’t let them tell you there’s no way to get the money.  They can do it.

Spread this call to action wherever you can—every listserv, PAC and influential group or person you can think of.  Drop me an email to let me know how it goes. Tell our Legislature not to send our hard-earned tax money out of state.  We have abundant skill and knowledge already here.  Keep Alabama resources in Alabama, and keep Alabama’s future—our children—healthy.

Section 103 of HR 676 is titled “Qualification of Participating Providers.” First, it says “no institution may be a participating provider unless it is a public or not-for-profit institution.  Private physicians, private clinics, and private healthcare providers shall continue to operate as private entities, but are prohibited from being investor owned.”

There’s an extra comma at the end of that sentence, but generally this bill is so much better written than the ACA.  The meaning is quite clear—HR 676 does NOT institute socialized medicine.  Your hospital, doctor, chiropractor, etc will remain in the private sector (unless already part of a public entity like the VA).

For-profit entities that want to be paid out of our national insurance fund will need to convert, and there is money in this section to reimburse their expenses over a 15 year period, through the sale of Treasury Bonds.  The exact amount isn’t specified—it is not for loss of business profits but for the expense of conversion only.

Facilities and physicians must meet applicable state quality and licensing guidelines to participate.  I’m not sure why this was necessary to specify, since it is already illegal to practice without a license. I guess it is just to make clear that the bill doesn’t replace state licensing with national licensing?  It goes on to say “no clinician whose license is under suspension or who is under disciplinary action in any State may be a participating provider.”

 That sentence might need to be tweaked, because some disciplinary actions require probationary status—the physician might practice under supervision for a period of time or get more training to correct a deficit.  I see notices like that in our state medical association newsletter.   How can the doc complete probation and regain full licensure status without being able to get paid?  Would you all rather just go ahead and cut loose any doc who shows a deficiency, correctable or not?   This might increase already strenuous efforts of doctors to cover up their own medical problems, etc, rather than getting appropriate help.

Disciplinary actions have also been used politically.  Dr. Sonnie Hereford talks about this in his book “Beside the Troubled Waters:  A Black Doctor Remembers Life, Medicine and Civil Rights in an Alabama Town.” Great read—I highly recommend it.

Health Maintenance Organizations that provide their own care (like Kaiser) could continue to do so as non-profits.  HMO’s that contract with non-employee physicians are basically just insurance plans—we’ll look at their fate next week.  I notice that a lot of Alabama folks aren’t as familiar with HMO’s as people in other parts of the country, but it really works fine just to think of them as insurers.

There’s a trend recently of large insurers setting up facilities with their own employed physicians, so that subscribers have to see those doctors  for full coverage.  I don’t think that has happened yet in Alabama, except sort of for mental health.  One large insurer here restricts coverage of mental health services to a single provider, Alabama Psychiatric Services, owned by a company called Managed Health Care Administration.  MHCA is a private company that subcontracts with the insurer to administer and provide mental health benefits, so it is “sort of” an insurer but not exactly.  It is owned by investors— the psychiatrists who work for APS.  The key is that the people who are treating you also administer the contract that determines what services you can get. They get a capitated (per insured person) fee to provide whatever services are needed.  What happens to the money not spent on your care?  They get to keep it.  Draw your own conclusions about whether that could be a problem.  I don’t know of anything specific that has happened, but my conflict of interest would prevent me from further comment if I did. 

Under HR 676, such arrangements wouldn’t be allowed, because the benefits covered would be determined by a separate agency accountable to voters.  It would also be prevented by the last, critical phrase in Section 103: “Patients shall have free choice of participating physicians and other clinicians, hospitals and inpatient care facilities.”  This is so radically different from our current arrangement that I’ll devote a separate blog post to it, next week.

Any comments on this section or changes you would make?  Let me hear from you and I’ll pass it on to the other board members of Physicians for a National Health Program.

I got a helpful phone call this afternoon from Dr. Robert Chappell with the hospital.  I am happy to say he told me the hospital has stopped charging this fee to publicly insured patients (those with Medicaid, Medicare and active duty Tricare military families).  People who have financial hardship are also not being charged.  He said that if patients refuse to pay, they are not being turned away.  I will let you know if I get contacted by anyone else.

