Wrong Target, Wrong Weapon

The hospital is a dangerous place. Sick people go there.  In fact, its likely the largest concentration of sick people in your town.  I mean sick sick, not seasonal viral cold sick.  So it should come as no surprise that there’s always a risk, when you go into a hospital, that you’ll get sicker.  Post-hospital syndrome is one of those illnesses.  Another is infections.  The CDC estimates that 648,000 patients acquired an infection while in the hospital in 2012.  CMS and the Affordable Care Act, in their infinite wisdom, have decided to target those infections.  Or rather, the government has decided to monetarily penalize hospitals whose patients get a lot of infections.  According to Kaiser Health News, (http://www.kaiserhealthnews.org/Stories/2014/June/23/patient-injuries-hospitals-Medicare-Hospital-Acquired-Condition-Reduction-Program.aspx) 761 hospitals stand to lose 1% of every medicare billing because their infection rates are higher than benchmark.

So which are these disease-laden dens of hygienic iniquity?  Large, city, teaching hospitals with a lot of poor people.  Are there a lot of mean, dirty people working in these hospitals who have no respect for poor people and are careless about cleanliness?  Are residents not washing their hands, or sneezing on patients’ open wounds?  Of course not.  Let’s look at the measures CMS is looking at.

1. Catheter-related infections, both blood and urinary.  So that means intravenous lines into large central veins or arteries, as well as catheters inserted into bladders to drain urine.  Who gets these catheters?  Sick people.  In the case of central lines, the sickest people in the hospital.  Where are the sickest patients?  Large, city, teaching hospitals.

2. Clostridium Difficile (that’s C-Diff to you).  This is an acquired infection in the bowels.  Who gets C-Diff?  People who have been in the hospital for a long time.  Who stays in the hospital for a long time?  Sick people, vulnerable to infections.

3. Methcillin-resistant staphylococcus aureus (MRSA).  If I had a nickel for every “MRSA” infected person in any hospital, I wouldn’t be writing for money.  Geeze, I’ve been in the hospital a lot.  I work there.  Maybe I have MRSA too.  Some places swab everyone’s nose regularly to check for MRSA.  If a patient has a “history of MRSA”, even if its vague, or we’re not sure, or it was 30 years ago, everybody gowns and gloves around that person and waves red alert flags wave everywhere.  Thousands of infection control nurses’ careers have been made off questionable MRSA histories.  I’m not saying real MRSA infections are serious.  They are.  It’s just not a good metric.

Of course there’s the fact that a New England Journal of Medicine study in 2012 found that docking medicare payments doesn’t improve “performance” on things like this (http://www.nejm.org/doi/full/10.1056/NEJMsa1202419).  But even if it did, infection rates are a lot more complicated than four data points.  Certain patient populations are more likely to get hospital-acquired infections.  Patients with diabetes, lung disease, or vascular disease are more susceptible.  The old and/or debilitated are more susceptible.  The poor and those without social supports are more vulnerable.  People getting complicated surgical procedures, especially bowel, are more vulnerable.  All of these conditions are more prevalent in large, city, teaching hospitals, even with the most draconian infection-control policies imaginable.  Once again, CMS is going after the wrong suspect and the largest target.

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Latest Health Wonk Review

Hosted by Julie Ferguson at the Workers’ Comp Insider, this is a Health Wonk Review worth reading. Check it out here.

 

The Geographic Divide: How Federalism Has Formalized Health Disparities

Jimmy Carter once said that America is not a melting pot, but a beautiful mosaic. We have all sorts of people here, but we want them to maintain their unique identities, not assimilate into some generic unity. However, this very characteristic that makes our nation so wonderful also provides the context for stigma, segregation, and hate crimes. We’ve come a long way in the past two centuries: from slavery to emancipation, segregation to civil rights. But de facto segregation still exists, and while it’s often about race, it’s also about poverty–and both race and poverty are often connected to health disparities.

