DOCTOR PUNDIT » Chronic Disease Management

Insurers Balk at Childrens Coverage under Reform; HHS Clarifies Administration Policies

Michael Douglas, MD, MBA — Thu, 29 Jul 2010 14:21:25 +0000

The theory of the moral hazard hypothesis goes something like this: moral hazard occurs when a party isolated (set-off) from risk may react differently than it would if it were fully exposed to the risk. In the case of risk aversion, insurers are stepping up concerns that families will seek coverage under new reform laws only after their children fall ill. They contend that the ability to keep this from happening will contain costs and premium increases.

The White House seemed to be waiting for the line to be drawn in the sand before responding to this potential reform-killing measure — that is, until Insurance essentially threatened ending children-only plans under reform altogether in some states.

Some state insurance commissioners expressed concern that, without an open enrollment period that was widely communicated, people might wait until their children got sick to enroll them in coverage, causing plans’ costs to increase. And we were concerned when last week, some indicated that insurance companies would choose to stop offering policies for children rather than cover kids with pre-existing conditions.

HHS has since clarified the administration’s position on this matter issuing an advisory stating the formation of open enrollment periods, outside of which coverage will not be provided. Now, the distinction between children with congenital and pre-existing conditions and those with acquired, high-cost diagnoses is more clearly defined — for the purposes of the insurance companies, that is. | LINK

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Maryland Program Aims to Establish Healthcare Exchange Standard under Reform

Michael Douglas, MD, MBA — Fri, 23 Jul 2010 13:24:48 +0000

What do you get when old-fashioned community activism meets 21st century social media tech? Perhaps the best politics-is-local example of reforming healthcare access so far after its passage on a national scale. Howard County, Md. – approx pop. 250 000 — is partnering with a tech firm with one simple goal in mind: to guarantee access to healthcare for its uninsured.

Its mechanism looks to be a harbinger for reform-based enterprises such as local healthcare exchanges/cooperatives (whether subsidized or not) within which members pay a monthly fee for basic services. These services may run the gamut of primary care — as acute hospitalizations, preventive medical treatments and screenings, and emergency medical access would be covered.

Perhaps even more important, the utilization of concierge providers as healthcare “coaches” as both an empowerment mechanism and compliance tool, ensures continued healthcare access, sound preventive care, and decreased future healthcare costs. Will it serve as a model for state-based healthcare exchanges under reform? Looks like it’s on its way. | LINK

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Under Reform, Insurers Will Cover Certain Preventive Medical Costs

Michael Douglas, MD, MBA — Fri, 16 Jul 2010 13:26:49 +0000

The U.S. Preventive Services Task Force, an independent, non-partisan body made up of primary care physicians involved in developing preventive medical guidelines based upon evidence-based medicine, has always reveled in its staunch self-governance. That could change ever so slightly in the new age of health reform.

The academic research-oriented group will continue to make recommendations on best-preventive practices and supply ratings (“A”, “B”, etc.); but this time, under reform, insurers will be required to cover services that receive such a rating. The Obama administration hopes that this increase in access (which will require a small premium increase by insurers in the near term) will reap savings in the future — as costs for preventive testing, screening for certain chronic diseases, vaccinations, and well-child visits would be covered (without health plan co-pays and deductibles) if so rated by the USPSTF.

Besides having to consider methodology involved in formulating its ultimate recommendations, the group will also have to contend with the specter of political agenda setting if lobbying groups and disease advocacy organizations have their way under this bit of legislation — scheduled to go into effect in September. | LINK

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Research Trends Positively Influence Approach to Alzheimer Dementia

Michael Douglas, MD, MBA — Thu, 15 Jul 2010 19:59:16 +0000

Research into better treatments and possible cures of Alzheimer dementia is one of the bright spots in the potential for better healthcare delivery in the decade of the 2010s. There are many signs that bode well for the approach to this disorder at the dawn of the second decade of the 21st century.

