Category Archives: 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

The Truth Hearing Report: Testimony on Healthcare


As promised, I am reporting back to you about our Truth Hearing held July 31 in Huntsville, Alabama.  It took a little longer than I anticipated—I wanted to be sure you could view all the video segments for yourself.

 

The purpose of our event was to obtain direct testimony from members of the public about difficulties getting necessary healthcare, without adding political commentary that might close off our thinking in regards to solutions.  In that spirit, I am going to provide limited commentary of my own and trust you to form your own opinions.   This will enable you to share it with friends across the political spectrum.

 

We had a few technical glitches—this was definitely a learning experience, and we will know better next year how to avoid similar problems.  I hope to do this event annually, so we can learn what is happening as our healthcare insurance environment changes.  Our volunteer videographer had a broken camera on the day of the event and so was unable to help.  I have to thank my husband, who stepped up to find and hire Brian Pitts of Pinnacle Video Services (does legal video depositions) at the last minute.  The sound was not as good on the first segments, and fortunately Brian realized there was a problem and fixed it.  My friend Sara Crocker and her husband Charlie also volunteered to video, and I used their broader angle for the opening segment. 

 

Here is the opening.  We invited several elected leaders—of those, Representative Laura Hall (Alabama Legislature) and Kenny Anderson (representing Mayor Battle) attended.  Dr. Richard Showers of Huntsville City Council had planned to come but was unable to do so.  Our two US senators, our County Commissioners, US Fifth District Congressional Representative, Regional Health and Human Services Office (will run our state Exchange), Alabama Medicaid Office and Governor’s office declined to attend. All were given the option of attending in person or selecting a proxy.

 

Community leaders who rose to fill the empty chairs:  Benard Simelton (Alabama NAACP President), Sara Crocker (Huntsville’s Human Relations Commission), Ann Denbo (board member National Alliance on Mental Illness, Alabama), and James Robinson (GLBT Advocacy and Youth Services). 

 

I counted 52 in the room, although I may have missed a few who entered after the beginning.  By sharing this blog with your friends, you can help keep attendance at our event growing.

 

I’m going to present the speakers somewhat out of order, in case you only watch a few, because it took us a bit to warm up to more personal stories. 

 

Bonnie Roberts, a fellow poet, told me later she had never imagined she would cry and was not looking for sympathy.  I am grateful that she did feel moved to share her deep feelings with us.  As you will imagine after viewing the video, she received offers of help (and help) after the event—she wanted most for you to know that she is by no means the only person in this situation.  Her story, to me, shows that for extreme medical expenses, most of us even with good jobs will not be able to plan well enough to avoid severe financial consequences.   It’s also a reminder that you may know people who need help and who will not tell you about it.  They are ashamed. Most of us want to be self-sufficient and to be givers, not receivers.  By talking about her situation, Bonnie is giving us valuable information—could this happen to us?  What would we do?  How would you respond to a person in her position? Bonnie has insurance—Medicare.  It did not keep her from having medical debt and ongoing medical expenses so high that she runs out of food at the ends of months.

 

Benard Simelton, in addition to serving on the listening panel, read Callie Greer’s testimony about her daughter’s death from cancer.  Callie so much wanted to attend herself but was unable.  I am grateful that she sent us her words and to Benard for reading them. Callie’s daughter was uninsured—she was sent home from the ER with early breast cancer, no physical exam, and a prescription for pain medicine.   When you hear it said that uninsured people can always get free care from the ER, this is the story you need to remember. 

 

Thomasin Cates told us how her insurance tried to refuse authorization for surgery to remove a football-sized, life-threatening tumor from her chest by saying it was cosmetic.  This sort of thing is more common than you’d think.  Here is the description of the policy that will form the benchmark for Alabama’s Exchange coverage—note page 41 where it says coverage excludes services “we determine are not medically necessary.”  All insurance policies I’ve seen have this clause.  All insurers I’ve worked with drag their feet and deny coverage with it, even when they know they will eventually have to give in.  During that foot-dragging time, illnesses can progress irreversibly.

