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Moody’s, S&P warn GOP plan would hurt hospitals


Moody’s Investors Service and S&P Global Ratings say that Republican legislation to dismantle the Affordable Care Act would hurt hospitals financially, including downgrades on their debt. Central culprits are that the legislation  relies on per-capita Medicaid caps and tax credits instead of mandates for individual insurance.

Also, taking issue with GOP assertions, S&P said that the legislation would probably be more likely to leave leave older and sicker Americans unable to afford insurance than to coax younger and healthier people to buy coverage.

“The overall payor mix for providers would weaken as the number of people without insurance would most likely rise, as would the hospital sector’s level of bad debt and charity care expenses,” S&P said.

Moody’s, for its part, predicted that the legislation would reduce the number of people with health insurance and “increase bad debt and uncompensated care costs,” by freezing Medicaid expansion as of 2020.

To read more, please hit this link.


La. looks at health effects of Medicaid expansion


In New Orleans’s French Quarter.

Has Medicaid expansion under the Affordable Care Act made people healthier? Governing magazine looks at the question. It reports:

“To overcome the spotty research that’s out there and to determine the impact of enrolling more people in Medicaid, Louisiana is putting a lot of resources into tracking the expansion’s effect. The state expanded its program last year and has implemented what it calls a Medicaid expansion dashboard. In mid-December, the dashboard was showing that under the expanded program nearly 360,000 Louisianans had obtained health coverage, more than 4,000 women had been screened for breast cancer, more than 3,600 people had received colon cancer screenings and more than 700 adults had been diagnosed with diabetes.

But not every state is willing or able to devote the resources Louisiana has to measuring the program’s impact. That’s especially true now that the future of the Affordable Care Act is up in the air with a new administration and Congress in Washington.

“What’s more, it’s really too early to definitively answer the question of whether Medicaid expansion makes people healthier in the long run. Expansions are only a few years old. But for Rebekah Gee, who is Louisiana’s health and human services secretary, the dashboard makes one thing completely clear. ‘This shows that there is a demand for care,’ she says, ‘and we do have the supply for it.”’

To read more, please hit this link.

Some GOP governors to try to block Trump efforts to stop Medicaid expansion


GOP governors in several states will push back against any Trump administration efforts to stop or reverse the Medicaid expansion that has taken place under the Affordable Care Act.

Ten states approved expansion under Republican governors, and even GOP-dominated statehouses.  The Wall Street Journal reports that ending  Medicaid expansion would take away insurance coverage for millions of Americans,   creating a political backlash as a result.

The WSJ noted that Medicaid expansion “has also slashed uncompensated care provided by the nation’s hospitals by billions of dollars annually. The states that have yet to expand Medicaid have forfeited hundreds of billions of dollars in federal funds.”

“Right now a lot of Republican governors expanded Medicaid and they have said they will fight to keep it,” Caroline Pearson, a senior vice president at Avalere Health, told the publication. Meanwhile prominent Trump supporter and former Arizona Gov. Jan Brewer told the Associated Press that she wants the Trump administration to see Arizona’s Medicaid expansion as model of cost-effectiveness.

To read the WSJ article, please hit this link.

Prospect of end to ACA spawns panic among some



For Kaiser Health News

The 20 million Americans who have gained health coverage under the Affordable Care Act don’t yet know exactly how the presidency of Donald Trump will change their lives — and reactions to that uncertainty range from anxiety to apathy.

“My phone is ringing off the hook,” said Billy Bradford, an insurance broker in Montgomery, Ala. “People are just in panic mode here.”

One call came from an older couple who had recently retired. Right now, the couple pays $57 per month for their insurance plan; without the subsidy they receive through the health law, the cost will shoot up to $2,000 a month. “They called me in tears afraid. They would not be hired back at their old jobs and are in poor health,” said Bradford.

But another set of consumers — who perhaps are healthier or feel like they are paying too much for too little coverage — may welcome a change. Trump told The Wall Street Journal on Nov. 11  that the law would be “repealed and replaced or amended.”

On Nov. 13, Trump was upbeat but vague about what that change might be, telling 60 Minutes: “It’ll be great healthcare for much less money. So it’ll be better healthcare, much better, for less money.”

It’s been well-documented that the public remains deeply divided over the law, which has been controversial since it passed in 2010. A recent Gallup poll found that 51 percent of respondents are in favor of repealing Obamacare, while 45 percent oppose repealing it.