Dr. Chappell says the fee is to cover paperwork expenses but does not think this is related to the Affordable Care Act.  I agree with him that there has been a steady increase in paperwork.  A lot of this is from multiple insurers with various prior authorizations and appeals.  Some is because of privacy regulations.  And a good bit is from other organizations.  You would not believe how many different types of school, camp, and sports forms we fill out daily.  Different ones for each group, including DHR foster care patient forms.  Even WIC (Women, Infants and Children program that provides food for young children) now requires us to send them a shot record, although there is a state immunization record online they could access.  I have to write notes giving permission for kids to go to the bathroom at school, use sunscreen, have a food substitute for allergies, etc, etc.  The form for working parents to get leave to care for their sick kids is several pages long.

This “formitis” is almost to the point of lunacy and I do wish there were a single, streamlined and standardized form every organization had to use.  If you run an organization and require a doctor to sign a form for something, I’d appreciate it if you think hard whether you really need that.  And parents, please, please quit losing those sports physicals and blue cards for school, so that we have to do it again!  Every time I sign my name, the signature gets more like modern art.

So I’m not arguing with the time cost of all these forms.  Some offices charge a fee for each item and for refills when there is no appointment.  I understand that is annoying, but it is actually a service you are paying for.

Here’s the problem– this particular $25 fee is not attached to a specific form/ service.  Some patients may not ask, in a year, for any paperwork beyond the usual insurance filing.  So if your insurance does not allow for administrative fees over your co-pay or deductible, these Huntsville Hospital-owned offices are likely breaking contract rules with the insurer.

Even though the average cost might be the same yearly if patients pay a fee per form, I believe the itemized charges are not only more likely to be legal but also safer.  If you don’t like the fee for a form, you can decide not to ask for it.  It might affect your child’s ability to play sports, but it won’t prevent you from getting medical care for him.  It won’t put you at risk for any arbitrary amount the office decides is ultimately necessary to cover their overhead for paperwork, entirely outside the insurance system but tied to your actual medical care.

If you have been charged this fee and want to challenge it, please contact me at pabston@aol.com.  I believe it can be challenged and put to a stop.  I’m sticking my neck out pretty far to do this, but if we don’t speak up, we are all at serious risk of this practice spreading and escalating.

I will say this has nothing personal to do with Huntsville Hospital.  I’ve practiced in a few different hospitals of varying size, and I can honestly say that at least the pediatric unit is one of the better ones I’ve encountered.   I’m proud of what our community has accomplished in pediatric healthcare.  The Pediatric ER is the ONLY place I feel safe sending children with emergencies in our area.  I want to see our local hospital succeed and thrive.  But I don’t want to stand by without speaking up when it gets out of line.

If you have any other specific questions, I will be happy to call Dr. Chappell for further information.

According to a report from WHNT, Huntsville Hospital is charging this fee on top of patients’ regular co-pays. [addendum: this fee only applies to physician outpatient offices, not to the ER, lab, xray or inpatient units].  WHNT says the Vice President of Communications and Marketing, Burr Ingram, blames the fee on increased physician paperwork associated with the Affordable Care Act.  I’m not sure what he is talking about—the only increased paperwork I’ve had to do is related to insurer requirements not specified in the ACA.  I’ve had a lot of increased “clicking” on my computer because of our electronic medical record upgrade, but this was in order for us to get the optional extra money for our EMR.  I’ve read the entire law, but I admit it is long enough that I could have forgotten part of it—I’m not a hospital employed physician so maybe there is something special they have to do.

WHNT quotes Ingram as saying “there is a move toward this fee structure all across the nation.”  I have not been able to pull up information on this online—all my searches bring up articles about Huntsville Hospital specifically.  Do any of you know of other hospitals doing this?  Please chime in. 

I know there are all sorts of “facility fees” charged by healthcare providers, but the ones I’ve seen are specified in insurance policies.  It is very common in Alabama for individual or small employer policies to allow large ($150 or more) facility fees for x-rays and the like, and the insurance manuals say the patients are responsible.

