Frandal Wright, who went 27 years without health insurance before getting HIP 2.0 coverage last year, makes his $1 monthly payment at the Wal-Mart in Anderson.

Because the store is on the other side of Anderson from where he lives, Wright tries to pay as much as he can at each visit to minimize the number of times he has to make the trip. Right now, he says, he’s trying to find someone to give him a ride to make his payment and determine if he has enough money to make a lump sum payment.

“I’m a little behind now because I almost forget about it,” said Wright, 46. “I want to pay for the whole year. I’m trying to do that this time. I’ll probably give them $20 if the Lord blesses me.”

Do Indiana’s poor Medicaid recipients really have skin in the game?

As I viewed my electricity bill today I was told by Alabama Power “You pay on average $5 a day for your electricity.” This means I have “skin in the game.” I have the power to determine if I pay nothing per day or $20 per day. Well, only a little as it turns out.  It seems that Alabama Power won’t let me come off the grid easily, so I will end up paying something no matter what. Also, my major non-air conditioner power usage corresponds to my use of the clothes dryer. I can minimize the use of the dryer by hanging a clothesline, I suppose, but elect not to.  What I have decided is that I cannot do  without electricity. So, although I have skin in the game, I can’t say “no, thank you, I’m using a cheap alternative to electricity so go away Alabama Power.” I rely on the Public Service Commission to negotiate fair rates and rely on the government to force my appliances to become energy efficient. Oddly, as appliances become more energy efficient, rates per kilowatt hour tend to go up. I now have less skin in the game (using efficient appliances less frequently still costs the same because I pay more per kilowatt hour) but still reflexively try to use less electricity. Modern life is confusing at times.

Many folks have asked me what I think is going to happen with health care. Conventional wisdom is that the people appointed dictate policy. Seema Verma, who helped design the Medicaid expansion in Indiana, is the new director of CMS (the agency responsible for Medicaid and Medicare). The buzzwords for poor people and perhaps all sick people will likely be “personal responsibility.”

Ms Varma has written on the philosophy she has used to design the system in Indiana (article found here). It seems that this is not just about making sure poor, sick folks have needed care but importantly involves  bootstrap repair as well:

[M]any of Medicaid’s enrollment and eligibility policies, which might make perfect sense for certain vulnerable populations, are not always appropriate for able-bodied adults possessing different capabilities and earning potential. Able-bodied adults need coverage, but not the same set of policy protections.

One of the precepts of President Lyndon Johnson’s War on Poverty, from which Medicaid arose, is that government assistance should exist to provide a temporary pathway for people to lift themselves out of poverty toward a state of self-sufficiency.

The recipients are given a Health Savings Account and are required to make their personal contribution to teach them responsibility (as was the client in the anecdote above). Finding rides to the insurance payment window, allowing continued access to lifesaving insulin and health failure medications, apparently, is freeing:

HIP respects the dignity of each member by setting a fair expectation of personal investment and engagement in his or her own well-being. Contributions are a way for members to demonstrate personal responsibility, but they also encourage members to stay engaged with their health plan, providers, and overall personal health. Because HIP Plus members’ own dollars are at stake, they have “skin in the game” and therefore an incentive to make cost-conscious health care decisions.

Well, maybe not…Turns out that for “frequent flyers” hospitals are seeing to it that the $1 premium is being paid. Because, if you miss a payment, you are kicked out. So it does seem that someone has skin in the game, just maybe not the patient.

As a pragmatist, I believe that the motive is unimportant if the desired result is achieved. Results to date are mixed. Ms Varma points out that those who have paid their premium continuously (folks with “skin in the game”) are more likely to have a primary care doctor, less likely to go to the ED, and more satisfied with their care. Critics point out that enrollment is not by any means what it should be as many folks can’t get a monthly ride to pay their dollar. Also, less that half of folks who were enrolled knew that they even HAD a health savings account much less how to use it. As they say, further study is needed.

In my professional experience, people believe they are healthy until they are sick. A monthly trip to Walmart to pay a dollar is likely not to change that. I hope that we choose to look at real measures of health and not try to do social engineering with our healthcare dollars.

Uwe Rheinhart, a noted health economist, was asked to predict what would become of healthcare under Trump leadership. He said “My hunch is that the “replace” in what is coming will reflect that conservative vision. It is bound to spell more hardship for the poor, the old, and the sick.” I am afraid that that is what “skin in the game” means.

Jean, an Arizona teacher whose employer provided group health benefits but did not contribute to the cost for family members, gave birth to her daughter, Alex, in 2004 and soon after applied for an individual policy to cover the baby.  Due to time involved in the medical underwriting process, the baby was uninsured for about 2 weeks. A few months later, Jean noticed swelling around the baby’s face and eyes.  A specialist diagnosed Alex with a rare congenital disorder that prematurely fused the bones of her skull.  Surgery was needed immediately to avoid permanent brain damage.   When Jean sought prior-authorization for the $90,000 procedure, the insurer said it would not be covered.  Under Arizona law, any condition, including congenital conditions, that existed prior to the coverage effective date, could be considered a pre-existing condition under individual market policies.  Alex’s policy excluded coverage for pre-existing conditions for one year.  Jean appealed to the state insurance regulator who upheld the insurer’s exclusion as consistent with state law.

