Category Archives: Healthcare reform

Medicaid and Media in the Alabama Primary: It’s Up to You


Several days ago, I told you about a false choice in the Alabama Primary—Fake Medicaid with Griffith vs No/Fake/Who Knows Medicaid with Bentley. Shortly afterwards, Kevin Bass released a statement to the press outlining his plan for Real Medicaid, with a copy to me in response to my query, and I passed it on to you. Among the corporate news outlets, I can find only ONE reporter who bothered to follow up, at the Tuscaloosa News. Google “Kevin Bass Medicaid” for the past week, and the first two links are his own, followed by the Tuscaloosa piece, and then my blog, and then… crickets.

Stacy Lee George has responded to me as well:  he said, in writing, “Yes, you can quote that I am in favor of Medicaid expansion, not the private option.” Real Medicaid, not Fake. He is opposing Bentley in the Republican primary.

Google “Stacy Lee George Medicaid” for all time, and the first link is his Facebook page followed by my blog. I don’t see a single corporate news article with any specifics about his plan. Yes, I know Google gives different rankings of results for different users. I wasn’t logged in when I searched, and I got a friend to repeat it under her account—same top results. If you get something different, please tell me.

Dr. Jennifer Marsden, who is running in November for State House District 93, took time to comment on my blog, “I support Medicaid Expansion without tricks or gimmicks and asked the Governor to expand it in person last year (he said no). “ I found only two articles mentioning her Medicaid thoughts in any detail—here’s the other. Neither asked how she would structure the program.

Now, I know I’m not a professional reporter.  I’ve never been paid for a blog piece and that’s fine with me. I sometimes go weeks or months without posting, when my work/ family schedule gets hectic. My cross-posts on Left in Alabama do reach a wide audience, however, and my regular blog gets followed by several professional reporters in the state. The first piece on Fake Medicaid got posted on New American Journal, a non-corporate national news site. The information was available for reporters who wanted to find it or who even did a simple Google search.

Even if I had not written about Fake Medicaid, what does this tell you about our corporate media and their role in elections and your policy choices? If you were a reporter, would you have perhaps at least asked other candidates to compare their plans to Griffith’s after he unveiled his specifics? Would you have taken time to educate yourself on the different Medicaid structures and their implications?

If you want others in the state who follow only corporate (fake?) news to know about our Medicaid choices before the primary, it is up to you to spread the word. To exercise choices, we must be aware choices exist. Will you be the media? And will you financially support non-corporate sources like LIA and New American Journal?

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Filed under Alabama Politics, citizen responsibility, Medicaid

Alabama Medicaid and the Primary: Follow-up


I posted two days ago to alert you to Parker Griffith’s plan for Fake Medicaid and to suggest the choice is not between that and fake/no Medicaid from Governor Bentley. There are other candidates, and there is also the possibility of strong pressure convincing Griffith or Bentley to change course if you get busy.

Because I criticized the plans or non-plans of those two, I think it is only fair to let you know about the press release from Kevin Bass yesterday, especially since the corporate media have not mentioned it.  I agree with everything he says, except the part about Fake Medicaid being a Republican plan.  Where these plans have been adopted, it has been in large part due to Democrat support, based on a false choice. I’ll repeat that it isn’t conservative at all, nor is it a better-than-nothing compromise of liberals—it is just a plain scam.

I don’t plan to participate in the primaries.  I don’t support the overall agenda of either party or their general non-responsiveness to voters.  I’m sticking with my intention to support decent independents or write-ins in the general election, and if you want to argue with me about vote-wasting, look me up on Facebook.  If enough of you put your foot down that way, we could see much better choices on our ballots. I do most of my political participation between elections.

I’d love to see a guy like Bass run as an Independent, and if he ever does, I’ll likely vote for him and campaign for him.  If I were a Democrat, I’d vote for him in the primary.  I’ve put a query in to Stacy Lee George in the Republican Primary regarding his position on Medicaid—he’s said publicly he is for the Expansion, but he hasn’t given specifics.  I’ll let you know what he says, if I get an answer.  I can’t even find a website or FB page to contact Bob Starkey, so I don’t suppose he is a serious candidate.  Please let me know if you learn otherwise.

Here is an excerpt from the Bass press release:

“Parker Griffith’s plan to pay third-party insurers to run an expanded Medicaid program in Alabama would waste Medicaid funds that otherwise could be – and should be – used for medical care and could subject them to fees that would discourage them from seeking care, charges Kevin Bass, Democratic candidate for governor.

‘Democrats have challenged Gov. Bentley’s unacceptable refusal to expand Medicaid,’ Bass says. ‘But instead of trying to maximize the funding available to our citizens, Griffith wants to let private insurers line their own pockets by spending as little as they can get away with.’”