My insurance policy says I have a $30 co-pay for specialist visits.  It does not allow for any other out of pocket cost for covered services.  Since this new fee is not associated with a particular service, does that mean it can be legally assessed outside the insurance contract?  If so, think about what that could mean! What is to prevent the $25 fee from becoming $250, $2500, or more?

If other hospitals and doctors start charging these fees, our health insurance could be rendered essentially meaningless.

I have emailed Huntsville Hospital to ask if there are income cutoffs for these fees.  For many of us, the current $25 would be an annual annoyance but not bankrupting.  I have patients on Medicaid, AllKids, and some employer policies for whom $25 is not going to be possible without putting them in the hole on food, rent, or utilities.  I found mention at Fox Army’s site that Tricare (insures military families) is aware of the situation and working on it, and they say there is a waiver for financial hardship.  I will let you know what response I get, if any. [Addendum: they are no longer charging publicly insured patients this fee, and there is a waiver for financial hardship].

Can any of you with legal background help me out?  Is this fee legal?  I know the hospital has a staff of lawyers who would have reviewed it thoroughly.  We need to take this development very seriously.

I can tell Burr Ingram and the paperwork-fatigued doctors how to cut their administrative costs without burdening patients:  help us get HR 676, Expanded and Improved Medicare for All.  With a single place to submit simplified billing, there would be tremendous overhead savings to providers in all settings.  And with all patients automatically covered, hospitals and doctors would be paid for all of their work.

To quote directly from the bill, the “health care benefits under this Act cover all medically necessary services, including at least the following:  1) Primary care and prevention ; 2) Approved dietary and nutritional therapies; 3) Inpatient care; 4) Outpatient care; 5) Emergency care; 6) Prescription drugs; 7) Durable medical equipment ; 8 ) Long-term care; 9) Palliative care; 10) Mental health services;  11) The full scope of dental services, including periodontics, oral surgery, and endodontics but not including cosmetic dentistry; 12) Substance abuse treatment services; 13) Chiropractic services, not including electrical stimulation; 14) Basic vision care and vision correction (other than laser vision correction for cosmetic purposes); 15) Hearing services, including coverage of hearing aids; 16) Podiatric care.”

The benefits are fully portable, to be available with any “licensed healthcare clinician anywhere in the United States that is legally qualified to provide the benefits.”  No more COBRA!  And a biggie—“No deductibles, copayments, coinsurance or other cost-sharing shall be imposed with respect to covered benefits.”  We will pay in advance, not at the door.

Primary care and prevention means your family doctor, internist, pediatrician, or ob-gyn doctor, nurse practitioners, midwives and physician assistants, as well as the labs and other tests we need.  Our current health insurance law attempted to cover those items, but far too many policies have remained “grandfathered” and don’t have to cover well person care, including my own insurance.   

Approved dietary and nutritional therapies—I hope this makes a lot of you happy!  This should cover not just formulas for tube- feeding people who can’t eat but also nutritionists and supplements.

Inpatient care means care given in a hospital, and outpatient covers care anywhere else, including home health, physical therapy, occupational therapy, speech therapy and specialist care.  Some hospital services are currently coded as “outpatient” even when patients stay overnight in the physical building of the hospital —a complicated bit of footwork insurers use to get out of paying fairly.  I don’t know that the bill needed to specify emergency care separately, but that’s fine.   Same with primary care, already part of both outpatient and inpatient care.  I do like the symbolism of listing primary care first, setting it as the cornerstone of our proposed system.

Long term care—that’s nursing homes and sometimes rehab hospitals.  Palliative care isn’t designed to cure an illness but to relieve symptoms.  Hospice, one type of palliative care, would be included.  

I’m interested that chiropractors get specific mention, since all categories of licensed providers are already included.   What is the electrical stimulation we won’t get, and why?  I don’t know—TENS units are mainstream, so I wonder if this is another type of device?  Anyway, if enough of you don’t like that part and want some sort of electrical stimulation, beneficial or not, feel free to insist on coverage.   I know right now some of my friends are going to have fun with that one—TMI.