From a 2005 Wall Street Journal article

People hate Obamacare. People in “real” America really hate Obamacare. Kaiser Family Foundation convened a series of focus groups in counties that voted for Trump to find out what EXACTLY Trump voters hated about Obamacare (article found here).  They hated that those that were really poor and on Medicaid didn’t have the same barriers to care (high co-pays and deductibles) as did those who were working hard. This was even when the groups included voters on Medicaid. They hated how expensive their premiums were, how high their co-pays were, and how much was not covered. They hated how complex the system is and how when you think you have it figured out someone throws another thing at you. They hated the mandate to purchase insurance.

There is currently a bill  being formulated to “repeal” significant parts of the ACA and replace it either with a “To Be Named Later” or with a mismash of proposals which would be labeled “replacement.” How pre-existing conditions fit into this bill remains unclear but is worth understanding (Kaiser article here). Prior to the passage of the ACA, insurance companies were state regulated, and in all states were able to do medical underwriting, This meant that they could effectively eliminate people with preexisting conditions. Although it would be possible to repeal the ACA and keep in the current underwriting rules, it is not likely this will happen. In the case of our pre-Obamacare insurance at our work, the “lookback” was “270 days, known or unknown, manifest or unmanifest.” This meant that, the human gestation being 270 days from conception, if you had your first day of work and went home and celebrated with your significant other (and one thing lead to another) you had best hope the baby was a week late. If not, you were paying cash. Much worse was the patient we had whose cancer was manifest 4 months after his employment commenced and we got to tell him that he had to pay $100,000 up front or die of his cancer. Kaiser estimates that 52 million people will be denied coverage if the old rules are put back into place. Perhaps not denied outright but effectively denied by bringing back these old favorites:

  • Rate-up – The applicant might be offered a policy with a surcharged premium (e.g. 150 percent of the standard rate premium that would be offered to someone in perfect health)
  • Exclusion rider – Coverage for treatment of the specified condition might be excluded under the policy; alternatively, the body part or system affected by the specified condition could be excluded under the policy. Exclusion riders might be temporary (for a period of years) or permanent
  • Increased deductible – The applicant might be offered a policy with a higher deductible than the one originally sought; the higher deductible might apply to all covered benefits or a condition-specific deductible might be applied
  • Modified benefits – The applicant might be offered a policy with certain benefits limited or excluded, for example, a policy that does not include prescription drug coverage.

Some have suggested that a “high risk pool” would allow these folks to obtain coverage and keep the cost down for the 50% of the population who have no need to access the healthcare system in a given year. We actually tried that before, turns out. As the Kaiser article points out, these didn’t work for a number of reasons. First is the nature of health care expenses. Some folks have a lot of expense in a single year (car crash) and the next year are perfectly fine. Others have a lot of expense in an ongoing fashion for a very long time (think Magic Johnson and HIV).

Planning for these disparate situations was tough and no one got it right. The reasons for failure included:

  • Premiums above standard non-group market rates – All cost a lot, the states with the most success provided a substantial subsidy.
  • Pre-existing condition exclusions – Once again, how do you deal with folks who wait until they get sick to pick up a policy
  • Lifetime and annual limits – Most ranged from $1 million to $2 million and others imposed annual dollar limits on specific benefits such as prescription drugs, mental health treatment, or rehabilitation.
  • High deductibles – The plan options with the highest enrollment had deductibles of $1,000 or higher.

The conclusion was that they could work but it’ll cost a lot to get it right.

Back to the focus groups. What Trump voters said they wanted was low premiums and little out-of-pocket expense for drugs, visits, and procedures. They wanted no mandate and no increase in taxes but felt that not covering pre-existing conditions was “un-American.”

They expressed confidence that as a businessman President-elect Trump could pull this off. Hope they are correct.

I had to quit my job because of the stress I had to endure was putting me at high risk for a stroke or heart attack and I couldn’t physically keep up anymore
I’m 56 years of age
My job was 32 hours a week
But because of Obama care my insurance was costing me $600 dollars a month for just major medical!
No dental no eye care no life insurance
So by the time I paid my rent, electric, water, sewer, garbage, car insurance, house insurance etc, I had enough money to put gas in the car to get to work and buy ramen noodles and some cheap hot dogs for food!
Over 60% of my net pay went to insurance that covered nothing!
Now I am unemployed with ZERO insurance
Its pretty damn sad when all the damn medicaide and dissabilty cheats are eating steak with perfect teeth and new glasses and are in perfect health while I have to bust my damn ass just to eat ramen noodles wityh bad teeth , basbasd eyes, and life threatening health problems!!