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Filed under Alabama Politics, Healthcare reform, Medicaid

Fake Medicaid or No Medicaid? Don’t Buy It


Governor Bentley has persisted in failing to offer hope for the uninsured poor in Alabama, through a Medicaid Expansion or otherwise. Behind the scenes, various insiders are passing rumors not to worry—he really will do it… after the primary. Or after the general election. If the rumors are true, the plan is to apply for a “private option” style Medicaid waiver similar to programs in Arkansas and a handful of other states, and he is making people wait for his personal political interests, without regard to their present needs. If the rumors are not true, one can imagine he might benefit from public perception that he is simultaneously accepting and declining the Expansion.

One of the candidates in the Democratic Primary, Parker Griffith, got supporters by promising to expand Medicaid. Now he has revealed his grand idea: private option Medicaid, the same type of program Governor Bentley is/is not planning.

Except it isn’t such a grand idea.

Private option Medicaid is Fake Medicaid. One writer called it “Conservatives’ Awful New Medicaid Ploy”—and it isn’t even conservative. It is just a way to siphon off federal and eventually state money into private pockets, away from providing needed healthcare. Instead of simply directly adding people to the existing state Medicaid program, to be funded mostly by federal money and with generally about 3% overhead, it uses those funds to purchase private insurance at significantly higher overhead and for profit. It’s a skillful bit of flim-flammery to convince conservatives that this is anything but a scam and liberals that it is the only choice—fake Medicaid or none.

These “new” – what scam is ever really new?—programs don’t just eat up healthcare funds.  They have to limit health services to turn a profit. How?

By charging people with no money premiums and/or co-pays, so they will be discouraged from applying at all or seeking care if they do. You may think $35 a month for a household premium isn’t much—if you do, you aren’t likely poor enough to qualify for Medicaid. Even $3 can mean the difference between filling a prescription and skipping it.

By adding “wellness programs” of no proven cost-savings, an additional time charge for workers without sick leave. See page xix of a large analysis on workplace wellness programs by Rand: “[w]e estimate the average annual difference to be $157, but the change is not statistically significant.” This doesn’t mean $157 isn’t significant—it means the $157 “difference” is most likely due to chance instead of a difference and could just as easily be a $157 loss.

By charging a fine for coming to the ER for a non-emergency, instead of making sure all patients have 24-7 access to primary care and developing better ways to triage and redirect patients to appropriate settings. By charging $50 for the crime of being sick enough to be admitted to the hospital.

Already, just a few months in, Arkansas is finding out how much this fake Medicaid is going to cost them.  Are we really looking to follow their footsteps? If you haven’t read Confessions of an Economic Hitman, I highly recommend it. I suspect we are currently the target of the same strategy used to bring developing countries into debt, except this time it is on our own soil.

Both Bentley and Griffith were practicing doctors. I find it hard to believe they are completely unaware of the harm a private option Medicaid could do to patients and our state’s economy. Even so, it may be worth your time to tell them.

For those who have decided the fake option is better than nothing, it might not be so. Once people get their Medicaid cards, they will no longer be able to visit free clinics, get charity care, or apply for patient assistance programs for medicines. I am not sure how to predict whether on balance more people will be better off. I can say with a fair amount of certainty that a good many people will be actively harmed. Sometimes a false front for a good thing is actually far worse than nothing.

Fortunately, there is no reason to believe the choice is between fake Medicaid and nothing. We have more options. We can support candidates who are supporting the real Medicaid Expansion. Democrats could consider taking a look at Kevin Bass in the primary. Those who are determined to support Griffith could put pressure on him to drop the fake Medicaid idea. Republicans could put Bentley on the spot, and decide not to support someone who is/is not doing—hasn’t done— anything specific to address un-insurance and its economic damage to hospitals around the state. You can speak up against wasting funds in a fake program.

In that same vein, there’s no real reason we need to keep putting ourselves in the position of choosing between only two parties, between private insurance and nothing, or between all manner of pretend reforms and nothing. Some of you reading this are donating substantial sums or time to a lose-lose game. Are you getting what you’ve paid for?

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Filed under Alabama Politics, Bad solutions for the uninsured, Medicaid

Serious Brain Illness: We Can Tear Down This Wall


Today, on the birthday of Dr. King, what will you do to honor his memory?  I took some time to think about the particular essence of the work he took up, the work that never gets completed and is always necessary.  I’d like to suggest there are two basic elements of that work.  First, we must always bear witness to our shared wrongdoing, by naming and calling out the human-made class, habit and stereotype driven barriers to human potential; and second, we must just as vigorously speak of our capacity for something better, offering each other enlivening glimpses of the possible future, through the yet-to-be torn down walls.

The barrier I want to call out to you today is the one we’ve created for those with serious brain illnesses like schizophrenia and other psychotic disorders.  We didn’t cause these brain illnesses, as best we can tell— they present their own barrier, for sure, but that’s not the one I’m naming. 

The barrier I mean is our special singling out of humans with life-threatening brain illnesses to be left largely without treatment, ignored and even criminalized.   If you watch this video of a man with schizophrenia, homeless due to his illness, being beaten to death by police instead of given desperately needed treatment, and you then learn his killing was not found criminal by a jury, you can see what our created barrier has done.