On the one hand, groups self-segregate for a variety of reasons, and it’s not entirely clear whether this is good or bad. Self-segregation may be about the joys and comforts of sharing a common culture or language, or it may be about banding together to survive oppression. The best thing I’ve come across on this topic is Beverly Daniel Tatum’s book Why Are All the Black Kids Sitting Together in the Cafeteria?

On the other hand, we segregate in other important ways that seem not quite right. We have affluent neighborhoods and low-income neighborhoods and there are a host of institutional factors and personal behaviors that reinforce these divides. For example, although illegal, realtors often steer potential homebuyers away from certain “undesirable” neighborhoods. Banks follow questionable lending practices. Local governments zone industrial plants near housing projects. You get the idea.

Capitalizing on these patterns of residence, the political parties gerrymander districts that will help them win elections. Have you seen a map of North Carolina’s Congressional districts? Those long skinny districts and the highly irregular borders are not drawn for convenience; they demarcate the racial composition of the population across the state.

All of these are primarily local issues. They occur because of people’s inherent biases and, with the exception of gerrymandering, they are not established by laws or regulations. They are just the way society seems to work. But, knowingly or not, the Supreme Court’s decision to make the Affordable Care Act’s Medicaid expansion optional for states has created the opportunity for health disparities to be formalized into law, thanks to federalism and our country’s deep partisan divide.

It’s old news that only 26 of our 50 states have decided to expand the Medicaid program to all U.S. citizens residing in their state with incomes below 138% of the federal poverty level, but the expansion has only been a reality for 6 months. Now we are seeing how it is playing out on a personal level. One of the concerns among policymakers was that low-income people would emigrate from non-expansion states and flood into expansion states. A consensus is emerging that, while this may happen to some extent, it is unlikely to be a major issue–mostly because low-income people don’t have the resources to relocate.

What is particularly striking to look at are towns on either side of a state border. In some cases, single towns actually span state lines. And, if one state has expanded Medicaid, while the neighboring state hasn’t, whether or not a low-income person has health insurance may depend on what part of town they live in. Texarkana is one such town, and Annie Lowrey writes about this issue in the New York Times. Her point–and the one I am echoing here–is that we have formalized the unequal treatment of similarly situated persons based on nothing more than where they happen to hang their hat.

Somehow we tend to be okay with this unequal treatment when there’s enough of a buffer in place. For example, if the low-income in California are treated differently than the low-income in Indiana, we’re able to come up with reasons–real or imagined–that allow us to reconcile that to ourselves. But reduce the geographic distance, and focus on the unequal treatment that exists between residents of Chicago, Illinois and Gary, Indiana, and suddenly it gets much harder to ignore. We may all be different, and our differences may be part of what makes us beautiful as a nation, but we are all Americans. As such, it doesn’t seem right to deny some of us health insurance just because we don’t live in the right part of town.

 

UnitedHealthCare in Massachusetts

We all want the advantage.  We put our kids in special pre-schools so they have the advantage.  We work 100 hours a week so our kids can do 8 activities and get the advantage. Tall people have an advantage, we’re told.  Poor people are “dis-advantaged”.  Well folks, there are a whole bunch of senior citizens in Massachusetts who are about to get dis-advantaged starting September 1.

Yesterday the Boston Globe told me that UnitedHealthcare will be cutting 700 doctors, or 2-4% of it’s providers (it has 18,600in MA), from it’s Medicare Advantage plans. UnitedHealthCare is a mammoth national insurance company, and one of the main things it does is provide Medicare Advantage programs.  In fact, it’s the largest provider of such private Medicare plans in the country.  UHC has done this in 11 other states as well, and in some cases has dropped whole hospitals from it’s roster.  Why?  Company spokespeople say “they hope that streamlining the pool of doctors will not just save money but ultimately improve the quality of patient care…”.  They do not specify how quality of patient care will be improved by abruptly removing peoples’ doctors from their insurance plans.  But it will definitely save money.  And why does UHC feel it has to save money?  Because there has been a gradual reduction in the federal reimbursements to private Medicare contractors.