So here I am, no job, no insurance, no hope

Patient’s story as posted on Obamacare stories

The average household income in the United States is $51,000. From that you pay for our food, shelter, children’s education, and movie tickets. Oh, yeah, and $5000 for a health insurance policy. One of the things that Obamacare did was begin to put a cost on our insatiable healthcare consumption. Turns out, that cost is VERY high.

If you are an average American, boy are you ticked off. Half of all Americans spend under $400 a year on healthcare. Pretty much a round of antibiotics for a sinus infection and, for women, a year’s worth of contraception. Not only that but because of high deductibles (to keep the cost down by discouraging consumption) you are paying $5,000 to the insurance company AND paying cash for your sinus infection visit and medicine. Then there are the drug companies and insurance companies that are colluding to raise the prices of formerly cheap antibiotics to get even more of your household income.

About 1% of the people in this country account for about a quarter (27%) of the health care spending. In 2014, this  was about $100,000 per sick person. Those in the top 5% of sick people were responsible for  almost $50,000 in health care costs. These numbers are unchanged since Obama was elected. So what has changed? Before, the costs of these people were hidden. They would get the care for “free” at a safety net hospital who would get money in other ways to pay for it. Or a sick person would use an insurance card then the payment would be denied as a pre-existing condition and the hospital would eat the cost. More likely, the sick person would get on disability, suffer for 2 years, and become Medicare eligible so we the taxpayer would pay. The care still cost money but was hidden in taxes. Insurance companies kept costs low, in other words, by shifting them to the federal government. Now folks under 65 who are sick can pick up an Obamacare policy and get exceptional care. Also on Obamacare stories are ones like this:

Thank you President Obama thanks to your healthcare plan I was able to continue to see specialists, this resulted in a diagnosis of a rare intestinal infection and even more concerning, two stage three colon cancer tumors, one on each side on each side of the colon. This required almost total colon removal from a top notch physician that was able to do my surgery without having to have a bag.

Only problem is, this type of care costs A LOT more than $5,000. .

So, if you bought an Obamacare policy and feel ripped off, let me tell you what your $5000 paid for. It wasn’t eye glasses and dental work for poor people that jacked up your bill. You spent your $5000 on people under 65 with heart disease and lung disease. You purchased them a lot of expensive tests, some time in the hospital, and some expensive drugs. You paid for the person with breast cancer’s $300,000 tab whose $5000 premiums were paid by the cancer treatment facility.  You paid for the person helicoptered in after rolling their car on Interstate 65 while trying to avoid a deer.  You paid for some very expensive medication for people with mental illness to keep them out of a mental hospital.

Did you pay too much? Yes. Other countries can do the same thing better for half as much or less. Perhaps the new adminstration will look at this as an opportunity to further retool our expensive, not very effective care delivery system and reign in some of the profiteering. Or maybe we’ll just continue to blame the poor…

 

'I would've retired years ago but I forgot where I work.'

My mother: Oh, there are some people in this place you wouldn’t believe. They don’t even know where they are

Me: Well, in Alabama, they could’t be there at all. If your memory slips too bad, you are considered too sick for assisted living and have to be moved out.

My mother: Well that makes sense.

Me: No, back to independent living. It is illegal to provide assisted living those with memory problems in Alabama

My mom and dad moved from Louisiana to Marietta Georgia after The Storm (on the Gulf Coast we now date everything by August 29, 2005. That’s the day Katrina made landfall in Louisiana). They were in Baton Rouge and were in their late 70s when the storm hit. They had their own home and could drive without too much effort to get necessary items and run routine errands. They had lived in their house for 53 years and were comfortable.

Post Katrina, their lives changed substantially. Baton Rouge almost doubled in size from the influx of New Orleans refugees. What was a simple chore (driving to the store) became a nightmare of left turns into rapidly moving oncoming traffic unimpeded by traffic lights. They were older people living in a first ring suburb in the sunbelt south. If you were older with failing reflexes you had to make the best of it. Without a car there was no food, no doctor, no post office.

They moved into an independent living community for older individuals in Marietta (by my sister). It is like what my kids used to call a college “wonder dorm,” only for older folk. Separate apartments, common areas for dining and socializing. Difference is that in college the turnover is dictated by the ebb and flow of college life. At the facility my folks are in, folks tend to stay. They stay, that is, until they lose their independence or they pass away. On my weekly phone calls I hear tales of which person is losing touch with reality. “Mr Soandso is grabbing everyone.” I’ll hear one week then two weeks later “Remember Mr Soandso, well they had to take him away.” Ambulances are a regular occurrence with the inevitable return of the resident just a little less functional than before he or she left. If only a little confused when they leave, they are a lot confused when they return. Soon, they are removed to another facility. My folks can’t help but wonder when the inevitable will catch up with them as well as they notice their memory slipping with age.