New research into alternate pathways of disease development is starting to generate excitement among primary care physicians and geriatricians (such as myself) as potential arenas for new classes of drugs to combat Alzheimer’s. Better care delivery models in long term care of the elderly as part of new initiatives in the Affordable Care Act are already starting to impact chronic disease care management strategies.

Perhaps most important, there is new evidence to suggest that earlier detection of this cognitive disorder can enhance those developments, and more. At an annual meeting of top dementia researchers, guidelines were proposed to expand on the research from the ’00s to diagnose the disorder earlier — a strategy that benefits more than just those potentially afflicted with Alzheimer’s.

If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.

Heavier use of newly discovered biomarkers for earlier detection of the pathology behind Alzheimer dementia will be a closely watched process by both physicians and health policy analysts alike. | LINK

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Obama Announces First National HIV Policy Strategy

Michael Douglas, MD, MBA — Mon, 12 Jul 2010 14:17:10 +0000

HIV is once again in the news lately — first with news of a new strategy to combat the infection with enhanced vaccination research, the commitment of HHS in reallocating funds for HIV research on a global scale, and now the creation of the first “national HIV strategy” by a sitting president.

In the report, the administration calls for steps to reduce the annual number of new H.I.V. infections by 25 percent within five years. [..] [T]he administration will redirect money to areas with the greatest need and population groups at greatest risk, including gay and bisexual men and African-Americans.

Obviously, simple “redirection” of federal funds for medications and treatments of HIV/AIDS is not the final mechanism of care access for the millions of patients afflicted with this chronic disease; it is unclear where these funds will provide an absolute siphon for spending. Kudos to the administration in its efforts to reacquaint an entirely new generation of Americans on the urgency of this disease, but it’s got a long way to go to reduce sharply its transmission rates and healthcare policy atrophy in this area. | LINK

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Access of Indigent to HIV/AIDS Service Delivery Threatened in Weak Economy

Michael Douglas, MD, MBA — Fri, 02 Jul 2010 01:53:58 +0000

Needy HIV+ patients a victim of the economic recession? With the rise once again in jobless claims in this country and the possibility of a much-maligned scenario of a double-dip recession, government programs that formed the cornerstone of HIV and AIDS treatment for patients who could not afford traditional access to those treatments are now closing — creating a fallout in states in which waiting lists are the result.

What’s more surprising than this development is the lack of safety funding for depleted federal and state programs; the Obama administration has yet to guarantee any sort of budgetary proposal or stimulus mechanism for saving these programs. In the state of Georgia, waiting lists for accessibility to HIV treatments is up to almost 1300 persons.^[1] In Florida, almost three-hundred.

An increasingly sad state of affairs in this early drive toward reform. This segment of the indigent care population could succumb to the same restrictions on eligibility those who are mentally ill perennially seem to face from many government-run programs. Will it take a redux of the same levels of prevalence rates of HIV not seen in 20 years to jar the Obama administration to attention on this issue? | LINK

Pregnant women, children and adolescents, and patients with “extreme conditions” can be exempt from the waiting list.

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A Tale of Two High-Risk Insurance Pools

Michael Douglas, MD, MBA — Wed, 30 Jun 2010 13:15:24 +0000

While many states, like Minnesota, aren’t interested in creating high-risk insurance pools using federal funds under reform at this point, Gov. Schwarzenegger is moving forward with California’s commitment to do so. Until 2014, when insurers are required to cover patients in spite of deleterious pre-existing conditions, Schwarzenegger has signed bills allowing a fraction of that state’s uninsured to purchase coverage in high-risk pools.