I had a hard time watching that.  I had to do it in pieces.  I said I wasn’t going to watch, because my imagination was painful enough, and because nothing about this event is actually new or unusual, and because I am a caregiver for a young adult with this same illness, and because I didn’t need another reason to cry about what is happening to sick people.  Lots of excuses, but bearing witness means we have to watch the hard parts.

Now you can take a breath, and I’d like to offer the second half, a glimpse of a future where we tear down the barriers to treatment we have built.  We made them:  we can take them down. 

We haven’t seen substantial national legislative effort to do anything until recently, with the Helping Families in Mental Health Crisis Act.  Representative Tim Murphy, a psychologist, has put forth a game-changing bill that would go a long way towards allowing people with serious brain illnesses to live safely and with dignity in their communities, instead of being consigned to homelessness, jail, and early death.  I have read and thought about the bill in entirety (there are links in the site above).  I endorse it strongly. I am contacting my legislators to request their support.  I believe it will do some work that seriously needs doing.  That’s my short version.  If you’d like to know a few more specifics, please read on and also see discussion of the bill here.  If there are questions not addressed, please let me know and I’ll try to get an answer for you.

Quick Summary of HR3717: Helping Families in Mental Health Crisis Act

This bill would restructure administration of planning and funding at the federal level in a shift towards known to be effective policy and an evidence-based approach to evaluating programs.  Focus would be put on services allowing persons with serious brain illness to stay in their communities while being effectively treated.  Specific parts of HIPAA (health information privacy law) would be modified to allow caregivers to know information necessary to health and safety. 

I have seen criticism of the bill from advocates with milder brain illnesses who fear mandatory treatment would be forced upon them or that choice would be removed from those who have done, as is typically said “nothing wrong besides being mentally ill and homeless.”  I can certainly understand why someone with a mild illness would extrapolate the same ability to think and reason clearly to someone more severely affected and be concerned about the ill person’s freedom.  Indeed, we all might do well to have the level of concern necessary to monitor treatment programs and legal action from misuse.  There will always be a gray zone where assessment of competency to make decisions is uncertain.  On the other hand, we don’t quit giving antibiotics to patients with meningitis just because they are used wrongly for viral illnesses. We don’t shut down hospitals that are needed but are not functioning well, because we still need somewhere to go when we have heart attacks—we fix them. Wait, we DID do that…but only for brain illnesses.

Reading this bill, I would say that if an error has been made, it appears more likely in the direction of slightly undertreating, due to long-standing fears of overcalling brain illness.  The gray zone has been largely excluded. Only those with the most severe psychotic illnesses are addressed by the bill, and some will still be left out in the effort to preserve rights.  Breaking down a barrier takes time and sometimes has to be done stepwise.

As I’ve discussed in prior blogs, those with severe brain illness often present with anosognosia—inability to recognize their illness.  Rational thought is lost due to the illness itself, which renders the choice of treatment or not meaningless to the person.  Paradoxically, mandatory treatment can sometimes restore thinking ability to the point of competency.  Even when that doesn’t happen, treatment increases the chance substantially that the person will be able to live in the community and enjoy the normal rights and potentials the rest of us enjoy.  A person having a stroke will be treated, even though he can’t ask for help.  A person with severe brain illness, whose illness steals his ability to understand why help is needed, is not treated because he doesn’t ask.  Both must be treated in order to access their ordinary civil rights.

Funds Currently Misdirected

SAMHSA, the Substance Abuse and Mental Health Services Administration, would come under direction of a new office, the Assistant Secretary for Mental Health and Substance Use Disorders, as part of the Department of Health and Human Services.  This person would have to be an actual psychiatrist or psychologist with research and clinical experience.  A National Mental Health Policy Laboratory would consult with the National Institute of Mental Health to identify evidence-based policy, implement it, and monitor outcomes.  An interagency coordinating committee would work to integrate all federal work on mental illness and would include representatives affected by brain illness under treatment, family members, and advocates.  Professional peer review would be required for all grants and proposals.

At present, SAMHSA is not administering available funds in a targeted, evidence-based manner.  Priority is not being given to those with the most severe though treatable illnesses and is being distributed to various fluff grants instead.  Sometimes redesigning administrative functions is just window dressing.  And sometimes, that is the only way to shake things up enough to change them.

A few years ago, I was offered a chance to attend a SAMHSA funded training session for healthcare providers on substance abuse screening.  Because I was in the process of helping a group of pediatricians in my state select a screening tool for teens, I registered, hoping I would learn more about how to use the tool.  I had a paid trip to Miami, where I stayed in a fancier hotel than I would ever manage on my own, for a 2 day session targeted primarily at screening and motivational interviewing for basically well people.  Instead of focusing on how we could work with patients ill with serious addiction, the thrust was on how anything more than 1 drink a night for women or 2 for men could be a health risk and how we could help people quit doing that.  Addiction was normalized and thus forgotten.  How many people could have undergone actual treatment for the funds taken to do that conference?  If the restructuring frees up funds to be used well, we can afford to do so much more.  Throwing money at a problem definitely doesn’t solve it when so much goes in the storm drain or gets blown away—aiming and directing money at a solution works much better.