 

Alix Morehouse has two stories, first about herself and then about her son.  She describes a classic Catch-22 in our healthcare system—she needs insurance to have surgery done which would allow her to work at a better paying job—with insurance.  She could probably get disability—but she doesn’t want to be disabled.  She wants to work.  Her son, who is insured, has had ongoing treatment for precocious puberty denied because the insurer dropped the only drug off their approved list and no longer covers it.  During the appeals process, his disorder has progressed for lack of treatment.  I am seeing more of this problem in my practice—dropping effective treatments off the formulary.  Alix’s son has an insurance card that is broken.  How many of us have broken cards and don’t know it yet?   How will we know?

 

Margaret Melton, who is insured, tells us how insurance rules have created barriers to getting her kidney stones diagnosed and treated and interfered with physician practice.  Her physician has told her that her insurance won’t “allow” primary care doctors to get diagnostic testing for the stones, only specialists.  I can’t speak to this, since I’ve not encountered it for stones—I wonder if the issue has to do with the red tape of getting prior authorizations for CT scans and if her doctor is tired of wasting time and getting denied.  It certainly does happen with me in my own practice for treatment of minor depression and ADHD, where many insurers will not certify me to do what I’ve been trained and licensed to do.  These children must wait for a psychiatrist appointment instead.  Bottlenecks occur at the specialist level, delaying care and saving insurers money.

 

Robert Partlow tells about his struggles to care for his wife through her serious illnesses.  Despite their attempts to be proactive, he and his wife have felt shut out of the process of choosing treatments.  She is now in a nursing home 100 miles away from him. What would have to change about our healthcare system to be more respectful, responsive and inclusive of the Partlows and others like them?  Have you encountered this access barrier of a different sort—inability to find meaningful care where your wishes were sought out and respected?

 

Don Ramsey tells about his difficulty getting healthcare, and his relief at learning he could get high quality care through the VA.  I appreciate his enthusiasm and desire to let others know—certainly any veteran who is eligible should take advantage of the care.  Unfortunately, about 1.8 million US veterans are not eligible for services through the VA.

 

Meg Tilden struggles with insurance that barely allows her to cover her costs and tells of her efforts to help others in our community with their healthcare.  She has encountered the world of Medicare Advantage insurers recruiting patients who then learn that their existing physicians and medications are not covered.   More competition without transparency means more confusion, and healthcare is not like a toaster we can return if it malfunctions.

 

Finally, John Jeter, who was actually the first speaker at the Truth Hearing, tells his story of being diagnosed in his youth with Type I diabetes. Good quality healthcare and personal responsibility have been critical to his survival.  Mr. Jeter puts his medication and hospital charges under much deserved scrutiny and offers his thoughts on healthcare reform.

 

In closing, I want to thank everyone who attended our hearing and who volunteered to help.  We had volunteers to run the sound system, to set up/clean up and to welcome guests.  This event would not have happened without them.  

 

Now you have attended our Truth Hearing.  What did you learn?  Did anything surprise you?  How can we do a better job informing each other of healthcare in the trenches?  What could we do differently, armed with the truth?

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Filed under citizen responsibility, Healthcare reform

The Light of the World is in You: It has not been Overcome


When I was 4 years old, I announced to my family that I was going to “be a doctor when I grow up.”  Why?  Because my preschool friend’s father was one, and I thought he was cool.  At age 49, 18 years into practicing pediatrics, my reasons have of course entirely changed.  I may or may not have grown up.

 

The same thing has happened with my advocacy for single payer.  When I started this, I was (in hindsight) incredibly naïve about the political world and the forces of power at play.  I did not have an inkling of how easy we are to dupe and manipulate—how our emotions can be hijacked by a researched phrase or just a word, and how we can imagine the resulting confabulations are our own.  I had spent decades in school and then working out the intricacies of how to take care of patients in the exam room.  I thought I was keeping up with politics the whole time, but I had only a very superficial grasp.

 

So when I heard about Medicare for All the first time, having been in practice long enough to be distressed by the strange abuses of economic power in medicine, I felt as if I had “come home”—that this was a beautiful solution to our problems and that all I had to do was make sure everyone understood it well enough to insist we have it.  It felt like a religious conversion must feel.  Everybody in, nobody out!  What could be better?

 

Don’t panic.  I’m not giving up.  It’s just that my reasons now are entirely different.

