Category Archives: Medicaid

Alabama Legislators Want “Blood on the Floor”: Especially the Blood of Children and Grandparents


Well. I heard from a very credible source yesterday that our state legislators are not playing chicken with the budget this time. You know, it seems like every year they expect us to display panic and beg them to fund essential programs– it is so predictable it is almost like we have a set script. We get tired of it, but at the same time we think jeez, if we don’t play our assigned role, maybe they will do the bad thing.

This year may be different, if my source is correct. Their plan this time is to go ahead and pass a severely cut budget, which the governor will refuse to sign, and then override him. Then when there is “blood on the floor” (and I quote), they expect us to come screaming to them to pass taxes and re-fund the state. They do not feel they have support from their base, otherwise.

I don’t know. From my perspective, we already have blood on the floor. People in this state have been bleeding all over the floor for a long time, and it hasn’t mattered so far as the budget. The only blood I think the legislators care about is corporate blood and their own, so maybe the point is that business will begin fleeing the state once Medicaid is defunct and all the people in nursing homes have to move in with their families or be dumped on the street.

Getting even a level budget for mental health would not be a win, because there is major blood on the floor with our current budget. Getting the expected cut to Medicaid ($320 million, taking the federal match into account) would make the floor downright slippery. The cuts to doctors will be so sharp, around 40% cut to payments already well below private insurance rates, that I have personally heard several pediatricians say their plan would be to immediately drop Medicaid. Most practices have overhead in the range of 60 to 75%, so that 40% is at least the entire salary of the physician. There will not be enough of us left to see those suddenly doctor-less kids, even if we worked 24-7 without sleep. The 2 Children’s hospitals will close, because they depend on Medicaid money to fund their specialists. And good luck trying to get programs like that rebuilt to their current level of excellence, once they are gone. It takes decades.

Who will be affected first? The elderly in nursing homes. Children (guess they should take more personal responsibility). Because people of color are disproportionately affected by poverty, this is also a racist move. Some advocates are making a case by reminding legislators and voters that middle class elderly are in nursing homes using Medicaid funds, and that there are more poor white kids than black ones. Why should that even be said, as if poor elderly and black kids matter less? Only a racist and classist audience would need to be told such things.

I asked it there is anything at all we can do to stop this disaster, and my source told me we need to call our legislators. I’m going to add that you really need to talk to your neighbors, co-workers, etc and explain what is about to happen. Because legislators have told me previously that although phone and email contacts matter, they also use their in-house polling results, which are secret. They call their base on a regular basis to check in, and I am betting they are getting the no new taxes response from those voters.

If our legislators were ethical, they would be calling those voters not to ask their opinion but to persuade them– they would be pulling out the stops to stop the bleeding. They would stop putting forward bills that they know will cause us to waste tons of money defending federal lawsuits. The fact that they aren’t doing so says a lot.

I remember the last time this type of cut was proposed, and the legislators came up with a Hail Mary to borrow money for Medicaid– I had prominent progressive friends telling me that I was just playing the game by begging for votes to save the program– that I should let things play out, let the blood flow, call their bluff. So it isn’t just conservatives who are the problem. I do not believe an ethical person who understands these are not numbers– they are human beings– would promote such an idea. We all have our preferred ideas of where the funds should come from, and y’all, we do not have strength in numbers to bicker over that right now. If we do, we will surely lose the farm. I can say that a lottery would come too late and is not a solution for the current funding gap, which could begin as early as June. Otherwise, I’d support whatever taxes they are willing to pass, even though I’d prefer to stop corporate subsidies first.

My source says the fed will not likely permit our Medicaid program to be cut so much without responding. We could be taken into some kind of Medicaid custody. But… the kicker is that they can’t MAKE us write a check, so this is different from school integration. They can put key decision-makers in jail, they can withhold federal funding as leverage, but they can’t issue money from the state, raise our taxes for us, etc.