Redirecting Funds: What is AOT?

There would be 50 grants available to establish new Assisted Outpatient Treatment programs (AOT).  AOT is an evidence based therapy to provide monitored treatment of brain illness in an outpatient, community setting.  The requirements are stringent—only those who are not able to provide for their own basic needs due to brain illness, who are likely to substantially deteriorate without treatment, who lack the capacity to make decisions, who have a history of violence, incarceration due to illness or repeated hospitalizations due to non-adherence with treatment, or who present a danger to self or others would be included.  AOT has been determined constitutional in court.  Typically outpatient commitment is ordered for a one year period and can be renewed, but only if the same conditions are still met.  At the court hearings for commitment to AOT, the patient would have legal representation and could give testimony.  No permanent or longstanding sentence is imposed.   If a year seems long, remember illnesses this severe and chronic are not likely to be going away.  And prison sentences for untreated persons are often far longer.

This does not mean the eccentric guy who puts out funky lawn ornaments is going to be held down and given a shot.  It does not mean every person who hears voices, or mumbles to herself in the grocery store, or is disheveled, or preaches on the street corner is going to be picked up by police.  Forget what you’ve heard about mental illness being so common and ordinary—it is not, not the kind covered by this bill.  We don’t have the money to do that kind of thing anyway.

The bill would increase funding for the most serious forms of brain illness and specifically devote a portion to illnesses associated with violent acts, in effort to find more effective treatments.  It would provide for education in schools on signs of brain illness and how to respond.  It would extend meaningful use funding for electronic health records to psychiatric facilities.  Liability protection would be extended to qualified volunteer physicians at outpatient psychiatric clinics.  Funding would be put into suicide prevention programs.

The bill would give grants to establish telepsychiatry programs and train primary care doctors to work in collaboration with psychiatrists.  It would give planning grants to 10 states to establish Federally Qualified Behavioral Health Clinics, which would be required to include child and adolescent trained psychiatrists and staff, training in dual diagnosis (addiction plus another brain illness), rehabilitation services, peer support, and supported education/ employment.   It would fund training for first responders to recognize brain illness and act appropriately to avoid killing the person they need to help or being killed themselves.  It would strengthen funding for mental health courts and veterans’ treatment courts.  It would protect medications from exclusion from state Medicaid formularies.  It would fund inpatient and residential treatment for those on public insurance between age 21 and 65.

Eliminating Obstacles to Sharing Vital Information with Caregivers

For patients being supported by a caregiver, usually a family member, at present HIPAA creates a dangerous barrier to good care.  In order to provide home care that is actually a form of residential, medical care, the parent or other family member must be able to know what medications are to be given, what side effects to look for, what symptoms of relapse are, and how to respond appropriately.  The caregiver must also be able to locate a hospitalized family member and be able to give crucial information to the treatment team.  We ran into a problem with this a few years ago, when we were not contacted upon hospitalization of our family member until he gave consent the next day.  He had been started on a medication that had given him dangerous side effects in the past, and we could have prevented that had we been notified.

The bill would allow only such pertinent information to be shared with caregivers, the same as it would be shared with nursing home staff.  If a person is not ill enough to need a caregiver, this section is irrelevant.  So it does not mean that your therapist is going to tell your mother about your session and what you said about her.

Flaws in the Bill

So, what are the flaws in this bill?  Every bill has them, of course.  These are the ones I see:  non-brain-based language is used throughout—“behavioral” is a particular annoyance.  People with heart attacks are having a “behavior” when they grab their chests, I guess.  The same-old same-old “quality” monitoring measures and incentives are proposed, which are not really measurements of quality care but of less sick patients.  Effective quality improvement can be done, and not like that.  The HIPAA improvements do not, for some reason, include 14 to 18 year olds.  A friend suggested to me this was because state laws regarding minors are so different.  However, at least it would be wise to include caretakers for emancipated minors in the safety-motivated release of information.  There is no provision to require medical information to be given to primary care doctors by psychiatrists, which turns out to be harder to get done than you’d think.  Many states have restrictions on sharing such information, despite it being crucial to safe patient care.  I see a lot of grants and funding which appear temporary, so I do have concerns that states may establish services that will then lose funding.   This is not a reason to avoid beginning, just a caveat that we will need effort to maintain what we start.  I do not see any of these flaws as critical to change before passing the bill.

Today, I have made my very small act in honor and appreciation of Dr. King and his life’s work.   I have called out a harmful, human-made barrier to the lives and dignity of those affected by serious brain illness.  And I have shown you a view of the possible, a better path forward.  Small acts can add up, when we all do them.  What do you see, in place of the barrier?  What will you do to help take it down?

