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Progress Notes features doctors and medical students across the country on the frontlines of our health care system. Our views and experiences are diverse, but we share common goals and values. We speak up to move toward a future where everyone can have access to affordable, high-quality health care. Please share our posts, and follow us on Facebook and Twitter!


Screening for Health Insurance Status: A Pocketcard for Healthcare Providers

Back in September 2013, I met with first year medical students at the University of Chicago Pritzker School of Medicine to discuss the ethics of student run free clinics. What could first year students ethically contribute to patient care in free clinics—when they hadn’t even learned how to listen to a heart yet and every pertinent question they asked would have to repeated with an attending? In the discussion, I shared the argument that the most ethical thing first year medical students could be doing in the clinics was getting patients OUT of the clinics. Patients connected to health insurance could get ongoing care with a dedicated provider.

Students at the University of Chicago Pritzker School of Medicine decided to take on the challenge of connecting patients with health insurance. A team led by MS2 Lauren Hobbs and MS1 Margaret Wang took on the task of preparing to train medical students to teach patients about their health insurance options. Along with Loyola law student Rachelle Sico, they supported the creation and dissemination of a pocketcard on Screening for Health Insurance Status. Loyola University medical student Aaron Silver was the main creator of the card, with content and editing support from internist Dr. Ram Krishnamoorthi, and myself.

It is an awesome card that I am proud to be able to share with healthcare providers.

 

The card is broken into four segments:

1. Why is insurance important?

2. How do you screen?

3. Frequently asked questions about the Affordable Care Act

4. Income qualification table for Medicaid and subsidies

 

 

To summarize:

1.     Being uninsured or underinsured puts you at increased risk of bankruptcy, stress, and death from cancer. Over 50% of personal bankruptcies are from medical costs. People without health insurance are five times more likely to die from cancer. Not having health insurance slows specialty appointments and expensive imaging, delaying care.  An estimated 26,000 people die each year from a lack of health insurance.

2.     Health care providers can screen with a series of three simple questions: do you have health insurance? Are you happy with what it covers? Are you happy with the cost? A no answer to any of these means you should recommend patients check out their options either on the federal or state exchanges. Healthcare.gov, or in Illinois, GetCoveredIllinois.gov. They can also call hotlines to find out how to get connected to a navigator. In Illinois, 1-866-311-1119.

3.     Pretty much everyone must have coverage by March 31, 2014 or pay a fine. The exceptions are undocumented immigrants, and people who are too poor to qualify for subsidies on the exchanges in the states where Medicaid did not expand. About half the states did expand Medicaid. You can check on healthcare.gov if yours did. On the exchanges, patients can buy bronze, silver, gold or platinum plans, with different co-pays and deductibles. No matter what the plan, no individual needs to pay more then $6350 each year on out-of-pocket in-network medical costs, and for families no more than $12,700.

4.     As for income qualifications: lots of people qualify for subsidies. Medicaid covers people up to 138% of the poverty line (up to approximately $15,000) except in the states that did not expand Medicaid coverage. People who are making up to four times the federal poverty line receive subsidies. To sign up, people must have proof of their last year’s income and proof of their identity with a social security number.

 

 The goal is to make checking health insurance status a routine part of every clinic visit, getting as many people signed up as possible in the next two months.

 

Social History: Do you smoke? Drink? Have health insurance? Are you happy with what it covers, and the cost?

Assessment/Plan: Uninsured/underinsured—refer to healthcare.gov or state exchange (getcoveredillinois.com). Or call the Illinois state hotline at 1-866-311-1119 to connect to a navigator.

 

We introduced the Health Insurance Status Screening pocket cards to about 30 medical students on a Monday. On Thursday, student organizer Lauren sent the following message:

 

Hey Everyone,

Just wanted to let you know that one of the MS1s ran up to me today to tell me that she used the pocket card with a pregnant patient with several health complications who is totally eligible for coverage but didn't have any.  Quote:

"The card works just like you said. I called the number and now a Navigator is coming to the shelter next week!  They know so much.  I'm really glad that you had that meeting" 

Good work team!  We made a difference :)

 

I believe the students are making a difference. And I encourage you to also—whether you’re a student or a practicing physician, check out the card, familiarize yourself with the basics, start screening your patients for health insurance status and refer them to healthcare.gov no matter what state you are in, and train your colleagues to do the same.

We can make a difference in patients’ lives, providing the most ethical care possible by connecting them with the health insurance they need.

 

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ACA outreach in OK is tough


. 7 Comment(s)

I'm not going to sugar coat it: ACA outreach in Oklahoma is tough. But being uninsured is tougher. 

One of my friends, in her late 50s, had been unable to afford health insurance for years, due to very high costs because of a minor pre-existing condition. Her job did not offer insurance, and she lived for years hoping she would make it to 65 so that she could get Medicare. Thanks to the ACA, her new affordable insurance started on Jan 1, and she is now scheduled for her first preventive care visit and mammogram in many years.