Why, you may ask, is the government using private, for-profit companies to provide Medicare services, and paying up to 14% more for the identical services provided by government-administered Medicare?  Excellent question.  Medicare Advantage, so called because these plans generally cover more services, like eyeglasses and prescriptions, was created after private insurers insisted that not only could they meet the medical needs of senior citizens and the disabled more cost effectively than the government, they could do so and still make a profit. (Thank you to Wendell Potter for that explanation.)  It became part of the Balanced Budget Act of 1997, but such plans have been available since the 1970s.  Well, it turned out that the claims were not true, and many of the private companies that participated dropped out when they lost money.  So the government essentially paid the companies to stay. Hence the 14% overpayment.

So.  Lot’s of money to be made.  15 million people are in Medicare Advantage plans, with payments from the government of $156 billion dollars, or 30% of all Medicare spending.  But you make more money for your shareholders if your patients don’t go to the doctor.  UHC cleared $1.1 billion dollars last year and increased it’s shareholder dividends by 30%.  So last week UHC informed a bunch of doctors in Massachusetts that they’ve been booted from the plan.  They’ll tell the patients this week. Oh, and the changes go into effect Sept 1 but you can’t change your plan until the next open enrollment period, which isn’t until October.

When UHC tried this in Connecticut, county Medical Associations filed a lawsuit and got a temporary injunction from a judge to stop UHC from dropping 2,200 doctors.  Here’s what UHC had to say about this ruling, according to Arielle Becker in the CT Mirror:

“In its statement, UnitedHealthcare said the ruling would ‘create unnecessary and harmful confusion and disruption to Medicare beneficiaries in Connecticut.  We continue to have a broad network of doctors that is designed to encourage higher quality, affordable health care coverage,’ the statement said. ‘We know that these changes can be concerning for some doctors and customers, and supporting our customers is our highest priority.'”

Right.  Because there’s no unnecessary and harmful confusion or disruption when you eliminate peoples’ doctors.

 

 

Joe Paduda Hosts Health Wonk Review

Wright on Health’s latest post about the Kentucky Kynect Kynundrum makes it into the latest Health Wonk Review, along with numerous other fabulous submissions. All of which are presented by our host Joe Paduda of Managed Care Matters. Read it here.

 

Kynecting the Dots on Obamacare

Even before the Affordable Care Act became law, public opinion over the proposed reform was caught in a paradox. We learned from numerous polls, including this one from the Kaiser Family Foundation, that people were adamant about disliking “Obamacare” while simultaneously liking all (or at least most) of its components. Then late night host Jimmy Kimmel aired a segment that asked people whether they preferred the Affordable Care Act or Obamacare. Obviously, it was a trick question, but you get the sense from watching the clip that people are reacting from partisan positions and have little understanding of the law itself. The lesson for politicians? That kind of messaging, no matter how patently false it may be, is incredibly effective.

Fast forward to today. The ACA is now law, and with only a few exceptions, the law itself has been fully implemented. That is, there are now expanded Medicaid programs in roughly half of the states, and federally subsidized health insurance exchanges are operational nationwide. What remains unclear is whether the public’s perception of the law has changed at all now that most of the key provisions are in place. On the one hand, we’ve heard from the disgruntled groups who lost their coverage despite the President’s claim that they could keep it. On the other hand, we’ve seen some 8 million people sign up for health insurance under the law in year 1 of the exchanges.

And then there are the politicians. We’re in a midterm election year, and we’re getting our first glimpse of how the politics of the ACA will play out now that the reform is much better established. Will people’s receipt of benefits under the law make this a less politicized voting issue? Not if politicians can keep people confused on the issue. It’s the same old story: People dislike Obamacare, but they like what Obamacare does. MSNBC’s Chris Hayes is one of numerous people reporting on how this issue is playing out in a key senate race in Kentucky, where the state marketplace “Kynect” is very popular, while Obamacare is very unpopular. How is that disconnect on the part of the public being handled? You can watch this video segment and see for yourself.