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Filed under addiction, evidence based medicine, Healthcare reform, mental health

Serious Brain Illnesses and the ACA: No Relief for the Weary


As a pediatrician whose patients and their families sometimes develop serious mental illnesses, and as a family member and caregiver, I can tell you the word “serious” is a euphemism, a polite understatement.  I have a friend with stage IV cancer who has received life-saving treatment for many years—she is able to work, care for her family, and enjoy her life despite the fatigue and side effects.  If she were to stop treatment she would likely die quickly.  Her illness is serious.  Treated, illnesses like schizophrenia and bipolar with psychosis settle to the level of serious.  They are not really “mental” either, which sounds as if we are speaking about nebulous, abstract, idea-based problems —they are brain illnesses.  Let’s call them what they are.  Untreated, these brain illnesses are not serious—they are devastating, catastrophic, and deadly.   Those who do not die wind up far too often in prisons unprepared to care for them or homeless, living—if one can call it living—under bridges and in doorways. 

 

Brain illness care has long been the red-headed stepchild of medicine—barely funded when required by law, and far too often, not even then.  For decades, advocates have worked towards parity, the equal treatment of brain and other body illnesses by insurance, only to witness seemingly solid legislation morph into a sieve of loopholes.  Anyone who has watched can testify to the creative genius of private insurers, against whom no legal barrier to patient abuse has so far succeeded.  Prohibit annual or lifetime payment caps and they limit the number of visits allowed.  Require inpatient hospital coverage and see new categories like “partial hospitalization” that don’t count.  Require outpatient coverage and get provider networks at payment rates so low hardly any doctors sign up.  Will the Affordable Care Act (ACA) along with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 do any better?  My short answer is “no.”  For the long version, read on.

 

 

Under the recently released final rules for parity, effective for plan years that begin after July 1, 2014, most private insurances (except for grandfathered small group policies) will have to provide some brain illness coverage.  The exact services covered will vary between states, because of the way the Department of Health and Human Services interpreted the ACA.  By making Essential Health Benefits depend on prior insurance offerings in each state, the word “essential” is stripped of any semblance of ordinary meaning and varies when we step over the state line between Alabama and Georgia.

 

The final parity rules removed an earlier stipulation for insurers to use clinically accepted standards of care for brain illness treatment authorization. If a treatment is recommended by national experts and advised by your own doctor, the insurer does not have to use the same guidelines and can deny payment.  Although plans are supposed to use similar methods to develop provider panels for psychiatric and other medical care, the parity rule discussion says disparate results in the composition of those panels don’t prove there is a problem.  So if your plan does not include sufficient psychiatrists on the panel accepting new patients (a common issue) but has plenty of other types of specialists, you may not have grounds to protest if the insurer can figure out an excuse.  If insurers are only providing certain elements of brain illness treatment in order to satisfy the ACA, they don’t also have to meet the full requirements of parity otherwise. 

 

There may be some relief to states and patients for coverage of court-ordered brain illness treatment, because insurances can’t restrict such coverage if they don’t restrict it for other court-ordered medical services.  For example, if a court-ordered blood transfusion for a child would be covered, then services provided during a court-ordered psychiatric hold should be covered as well.  I am uncertain if insurers will be permitted to exclude the entire category of all court-ordered treatments to evade this element—I do not see reference to this in the ACA itself.  If that is an available loophole, we will certainly see it used.

 

If insurers cover a certain type of care for medical illnesses, such as outpatient rehabilitation or residential treatment, they must now also cover it for psychiatric illnesses.  That sounds good on the face of it— funding is greatly needed for day treatment programs and other levels of supervised care.  Unfortunately, the option is still wide open for insurers to deny or limit authorization for such services based on… well, whatever they want to base it on, absent any requirement for using accepted standards of care.  I expect we will have services mainly in theory, denied in practice by some set of arbitrary criteria.

 

In a particularly odd arrangement, insurers that can demonstrate a 2% or more increase in costs during the first year of parity can request exemption from parity the next year, and afterwards a 1% cost rise gets them a one year exemption.  Potentially, subscribers could have brain illness coverage every other year.  If my friend with cancer got her chemotherapy only every other year, what do you suppose would have happened by now?

 

The point-of-service cost-sharing barriers are substantial under the ACA.  For those with lower incomes who don’t qualify for Medicaid and have subsidized plans, a $30 co-pay might as well be $300 if they don’t have it.  A $2000 deductible or out of pocket limit?  Unimaginably out of reach.  People affected by serious brain illness are more likely to have lower incomes and thus likely to forgo necessary care at a lower level of up-front cost.

 

Some with serious brain illnesses who have not been able to get private insurance due to their pre-existing conditions may now get private policies.  Those under 26 can now stay on parent plans—but will these newly covered persons have access to care?  Having an insurance card is not at all the same thing as being able to get treatment.  At the onset of illness, many already had private insurance that failed to meet their needs.  I have seen no improvement at all in access for my privately insured patients to appropriate care for brain illnesses.

 

For long-standing serious brain illnesses, partly because treatment barriers and gaps have contributed to loss of function, public insurance is common—either Medicaid, for those with SSI Disability, or Medicare for those with SSDI.  I do not see the kind of changes in either of these programs that would be needed to prevent care gaps.  The “donut hole” for Medicare prescription coverage is closing, but there remains substantial out of pocket cost.  There is no parity requirement for payment of psychiatrists in Medicare and payment is low compared to other outpatient services.  Consequently, finding a psychiatrist who accepts Medicare isn’t easy.  In my city, the only option is the county Mental Health Center, already overloaded.