 

The first time I spoke publicly on healthcare reform, I was terrified before standing at the microphone.  I had never been a natural public speaker and used to have a tendency to be shy.  What happened, right as I opened my mouth, seems to have been lasting, because I’ve never been afraid of speaking since.  As I looked out at the audience, I could see who was there supporting the cause, who was uncertain, who was ready to give me what-for—and all of the sudden, I realized I loved them.  Instead of wanting approval or love from them, I felt an deep sense of compassion and affection in my heart, for them.  I thought, “Look how hard we are trying to get this right.”  I wanted to do my best job to pitch my lot in, not with only some of them but with everyone there.

 

In the years afterwards, I have slowly learned more about politics, power, and human nature.  I’ve given up the Democratic party, many subtle forms of utopianism, the myth of progressive evolution of our species, and the hope that single payer would work here the way it has in other countries.  I’ve given up my school-girl belief that our government is in any way composed of “we the people” and realized that both self-described conservatives and liberals are pawns in a game we will probably never fully understand, both seeing some true problems in each other but neither seeing our own.  At the same time, I know that because I’m human too, I am most certainly under the influence of wrong ideas I also cannot see.

 

The extent of entwinement of Capital in our governance is now so tight and the wealth and power disparities among us so gaping that I no longer think any of the traditional routes of change, using civilized and orderly processes, will do anything to influence our course.  Even social issues like marriage equality are probably not shifting for the reasons we think.  As we enter into more and farther reaching global trade agreements, it will become progressively less important for Capital to worry about keeping us pacified, and the disconnection of our votes from policy will become more apparent.

 

In this setting, I have to agree with my conservative friends that handing over health insurance financing to the government sounds suicidal.  We will get single payer, friends—when Capital has worked out how they can do it and still profit.  So it won’t be the same egalitarian and high-functioning system we’ve seen elsewhere.  On the other hand, our health financing is already under the thumb of Capital and Unelected Governance.  And we already all pay for the whole thing.  We are, right now, in it together.  We just can’t see it, and those running the show don’t want us to.

 

Some of my friends think the order of change needs to be campaign finance reform, a third party, an amendment to remove the personhood of corporations—then Medicare for All.  I toyed with those ideas, but I think now it is impossible. If we got those things, it would be in name only.  Real change of that sort would be too unacceptable to Capital. 

 

Throughout history, when great wealth and power disparities have become intolerable to the masses, the result has always been revolt.   Disparities are destabilizing.  Utopians for the underdog arise (often highly anti-intellectual), power is overthrown, and the whole cycle starts again.  The problem is that now the tools of battle have changed.  I do not believe the planet can survive the process of another American Revolution or Civil War.   And even if it did, unless we have learned to see each other differently—the way my perspective shifted when I looked out at that first audience—there would be no point in revolution anyway.  It would be palliative care, hospice for humanity.  Eventually we’d wind up right back here.

 

If there is no escape from malign power, what then?  I support single payer, because I think there is a ghost of a chance that seeing ourselves with a common purpose—a decent healthcare system—might help us also have different eyes for each other.  It is a tremendous long shot.  I don’t expect or want Utopia to result—just a little moderation of the divide between us.  I don’t see that we can pursue entire withdrawal of energies into small communities and let government pretend to drown itself in a bathtub.  That’s just a word game, and we are the losers.  The power won’t release us—it will just change its name.

 

What else?  Insurance reform, even single payer, can’t possibly be a whole response to the brutality of our healthcare system.  Not knowing how on earth to make a difference in this mess, I keep coming back to the one thing I can do, immediately and every day—practice love.  Love is the ultimate subversion to power and Capital.  Power has no idea what the hell to do with Love—it has no weapons or means of control against it.  If you want to love, no one on earth can stop you.  It isn’t real love, though, if it only applies to those who accept your particular ideology.  Love means, in whatever circumstance you find yourself, whether that’s on Facebook or facing a room of the “enemy”, that you refuse to play by the rules of labels and stereotypes.  For us, right now, we can say “everybody in, nobody out.”

 

Some of my friends in religions believe in a Utopia where the powers of good triumph over evil, finally and definitively.  I don’t.  Neither do I believe in the converse.  I’m not a supernaturalist, and if I use the word God I am speaking metaphorically.  The most resonant words in the Bible for me are “The light shines in the darkness, and the darkness has not overcome it.”  Not the light burning up the darkness.  Just shining on in spite of it. At the end of the world, even if we annihilate ourselves, in our last breath and heartbeat, we can keep that light of love, our stubborn kingdom of heaven, on fire. Amen.