All that said, I would still call your legislators. I would tell them that level funding is not enough for mental health and that it is killing people as we speak, because of waiting times. And if you happen to have a job opportunity out of state, you might want to strongly consider it, especially if you have children. I’m going to stay as long as I can, but I do have a disabled adult family member who depends on both Medicaid and me, so there will be a limit. I don’t know how long my employer will be able to keep me, if well over my entire salary is defunded. Feel free to share all or part of this post if you think it will help.

4 Comments

Filed under Alabama Legislative Session 2015, Alabama Politics, Children's Issues, Medicaid

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?

5 Comments

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.’”

3 Comments

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?

8 Comments

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

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.

2 Comments

Filed under HHS rules on ACA, Medicaid, mental health

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.  

5 Comments

Filed under Children's Issues, Medicaid

Alabama Medicaid: a Sandcastle by the Pink Pony Pub


In a little over 6 months, adults in most states who qualify for Medicaid under the ACA Expansion will suddenly have Medicaid cards.  We’ve made no moves towards that in Alabama.  We’ve said to our minimum wage workers, “What’s in your wallet?  Oops, nothing! Hate it for you.”  If you’ve listened to Governor Bentley closely, he has been mighty careful with his phrasing—instead of saying an absolute no, he says he will not agree to expand Medicaid as it is currently structured

 

The legislation to do that was passed and signed, but it will not be fully in effect until October 1, 2016.   However, with the Expansion fully funded by federal money for the first 3 years, the timeline for restructuring would allow Alabama to have the new program in place before we have to foot any of the bill for newly covered persons.  That means we should jump right in at the earliest possible time for the Expansion.  Don’t let Governor Bentley off the hook—he is getting what he asked for.

 

I agree our current structure is a sandcastle by the Pink Pony on the Redneck Riviera, waiting for a hurricane.  It is oddly dependent on overuse of ER and hospital services to draw down extra federal matching money.  Instead of just a 2:1 federal match, we were getting an effective 9:1 match once the money had been recycled in various legal but bewildering ways—and an effort to decrease excess hospital use would have removed funding needed for outpatient services.  So, yes, it had to be revamped.

 

There are some good things in the new design, mainly the flexibility to use funding for nonmedical items that would improve health and keep patients out of the hospitals, like the air conditioner example.   There are also enormous potholes—no, make those sinkholes—in the new proposed design.  I’m not even going to count the number of times the word incentive is used or try to fix that right now.  The only incentive is a perverse incentive, unless it relates to satisfaction in doing good work. But pay for performance is the zeitgeist. 

 

Here’s the big rub: the legislature intends to “transfer risk” to providers and away from the state.  The Medicaid budget is a hot potato they want to throw somewhere else, anywhere else.  So instead of dealing with this risk by increasing revenue, what did they do?  Decide that providers would have to worry about making ends meet, not the state.

 

The law sets up RCOs—Regional Care Organizations—to manage patients within regions.  Each RCO would be given a set amount of money per covered patient – capitation—and then required to cover any needed care.  If medical expenses in that region unexpectedly are higher than the budgeted amount, the RCO has to cover the costs.  The RCO must have a reserve of $ 2.5 million of provider front money in order to be given the contract, so we are not talking about a group of pediatricians and family doctors.  From what I am hearing, mainly hospitals will be the “at-risk” providers.

 

The law says these RCOs are not to be considered insurance companies.  Come on, folks, give us a break.  That is exactly what they are—they will be insuring Alabama’s Medicaid program.

 

Why is this a problem?  Let me count the ways.  First, we have a history of providing insufficient per person funding for Medicaid, because we won’t stop our corporate handouts. We have one of the worst funded programs in the country, 3rd from the bottom in per person spending for Medicaid but 10th from the bottom in overall healthcare spending per person.  Don’t believe it if you hear we are spending too much money on our current program.  Dividing those inadequate funds into RCOs will not help.  If you don’t have enough money in the bank to pay rent, writing 5 smaller checks to the landlord is an interesting thought—but sweetie, I’m sorry to tell you, at least one of those checks will bounce.  The state plans to pass the blame on to the providers for not performing magic tricks. Providers won’t put up with that for long.  They will exit the program and leave patients in the hands of a third party payer, in a system with few remaining physicians.