 

Medicaid appears to be affected by parity only if it is administered through Managed Care Organizations or Alternative Benefit Plans.  The Medicaid Expansion, in states that adopt it, will add some with brain illnesses who have not been able to get disability benefits.  The main barriers to care for those with Medicaid are funding, generally severely inadequate at the state level, and commitment laws that hinder timely treatment when the patient is sick enough to be unaware of the illness (anosognosia).   When it comes to strokes and heart attacks, we hear “time is tissue”—the rush is on to treat patients urgently, conscious and asking for help or not.  With serious psychosis, just as damaging to brain tissue if untreated, we bizarrely decide the ill person, unable to make rational decisions, does not want help.   Staffing at Mental Health Centers is limited, wait times are lengthy, and necessary community supports are minimal to absent. There is no move towards building a serious brain illness treatment infrastructure in the ACA.  If care is affordable but not available, patients are left behind just the same.

 

Although Medicaid pays for residential care of those with intellectual disabilities, there is an “IMD exclusion” prohibiting federal matching funds for care in a psychiatric hospital.  This has helped cause deteriorating service quality at state hospitals and made it appear cheaper for states to put those with serious brain illness in jail than to hospitalize them.  The ACA includes a “demonstration project” to pay private psychiatric hospitals with Medicaid funds to provide emergency services in some states. Because private hospitals have higher administrative overhead, proportionately less money may be used for actual patient care than in lower overhead public facilities.  The demonstration project funds are not available for public psychiatric hospitals, although the money is public in origin. Why not use those funds to improve state hospital care and coordinated transition of care to communities?

 

Because milder brain illnesses are more common and seem to garner more popular sympathy than serious cases, I am also concerned about wise use of scarce resources. The ACA does nothing to ensure that priority will be given to those most severely affected, both in terms of initiating treatment and maintaining it.  The spectrum of brain illness is broad, just as for other medical illness.  It is being absurdly stretched to include non-illness ordinary frustrations of life so providers can be paid for their preferred “patients.”   

 

I would not begrudge a person with a mild brain illness appropriate treatment any more than I would a person with a mild asthma flare-up.  Mild problems can become serious without good care.  At the same time, I would not leave a person in my waiting room gasping for breath to see one with a head cold.  I would not stop insulin for my patients with diabetes just because they “look good right now” in order to counsel basically healthy people on how to eat more vegetables.  And that is the sort of mindlessness happening in brain illness care right now—priority is given to the worried well.   

 

Although we have no cure for the most devastating brain illnesses, we most certainly do have multiple proven interventions that can, much of the time, bring those affected to the level of the merely seriously ill.  Treatment reduces the risk of relapse and allows many to have meaningful lives in their communities.  Just as with cancer, brain illness can sometimes worsen even during treatment so that the care plan needs to be adjusted—this can only be effective when care is continuous and frequent enough to catch the early signs of trouble.  Each relapse not treated quickly and skillfully may cause cumulative, permanent, unrepairable damage to the brain.  Treatment gaps in a system full of cost and access barriers can mean death. 

 

Any reform of healthcare that fails to address the needs of people with serious brain illnesses, including their critical need for continuous care with no loopholes or gaps, is a sham, a travesty, and a parody of reform.  I am weary of seeing tragic headlines about those we have failed, when I know we already have the knowledge and tools to do better.  My grade for the ACA on brain illness?  Fail.

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Filed under HHS rules on ACA, Medicaid, mental health

Lost in the Marketplace: Thoughts on the ACA Exchange


Like many of you, I have been unable to apply for an insurance policy on the Marketplace that opened October 1.  That was also the start of “open enrollment” at my work, and I was hoping to see if there was a cheaper option for my family available with similar coverage, even though I would not qualify for a subsidy.  I also wanted to be able to give you more detail about the process and possible pitfalls by trying it myself, since I didn’t have time to train as a navigator.  My window of choice closed for a year, and I gave up trying to log in to stay out of the way of those still trying. 

 

Twice, I got a user name and password and was sent an email to complete the registration process.  Although I clicked the email link as quickly as my fingers would go, within 10 seconds of receiving it and 30 seconds of completing the password entry, the healthcare.gov site said I was too slow—sorry, go back to the beginning and try again.  Perhaps I would have had to grow up with video games to get the required hand-eye coordination speed? Maybe it was a subtle way to get younger, healthy and well-coordinated sign-ups first?

 

It is possible to look at the available plans for a given county without registering—in my county, for an individual/ family policy, I would have a choice of BCBS or Humana.  There is no link within the site to provide nitty-gritty details though.  To get those on your own, you have to apply.