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Filed under citizen responsibility, Healthcare reform

Truth Hearing: Your Help Needed!


Now that I’ve finally done worrying with and studying for my every 10 year board recertification, it’s time to get busy for a more important project: Truth Hearing.  On July 31, the day after Medicare’s birthday, I have reserved the big room in the Huntsville Main Library from 6 to 8 pm.  I will invite local and state leaders to sit on a panel of listeners, while members of our community testify about their personal experiences and difficulties accessing healthcare.

 

Healthcare Now came up with this idea several years ago.  I only learned about it recently and thought it sounded just right as a project for North Alabama Healthcare for All (NAHA, our chapter of Physicians for a National Health Program).  In this Truth Hearing, leaders will be asked only to listen—not to question us or respond with canned speeches.  Of course, I expect many of them will want to hang around afterwards for conversation, and that’s fine.  But I don’t want any of them using this as a chance to push their own agendas.  There will be no PowerPoint presentations or speeches.

 

Just us, telling our stories and listening to each other.

 

There is an onslaught of propaganda from every direction, and not only from Fox and MSNBC or other media avenues.  We have let ideologies, stereotypes and sound bites invade us on our Facebook pages and in everyday conversation.  Reminds me of wearing designer clothing labels and paying to advertise someone else’s product on our rear ends.  It’s high time to unplug our ears, rip off the labels, and find out what is really happening, in the homes of those we share our weather with.  Not only that—we need to do it repeatedly, at least once a year, to learn what the corporate press and the politicians are not going to tell us.  As the ACA rolls out, we should be sure to learn the real effects of turning our health over to the unelected governance of private insurers.

 

I know it won’t be a random sample.  Sometimes it seems ridiculous that we respond so intensely to stories, statistics be damned.  But maybe we can put our story-loving selves to good purpose.  A story of injustice, with a face and a voice, can be a tipping point—if not for social change, it can change us on the heart level, and that’s where real healthcare reform needs to begin.

 

To do this right, I need some help.  Our core membership for NAHA is very small, and I am not a great organizer.  I hope some of you can pitch in for this event.  I want to fill up those 200 seats.

 

This week I am going to send out invitations to listening leaders.  I’d like your feedback on the composition of the panel, which I think should be no more than 10 to 15 people.  Each invitee will be allowed to send a suitable proxy if unable to attend—failure to appoint a proxy will result in an empty chair with a name card.  Here’s my working list:  2 members of the Madison County Legislative Delegation (one from each party); 1 member of City Council; 1 member of the Madison County Commission; the Mayor; Mo Brooks; our two Senators; our Governor; our regional Health and Human Services director Pamela Roshell (because our Exchange will be run by the fed).

 

I need two people to help with coordinating audio services with the library.  I have paid the fee out of my pocket to reserve the room and will also pay to rent the microphones/ speakers, but I do not have a free day between now and July 31 to get trained in using the library equipment.  I think two people willing to commit to that would be safer than one.

 

I need helpers to sit up front, to be ready to stand with those who want to testify but are anxious about standing alone.  Needs to be folks who are comfortable holding hands with strangers if asked.  I need greeters at the door to welcome attendees.

 

I need help with getting the word out.  I will have a flyer ready by the beginning of July (although if any of you are good with catchy artwork, your help is very much welcome), and I need people who will commit to sending it out by email, posting it around town, and pestering their friends to come.  I need help making contact with press, so we can get coverage.  I know a fellow who has recently started working with Story Corps at NPR and will ask him if he might want to attend, in case he would like a follow-up interview with a family. When I have the flyer ready, I will also put an event page on FB and ask you to share invitations with friends.

 

I need 2 camera people (with equipment) to video the event, so we can put coverage on YouTube afterwards.  Those testifying will be asked to sign a release, although we will have an option for those who desire not to be recorded to have either only their voices heard or to be omitted from the video completely.

 

I need people willing to tell their healthcare access stories—not their political solutions or problems but the stories of what actually happened to them because of difficulty getting healthcare.  It would be ideal to have at least 12 committed in advance, since each person will have 3 to 5 minutes to speak. I know talking about personal health and financial matters in public can be difficult. Heck, public speaking on anything at all can be scary!  We are ready to stand with you.  We need a few brave souls to tell the truth—the whole point of a Truth Hearing.  You are certainly welcome to omit the specific details of your medical diagnosis and focus only on how your life has been affected.