 

Second, once we turn hospitals into insurers, can we talk conflict of interest?  Faced with a risk sinkhole, our hospital-insurers will be forced to limit services.  I have already heard talk that in one region, children may not be allowed to go to the Children’s Hospital in Birmingham but could be sent to Vanderbilt, because the costs to the RCO will be lower.  I don’t have any problem at all with Vanderbilt and send patients there regularly, but the choice of Children’s Hospitals should not be made on the basis of cost.  It should be based on the skills of the particular specialists.

 

Let’s say that against all odds, we do fund the program fully.  If our hospital-insurers come in under budget, they get to keep the surplus.  Anyone can be corrupted with a carrot like that.  I would far rather have my local hospital put in that position than one of the out of state third party payers like Centene.  But we are all human, and every one of us is vulnerable to perverse incentives.

 

I knew, while this bill was in progress, that there was no way to interfere with the intention to transfer risk.  The legislature was hell bent to do it.  I think now is the correct time for some effort at damage control, because the state has to get a waiver approved before the restructuring can happen.

 

I admire and respect the people running the Medicaid program in Alabama, especially Don Williamson, who has always been a friend to children.  He has taken a bad piece of legislation and is trying to make the best of it.  I think we should help by asking the feds to fix what our legislators would not.  No matter how much they try to wiggle out of the risk, the truth is that all of us who live here share the risk.  A failed Medicaid program will come down on our heads, in failed hospital systems and loss of shared medical services.  So let’s make this work! We need a restructured Medicaid to do the Expansion.

 

 Here is the link to the concept paper submitted to CMS (Centers for Medicare and Medicaid Services).  When the final application is submitted, we will have a 30 day comment period with CMS on their public site.  I don’t know that date yet but expect it soon.  I thought I’d let you know now, so you can study this a little and be working on your comments.

 

Here are mine, so far.  If you have suggestions, please comment.  There may be a better way to design the capitation floor in my first element.  I’m setting the bar at what might sound low to you, the 25th % tile, but it would be higher than our current rate.

 

Dear CMS,

 

As a pediatrician in Alabama who helps care for the poorest children on Medicaid, I am concerned about Alabama’s 1115 Medicaid Waiver application for RCOs.  It is very important for the plan to be approved expeditiously, because the possibility of our state accepting the Medicaid Expansion hinges upon restructure.  However, the plan as it stands will put our hospitals in the position of insuring the state against high medical costs in an environment of historically inadequate funding.  In addition, if adequate funding is provided, the plan creates a perverse incentive for RCO providers (whom we anticipate will be primarily hospital systems) to cut needed patient services in order to retain surplus funds.  I believe these problems can be mitigated by the following:

 

1) Require the state to maintain a capitation payment rate that is never lower than the 25th percentile of per patient cost in the southeast region, to guard against insufficient funding of the program.  A floor on capitation payments is critical to prevent collapse of Alabama Medicaid.

 

2) Require that any surplus funding an RCO does not spend be used for patient-related improvements to services in the regions (not for construction) OR be returned to the state general fund.  This avoids the risk of perverse incentives for hospitals to cut patient services in order to increase their income and allows the state to receive the benefit of any cost-saving.

 

Sincerely,

 

Pippa Abston, MD, PhD, FAAP

Huntsville, AL

 

As always, I want to remind you that we can more effectively cope with the Medicaid funding woes by changing to a much larger risk pool—all of us.  We all share the real risk, so let’s design our system to reflect that.  Improved, Expanded Medicare for All, not Medicaid, is what we need.

2 Comments

Filed under Medicaid, SCOTUS Ruling on ACA