We will have brains (mental health and addiction), teeth, eyes, ears and feet finally become legitimate body parts—hurray!  Reminds me of one of my husband’s favorite funnies.  What do you call a deer with no eyes?  No eye deer.  What do you call a deer with no eyes and no legs?  Still no eye deer.  What do you call a deer with no eyes, no legs and which is on fire?  Still no flaming eye deer!  Yeah, I know the R rated version.   What do you call a person in our current insurance system with depression, a cracked tooth, TMJ, nearsightedness, hearing loss, and bunions?  SOL!  And that’s no joke.

Comparing your own wish lists to HR 676, do you see anything left out?  If so, speak up now—we have time to get it in there.  Do you see anything included but think we don’t need it?  Let’s talk.  Next week, we’ll take up section 103, Qualification of Participating Providers.

Instead, I’m going to spend the next few weeks reviewing the bill I want to replace the ACA:  HR 676.  I’m using the most recent version, introduced in the 112^th Congress last February.  Please do read it and follow along—if you’ve never read actual legislation, this is a great way to get your feet wet!  It is short, 30 pages, and very straightforward.

The Short Title is “Expanded and Improved Medicare for All Act”.  It continues to get stuck in committee every year, but we can change that if we exert enough pressure.   We all need to read it, study it, and then get busy pressuring our congressional representatives to co-sign.  All the states surrounding Alabama in the South currently have or have had co-signers.  We have only one at present– Terri Sewell.  Can we get more?

I’ll review the first section under Title I, Eligibility and Benefits.  Section 101, Eligibility and Registration, says that “All individuals residing in the United States (including any territory of the United States) are covered under the Medicare For All Program entitling them to a universal, best quality standard of care.”

Take a minute to read that sentence again.  To me, it is the absolutely most important sentence in the document.  No healthcare reform law that starts out any other way is worth considering further.   I read PPACA, but I’m not going to spend so much valuable time again on similar legislation unless I see those words “all individuals” at the front!  When I was younger, I used to feel like I had to finish most books I started, don’t know why exactly—but now if one doesn’t grab me by the end of the second chapter or so, unless a friend absolutely promises me I should press on, it goes in the give-away pile.  Life is too short to waste on garbage.

The bill goes on to say we will each get a card in the mail, not related to our social security numbers.  We will fill out the applications at a health care provider’s office, and the form will not be longer than 2 pages.  Until we get our cards, we “shall be presumed to be eligible for benefits.”  Good, because both my grown children are constantly losing their cards!  My hubbie sometimes, too.  Why have cards at all?  Because we do need to track these for billing purposes, and attempts at provider fraud will not magically go away.  Maybe there will be an iPhone app.

Now a little sticky point I am uneasy about, as it leaves some room for nastiness—the bill says the Secretary (of HHS) will make a rule with criteria for determining residency.  This doesn’t say one has to have a green card necessarily to be called a resident—I would hope just proving that a person has lived  here for some minimum amount of time would do it.  But weird things can happen in the executive branch, so I do wish the language were a little more definite.

This is followed by a statement saying the Secretary will establish rules about visitors from other countries seeking non-emergency surgical procedures, to allow for country-to-country reimbursement or self-pay arrangements.   Interestingly, this section leaves out emergencies or non-surgical non-emergencies.   Since cosmetic procedures aren’t covered at all, what would these non-emergency surgeries be?  We’re talking hip replacements, possibly surgery for cancer, some heart surgeries—that kind of thing.  So this would provide some reasonable protection from being swamped with medically stable people who could already get such procedures elsewhere. 

Medical tourism is on the rise—not people coming here but leaving here to get cheaper care in other countries.  A friend of mine and his wife recently traveled to Canada and spent quite awhile being questioned in detail by border agents about their health.  My friend said the questions got so pointed that he finally asked the agent “are you trying to make sure I’m not coming here to get medical care?”  The agent said, sotto voce, “Yes, but I’m not supposed to tell you that.”

Obviously emergency surgeries such as appendectomies or trauma surgery are already done without regard for ability to pay– but they are later billed to patients, also without regard for ability to pay.  You can get the care, but later you might lose your house.   I don’t see any mention of how such bills would be handled for visitors.  On one hand, I do think it would be fair to expect other countries with national healthcare systems to pay us back if we treat their citizens (and we should do the same).