Why have we not come up with a better way? As I told my parents, in Alabama it is even worse because, with any type of dementia, regular assisted living is out. Alabamians have to move into a “specialty care assisted living.” There are only about 300 of those in the state with a total of 3000 beds. To quote a recent article:

The quality of care can vary significantly from one facility to another. The best assisted living facilities provide comfortable and healthy homes for patients in early and moderate stages of physical and mental decline. But inspection reports reveal that many fail to adequately staff facilities and train workers caring for patients – leading to falls, errors, abuse and even death.

In Alabama, we have 89,000 people living with dementia. With only 3000 beds, what happens to the rest of these folks? Some are admitted to the nursing home, losing their independence prematurely. In fact, the Alabama Medicaid crisis is precipitated in part by the $808 million spent annually on dementia care (about 20% of the budget). Most are cared for at home by a “volunteer” caregiver. In Alabama it is projected that 302,000 caregivers provide care for these folks. This is $4 billion of unpaid care with a huge toll on the caregiver’s health.

The baby boomers changed our society. We embraced the car. We became much more mobile. Little remained untouched. Boomers are now hitting their seventies. Inevitably they will lose their independence. Inevitably, many will lose their cognitive functions. Will they (and their caregiver children) demand better care for those who are aging out? For my sake I hope so.

Healthcare is almost 20% of our economy. A future President Clinton or a future President Trump will, through executive action, have a lot to say about how that money is spent. Commonwealth fund (found here) has an exceptional comparison of the two candidates’ proposals and how they would effect the budget. If you care about fiscal responsibility, for the record, the balance sheet is found below:

screen-shot-2016-10-10-at-3-28-22-pm

So, the Trump plan is not, despite what he claimed in the debate, the way to fiscal solvency.

Kaiser Family Foundation has put together a specific list of issues (found here) that folks appear interested in and has evaluated each camp’s claims.  The Cliff’s notes version is as follows:

Health insurance coverage and cost – Issues include overarching reform of health system remains unpopular in a partisan manner. Affordability hampered by a glitch where family coverage became more expensive, “cost sharing” was not controlled by the law, enrollment was not implemented well, and transparency provisions not implemented. Market place competition is limited, especially in rural areas.

  • Clinton
    • supports policies to maintain and build upon the ACA.
    • increase premium subsidies in the marketplace so no participant is required to pay more than 8.5% of income for coverage.
    • fix the “family glitch” and allow people to buy coverage through the marketplace regardless of their immigration status.
    • make a public plan option available in every state and give people the option of buying into Medicare starting at age 55.
    • invest $500 million annually in outreach and in-person assistance to enroll more uninsured in coverage, and she would enforce ACA transparency provisions.
    • authorize the federal government to review and disapprove unreasonable health insurance premium increases in states that do not have such authority, repeal the Cadillac tax.
    • proposed new private plan standards to waive the annual deductible for at least three sick visits per year, limit monthly cost sharing for prescription drugs to $250, and protect against surprise medical bills when patients inadvertently receive care out of network.
    • proposed a new refundable tax credit of up to $5,000 to subsidize out-of-pocket health expenses (including premiums in marketplace plans) for all Americans with private insurance.
  • Trump
    • complete repeal of the ACA, including the individual mandate to have coverage.
    • create high risk pools for individuals who have not maintained continuous coverage.
    • provide a tax deduction for the purchase of individual health insurance.
    • promote competition between health plans by allowing insurers to sell plans across state lines; an insurer licensed under the rules of one state would be allowed to sell coverage in other states without regard to different state laws that might apply.
    • promote the use of Health Savings Accounts (HSA), and specifically would allow tax-free transfer of HSAs to all heirs.
    • would also require price transparency from all hospitals, doctors, clinics and other providers so that consumers can see and shop for the best prices for health care procedures and other services.

Medicaid – Issues include states’ concerns regarding financing and unwillingness to expand to those too poor to qualify for a tax rebate required coverage

  • Clinton
    • encourage and incentivize states to expand Medicaid by providing states with three years of full federal funding for newly eligible adults, whenever they choose to expand.
    • would also continue to make enrollment easier and launch a campaign to enroll people who are eligible but not enrolled in coverage.
  • Trump
    • supports a Medicaid block-grant and a repeal of the ACA (including the Medicaid expansion).
    • would cover the low-income uninsured through Medicaid after repealing the ACA.
      • The House Republican Plan, which is part of a larger package designed to replace the ACA and reduce federal spending for health care, would offer states a choice between a Medicaid per capita allotment or a block grant.

Medicare – Issues include prescription drug costs, fate of provisions in ACA, public option for those 55-64

  • Clinton
    • supports maintaining the current structure of the Medicare program and opposes policies to transform Medicare into a system of premium supports. On the issue of prescription drug costs
    • supports allowing safe re-importation of drugs from other countries, allowing the federal government to negotiate drug prices in Medicare, especially for high-priced drugs with limited competition, and requiring drug manufacturers to provide rebates in the Medicare Part D low-income subsidy program equivalent to the rebates provided under Medicaid.
    • does not support repealing the ACA or any of the Medicare provisions included in the law; rather, she supports expanding the law’s value-based delivery system reforms.
    • proposed to allow people ages 55 to 64 to buy into Medicare.
  • Trump
    • No position on the issue of Medicare program restructuring or whether to allow older adults ages 55 to 64 to buy in to Medicare.
    • supports repealing the ACA, which would presumably mean repealing the law’s Medicare provisions.
    • supports allowing safe re-importation of prescription drugs from other countries.