People here are proud of the fact that Oklahoma is the “reddest” state in the Union, and it’s been hard to find anyone brave enough to speak out in favor of the Affordable Care Act – but the partners I have been able to find are amazingly courageous people that I would never have met any other way. I’ve driven all over Oklahoma, from Tahlequah to Durant, speaking to groups of citizens and on country radio shows (where I once had to pause for a hilarious commercial for barbed wire.) We held a Coverage is Good Medicine poetry reading in a packed theater, and I have spoken at several conferences for agencies that work with the poor.

The stakes could not be higher in this state, where over 600,000 people, most of them working poor, are uninsured, and we rank near the bottom in most major health categories. Sadly, our governor has shown total opposition to the ACA, including rejecting federal funds to provide coverage to our lowest-income adults. With states like Utah now expanding Medicaid, I believe we have reached a tipping point.  We are winning the battle, so it’s critical that we keep fighting for our patients.

Open enrollment ends in a little over 60 days. Help win the future for your patients. Take two minutes and put up this flyer. Then email it to 5 doctors and medical students and ask them to join you in reaching thousands by posting it in their community sometime in the next two weeks. Be sure to take a photo and share it with us!

Together we can make a difference,

Kathy

Dr. Katherine Scheirman is the Oklahoma State Director of Doctors for America and a retired US Air Force Colonel.

 

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Fun With Numbers

By Dr. Chris Lillis
. 2 Comment(s)

It’s January 10, 2014, and civilization has not collapsed due to the menace of the Affordable Care Act (a.k.a. Obamacare).  While this persistence of social order is not a surprise to me, many of the most vocal opponents of the ACA might be left wondering what happened to the cataclysmic predictions that have yet to come true (death panels! Death spirals! Government run healthcare!).

Seeing as the law has been more fully in effect for only 10 days, I am quite confident new problems, unforeseen consequences, and hiccups will arise, but the ACA is the law of the land that will thrive with tweaks and course corrections just like other significant reforms in the past. 

I find it valuable, at this moment, to take a tally of all that has changed since the ACA was passed, and I have had a lot of fun learning these numbers:

  • 9,781,525 -Americans who newly have health insurance since 2010 (almost 10 million people!)
  • 2.4 Million - newly insured through the federal and state-based health insurance exchanges
  • 4.5 Million - newly enrolled in Medicaid in states that chose to expand their program
  • 3.1 Million - young adults under the age of 26 are covered through their parents health insurance
  • 40 Million – Americans who could be eventually covered once the ACA reaches all who are uninsured and eligible
  • ZERO – Americans who can be discriminated against due to a pre-existing medical condition
  • ZERO – the out of pocket costs for qualified preventive health services, which 105M Americans used in 2011 and 2012
  • $1.1 Billion – dollars refunded to consumers from insurance companies for over-charging
  • 360  - new Accountable Care Organizations, providing care to 5.3 million Medicare beneficiaries
  • Hundreds, if not thousands, of new Patient Centered Medical Homes
  • 236 – Community Health Centers expanded by the ACA extending care to 1.25 million more patients.
  • $8.9 Billion – the total amount seniors have saved on drug costs since the ACA passed
  • $5000 – the annual savings my family will realize in 2014 thanks to the Small Business Exchanges!
  • 3.2% - the annual rate of growth in Medicare spending, the lowest in decades, (the cost curve is bending) and the first time it is BELOW growth rates for our national GDP.
  • 23 – the number of states NOT expanding Medicaid, leaving 4.8 Millions Americans without health insurance who were intended to be covered by the ACA
  • 298 – days until Election Day. Just sayin’.  If you want to see the successes of the ACA built upon, if you want to see the nearly 5 million people eligible for Medicaid gain the coverage that was intended in the ACA, and if you want to see a more high quality and high value health care system, think carefully about how you vote.

The Affordable Care Act is the most significant overhaul to our private, for-profit, health care system since the inception of Medicare.  It’s easy to lose sight of the benefits of the law when the media is focused on broken websites (getting better every day) and Americans getting cancellation notices.  It may also be easy to forget that our health care system has been broken for quite a while, and it will take a while to right this ship.  But I have said before, and I will say again and again, the ACA is going to help ALL Americans have higher quality and less costly health care in the decades to come.  

 

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2013 has been the BIGGEST year ever for the Doctors for America movement!


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In 2013, thousands of doctors, medical students, and other supporters came together to make a huge difference. Your stories, actions, and support have helped the Doctors for America movement lead our nation toward better health and access to affordable, high quality health care for everyone. 