 

I’m going to recommend you work with a navigator unless you are very well versed in health insurance policies.  Be very careful of fraud and check the credentials of whoever you are working with.  Here are some factors to consider.  Remember that the 60% cost coverage on bronze policies and 70% for silver does NOT mean it will work out that way for you personally.  All that means is that for a “typical” subscriber, the insurance will pay 60 or 70% of the total covered services after the premium.  From what I am hearing, the costs to subscribers will be front loaded in the form of significant deductibles that must be paid before the insurance kicks in.  I would advise not selecting a deductible of an amount you don’t have already in savings.

 

If you don’t have insurance now, you may be getting some services from a free clinic, discounted/sliding scale service from a physician or clinic, and/or free medications from a Patient Assistance Program.  I know none of these safety net services is ideal and that people with insurance generally have more options than you have right now.  However, you need to know that once you have insurance, these options will no longer be a plan B for you.  You can’t go to the free clinic on a day when you don’t have your co-pay or co-insurance money unless you are going to lie, because the ones I know of only accept uninsured patients. Your doctor or clinic may not be able waive a part of your co-pay or deductible—that is considered criminal fraud in some cases, against their contracts with the insurer.  Every policy I’ve ever had says, in fine print within the manual, that my policy can be cancelled for breaking the contract if I don’t pay my share through co-pays and deductibles.  So you want to check and see if that is in a policy you are considering.

 

Medication co-pays can add up quickly.  If you are getting 4-5 medications through free Patient Assistance Programs, even if they aren’t the most effective ones for your condition—will you have the funds to buy them? Depending on the co-pay tier, you could be shelling out $150 or more a month. If it is possible to view the formularies for the plans you are considering, and find out the co-pays for your medications, I would recommend it.  You need to know that insurers can change their formularies without your permission and without warning.  If you aren’t in an open enrollment period when that happens, you’ll be stuck with it for awhile.

 

If possible, it would be good to look at the provider networks for each plan, for both primary care and specialists you need, and see if they are taking new patients.  Be careful to note if there are restrictions on laboratories and radiology facilities you can use—I have learned there are a couple of new plans that will restrict lab services to only one company, Quest.  You don’t want to go to a non-contract lab for blood work and find out later the bill is fully on you.  If you see mental health providers, check to see if there is a carve-out policy that delegates management to a sub-insurer.  I’ve been told by a navigator this is not an issue with the plans in our county.  These can be a significant barrier to care, in my experience.  Even without a carve-out, check the mental health provider network and ask if your primary care provider can be included—a critical feature to allow initiation of treatment while you are waiting for a mental health referral.

 

If you are uninsured and have significant chronic conditions already being managed through charity services, you may find out that you can’t afford to switch to insurance even with the subsidy and even considering the tax penalty.  Being uninsured is frightening, because the gaps in charity coverage are tremendous and you never know if you will acquire a new condition and be left without help.  At the same time, you do not want to be left unable to purchase ongoing treatment you already know you need.  You don’t want an insurance card you can’t afford to use.  I have seen this happen many times, in person, to families who had insurance and too much income for their children to get Medicaid or AllKids but not enough to pay for services or prescriptions.  It is a difficult decision—don’t make it lightly.

 

If you have no chronic conditions, you may decide it is worth the risk to sign up for insurance.  That’s the function of insurance, as you know—it is a risk pool, where we enter not knowing who will need to use the funds we add to the pot.  We don’t expect to each get back the amount of services we have paid for with our premiums—we don’t even want to, because that would require illness or injury.  The more healthy people who sign up and contribute, the lower the cost for everyone in the pool, and the more total profit for the insurers.  You could be helping other people in your state more than yourself, or they could wind up helping you. 

 

One thing is for sure—we are all, through the forced wealth transfer in the ACA, helping to line the pockets of private insurers and strengthen their position at the lobbying table.  We are taking a large step away from single payer, a public option and even community level grassroots safety nets by doing so.  Ought we to use much time and energy to prop up a plan with such fatal flaws at the core? 

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Filed under Exchanges, Healthcare reform

Poop Happens: New Rules for Alabama Medicaid


In the ongoing effort to squeeze more juice out of the budget turnip, Alabama’s Medicaid office has revised pharmacy benefits.  There are new limits on the number of prescriptions per month for adults, and for all ages, the program will no longer cover any over the counter medications as of October 1.

 

Were you aware our Medicaid program covered some (not all) OTC medications if prescribed?  After all, most private insurances do not, and neither does Medicare.  This is an optional coverage by states—we don’t have to do it, and now we won’t.

 

 Most of the OTCs I prescribe for kids are fairly cheap—for instance, 1% hydrocortisone for mild eczema is under $5 a tube.  Others are a little pricier—polyethylene glycol for constipation is about $12 to $36 for a one month supply depending on the dose.  For most of us, that’s still less than the typical pharmacy co-pay anyway, so what’s the big deal?

 

You’d be surprised how many families tell me, as they are leaving the office, that they can’t even afford to buy ibuprofen to give their children pain relief, or a thermometer, or a bulb syringe to suction a baby’s nose.  Children with Medicaid live at the very lowest income levels, so sometimes there really isn’t $5 or $10 for an OTC medicine.  Sometimes, maybe there is—maybe the household budget is out of line and maybe that $5 was spent on something you might judge wasteful or frivolous.  The problem for the kids is that whether their parents could budget differently or not, many will simply not get their medications unless Medicaid covers them. 