But what about countries that don’t fund healthcare?  I don’t think their citizens should be automatically considered self-pay for emergency care.  At least we should have some income criteria.  It seems like the potential for intentional abuse would be lower here—who is going to say to themselves “hmmm, I feel like I might be about to have a car crash in the near future, so I’ll go visit Alabama.”  On second thought… Memorial Parkway in Huntsville might just do it!  Especially with the weather today. 

Most bills like this do leave room for executive branch refining.  Otherwise they get too long and complicated, and they can’t change quickly enough with new information.  But it  means we will have to stay on top of HHS during the rule-making process.

Thoughts?  Next week we’ll talk about what medical services will be covered.  If you are reading along in the bill, try something for fun—make a wish list of services you think ought to be covered for all of us, and then read Section 102. 

As long as we allow corporations to commandeer our medical care, we will have to engage in a futile, expensive attempt to regulate them.   And they will always manage to get one step ahead of us.

This week, I’d like to open the floor to a discussion of insurer sneakiness and rule-bending.  What dirty tricks have you personally experienced at the hands of these devious bad guys?

I’ll give you a couple of examples as starters.  Both are from the mental health/ addiction treatment area but could easily work their way in to other parts of medicine.  First is a way to get around coverage descriptions in the benefits booklets we receive.  I know a parent whose booklet says inpatient addiction treatment is covered 100%, with no co-pays or deductibles, if provided at a certain out of town hospital.  This parent pays through the nose for family coverage through an employer and drove a teen in active withdrawal hours away for treatment in order to get this fully covered service.

On arrival, the parent learned that addiction treatment is never considered “ inpatient” by this insurer.  Instead, it is called “partial hospitalization”, on the premise that the addict could potentially eat and sleep outside the hospital, even though this is not allowed by the rules of the program.  So the parent had to plunk down an unexpected $3000 deposit by credit card, just for starters.  Visits with the teen’s physician and counselors required daily co-pays, plus room and board, and there were outpatient co-pays for all medications.

The parent’s benefit booklet says nothing at all about partial hospitalization fees, which means the insurer can divide expenses pretty much however they want to.  It would be very easy for insurers to begin using this tactic for other types of hospital care, and I see nothing in the current regulations to prevent it. 

It gets worse.  Despite abundant research showing that addiction treatment success hinges on adequate length of treatment, the parent got a phone call from the panicked teenager after two weeks.  The teen had been told insurance was denying any further care at that level, and discharge was in progress.  The teen was still in withdrawal and being tapered on medication, but the insurer ruled this could be done at home and didn’t meet their criteria for continued care.

What criteria, you ask?  It turns out this insurer does not use the nationally accepted ASAM (American Society of Addiction Medicine) Patient Placement Criteria.  They found a firm that made up their own criteria, which they refuse to share with the parent or the teen’s physician.  Could this be done for other medical conditions?  Of course.

It is common for insurers to try out this stuff on less socially acceptable diagnoses.  Patients and family members are less likely to complain publicly because of the stigma and desire for privacy.  This parent was told by a friend that if the teen knew about the cost, maybe that would be a deterrent to future relapses, and I would imagine that some of you reading had the same idea.  Unfortunately, high cost-sharing works the same for addiction as it does for other illnesses—it doesn’t do a whit to prevent illness but does a good bit to delay seeking care.  This particular teen was aware of the cost of a previous admission and waited, almost too long, to admit the problem to the parent.  The teen tried to self-treat instead, with near-disastrous results.

Imagine this scenario—your 60 year old spouse suffers shoulder and jaw pain and calls 911.  She is taken to the ER, and her initial labs and EKG are normal but her doctor is concerned enough to admit her to the cardiac unit for observation and repeated tests.  The family is told that this is a partial hospitalization, since she could theoretically go home between the tests with home oxygen and call 911 if she worsened, even though they are keeping her hooked up to monitors in the ICU.  Because of this, her hospital coverage doesn’t apply and the family will have to deposit several thousand dollars. 