Prescription drugs – Issues are pricing (generally more expensive in US than in other countries despite being manufactured in the same facility) and out-of-pocket costs (many plans have gone to a cost sharing rather than a deductible strategy

  • Clinton
    • proposes prohibiting “pay-for-delay” deals whereby companies make payments to competitors for agreeing to delay market entry
    • increasing funding for the FDA Office of Generic Drugs to reduce their approval backlog
    • reducing the market exclusivity period for biologics
    • and directing the FDA to prioritize biosimilar drugs with few competitors. To address price increases for generic drugs
    • proposes to establish consumer oversight in federal agencies
    • penalize drug companies for unjustified price increases
    • allow importation of lower-cost drugs from countries with similar safety standards.
    • She also supports eliminating tax deductions for direct-to-consumer advertising
    • requiring FDA approval of advertisements
    • tying federal support for drug companies to their investment in R&D
    • increasing transparency of the additional value new drugs have over existing treatments
    • allowing Medicare to negotiate drug and biologic prices. To address OOP spending on prescriptions,
    • proposes a $250 per month cap on cost sharing for covered drugs; and a rebate program for low-income Medicare beneficiaries that mirrors those in Medicaid.
  • Trump
    • supports allowing importation of drugs from overseas that are safe and reliable but priced lower than in the U.S.
    • supports greater price transparency from all health providers, especially for medical exams and procedures performed at doctors’ offices, clinics, and hospitals, but does not specify whether this policy would also apply to retail prescription drugs, which typically are not considered services or procedures.

Opioid epidemic – Issues include increased use (1 in 20 nonelderly adults used opioids for nonmusical purposes), increased addiction ( 2 million non elderly adults with of the level of opioid use increases to the level of opioid use disorder, often referred to as abuse, dependence, or addiction), increases in overdose deaths (those involving opioids have quadrupled since 1999).

  • Clinton
    • released a $10 billion (over ten years) plan to fight drug addiction.
      • includes a federal-state partnership to support education and mentoring programs
      • development of treatment facilities and programs
      • efforts to change prescribing practices, and criminal justice reform.
      • direct federal action to increase funding for treatment programs
      • change federal rules regarding prescribing practices
      • enforce federal parity standards
      • promote best practices for insurance coverage of substance use disorder services
      • issue guidance on treatment and incarceration for nonviolent and low-level federal drug offenders.
  • Trump
    • Will build a wall on the U.S.-Mexican border
      • will help stop the flow of drugs and thus address the opioid epidemic.

Reproductive health – Issues include access to preventive services, publicly funded family planning, and abortion services

  • Clinton
    • supports policies that protect and expand women’s access to reproductive healthcare, including affordable contraception and abortion.
    • defends the ACA’s policies, including no-cost preventive care and contraceptive coverage. promised to protect Planned Parenthood from attempts to defund it and would work to increase federal funds to the organization. called for the repeal of the Hyde Amendment which she believes limits low-income women’s access to abortion care.
    • would appoint judges to the Supreme Court who support Roe v. Wade, ensuring a women’s right to choose an abortion.
  • Trump
    • called for defunding Planned Parenthood if they continue to provide abortion
    • He states he is pro-life but with exceptions when the pregnancy is a result of rape, incest, and life endangerment.
      • has promised to appoint pro-life justices to the Supreme Court that seek to overturn Roe v. Wade
    • would also work to make the Hyde Amendment permanent law
    • would sign the Pain-Capable Child Protection Act, legislation that would sharply limit access to later term abortions.
    • would also repeal the ACA, which would eliminate minimum scope of benefits standards such as maternity care in individual plans and coverage of no-cost preventive services such as contraceptives in private plans.

 

 

cartoon1015

As a family physician, one of the more fun conditions for me to care for is pregnancy, childbirth, and the well child checkups that follow.

I meet women at the start of their pregnancies and learn a little about their lives beyond their pregnant “condition.” I see them every month for a long stretch, meeting mothers, mothers-in-law, friends, and husbands along the way. As things progress I see them every two weeks, and then weekly.

By the time the weekly visits occur I find out what my patients are made of – and they get to know me, as well. Mama is very pregnant, and my job is to convince her that every day inside, even past the mythical due date, is good for the baby. I then get to witness the miracle of childbirth (and occasionally play a larger role).

In my practice, mother and baby come back to visit weekly, monthly, and then annually as the children reach toddlerhood. We continue to have conversations around the new family and the transitions up until the age of three.  After that, if the child is well, we are limited to an annual “Hi, how are you doing?” For the most part, they are moving on with their lives as a young family and fortunately do not need my help. In the words of the Lone Ranger,”My work here is done.”

