Category: Investigations

“In the shrub steppe of Grand Coulee on the banks of the Columbia River, Wash., the town’s two family doctors practice at an unrelenting pace, working on call every other night and every other weekend.
In the coastal town of Port Angeles, the doctor shortage is so acute that a clinic is turning away 250 callers a week seeking a physician.
George and Lynne Rudesill are two of those people. Since learning earlier this summer that their primary-care doctor in Sequim was retiring, the couple have scrambled to find a replacement. Their calls are being met with waiting lists hundreds of people long or advice to call again in a month.
“I’m going to have to drive all the way to Silverdale or Bremerton to see a doctor,” George Rudesill said, citing cities that are about 70 or more miles away from home. “This area is in a medical crisis right now.”
Rural areas have long been strapped for doctors, but now the Affordable Care Act (ACA) is further straining those limited resources. More people with insurance means more people will want to connect with a doctor — just as aging baby boomers require more care and the doctors are retiring.”

“Consumers may soon find a surprise in their mailbox: a notice that their health plan is being canceled.
Last year, many consumers who thought their health plans would be canceled because they didn’t meet the standards of the health law got a reprieve. Following stinging criticism for appearing to renege on a promise that people who liked their existing plans could keep them, President Barack Obama backed off plans to require all individual and small group plans that had not been in place before the health law to meet new standards starting in 2014. The administration initially announced a transitional policy that, with state approval, would allow insurers to renew plans that didn’t comply with coverage or cost standards starting in December 2013 and continue doing so until October 2014. Then in March, the administration said it would extend the transitional policy for two more years, meaning that some people will be able to hang onto their non-compliant plans through 2017.”

“Last week, the Obama Administration announced the appointment of a new chief executive officer (CEO) for the federal health insurance marketplace under the Affordable Care Act (ACA). Kevin Counihan—who headed up Connecticut’s health insurance exchange, which worked quite well—will fill the newly created position.
Calling this position a CEO represents semantic gymnastics of a sort. That’s because CEOs generally have near-total autonomy to manage an organization, reporting only to a board of directors. Nothing like that really exists in government, short of the president. In this case, the new CEO reports to the administrator of the Centers for Medicare and Medicaid Services, so he is firmly ensconced in the normal federal agency bureaucracy. That may be a positive, because it respects the traditional lines of authority and accountability that help the government function.”

“A research network funded with millions by the Affordable Care Act will begin conducting vast studies next year to compare standard medical treatments. But what about the 100 million patients in the network — do they have a choice in the matter?
Will researchers get permission from each of those patients? And if patients are told about the studies, what, exactly, will they be told? These questions have bioethicists, scientists and health care officials debating how to bring the question of patient informed consent into the 21st century.
Obamacare is best known for extending health coverage to more Americans. But the health care law has many provisions aimed at improving health care outcomes and safety while lowering costs. One element is “comparative effectiveness” research: not just finding out whether a drug or treatment is safe and effective but comparing drugs head to head to find out which is better, for everyone or certain populations.
And with electronic medical records and vast pools of data, some of these studies have the potential to make lightning-fast, dramatic discoveries. But informed consent issues have the potential to slow such studies and make them too expensive.”

“Over the past few weeks, the American Medical Association has complained publicly and privately to the Centers for Medicare and Medicaid Services over its so-called Open Payments database, which will display what drug and device makers pay physicians. The system was created in response to concerns that medical practice and research may be unduly influenced by industry. But the database has been plagued by delays and technical glitches. The AMA is concerned that physicians lack the needed time to ensure correct data is displayed and that the public will understood what they see. The database is expected to go live on Sept. 30, but the AMA wants a six-month postponement to compensate for the problems. So far, CMS says no. We spoke with AMA president Robert Wah about the frustrations. This is an edited version.”

“Enrolling in Missouri’s Medicaid program has not been easy.
Many applicants have experienced a barrage of problems when trying to sign up for the program, including long delays until coverage kicks in, lost paperwork and a lack of one-on-one interaction with caseworkers. State officials have blamed a new computer system used to process Medicaid applications.
But there is another reason why some Missourians struggle to get help.
When Deborah Weaver, 28, had issues enrolling in the state’s Medicaid coverage for pregnant women, a switch from her Medicaid disability coverage, she was directed to use a toll-free number, 1-855-373-4636. When she called, Weaver endured long waits and received no guidance.
“I called them three or four times and each time it would take a minimum of 15 to 20 minutes to get through to a human being, only to be given the runaround,” Weaver said.
One time the wait dragged on for so long, Weaver ended the call, worried she was racking up too many minutes on her family’s cellphone plan.”