 

I know I’m asking a lot, and all of you have other work to do.  If I don’t get sufficient help, I will play Little Red Hen and do what I can—but if you want a meaningful, effective event, please step up! Email me at pabston@aol.com and tell me what you can contribute.

 

I have been listening to healthcare stories for my whole career.  Families in my office who have suffered the ill effects of being uncared for and rejected by our profit-driven medical system tell me on a daily basis what it is like.  More than anything else, their stories have made me determined to stick with advocacy for Improved, Expanded Medicare for All—everybody in, nobody out.  I have the numbers and knowledge of experience in other countries to back the concept up, but at the end of the day, it is always real people that keep me in the fight.  Will others in our audience and on our panel be similarly moved?  Let’s listen to each other and see what happens.

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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

Cruelty or Care? The Choice is Yours


Well.  From the beginning, I have been telling you all that the so called “Patient Protection and Affordable Care Act” is neither protective nor affordable to patients.  We can keep the same PPACA abbreviation and call it what it is:  The Profiteering Protection and Affordable Cruelty Act.  Although I read the whole darn thing, I lack a background in law or politics.  As the specific corporate protections emerge from this convoluted mess, I have to say I didn’t foresee some of them.  I knew it would be bad, just not all the details of said badness.

 

The latest in our story of woe?  Insurers and some employers have discovered an irresistible loophole that allows skimpy policies covering only a few outpatient services.  The key phrase is “minimal essential coverage”, previously defined in federal law under the IRS Act of 1986.  I noticed some folks had conflated that term with “essential health benefits”, but EHB are mandated items on state Exchange policies starting in 2014.  No plan will be allowed to put lifetime or annual dollar limits on coverage, but outside of the Exchanges, other details of minimal essential coverage are minimally described.

 

I think I was fooled by the ACA’s opening paragraphs allowing insurers to temporarily restrict annual limits on essential health benefits until 2014.  I missed the absence of any requirement to offer those benefits at all, at any date, except on the Exchanges.  Insurer can’t restrict annual dollar amounts of those benefits if they are offered.  In a stunning twist on catastrophic coverage, it is possible for insurers to cover only the required preventive services and omit the catastrophes.  You can get your colonoscopy “free” if you have a non-grandfathered plan, but any follow-up surgery is entirely on you.     

 

The most minor effect is that employers who offer bare-bones policies and employees who get them are exempt from the ACA penalties.  I see some reference to this loophole only applying to large employers, but I don’t know how that was determined.  I don’t see it in the IRS code that I found, which includes as minimal essential coverage “B) any other plan or coverage offered in the small or large group market within a State.”—it may be elsewhere.  It seems to me it would apply to any size group policy offered outside of the Exchanges. If one of you can find me the relevant law making this only applicable to large employers, I’d be grateful.

 

The worst effect is that employees who have minimal essential coverage are not eligible for premium subsidies on the Exchanges, as far as I can tell.  This also seems to be the IRS’s interpretation: “A month is not a coverage month for an individual, and thus no premium tax credit is allowable for the individual’s coverage, if the individual is eligible for minimum essential coverage other than coverage offered in the individual market for that month.” If you can show me in the law itself or in administrative policy how it can be read otherwise, please post a link.  Maybe the IRS can do some creative adjusting.  Generally their creativity seems to apply only to corporations.

 

How many employers will use these plans to avoid penalties and thus apply this affordable cruelty to their employees in the process?  You know it will start with those who already pay poor wages.  As healthcare costs rise, don’t be surprised if you get this offer you can’t refuse in your own benefits package.   

 

Do I have grounds to put the word “cruelty” in place of “care” in the ACA?  The law is no longer new.  It is now part of our healthcare system.  I don’t know what else to call a system that not only allows but entrenches the abuses I see in my office.  Children who desperately need skilled child psychiatrists but whose insurance does not have a single child psychiatrist, skilled or unskilled, on the panel.  Children who don’t get the care they need because their parents delay over co-pays and deductibles.  Parents who work long, hard hours at low pay, producing goods and services we use without gratitude or notice, whose “non-emergency” pain goes untreated because of money.   Who try to smile at me in front of their kids, as if it doesn’t hurt, but cry when I take them in another room.  I refuse to make excuses for this awfulness or play around with euphemisms.  Cruelty, brutality, callousness—many words apply, and none of them is “care.”