In Massachusetts, where everyone is covered, premium rates continue to soar. Because that state subsidizes everyone’s care, those purchasing short-term plans within that its healthcare marketplace often drive up costs for those who are responsible for paying into the system — both individuals and employers. It appears that short term coverage for sicker people increase the cost of care delivery at a greater rate than anticipated among Massachusetts’ more chronically ill. The governor and insurers are working to close this loophole by restricting purchasing periods. | LINK

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Study: United States Falls Short on Quality of Healthcare Delivery Compared to Other Nations

Michael Douglas, MD, MBA — Thu, 24 Jun 2010 16:40:18 +0000

A study commissioned by the Commonwealth Fund confirms for some the dire straits quality healthcare delivery finds itself in today in the United States on the cusp of a reform effort. While, superficially, results like this are designed to provoke an immediate response (like from those on par with the Michael Moores of the world) — I find that the greatest asset findings like this can generate is creation of tough questions when one is forced to take a look at key quality indicators that reform will impact over the next decade.

On quality, the U.S. stood out “particularly with symptoms of more fragmented, poorly coordinated care,” Schoen said. In 2008, for instance, 14% of American adults with a chronic condition reported receiving the wrong medicine or the wrong drug dose in the past two years.

When compared to, say, Sweden or any other European country — an interesting stat. But getting out of the apples-and-oranges mentality allows us to see nuggets like this in a more sobering light. When placed in the context of Obama’s reform plight, it signals a call for urgency in healthcare delivery. | LINK

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Study: Medicare Part D Provisions Create Access Hardship for Latinos, Blacks

Michael Douglas, MD, MBA — Sat, 22 May 2010 16:05:04 +0000

How’s this for the ultimate Medicare entitlement irony? Medicare Part D offers, among many other benefits, the option for qualified beneficiaries to enroll in medication therapy management (MTM) plans with their pharmacy. The goal is to create a better informed patient-as-consumer among myriad Medicare D beneficiaries who suffer from many chronic illnesses requiring substantial polypharmacy — and hence, costs, to maintain their current state of health, improve it, and hopefully prevent further comorbid decline. To qualify for such a benefit within Part D, the beneficiary must be enrolled in the Medicare Part D drug program, have at least three chronic health conditions, take eight or more medications covered by Part D and spend at least $3,000 yearly on the medications.

Sounds fair enough and tailor-made for many seniors in the program. But there’s one problem: expense. Increasing numbers of racial minorities — predominant among them, Latinos and African-Americans — cannot afford many of those Part D-covered medications. They are less likely to gain medical access for a host of reasons, and cultural encumbrances make that latter problem more profound. Researchers studying this issue cite the potential problems that may occur with widening the racial healthcare disparity in terms of access — whether it be for affordable pharmacy or acute medical care. If it is incumbent upon the Obama administration to enrich Medicare on many levels, the systematic exclusion of many patients not able to take part in any part of the entitlement may set out to increase future healthcare costs if access to these government programs remains prohibitive | LINK

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NEJM Study Highlights Daily Administrative Hassles of Primary Care Physicians

Michael Douglas, MD, MBA — Thu, 29 Apr 2010 13:13:54 +0000

A study out this week [PDF] in the NEJM highlights the uncompensated “care”^[1] family physicians — correctly referred to in this NYT piece as medicine’s “embattled frontline” — must carry each and every day they continue to earn, at most, 50% of what many specialists pull in as income.

The study set out to show that the daily non-patient logistical workflow is a both a critical and burdensome task needed to be mastered in order to provide appropriate healthcare to patients — and as such, should be compensated. The study also highlighted the need for streamlined health information technology to incorporate these administrative tasks into a model that allows for the determination of compensation for primary care physicians.

A snapshot:

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 x-rays and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

Credit the NYT for bringing this to the fore, but, if recent history is any indication; the continued erosion of interest in primary care for new medical school grads, the slow pace of legislative action on the issue of Medicare reimbursements in the age of continued cuts, and the seeming disarray and delay of the Obama administration in creating some sort of unified and prioritized timeline for implementation of IT enhancements — will continue to make the dystopian daily life of the busy primary care physician reliable and somber fodder for media outlets.

This is in reference to the myriad background logistical workflow issues family physicians must deal with on a daily basis on top of the direct patient interaction once thought of as the discrete point of care.

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