“NORTHPORT, Maine – By the time Laura Tasheiko discovered the lump in her left breast, it was larger than a grape. Tasheiko, 61, an artist who makes a living selling oil paintings of Maine’s snowy woods, lighthouses and rocky coastline, was terrified: She had no health insurance and little cash to spare.
Laura Tasheiko, 61, sits in her home in Northport, Maine (Photo by Joel Page for USA TODAY).
But that was nearly six years ago, and the state Medicaid program was generous then. Tasheiko was eligible because of her modest income, and MaineCare, as it is called, paid for all of her treatment, including the surgery, an $18,000 drug to treat nerve damage that made it impossible to hold a paintbrush, physical therapy and continuing checkups.
But while much of America saw an expansion of coverage this year, low-income Maine residents like Tasheiko lost benefits. On Jan. 1, just as the Affordable Care Act was being rolled out nationwide, MaineCare terminated her coverage, leaving her and thousands of others without insurance.
Maine Gov. Paul LePage’s decision to shrink Medicaid instead of expanding it was a radical departure from a decade-long effort to cover more people in this small rural state of farmers, lobstermen, craftsmen and other seasonal workers, which at least until recently, boasted one of the lowest rates of uninsured in the nation.”

“It’s not a news flash that health insurance can be complex and confusing. But the health insurance maze can be a problem, especially if you have never had health insurance before or have not had it for a long time. That’s the case for about half of the uninsured and for many people enrolling in the new insurance marketplaces set up under the Affordable Care Act.
Consider:
37% of enrollees don’t know the amount of their deductible. The deductibles in the plans sold on the exchanges are large; on average $2,300 for single coverage in the most popular plan, a Silver plan. For many people their deductible will be as important to their family budgets and their ability to get health care as the premium they pay, especially if they get a premium subsidy as most do in the exchanges. If people don’t understand their deductibles and copays they may pick a plan based solely on the premium and be in for a nasty surprise when they begin to use care and their deductible hits. It can also be important to know if services such as some physician visits and tests or generic drugs are exempt from the deductible.
Speaking of the subsidies, 46% of enrollees in the new insurance marketplaces say they’re getting a subsidy, when official numbers indicate about 85% actually get them. And even among those who know they’re receiving a subsidy, 47% don’t know the amount of the subsidy. A political implication is that many people getting help from the ACA don’t know it.
Many enrollees also don’t grasp basic insurance terms. A study of people eligible to enroll in the marketplaces showed that many were not confident in their understanding of a premium (36%), deductible (31%), copayment (28%), coinsurance (48%), maximum annual out-of-pocket spending (38%), provider network (36%), covered services (35%), annual limits on services (39%) or excluded services (40%).”

“Federal officials are floating the idea of expanding Medicare’s Pioneer model for accountable care organizations, but they might struggle to recruit any new participants.
Some prominent ACO leaders shared their skepticism in letters to the CMS that the agency released this month. The program, designed and administered by the CMS Innovation Center, is the government’s earliest and most aggressive test under the Patient Protection and Affordable Care Act of new financial incentives for hospitals and doctors to hold down medical costs and meet quality targets.
The Pioneer initiative’s rules put doctors and hospitals at too much risk of losing money with too little control, officials with Universal American, CHE Trinity Health, St. Vincent’s Health Partners, the Franciscan Alliance and others said in the comment letters to federal officials.
Pioneers must agree to accept potential losses with the promise of bonuses after the first year. ACOs participating in the Medicare shared-savings program, in contrast, can go three years without the risk of owing Medicare money if they fall short.
“Organizations are not gravitating toward the Pioneer ACO model because the downside risk is not outweighed by the opportunity for economic gain—the business case is not compelling,” wrote officials with CHE Trinity Health, a Michigan-based system. The system’s CEO is Dr. Richard Gilfillan, who oversaw the launch of Pioneer ACOs as the Innovation Center’s director before his departure last June.”

“Unhappy with the choices her insurance broker was offering, Denver publishing company owner Rebecca Askew went to Colorado’s small business health insurance exchange last fall. She found exactly what she’d been hoping for: affordable insurance options tailored to the diverse needs of her 12 employees.
But Askew is in a tiny minority. Only 2 percent of all eligible businesses have checked out so-called SHOP (Small Business Health Options Program) exchanges in the 15 states where they have been available since last October under the Affordable Care Act. Even fewer purchased policies.
In November, three more state-run SHOP exchanges are slated to open, and the federal government will unveil exchanges for the 32 states that chose not to run their own.
SHOP exchanges were supposed to open nationwide on Oct. 1, the same day as exchanges offering health insurance for individuals. But the Obama administration postponed the SHOP launch, citing the need to fix serious technical problems with the exchanges for individuals, which it said were a higher priority.”