 

I can hear the defensive talk already, from people who won’t be able to believe their beloved party would intentionally expose us to this treatment.  It was an oversight, right?  The law is complicated.  We missed this problem, and they did too.  We have a bumbling, well-meaning but hapless government, like a dog that’s so ugly it’s almost cute.  Don’t buy it.  Somebody had better ask what the President and insurers knew and when they knew it.  Remember the industry was mighty cozy with our Executive Branch during construction of the law.  Is it just now that this minimalist option has been discovered?  Or is this a convenient time for discovery, well into the second term?  Will we allow the President to wash his hands of the disaster and pretend he never imagined anyone would behave so?

 

What will it be, folks?  Do you want to keep trying to pass legislation to close loopholes, even though the insurers are always one step ahead?  How long will you continue to support and vote for people who cater to them?  When will you finally say “don’t let the door hit your butt on the way out”—and insist on real insurance and real representation?

 

Improved, expanded Medicare for All is a simple, achievable, affordable, practical next step.  It doesn’t require revolution, utopia or socialism.  Even conservatives can embrace it.  We have the structure in place.  We are only waiting for you.  Will you speak up?

4 Comments

Filed under citizen responsibility, Exchanges, Healthcare reform

Redefining Affordable: The Future of Health Insurance Premiums under the ACA


In a move that goes beyond redefining the word “is”, the IRS has released its final rule on what will be considered “affordable” premiums for families.  Although you will not be on the hook for a tax penalty if the premiums for your entire family exceed 8 % of your income, an increasingly common problem, you will not be eligible to purchase a subsidized plan on the coming Exchanges as long as your individual premium for your employer plan is 9.5% or less of your household income.

 

Do you see where this is going?  Let’s say your employer really doesn’t want to pay the wrist-slap penalty for failing to provide you with an “affordable” insurance option.  So she finds a policy that costs exactly 9.5% of your total household income, which includes your spouse’s two part-time jobs.  You have two children, and your spouse’s jobs don’t include benefits because they are part-time.  Could a policy covering all four of you cost 38% of your income?  I used to have an option for individual or family coverage through my employer, but now there are premiums based on number of persons in my family.  Even those of us with decent incomes are going to be hard-pressed to come up with that money, and remember—this is only the premium.  It does not include the “cost-sharing” of co-pays, deductibles, and non-covered services.

 

For low-paying jobs, where it would be hard to find a policy that meets the criteria of essential health benefits for 9.5% of salary, look to insurers and the feds to get really creative finding loopholes.  Less of your body might be essential than you now imagine.  There are already waivers for so-called “mini-med” insurances until 2014.  Do you really believe the waivers will disappear on schedule?  I’m not holding my breath.  Some sort of redefinition is probably already in the works.

 

If a state refuses to participate in the Medicaid Expansion, your children might still be covered if you are under the poverty line.  Children in families up to 300% of poverty are generally eligible for the SCHIP programs (ALLKids in Alabama).  But what about you and your spouse?  Oh, well, the IRS says.  You don’t have to buy insurance—we won’t penalize you.  You can “keep the coverage you have”, even if it is no coverage.

 

Can you hear me now? As long as private insurers are part of our healthcare system, our health is at risk.  The insurers need to keep our care costs high, so they can rake in their allowed percentages, so there will be little effort to make serious improvements to healthcare that would keep us healthy at less cost—steps like eliminating subsidies for producers of toxic and obesity-promoting foods, getting corporate food out of the school lunch program, repairing the broken FDA, reducing our exposure to environmental poisons, or financing our public health system effectively.

 

Let’s get serious about healthcare reform—we need Medicare for All, now more than ever.  Look at the estimates for taxpayer funding under this system, a pre-paid plan with no co-pays or deductibles.  It’s affordable for ALL of us, no creative re-defining needed.  Medicare for All—everybody in, nobody out.  Look for a chapter of PNHP (Physicians for a National Health Plan), Healthcare Now, or other single payer groups in your area, and find out what you can do to make it happen!  If you are in North Alabama, we’ll be expecting you.

3 Comments

Filed under HHS rules on ACA