 

I wasn’t the only pediatrician who thought the change sounded like a problem.  Several of us made lists of the most commonly used OTC medications for which there is no good or inexpensive prescription substitute.  The list was submitted by an advocacy organization to our Medicaid agency, along with an explanation of our request to have an exception for these limited items.  A few days ago we got our answer—no.

 

We are told this is because of federal rebates for prescription drugs, not available for prescribed OTCs.  I understand how that would work in general, but not for everything.  1% hydrocortisone, for instance, can be used sparingly on the face for eczema (along with a thick moisturizer).  Stronger prescription steroids are not a great idea on the face for extended use.  So our next step up from the $5 OTC is… pimecrolimus or tacrolimus, priced online at $150 or more.  I don’t know what Medicaid pays and gets back as a rebate, but I’d be surprised if it isn’t a money loser by comparison to the $5 product.

 

One of my friends out of state suggested the decision may also be related to Medicaid’s possible switch to Pharmacy Benefit Managers.  If we go with third party, for-profit PBMs, they make their profit on our prescriptions and would likely object to any coverage of OTC meds.  I’ve asked around and have not been able to find out if PBMs are a factor.

 

Now I’m going to talk about poop, so if you are eating or squeamish, skip to the end.  Pediatricians are bad about poop talk in front of nonmedical people, even at parties.

 

Constipation is a common problem in babies and children—hard stools that not only hurt but can even tear the anus.  I’m talking blood.  Children are scared to poop afterwards—they expect pain and they hold back, resulting in more stool buildup and more pain the next time.  Eventually, this pain/holding cycle can lead to encopresis—large amounts of hard stool in the now dilated rectum with thinner, liquid stool leaking around it and out into the underwear.

 

Parents may think their children are not wiping or are having accidents.  The kids are embarrassed.  It smells bad.  They get called names.  Whenever I see “train tracks” in a child’s underwear, I know I need to do a rectal exam and see what’s up in there.  After diagnosing and explaining the problem, I outline a course of treatment in which we need to get the poop cleaned out and then keep it very soft, like pudding, for several months to avoid new tears and recurrent buildup.

 

Treatment is almost always successful.  OTC polyethylene glycol, PEG, (aka, Miralax is the best thing going for encopresis—both for the initial cleanout and for maintenance.  It isn’t absorbed into the body—it pulls water into the stool to soften it.  When I was in training, we had mineral oil—a chore to coax children to drink even with heavy flavoring, and there were cases of aspiration pneumonia when the oil got into their lungs.  Then we had lactulose—better accepted than mineral oil but not quite as effective as PEG and rarely with significant side effects, including obstruction of the bowel.  We had various fiber supplements, which helped inconsistently.  For cleanouts, we often had to resort to milk and molasses enemas.  Finally we started using PEG.  Kids will drink it, it works most of the time, and there are minimal side effects.  Life for constipated kids got much better. 

 

Now, depending on the dose needed, families may have to spend as much as $36 a month to keep treatment going.  Some will manage to do it, and others will not.  Say whatever you want about what the parents “should” do—if it doesn’t happen, it doesn’t happen, and the kid will be the one with a bleeding bottom.  Or in the ER for abdominal pain.  The number one cause of abdominal pain in children who visit the ER is constipation.  Untreated constipation can lead to urinary tract infections.  It can lead to CT scans and repeated radiation exposures in the ER.  Sometimes we have to admit children for cleanouts, with PEG dripped through a nasogastric tube.  I have had kids who got so constipated they vomited fecal material, but not since we’ve been using PEG.

 

I know some of you by now are asking why we are using medication for constipation at all.  Isn’t it a crutch?  Why not fix the diet, try juice, prunes, coconut oil, stop all the dairy products, or whatever your favorite home remedy is.  We do!  If you have been in my office with your child and we haven’t talked about diet, one of us has had memory loss.  The problem is sometimes the same as with the cost of the PEG—reality.  The children are not buying their own food.  And to be fair, some parents really do provide healthy food and the constipation remains.

 

Whatever your thoughts about how children ought to be eating, when they get painful constipation or encopresis, OTC PEG gets them out of misery.  And coverage for it is going away for many of our patients on October 1.

 

I don’t know if our Medicaid will track ER visits for constipation or complications like UTI to see if costs go up. Will we save money on medications only to spend extra elsewhere?  I doubt it will take very long for us to see problems in our practices.   I plan to let the state know if I do.

 

 I want the Medicaid money to stretch as far as it can, so that no one goes without needed care.  I appreciate the state’s creative efforts to work the budget.  This particular change is probably not going to be as bad as the limit on prescriptions for adults, which will land some in the hospital (what do we skip this month—the diabetes medicine, the blood pressure medicine, the heart rhythm medicine?), but it will cause some definite problems.  No matter what insurance system we have, even if we had single payer, we would have to think about this type of decision.  

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Filed under Children's Issues, Medicaid