However, it isn’t quite as easy as that. Doctoring is a funny gig when it comes to personal relationships. I’m sure there are others just as funny, dentistry probably being one. I see these folks back for a visit after a couple of years, or at a community activity, or elsewhere in Mobile and surrounds, and the mothers will proudly say to their (very embarrassed) twelve-year-old,  “There’s the first person who ever saw you.” We’ll make some small talk — what do you say to a twelve year old after nine years? — and typically the mother will ask about my family and my kids.

Because, as it turns out, while they were sharing a part of their story with me, I was sharing a little of my story with them. I used my children as examples for feeding and discipline problem-solving, as both good and bad examples. I discussed my wife’s meal-time solutions for feeding grown-ups and kids at the same table. In other words, I shared with them as they were sharing with me. A little piece of my version of how we put our kids to bed has entered into the bedtime strategy of many of the families that I have cared for. If “Good Night Moon” did become a successful part of their ritual, I hope they think of Dr. Perkins in a really good way (after the toddler is actually asleep, of course).

I don’t get to care for a lot of young families any more, given my other duties, but I do still see folks that I have cared for over the last twenty years, people with whom I have shared family anecdotes in this manner in the hope of leading them to better health.

It has been six months since my wife’s death. Many of my patients, coming in for a variety of reasons, or running into me around Mobile, have wanted me to know that they are here for me just as I, and our family, and some of my
wife’s child-rearing strategies, were there for them. It has meant a great deal to me.

Nurse: Dr Perkins, Mr Smith called. He said he called his insurance company and they told him that if YOU will fill out the form saying he REALLY needs the Lantus insulin, they will pay for it.

Me: I have filled out that form. That insulin is Tier 2 on his insurance. It isn’t that they won’t pay, it’s that he has to pay 50% of the cost until he reaches his maximum which is $7,000 in a year.

Nurse: He won’t like that.

Me: (exasperated) Have him call President Obama. Or, if he’d prefer, give him George W Bush’s number.

Prior to 2006, people on Medicare did not have prescription cover. Folks on Medicare would be discharged from the hospital after their congestive heart failure was made better through diuresis only to go home to a Lasix free household and re-accumulate fluid. Predictably, within the next several weeks the patient would be back again, drowning in their own fluids. We would try to cobble together enough samples and inexpensive generics to keep these folks out of the hospital. Another strategy was to talk them out of eating so they could afford the “good” medications.

In 2003, as part of the Medicare Modernization Act, Medicare Part D was created. The law, rather than directing Medicare to negotiate with the drug companies directly, created opportunities for private companies to “compete” for patients and to negotiate with drug companies. While not ideal, for the first 10 years it worked pretty well. My patients were able to get necessary drugs (with an emphasis on generics) for relatively reasonable prices.  Part D Providers were required to have drugs in each of the therapeutic classes making care relatively straightforward. Patients with congestive heart failure could be on the medicines necessary to avoid readmissions. Pharmacies were reimbursed for their services and pharmacists were elevated to part of the care team.

The design of the benefit was a little different from that of traditional medical pharmacy benefits. Instead of non-specific co-pays, the design included “tiering” (having a group of drugs that has low out-of-pocket costs and another group that is typically equivalent and name brand but less cheap) and included the concept of co-insurance (instead of paying a flat $25 co-pay, one might pay 25%-50% of the costs) for the so-called specialty drugs. At relatively high level, the out-of-pocket costs were capped which protected the patient to an extent but only after about $7,000 had been paid. The law dictates that only the Part D Providers may negotiate and that the federal government is directly prohibited from doing so. The patient, as is alway the case, doesn’t get to negotiate with anyone.

After 10 years of flat growth, the costs of drug benefits are rapidly escalating. This is being passed on to the consumers. The reasons are several fold. First, number of specialty (Tier 4) drugs have increased from 20 to 200. These drugs typically require coinsurance and thus result in  a lot of the out-of-pocket increase. One pill of a new cancer drug might cost $1000 and might cost the patient $500 until his or her deductible is reached, typically at about $5,000. Second, a number of plans have moved drugs formerly covered under a co-pay into a tier requiring coinsurance.  Approximately 60% of Medicare beneficiaries are in plans that have had common drugs such as Crestor and long-acting insulin moved into a tier where coinsurance used instead of a co-pay. The law does not set limits on coinsurance and some of the rates are as high as 50%.  Lastly generic drugs, which used to require the lowest co-pay, are being priced much higher and are being placed in co-insurance tiers by insurance companies.

This increase in prescription costs is not limited to Medicare beneficiaries. Many people with high deductible “bronze” plans purchased (family deductible about $12,000) on the exchanges are noticing the same thing. The EpiPen controversy, in part, is a consequence of people moving to these higher deductible plans without looking into exactly how the savings in premium might translate into increased out-of-pocket costs. In fairness to patients, having spent some time trying to figure out what the out-of-pocket cost might be for an EpiPen under a given insurance, I do not blame them for being confused.