HIGHLIGHTS OF WHAT WE DID TOGETHER IN 2013…

GETTING PEOPLE COVERED: COVERAGE IS GOOD MEDICINE

In this historic time for health care coverage, here’s some of what YOU have done to help get people covered:

  • Organized 25+ ACA webinars for health care providers, including 10 Webinars on 10/1
  • Trained 1,000+ health care providers and supporters to educate patients 
  • Spoke at 60+ ACA education events across the country
  • Organized an Enrollment Roundtable convening 50+ national health care provider organizations to work together on patient and public outreach on enrollment

Since October 1, over 1 million Americans have signed up for coverage through insurance marketplaces, Medicaid, and CHIP.  As a trusted voice in a confusing time, our outreach is making a difference! 

SPREAD THE WORD IN NATIONAL AND STATE PRESS

Many Doctors for America members shared perspectives from the front lines of health care in national outlets like MSNBC, FOX News, CSPAN, AP, Kaiser Health News, McClatchy, NPR, CBS News, Huffington Post, Daily Kos - plus numerous statewide publications like the Tampa Bay Times, San Antonio Express News, Charlotte Observer, and the Dayton Daily News. 

RACED FOR COVERAGE 

Our Docs Run pilot ballooned into a national Race for Coverage! 156 doctors, medical students, and supporters have run, biked, walked, hiked, and even read poetry to raise awareness of new coverage options. These individuals including teams in Texas, Florida, California, and Massachusetts got in shape, had fun, and raised much-needed funds to spread the word on ACA enrollment. 

MOVED STATES TOWARD MEDICAID EXPANSION


Doctors and medical students held press conferences, spoke at hearings and organized rallies to advocate for the expansion of Medicaid in states that have previously rejected funding.  You rallied in white coats in state capitols from Utah to North Carolina to Texas and held a town hall with legislators in Florida. You got the Texas Medical Association’s support of expansion, and helped Ohio successfully moved to expand.

ADVOCATED TO PREVENT GUN VIOLENCE

4,000+ doctors, medical students, nurses, and other health care professionals in all 50 states signed our petition for common sense gun rules. Vice President Joe Biden took notice and asked us to present our recommendations to his Task Force on Gun Violence. 

Your stories and voices helped move President Obama to issue key executive orders: 1) allowing the CDC to conduct research on gun violence, 2) making sure insurance plans cover mental health the same way they cover medical care.

GAINED NEW SKILLS AND CONNECTIONS AT THE 2013 NATIONAL LEADERSHIP CONFERENCE

This year’s conference was our biggest yet. U.S. Senator Sherrod Brown of Ohio talked about the impact Doctors for America has had on advancing health reform. Surgeon General Regina M. Benjaminled us through the Electric Slide and Wobble. Wendell Potter, former Vice President of Corporate Communications at CIGNA shared insights on messaging. And conference attendees shared questions and perspectives from the front lines with leading policymakers and Administration officials. 

2014: LET'S SEAL THE DEAL AND GET AMERICA COVERED!

Tens of millions don’t even know that they can now get covered.  Five million low-income people live in states that have not yet expanded Medicaid.  Let's get America covered in 2014 so we have a strong foundation for transforming health care in our clinics and communities in the years to come. Make a year-end tax-deductible donation today!

 

 

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Thoughts and prayers with Newtown today

By Nina Agrawal
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Today, we remember the lives lost in Newtown one year ago and those lost every day in communities across the country.

As we keep the Newtown families in our hearts and prayers, let us continue our resolve to use our unique position as America's healers to put an end to these tragedies.

As a pediatrician, I am disheartened that 7 children still die every day from gun violence in our country, and that gun injuries cause twice as many deaths as cancer and 5 times as many deaths as heart disease.

Gun violence is an urgent public health crisis and as physicians on the frontlines of health care delivery it is our obligation to take action to keep children and families safe by talking with our patients about guns.

We have included some helpful resources from The Center to Prevent Youth Violence and the American Academy of Pediatrics to make talking about guns with your patients easier. And you can also read more about our gun violence prevention campaign and how you can get involved.

Gun violence is everyone’s business. When a child dies needlessly, it is everyone’s responsibility to do something about it.

We work every day to protect our patients from deadly diseases like heart disease-- it's time to do the same for gun violence.

Please join me in preventing the loss of more young lives and keeping children safe.

Dr. Nina Agrawal is a pediatrician in New York and a DFA Campaign to Prevent Gun Violence Coordinator.

 

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The ACA: Far More than a Website

By Lindsey Shultz
. 2 Comment(s)

As we enter the depths of the holiday season, the narrative over the Affordable Care Act continues to cycle around the story-of-the-day.  On good days, these become real conversations about the challenges, both short-term and far, to improving upon an industry that straddles the public and private sectors and encompasses 18% of our GDP.  The ACA has laid the groundwork for a great number of shifts in how we look at both our health and the care we receive.  But there are always initiatives for improvement, tweaks to be made to help achieve its goals in a more timely and equitable fashion.  On the worse days, however- which lately seem to be out-shouting the good- critiques of the health care law and its implementation become the latest fodder for a media echo chamber where the competition is for the best chyron, the loudest host, the most shocking story.  