But of those Americans actually enrolled in either marketplace coverage or expanded Medicaid, about 80 percent say they are somewhat or very satisfied with the coverage, according to a survey by the Commonwealth Fund.

Denise Martinez Gascoigne, 49, in Greenland, N.H., has been paying $1,130 in premiums each month for insurance for her family of four that she purchases through the state’s exchange. Their deductible is $5,000 per person. Gascoigne and her husband are both self-employed and earn too much money to qualify for a subsidy.

“It’s so ridiculous that we pay over $1,100 a month, and we’re still left footing the bill for whatever prescription or procedure we might need in addition to the health insurance,” she said. “We just don’t go to the doctor.” Her premium is set to increase to nearly $1,330 in 2017.

Gascoigne, who is a Democrat, is “very disappointed and distraught” over the results of the election and supports a single-payer health system. Nonetheless, she said, she’s “somewhat indifferent” to the impending changes to the Affordable Care Act.

But in Crystal, Minn., Xochitl Mendoza Ramirez is far from indifferent. She fears that she will lose her coverage: “I felt like throwing up. The past two days, it’s been me having these moments of crying at work.”

Ramirez, 22, has made good use of the insurance she gets through her state’s expansion of Medicaid, the government’s program for low-income adults. “If it wasn’t for the Affordable Care Act, there’s no way I would have gotten my gallbladder out or even gone to the doctor. I just couldn’t afford it.”  She also relies on the insurance for therapy and medications for bipolar disorder.

Ramirez doesn’t know how she’ll get health insurance without the Medicaid expansion. She works two part-time jobs in retail, but neither provides health insurance. Any changes to the law are likely to take months or years before they go into effect, but Ramirez is already preparing for the worst.

“As soon as I found out he was elected, I started making phone calls to get an IUD,” she said, referring to an intrauterine device for long-acting birth control. She found a doctor to do the procedure this week.

Tuan Nguyen, 38, in San Jose, Calif., has been paying $105 for a subsidized plan on the exchange. Recently, he’s been diagnosed with digestive problems and acid reflux and was pleased that each doctor visit cost him just $5.

“I’m happy with the plan. I’m just sad to have it taken away from me right when I really need it,” he said. “If the subsidy goes away, I’ll have to pay full price. That’s close to $500 or so. I can afford it, but it’s something that will definitely take a chunk out of my income. It would be a crunch.”
Rebecca Geitz of Austin, Texas, said her subsidized premiums have been affordable, but her plan “is the most useless thing in the world. No one takes it!” When Geitz, 33, did get sick, her co-pays were so expensive that she said it was cheaper for her to just pay an urgent care clinic out of pocket. Nonetheless, she said, “I do know that if a serious emergency happened my coverage would help to some degree.”

If the law is repealed, she worries, she may not even have that. But he’s much more worried for his mother, who is being treated for Stage 4 lung cancer and receives her insurance through California’s Medicaid program.

Nguyen worries that if the Republicans change how they pay for Medicaid by making it block grant program, as they’ve promised, the funds for her $8,000-a-month medications could dry up. “I’ve thought about this the past few days. It’s been on my mind like crazy,” he said. “Right now she’s getting medication that’s extending her life. It could allow her to live years instead of months. … Are they going to pull the plug on her medications?”

Richard Coppola, 48, believes that the Affordable Care Act has been a failure. He pays $378 a month for a plan with a $2,000 deductible, and his premiums are going up to $480 next year.

But still, he said, he’s “terrified” about going back to a world without it. He worries about a system where he could be denied coverage for once having a mole removed years ago. He’s also concerned about lifetime cost limits being restored and the loss of subsidies for people with low incomes.

“The ACA is a piece of garbage,” Coppola said, “but the Wild West before was a lonely place.”


4 ways Trump could affect hospital revenue cycle


Becker’s Hospital Review presents four ways  in which President-elect Donald Trump’s proposed healthcare reforms could affect hospitals’ revenue cycle:

“1. Tax-free, inheritable health savings accounts. Mr. Trump said he would sign legislation to promote tax-advantaged HSAs to encourage consumers with high-deductible health plans to set aside money for out-of-pocket healthcare costs.

“Mr. Trump would also tie HSAs to a person’s estate, meaning an account could pass on to next of kin without facing federal taxes.”