What should our response be? Over 70% of Republicans and 90% of Democrats feel that the government should be directly involved in price negotiations, at least for Medicare. If not directly, similar rebates to those given to Medicaid would potentially lower costs for all consumers.  Lastly, patients can ask for substitute medications rather than use those that require significant out-of-pocket outlay. For the EpiPen, where the manufacturer has been “ruthless in fending off competition and in getting support for its predatory pricing practices, including within the US and the EU” it may not be possible but for others it never hurts to ask.

Over half of all Americans pay under $400 annually for out-of-pocket medical costs of all types and many pay nothing. As health economist Uwe Rheinhart pointed out last week, we need to get everyone engaged in the health system  to create the political will to fix it.  We can accomplish this by strengthening the penalties for non-participation so that  everyone will be affected. Or we need to get over this notion that everyone deserves access to healthcare and only the rich should be protected at all times from anaphylaxis. After all, J. Wellington Wimpy didn’t get a hamburger every time he asked.

 

 

Are you going to provide free clinics for sick underprivileged children? Will you do in Alabama what you do on mission trips to other states and countries?

Senator Jim McClendon, explaining why he is sponsoring not one but TWO lottery bills

The legislature in Alabama is meeting in special session starting today to see if they can find more money for the General Fund budget. The budget passed in the regular session was about $100 million short for what was needed to maintain the Medicaid program at its current bare bones level. Medicaid and corrections are the major programs funded by this complicated and convoluted budget process and, as you can imagine, the constituency tends to be silent. The legislature comes back into special session today to determine whether Alabama will become the first state to reduce Medicaid funding below the threshold required for the match.The funding possibilities are as follows:

  1. Governor Bentley’s proposal- a $225 million lottery, with proceeds going to the General Fund. Would require constitutional amendment. Money not available for about a year.
  2. Jim McClendon’s bill, which would include electronic lottery machines in four counties – Greene, Jefferson, Macon and Mobile – with a bond issue to pay for Medicaid in the coming year. Would require constitutional amendment.
  3. House Minority Leader Craig Ford, D-Gadsden, said he’ll bring a lottery-only bill that would set aside lottery proceeds for education. Another Ford bill would include casino gambling as well.  Would require constitutional amendment. Money not available for about a year.
  4. The legislature may create a compact with the Poarch Creeks, allowing them to offer more types of gambling in exchange for an annual fee or a cut of the proceeds. Critics worry that under federal gaming regulations, a lottery could open the door to Creek expansion without a compact. Unclear how this would work. Likely would draw a lot of attention form the feds.
  5. They may opt to use the BP money to fill the gap this year, leaving the hard work for next year.
  6. They may, and possibly will, do nothing and allow Medicaid to become a non-compliant program

If they fail to act. the feds will do one of two things. Because the program’s recipients are disproportionately poor and of color, the feds may sue under the Fourteenth Amendment and require us to find $100 million to maintain a $6 billion program, maintain access to healthcare for ALL Alabamians, and not force the layoffs of tens of thousands of individuals who work in healthcare. Conversely, the Supreme Court has ruled that Medicaid is an optional program. The feds may just allow us to opt out and allow our natural experiment to continue. Let’s see how many folks will come to Alabama instead of Ecuador for mission work.

 

I will be appearing at a press conference on Friday, August 5th as a representative of the Alabama Academy of Family Physicians. Beside me will be representatives from the Alabama Academy of Pediatrics, the Alabama Hospital Association, and the community. We will share the following message. This message is being shared in across the state in a series of press conferences beginning Monday:

On August 1st (tomorrow), Alabama begins applying cuts to the state’s Medicaid system that will impact the quality of care all Alabamians receive. In Alabama, Medicaid:

  • Provides health coverage for eligible children, pregnant women, and severely disabled and impoverished adults
    • About 1 million Alabamians
    • More than half the births in Alabama
    • About 47 percent of Alabama’s children
    • About 60 percent of Alabama’s nursing home residents

These cuts are devastating and dangerous. Because Alabama already operates a bare bones program, the following will occur:

  • Reduction of payments per visit to primary care physicians by 50% beginning tomorrow
  • Reduction of reimbursement rates for ambulatory surgical centers, all other specialty physicians, dentists, optometry, hearing and other programs
  • Elimination of the prescription drug coverage for adults for the first time
  • Elimination of adult eyeglasses
  • Elimination of outpatient dialysis
  • Elimination of prosthetics and orthotics
  • Elimination of Health Home and Physician case management fees
  • Consideration of a pharmacy preferred provider program

As a result of the Medicaid cuts put in place August 1, my colleagues in primary care are being put between a rock and hard place. Medicaid rates will not cover the cost of keeping the practice open. My primary care colleagues will either accept fewer Medicaid patients, limit the number of office locations, lay off staff – including nurses and other clinical staff. In some cases they will make the very tough decision of closing their practice and moving to a state that has a more hospitable practice environment.