Even more sober reporting now continues to focus almost exclusively on the faulty roll-out of the ACA website.  To be clear - most of the technical obstacles were foreseeable, and quite frankly unacceptable.  The memories of one or two college-level computer programming courses buried deep in the recesses of my brain have gotten far too much dusting off lately.  I am resentful that I can discuss the failures of waterfall approaches to IT development and the much more flexible and robust approach of agile development so fluently.  The fact that 834 forms are now in the public discourse - all of this has pulled us away from where we would thought the story would, and should be. But to focus on these as the crux of the story for health reform is sorely neglecting  everything else that the ACA represents and has already begun to achieve.

The first steps to revamp the website seem to be moving along, with a significant improvement cited by the administration by December first.  New oversight is in place, a new (and unfortunately late) emphasis on transparent collaboration between the administration, CMS, and private contractors building components of the websites seems to have taken hold.  More importantly, new efforts are being discussing to amend the way the federal government does  acquisition for IT projects.  The challenges faced by healthcare.gov are not unique:  the VA struggles through its backlog to reconcile its systems with the armed forces, the armed forces struggle to integrate with each other, the intelligence community continues to struggle to across institutions.  All of these are symptoms of how large institutions with ingrained politics and interest groups are grasping for ways to enter the technological world many of us already live in.  But beyond the public sector, health care has long struggled with IT.  Electronic health records have proven a Sisyphean task to implement, across both public and private facilities.  Seeking to overhaul an industry upon whose successful functioning literal lives rely has been difficult long before the healthcare.gov roll-out, and will continue to be so.  We would be far better off using the past few months as motivation to work for more extensive changes, both in the federal sector and without, to remedy the problems that have longed plagued these system- rather than boiling the conversation down to what this means for the 2016 elections.  3 years before said elections.  I know i personally can’t maintain my sanity with countdowns that would essentially be:  1000 days until the next thing that matters a lot!  365 until the next thing that matter a little!

So instead it is up to us to change the narrative, to help refocus the discussion on the real challenges, but also the real reforms that will play out over the next few years (and coming decades) to improve the state of our health, and in turn, our functioning as a happier, healthier society.  The administration recognizes this need: to encourage enrollment now that the first real deadline that matters is in sight.  And not for the media, but for real people:  December 23rd.  A premium paid on the new exchange by this day, and coverage begins January 1.  For many it will be the first day of a new experience with their health, one where they can be active participants rather than onlookers from the sidelines.  But in addition to this short-term priority- the administration, beginning today, will be rolling out a new campaign.  Each day- a different benefit will be highlighted, serving as a reminder to the public- and to us, in the medical community and media arena- why this was all so necessary in the first place.

This campaign coinciding with the holiday season works well to remind us of how much we have to be thankful for, despite the challenges which continue.  Just the issues highlighted in just the first week of the campaign are life changing for many of our fellow citizens who have gotten lost in the maze that healthcare has for so long been.

We will never go back to a pre existing condition making you uninsurable.  And with chronic illnesses on the rise, and the longest life expectancies seen in history- this is a trap that almost all of us would have eventually fallen into.  Never again.

Preventative services are now free.  No more foregoing screenings because of cost.  Now its up to those of us in the field to help ensure people follow through.  It’s easy for all of us to fall into the psychological disconnect between a small inconvenience now and a major risk in the future.  Even small costs have been should to discourage uptake of these services.  Now that barrier is gone.  The rest of it is up to us.

Insurers are now required to cover maternity care and cannot charge a higher premium simply for the outcome of the genetic lottery of being a woman.  

Mental health parity is now a given, meaning insurers have to cover mental health just like every other medical diagnosis.  This will have far ranging effects, from helping people suffering from illness, to helping to end the stigma of seeking help for a malady every bit as real as one with physical signs, to helping afford new outreach programs which seem to get a brief spotlight every time a tragedy like a mass shooting event occurs.  These can’t fade into the background of “Wouldn’t it be nice if we could have done something” anymore.

Innovations in how we pay for care are just beginning to change how care is provided, how we incentivize good outcomes instead of just “more” outcomes.  Payments based on value of care, rather than quantity are rolling out.  Evidence of declines in avoidable outcomes like readmissions after discharge and hospital acquired infections are already showing great improvement, in only a few years.  Accountable care organizations creating multi-sector teams are working to treat the whole patient- as a person, rather than a set of kidneys, a heart, a blood pressure number.  And these are just in their infancy.