“2. Federal mandate for provider price transparency. Mr. Trump said he would require ‘all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals,’ to disclose service prices to consumers prior to treatment. This could speed the rate of price transparency adoption at hospitals across the nation.”

“3. New Medicaid funding method. Mr. Trump proposed dismantling financing for Medicaid expansion under the ACA and converting the program to a block grant to contain healthcare costs. Block grants would give states more authority over their Medicaid programs in exchange for accepting a fixed amount of funding from the federal government. This means states would not be required to cover certain groups of people, such as children, pregnant women and the elderly, to receive federal money. ”

“4. Repeal of the ACA. Mr. Trump vowed to repeal the ACA as one of his first presidential acts. Bill HR 3762, introduced into Congress October 2015, would: repeal ACA tax credits, end Medicaid expansion, repeal major taxes used to fund insurance expansion and create a two year transition period to dismantle ACA infrastructure. The Congressional Budget Office estimated 22 million people would lose insurance if HR 3762 is signed into law without a Republican replacement plan. The rise in uninsured Americans could negatively affect healthcare providers by increasing their uncompensated care and bad debt rates to pre-ACA levels.”

To read the full article, please hit this link.

Va. governor to keep pushing Medicaid expansion


Gov. Terry McAuliffe (D-Va.) says he will continue to fight for Medicaid expansion in the state despite being blocked so far by the Republican-controlled legislature. He has asserted that such an expansion would not only save lives but also create more jobs in the Old Dominion.

“I have been a spectacular failure at being able to close the coverage gap in the Commonwealth of Virginia,” Mr. McAuliffe told his audience at AHIP’s National Conference on Medicaid, Medicare and Duals.

“It has not been for want of trying.”

Republicans’  rationale in many states for rejecting expansion is that states could at some point  be financially liable, if the federal government goes back on its vow to cover at least 90 percent of the costs.

With 66 of the 100 members in Virginia’s House of Delegates Republican, he has been prevented him from getting even “creative” waivers enacted that would eliminate state liability.

To read a Med Page Today article on this, please hit this link.


Psychiatrist/author criticizes population-health focus


Kaiser Health News

In his recent book, The Finest Traditions of My Calling,  Abraham Nussbaum,  M.D., 41, makes the case that doctors and patients alike are being shortchanged by current medical practices that emphasize population-based standards of care rather than individual patient needs and experiences.

Nussbaum, a psychiatrist, is the chief education officer at Denver Health Medical Center and practices on the adult inpatient psychiatric unit there. I recently spoke with him and this is an edited transcript of our conversation.

Q. Your book is in some ways a lament for times gone by, when physicians were “artisans” who had more time for their patients and professional independence. But you’re a young doctor and you must have known at the outset that wasn’t the way medicine worked anymore. Why do you stick with it?

A. The first thing I’d say was that I didn’t know right away that medicine is no longer universally understood as a calling instead of a job. We are describing health as if it is just another consumer good, and physicians and other health practitioners as the providers of those goods. That is the language of a job. When you remember that being with the ill is a calling, then you remember that it is a tremendous privilege to be a physician. People trust you with their secrets, their fears and their hopes. They allow you to ask about their lives and to assess their bodies. So my lament is not for the loss of physician privilege — goodbye to that — but to the understanding of medicine as a calling.

Q. You don’t like checklists and quality-improvement measures that dictate how physicians care for patients because you say it turns doctors into technicians and is an obstacle to “moral reasoning.” But those tools, which generally take a systems approach to providing care and rely on evidence-based guidelines, aren’t going away anytime soon. How do you do the kind of doctoring you want to do in this environment?

A. Quality improvement seems to be here to stay. Regulators at all levels require it. But I believe that evidence of its success is not as clear as they suggest. Just last week, the British Medical Journal published a study that found no evidence that introducing quality metrics has resulted in a significant reduction in patient mortality. The leaders of the quality movement’s version of quality improvement developed out of industrial engineering, so they are always comparing the care of patients to things like the production of cars or the flying of airplanes. People are far more varied than cars on assembly line or planes on the runway. So quality metrics always feel forced to me, especially for the more interactive medical encounters.

Q. But not all physicians are equally skilled or conscientious. As a patient, I feel more comfortable knowing there are rules and standards that doctors have to meet.