A few hours later, they get a call saying insurance has determined she doesn’t meet their criteria for even partial hospitalization. This insurer doesn’t use the American Heart Association guidelines—they use a group called Bubba’s Budget Hearts.  Fortunately, this time she is not having a heart attack.  She goes home, and a couple of months later she has similar symptoms.  She doesn’t want to put her family through all that trouble and expense again, so she says nothing.  She tells them she is going to take a nap, and she dies in her sleep.

That’s not a crazy fantasy—that’s the reality of what will happen to our loved ones if we don’t do something to stop it.  Will we say “they let the addicts die, and I said nothing.  They let the mentally ill go homeless, and I did nothing to stop it.  They let the smokers and cheese-burger eaters suffer the consequences of their lifestyles, and I let that go.  Then I got melanoma from my childhood sunburns and couldn’t afford treatment, and nobody spoke up for me.”

With HR 676, Improved Medicare for All, we as voters would specifically budget funds for our care and require the money to be spent on services, not handed out in profits to shareholders.  We would pay our way in advance, through taxes, and not be tempted to delay getting help we need later.  Criteria for our care would be evidence-based, through transparent and easily accessible guidelines.

Tell your stories—how has your insurer managed to get around the benefits booklet?  What are you willing to do, to put an end to it?

Despite laws limiting the extent to which adults are allowed to injure children, we still protect the choices and freedom of parents more than we do the civil rights of young people.  Conservatives who would imprison or give the death penalty to doctors for abortions fight us tooth and nail when we try to protect children after birth.  It took years of wrangling in the Alabama Legislature to get the most minimum child passenger safety law passed, despite motor vehicle collisions causing the plurality of child deaths over age 1.  When pediatricians were lobbying for it, I called in to one of the talk radio shows—I was snarkily accused of promoting a “nanny state.”  We got the law, but it is minimally enforced, as is the bicycle helmet law for children.

As a pediatrician, I do see and report cases of frank abuse that would horrify you and that don’t usually make it into the press.  More often, I see neglect, endangerment or psychological abuse that doesn’t rise to the level DHR is willing or able to address.  I see children forced to breathe smoke fumes all day, who wheeze and cough their way through life.  Children who never so much as enter the same room as a vegetable, so that they are deprived of cancer prevention while their bodies are in a state of most rapid growth.  Children left behind in our dysfunctional school system because we refuse to contribute enough resources to educate them properly.  Can I ask DHR to round up every adult voter who blocks taxes for schools?

Progressives can be just as culpable.  We fight legislation that might protect children from permanent neurologic damage in the womb (such as from exposure to drugs) because it might cross the line into outlawing abortion.  We neglect to consider the emotional impact on children of unregulated free speech, in media such as violent electronic games or manipulative advertising targeted directly at them. Some of us focus exclusively on the needs of children and ignore the needs of their parents and community, although children cannot be truly healthy in a neglected community.  The American Academy of Pediatrics does this by supporting universal healthcare for children without including the adults who care for them. 

Children are not special because they are cute.  They evolved into being cute and appealing to us because they are critical to our survival as humans.  That’s not how I think of them, of course—I have that same biologically driven protective, nurturing and “aww” feeling towards them that most of you do.  I had a toddler in the office a couple of weeks ago who, when told by his aunt “I love you”, responded “I love you more.”  Whereupon she spontaneously told this gorgeous boy “You can have anything you want that I own.  Just ask.”  He didn’t know what she meant, but I do—I wanted to give that baby the moon.

Children need extra protection by the law because they are helpless to assert themselves against poor adult choices.  There is no way possible for the police and DHR to tackle the majority of endangerment, abuse, and neglect.  They can take only the worst cases. 

Our current murky, vague treatment of child rights has created a milieu where corporations and celebrity and even football are given more priority than our nation’s children.  It’s a breeding ground for disaster.  We can do differently.  A good start would be ratification of the UN Convention on the Rights of the Child.  If you are not familiar with this document, please take a look.  Pick one of the elements and commit to working on it in some way.  Examine your own politics closely and see where you may have let any other principle supersede what children need to thrive.  Report abuse to the police—report social conditions that perpetuate it to your communities and elected officials.  Then you can earn the right to say, like a pediatrician friend of mine says when asked if he is a Democrat or Republican, “I’m in the Children’s Party.”