Changes in payment structures are also already playing a role in driving down the growth of health care costs to their lowest in decades.  For the past few years, annual rates of increase have fallen to 1.3%, more or less the rate of growth of GDP, an ambitious target long thought to be a reasonable level to seek.  A decade ago- growth was at 5%, and while some of this is attributable to the economic recession- it seems a good piece is left unaccounted for this way, meaning the changes being rolled out across the industry are likely creating institutional change which will have long-lasting effects.  Even the dialogue around how much we spend and how little we seem to get for it, has a real and measurable effect, meaning a different set of media narratives could have a real and lasting impact on health care, far beyond the page-clicks of the story-of-the-day.  And this impact is not limited to individuals- costs to Medicare, Medicaid, and other public programs will reap the benefits of these cost slow-downs, providing less expensive, verifiably better care to even more people.

Finally- we should be thankful that hundreds of thousands, if not more, fellow citizens are finally already able to receive coverage- through the health exchanges and states accepting Medicaid expansion.  At least 1.5 million people have enrolled in Medicaid or CHIP since October 1, and this with only about half the states taking up the Medicaid expansion to 133% of the federal poverty level.  The latest numbers floating around indicate a 4-fold increase in people signing up for private insurance on the federal exchange in November, up to 100,000 friends and family members across this country who now are guaranteed to same access to health care as the rest of us.  A record-setting December 1, early numbers indicate 18,000 people signed up for coverage, a daily record.  And yes, technical bugs still exist.  And yes, some individuals ran into problems.  But those individuals are fewer, and those times farther between.  And this number will continue to go down, and the number enrolled will continue to go up- and for this we should be most thankful.

The Affordable Care Act is far more than a website. Far more than just an individual market in upheaval.  As Deval Patrick summed it up, “It’s a value statement.”  And a statement we need to make sure is heard alongside the website problems, the policy changes, and anecdotes.  It is a statement of principles we stand firmly behind:  We all deserve a chance to live healthy, productive lives.  And the ACA is a strong beginning to that aspiration.

 

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An Open Letter from a Physician and Patient

By Dr. Rebecca Love
. 2 Comment(s)

I'm 62 years old, disabled but not eligible for Medicare until 2015. Because of my all too common preexisting conditions like arthritis from injuries, migraines and hay fever I was not able to buy health insurance for many years. The ACA required states to form insurance pools to provide a last ditch insurance vehicle for people like me. So I had health insurance for several years after my COBRA benefits expired. But in 2011 my rate rose by more than $150/month. Paying $785 a month for a $2500 deductible policy with a very narrow provider network was financially untenable and I dropped the insurance.

My doctors are in Colorado since its only 110 miles from Moab to Grand Junction. They continued to treat me as a cash pay patient. But I have a degenerative disease that is progressive. I have put off preventive procedures because of the expense. I need insurance.

The ACA web site's problems are frustrating. But I'm a patient adult. I was able to create an account the first week and was able to see my options by the third week.

I am not entirely happy with the insurance I chose. The state approach to regulating insurance means that people are mostly restricted to networks in their locales. But here in Utah that means I will be required to drive to Salt Lake City for specialty care, almost 300 miles while my neurologist, neurosurgeon, orthopedist and internist are all only 110 miles away over a much safer highway. I will have to choose one of four local doctors. All were colleagues. None of us are comfortable with this arrangement.

There are economic, social and ethical imperatives driving this social change. I am pleased to support the ACA despite losing my physicians. I expect to ask for exceptions to the network rule so this I can continue to see the people who have gotten me through crippling disease and 3 big procedures in 2 years. I expect to be denied and to appeal.

I used to stand in the midst of the chaos that is urban emergency medicine and propose that "anything is better than this". The ACA is better. My hope is that this is the first step toward reigning in the profiteering and marketing in medicine. Simply insuring everyone will improve the health of the nation. Reforming the way American physicians practice medicine, banning drug and procedure advertising and lifting the burden of debt newly trained physicians face are all parts of this puzzle.

Rebecca Love MD

PS. Someone needs to point out that the governors who rejected Medicaid expansion and refused to run state based exchanges bear much of the responsibility for the federal marketplace's problems. If they had acted responsibly there would have been no need for a federal marketplace. Low enrollment numbers in states that spent no money to promote the exchanges are to be expected. Withholding encouragement and information is a disservice to the public and yet another form of obstructionism from the Republican Party. 

 

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Two Cheers for the New Mental Health Parity Rules

By Dr. Julia Frank
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Access to insurance, YAY!!

Better coverage for substance related conditions, YAY!!

Access to care…?

We have much to cheer in the long awaited final federal regulations covering insurance for mental health and substance abuse care. The final rules declare mental health and substance abuse benefits to be part of the essential benefits package required by the exchanges. The regulations require the benefits to be real, that is, insurance companies may not apply different lifetime limits, pre-authorization requirements, or separate deductibles to mental health services. They also require insurers to maintain adequate networks of providers and to offer out-of-network benefits on the same terms as those offered for general medical care. Moreover, plans must now cover screening for depression and substance misuse/abuse without “cost sharing” (i.e., copayment) on the part of the patient. This provision will specially benefit generalists, who often see depressed or addicted people but cannot bill for identifying a problem and counseling a patient on what should be done about it.