A. In my own specialty, the current quality metrics all encourage me to perform standardized screens on patients or to document carefully. None of them require me to develop a relationship with a patient so that I can, say, foster hope after a suicide attempt, or knit a psychotic person back into the life of their family. Yet that it was my patients want, those human relationships. It is also what physicians want, and the most recent studies suggest that most physicians are dispirited by quality metrics.

I don’t think  that physicians should be free to do whatever they want. Their thinking and decision-making should be held up to scrutiny. A physician’s standard of quality should be evidence-based, but even more, it should be patient-centered. The standard should be what the patient defines as what matters. So if you are suffering chronic pain, it is not just a reduction of your score on a standardized pain scale, but your ability to resume the activities you identify as constitutive of your life.

Q. You talk about wanting to be able to sit with patients and talk with them, to really “see” them. All that takes time that physicians don’t generally have. I understand your book isn’t a how-to manual. But, really, how can physicians do this, even if they want to?

A. It’s a real challenge. It’s important to use the time you have in service of the patient’s needs. I don’t review records while I’m in the room with a patient. I try to make every question be about the patient. I have to ask standard questions, but I try to do that as way to get to know the patient. For example, if I have to ask questions about what they can remember, I’d ask about a book they have with them. Part of my concern about checklists is that they train you to follow a script instead of following your patients.

Q. Only 55 percent of psychiatrists take insurance compared with nearly 90 percent of physicians in other specialties. That puts their services out of financial reach for many people who could use their help. How does that square with your vision of doctors as healers and teachers?

A. It’s deeply concerning to me. I’ve made a conscious choice to work at a safety-net hospital, so I can see people regardless of their ability to pay. I hope that through things like the Medicaid expansion and mental-health parity, more psychiatrists will work with people who have mental illness.

Q. You talk about the virtues of “slow” medicine, similar to the slow food movement, where physicians reject providing care in a standardized, mass-produced fashion. One path that some physicians have chosen is to establish boutique practices that accept a limited number of patients who pay extra fees for more personal attention and better access. What’s your perspective on that?

A. It sounds appealing to me. In most descriptions of boutique medicine, they talk about it like a lovely restaurant, one that I couldn’t afford to go to every night. I think it’s an interesting model but not a solution to the large problems facing medicine, in particular the ability to provide care to the most needy among us and the indigent.

Okla. considers Medicaid expansion


Yet again, a Red State that has fought Medicaid expansion under the Affordable Care Act is considering joining in the expansion, reports Forbes. In the Sooner State, it’s being pushed by low oil prices and state overspending.

Four things to know about the possible expansion:

1. The state could move 175,000 women and children into subsidized coverage while opening Medicaid to 628,000 working-age adults.

2. The cigarette tax might rise 146 percent ( by $1.50 per pack)  to help fund the  expansion.

3. The American Journal of Managed Care said that Oklahoma legislators who had  resisted Medicaid expansion said fiscal realities are driving the reconsideration. Oklahoma’s Medicaid chief, Nico Gomez, said that without expansion, rural providers would not survive and would have to relocate, the journal notes.

4. Talk of Medicaid expansion comes soon after hospitals launched an initiative to get  lawmakers to broaden  coverage under Insure Oklahoma, a state-run insurance program that helps provide health insurance to small-business employees and people who don’t have access to employer-sponsored insurance.

Medicaid expansion’s economic impact in states


In this HealthAffairs blog entry, healthcare economist Michael Chernew analyzes the economics of Medicaid expansion in various states under the Affordable Care Act.

One of his observations:

“{I}f Medicaid expansion induces previously Medicaid-eligible beneficiaries who were uninsured to enroll at the lower match rate, the state would have to finance that enrollment with less of an economic bounce. This is offset to some extent by federal support for programs otherwise funded by the state. Overall, with reasonable assumptions, a full accounting of the impact of Medicaid expansion on the state budget suggests states may break even, or even come out ahead, particularly if there is a lot of slack in the state economy.”

Louisiana hospitals prepare for Medicaid revenue flood



At a Cajun celebration on Louisiana.

The New Orleans Times Picayune  reports on how the new Medicaid expansion in the state, under its  new Democratic governor in Louisiana (the previous, GOP governor had blocked it), could mean big changes for hospitals across  that state as they see new revenue from patients who had been uninsured. Medicaid expansion obviously has a particularly big impact in a jurisdiction, such as Louisiana, with a very high percentage of poor people with chronic conditions.

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