So what? Turns out primary care doctors are the economic engines of small communities and provide economic vitality to all communities.  Combined, we support 83,095 jobs and generating $11.2 billion in economic activity, according to a report by the Medical Association and the American Medical Association. Specifically:

  • Jobs: Each physician supported an average of 9.5 jobs, including his/her own, and contributed to a total of 83,095 jobs statewide.
  • Output: Each physician supported an average of $1.3 million in economic output and contributed to a total of $11.2 billion in economic output statewide.
  • Wages and Benefits: Each physician supported an average of $758,744 in total wages and benefits and contributed to a total of $6.7 billion in wages and benefits statewide.
  • Tax Revenues: Each physician supported $46,148 in local and state tax revenues and contributed to a total of $404.9 million in local and state tax revenues statewide.

When these cuts take effect, doctors will leave. Consequently it much more difficult for any patient in the state – including those on private insurance like Blue Cross/Blue Shield – to make an appointment with a doctor of their choice at a time convenient for their schedule. Jobs will leave these towns, towns will die.

Isn’t Medicaid full of fraud? Turns out, not. In fact state lawmakers recently conducted an extensive review of Medicaid’s funding and operations. Our program is one of the most frugal health plans available.

What needs to happen? In order to protect the state’s fragile healthcare system from collapse and ensure that all Alabamians have access to the doctor of their choice, legislators must find a long-term, sustainable solution to fund Medicaid, and shore up funding for the coming year.

How can you help?  Visit IamMedicaid.com  for more information and go HERE to contact state leaders to let them know how you feel.  Encourage them to protect Alabama’s healthcare system by fully funding Alabama Medicaid. Let them know that you are concerned and you vote!

“Trade, we are going to fix it; health care, we are going to fix it; women’s health issues, we are going to fix it,” Trump said.

Mobile, Alabama August 21, 2015

I was in of of the 30,000 (well, more like 15,000) people in stands at Ladd-Peebles stadium when Donald Trump announced his health care position. My late wife Danielle Juzan live-tweeted the rally as well.Whatever was wrong, he said, he would fix it.

My friend Josh Freeman just posted a blog where he cites the JAMA article written by President Obama to detail the successes and failures of the Affordable Care Act (now in year 6 of being enacted and year 4 of implementation). Bottom line, in those states that have expanded Medicaid, poor much better off. In all states, health insurance for those working still too expensive. In all states, quality of care is beginning to improve. It is widely assumed that a Clinton/Kaine administration will work to strengthen the gains made through Obamacare.

Trump declined to explain how he would lower insurance costs (other than saying “more competition”), but he did specify how he would deal with those who lack insurance. He said that the government would negotiate with hospitals to cover the uninsured.

60 minutes, September 27, 2015

In the evolution of Donald Trump’s health care policy, he has transitioned from universal coverage. As a business man with interests in many countries, he has seen the impact of more healthcare delivery in countries such as Scotland and has admired the ease and efficiency of care. In one of the debates, in fact, he expressed his admiration for other country’s care delivery.  “As far as single payer, it works in Canada. It works incredibly well in Scotland.”

“We will repeal and replace disastrous Obamacare,” Trump said. “You will be able to choose your own doctor again.”

Donald J Trump’s acceptance speech, Republican National Convention

Upon wrapping up the nomination, the Trump campaign fleshed out his healthcare position (found here). Aside from “repeal and replace with something terrific” the plan is a little light on specifics. However, as this is a presidential candidate and we have to assume he has a shot at being elected, I feel compelled to analyze his stated position on how almost 20% of the GDP will be managed and 25% of our tax dollars will be spent. The key points are as follows:

  • Want universal coverage? The Trump position is to eliminate the mandate BUT keep the pre-existing condition coverage. Policy analysts are a little confused about how this would impact the care delivery system.
  • Like a bare bones policy? Trump proposes eliminated limits on intrastate policy sales. So your company might buy your insurance but there may be no local care delivery options, so you might have to drive to Delaware for care.Now THAT would be bare bones.
  • Allow deductions of premiums from income taxes and use of a healthcare savings account. A nice position to take if you want the vote of young, healthy people. As most chronically ill people make very little money and spend a lot on healthcare, this does not benefit those who are sick.
  • Require price transparency. Now this one, I can get behind. Check out health care blue book, kinda coming anyway.
  • Block grant Medicaid. Theory is “States know how to use the money best.” Bill Clinton did this with “welfare” (actually cash payments known as TANF) in the 1990s. The outcome? Total money available was reduced and less money was spent on child care (increasing the penalty to working parents who needed assistance). In fact, half of the money the federal government sent for TANF-like programs went for things like middle class tuition reimbursement.
  • Allow people to negotiate with foreign drug companies. This started out as “Medicare ought to negotiate for lower drug prices” but has ended up “feel free to mail order drugs from Canada.” Kinda odd how our negotiator-in-chief let that happen.

Should make for an interesting debate.

 

 

Archives