Parity regulations also now clearly apply to partial hospitalization, which the insurance companies must treat the same way they treat other intermediate services (like rehabilitation and short term nursing care). Partial hospital programs provide intensive services to people who are not imminently dangerous, but still ill enough to need more than occasional outpatient visits. Partial hospitals and intensive outpatient programs have the potential to significantly reduce the discouraging (and costly) relapse and re-admission rates that occur when patients achieve remission of illness or abstinence from substance use in a tightly controlled setting, then return abruptly to the environment that induced and maintained their condition in the first place. Anything that helps disentangle the issues of providing care for people because they are ill, rather than controlling people because they might be dangerous, is cause for real celebration.

So why only two cheers? Access to insurance does not, unfortunately, equal access to care. The rules apply only to insurance companies. They do not reverse the trend of states draining mental health resources (inpatient or outpatient) from their budgets. Nor do they establish fee schedules or staffing patterns that would allow mental health professionals to be fairly reimbursed for their work. Currently, rates of reimbursement remain so low that mental health professionals outside of salary based systems like the VA often cannot afford to treat the patients who need them most, including those who have been the most responsible about buying insurance that should cover their care.  

Many psychiatric conditions are chronic illnesses that require varying levels of intervention at different points in a person’s life. The draconian restriction of mental health care through intensive case management has been based on a model that that treatment must be time-limited, short term, and applied only to those who are imminently dangerous. Changing the terms of this oversight, though necessary, does not reset our priorities to create a system that provides appropriate care, at appropriate times, for disorders that may require lifetime intervention.

The recent atrocities perpetrated by mentally ill people expose the many weaknesses in our non system of mental health care. I rarely agree with Charles Krauthammer (a psychiatrist turned conservative pundit). He was, however, right on when he noted after the Navy Yard shooting that our ability to provide effective treatment is limited by overly restrictive commitment laws, huge gaps in the continuum of services, and lack of appropriate facilities and resources.

The resources that do exist are tragically mis-allocated. In 2006, 10 times as many mentally ill people were incarcerated than were in publically funded mental hospitals. Governments across the nation spend millions to house the disruptive mentally ill in jails and prisons, then starve the hospitals, clinics, and social programs that might help them resume productive lives. (Thanks to the sequester and the systematic erosion of funding for the agencies that collect this information, more current statistics about this and many other problems are simply unavailable.)

Discriminatory insurance coverage for mental health services is both a cause and an effect of the stigma and confusion that characterize society’s understanding of mental illness. Strengthening the regulations that combat insurance discrimination against the mentally ill (including many alcohol and drug users) is long overdue. Two cheers are certainly warranted. But correcting abuses in current forms of oversight will mean little if the facilities and services that patients need are unavailable, undervalued, and uncoordinated. Only when those problems are addressed, will I climb the pyramid, turn a cartwheel and shake my pom poms with mad enthusiasm. 

 

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I Will Direct My Apologies Elsewhere

By Dr R Scott Poppen
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‘Tis the season for apologies.  Fellow Progress Note blogger and ACA advocate Dr. Chris Lillis fretted about any overstatements he had made in his advocacy for the new law.   Then it was President Obama’s turn to take a public beating and say he was sorry he promised people that they could keep their current insurance if they liked it.  But as for me, no lost sleep here.

 President Obama probably should have been more careful.  But it was probably inevitable, in light of our nation’s absurd reliance on 15-second sound bites as a substitute for thoughtful discourse on critical public policy issues, that he would put his foot securely in his mouth.

We Doctors for America advocates had a slightly less daunting task.  We had a whole 30 minutes, and a couple dozen power point slides, to summarize one of the most complicated pieces of federal legislation ever promulgated.  Or we had a few minutes to talk with someone on the street, answer tough questions, and summarize the important parts of the law.  In my advocacy efforts I have always tried to honestly portray the law, warts and all, and not overstate what it would accomplish.  I have observed my fellow advocates doing the same.   But given the complexity of the subject and time limitations, generalizations, which could later be picked apart to show some exceptions, were unavoidable. 

 Anyone who truly understands the law, and understands insurance, should have known that the ACA would produce, at least short-term, financial winners and loser.  Should we have stated that up front?  Maybe.   But we were unlikely to do so in light of the ferocity and untruthfulness of the attacks made by the ACA’s most vicious opponents.   Maybe it is time for a soul searching discussion about the ethical responsibilities associated with advocacy related education.

 So everyone is now apologizing to folks in the individual health insurance market who can’t renew their current cherished policies, some of which are so crummy that it is a stretch to call them insurance, and will be paying much more in the Marketplaces because they make too much money to qualify for a subsidy.

 So, since repentance is the order of the day, here is mine.

 To the woman who testified at my state’s Medicaid expansion hearings last July  I’m sorry that you developed advanced breast cancer several years ago, lost your job during your radiation and chemotherapy treatments, couldn’t afford your COBRA payments to keep up your insurance, and had to stop your chemo prematurely.  I’m glad you got a new job, albeit without health insurance benefits.  I was so sorry, and sad, to learn that your breast cancer has returned, is metastatic, and that you have no insurance. 

 I’d like to apologize for a member of our legislature, a health care provider himself, who an hour after your testimony stated publically that he didn’t want to hear anymore testimony from patients.  You see, his innate compassion for your situation is colliding with his anti-government ideology producing painful cognitive dissonance.  His only option is avoidance. 

 Perhaps, if you are still alive, you can sit down with some of the folks who are going to have to pay more for their insurance and help them find a cheaper cell phone plan, alternatives to cable Ty, or more affordable vacation options.  That is, of course, if you are still alive.

 To the woman who sat at my table at our governor’s health care summit.  I’m sorry I did not get a chance to meet and talk with you.  I noted that you are wheelchair bound, carrying portable oxygen, that the skin around your face was terribly tight, that you looked ill, and that you ate none of lunch provided.  It was only later that I learned about your terrible autoimmune disease, systemic sclerosis, and that you had no employment, no health insurance, and limited access to what you need to manage your illness. 

 I would like to apologize to you for our state’s legislators.  You see, the majority of them feel they are doing you a favor by not expanding Medicaid and thus preventing you from becoming dependent on government handouts and therefore motivating you to work and get your own insurance.

 Perhaps, before your terrible disease turns your skin and internal tissues into rocks, you could discuss household budgeting with someone who is employed, insured, making over 400% of Federal Poverty Level but is complaining about a premium spike.

 Finally, a shout out to the guy who sat next to me at the governor’s summit.  I’m sorry that you got multiple sclerosis, lost your job as an electrician, lost your union benefits, your COBRA lapsed, you lost your house, and your marriage failed.  It must be rather humiliating to now be living in your friend’s basement.  I was really impressed when you ambled over to the governor’s table, got past his body guards, and explained to him why you can’t afford the expensive medication needed to manage your MS.

 Let me apologize for the governor.   It has been nearly two months and he still cannot decide whether expanding Medicaid is good for our state’s citizens.  You see, he is fearful that the several hundred million federal dollars that our state will receive over the next few years will bankrupt the U.S. treasury and turn us into Greece.

 But hey!  Did you see the picture in the paper of our brand new nuclear aircraft carrier, the U.S.S. Gerald R. Ford?  What a beauty and soon to be carrier number 12 in the fleet.  I thought of you because although the federal government has already spent several billion on this state-of-art warship, they still need to spend a few more billion as they get her fitted out for sea trials.  I’ll bet they will need some cracker-jack electrician like you.  Maybe the governor could loan you the money to get your medicine and you could get working again.  Just don’t tell him how much the ship costs ($13 billion) cause we don’t want to worry him.

 Yes, the ACA is producing winners and losers.  But in my mind the financial setbacks facing the few losers are greatly outweighed by the improved health, prolonged life, financial security and access to affordable insurance available to the many winners.  It may never happen, but I hope  that those who think they have lost financially will someday see that the health insurance security that the ACA will establish in 2014…guaranteed access, guaranteed continuation, and guaranteed limits on out-of-pocket costs…makes us all winners.   The financial sacrifice by some is well worth the health insurance security gained by all.    

 

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From the Heart

By Dr. Chris Lillis
. 10 Comment(s)

If you have read some of my previous blog posts, you might think I add WAY too many links to my source material.  I am not going to include any links in this piece.

The truth is, I have invested almost 5 years of blood, sweat and tears into ensuring that the Patient Protection and Affordable Care Act was written, passed by both houses of Congress, signed by the President of the United States and survived a Supreme Court Challenge.  Now I am spending my time doing my best to see that the law is implemented.  As much as anyone, I am terribly frustrated with the deficiencies of the website healthcare.gov.  I am more frustrated that a few million Americans may see their health insurance premiums rise as their old policies are cancelled by insurers while making just too much income to qualify for offsetting tax subsidies.  These folks, especially if they are healthy, may not feel that there is any benefit to them to purchase a more comprehensive health insurance policy that they rarely use. 

But here’s the deal: we are all going to be better off.  By expanding the individual health insurance marketplace, we will see health insurance premiums stabilize.  This has not been the case for the past 30 years.  We have seen double digit premium rate increases, year after year, through many presidential administrations, without any legislation passed to protect consumers.  The Affordable Care Act finally protects consumers.  The law mandates that insurance companies spend at least 80% of all premium dollars collected on your health care, a needed provision when all of the major insurers’ CEOs get paid tens of millions of dollars every year.  The law forbids insurers from continuing the horrible practice of rescission, where policy holders are suddenly dropped once an illness is discovered.  The law ensures that your policy is renewable even if you get sick.  The law provides consumers access to an affordable policy, one that does not turn them away for having a pre-existing condition as trivial as heartburn or allergies.  The law prevents an insurer from cutting off support for medical bills since annual and lifetime benefit caps are no longer. 

The law has baked into it pilot projects attempting to revolutionize health care delivery systems.  Currently, we have a fragmented system – hospitals, doctors’ offices, pharmacies, and other providers administered care without much coordination.  The right hand of the health care system often was not aware of what its left hand was doing.  But coordinated care is now the hottest topic in health care thanks to the dialog begun by the Affordable Care Act.  The law has allocated funds for these pilot projects, although many coordinated care initiatives are being led by private hospitals, insurers and communities because of its transformative potential.  This would not have been so without the national debate begun with the Affordable Care Act.

I must admit, the single greatest driving source inspiring me to advocate for the Affordable Care Act are the innumerable uninsured patients I have cared for in Emergency Rooms, Hospitals, Free Clinics, and my office – beginning in medical school over 17 years ago.  I do not ever want to say to a patient, who is desperately asking me “how am I going to afford this,” that I am not sure how we will obtain a test, procedure or life saving medicine.  I want to be able to say, “You’re covered.” 

The Affordable Care Act has standardized – across Medicare, Medicaid, Tricare and private insurers – that preventive care is to be provided without out of pocket costs (co pay or deductible).  My practice experience has made it crystal clear that out of pocket costs shape the decisions of patients.  If it is unaffordable, they will delay needed care.  Without out of pocket costs for preventive care, it’s not quite as much of a challenge to help patients participate in recommended disease screenings.  

Underappreciated by all, The Affordable Care Act is going to encourage providers to focus much more on the costliest element of our health care system: those individuals who require complicated, ongoing, disease management.  When chronic care is executed poorly, preventable complications occur in patients with skyrocketing downstream costs.  Our sickest patients with the greatest need represent 84% of total health care expenditures – 99% of all Medicare spending.  The Affordable Care Act is going to encourage providers to screen for chronic diseases and intervene early while those conditions are still easily manageable using effective and efficient coordinated care. This will allow us to reduce health care spending for all of us – everyone who pays taxes and everyone who pays health insurance premiums.

The mantra of the Affordable Care Act among “insiders” mirrors the mission of the Institute of Healthcare Improvement – better individual care, better population health, at a lower cost for all.  This is the so-called “triple aim” drilled into us by Dr. Don Berwick.  I strive for this, as I know the 16,000 members of Doctors for America do every day.

You cannot communicate all of this in a sound bite.  Even harder is communicating all of the provisions in the law in a discrete period of time (think cable news).  I can speak ad nauseum about our $2.3 Trillion dollar health care system – we spend more on health care than the size of the entire national economy of all but 6 other countries. It is remarkable, and discouraging, to know how complex our health care system is and just how complex this law is, meant to attempt to improve just about every aspect of it. 

The Affordable Care Act will improve our health care system so long as it is allowed to work and provided some help in properly achieving implementation.  I am privileged in my career to have been witness to the most affluent and high tech care in the Duke Medical Center Intensive Care Units and the most impoverished care on the trauma surgery service at the District of Columbia’s General Hospital.  After taking care of thousands of patients in my lifetime, and immersing myself in health policy in the last 5 years, I want to see the Affordable Care Act succeed. 

Success will depend on advocates like Doctors for America sticking with this effort – learning about loopholes and problems and applying the proper fixes to the law.  This has a long tradition in our great nation.  After Medicare’s passage in 1965, there have been both major and minor changes to the program every year to make it better.  The Affordable Care Act has the same potential to improve year-after-year. 

The Affordable Care Act is here to stay, but without better public education and understanding, the effectiveness of the law is in jeopardy.  It would be foolish to abandon this critical law simply because a website is temporarily not functioning.  A website can be fixed. 

We need to meet the Americans who are losing their previous insurance policy and make too much to qualify for a subsidy.  These folks are angry, and understandably so.  I hope with good information, they will see that they will benefit in the long run.  I hope they never have to learn of the protections of their new policies due to a devastating illness, but I am glad if they get sick they will avoid bankruptcy. 

Every victory for this law brings new challenges, and that’s OK by me.  The law was never going to be perfect and fix everything.  It’s a start.  I have a feeling that I and my colleagues at Doctors for America will need to continue to work to improve our healthcare system for quite some time to come.  We plan to see this through.                          

 

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