Tag Archives: Patient Protection and Affordable Care Act

Women’s health and the ACA: Look beyond contraception

If you have been listening to the contraception debate in Washington (sort of hard to avoid, isn’t it?), you may be under the impression that preventive health for women equals contraception. Or contraception equals women’s preventive health. (We’re putting aside, for the purpose of this post, the debate about religion, conscience and the role of government).
Health Reform core topic

The Senate has defeated one bid to overturn the administration rule requiring employers to provide an insurance plan with first-dollar coverage of birth control, and it’s not clear what the House will do. But the issue is likely to percolate in Washington, state legislatures and the courts for some time to come.

The health reform law, and the regulations being developed to implement it, has a far more expansive definition of prevention and what it means for women’s health. Here are more details on the new regulations and a tutorial from Kaiser.edu. According to the new women’s preventive health rule, new health plans must cover, without cost-sharing, a lot more than the pill:

  • well-woman visits;
  • screening for gestational diabetes;
  • human papillomavirus (HPV) DNA testing for women 30 years and older;
  • sexually-transmitted infection counseling;
  • human immunodeficiency virus (HIV) screening and counseling;
  • FDA-approved contraception methods and contraceptive counseling;
  • breastfeeding support, supplies, and counseling; and
  • domestic violence screening and counseling.

These requirements will go into effect in August (with another year allowed to finalize how the religious exemptions will work). Grandfathered plans won’t have to follow the new rule, while they maintain their “grandfather” status. Over time, many health plans will go through changes that will mean that they will no longer be “grandfathered.” Then they too will have to follow the new regulations.

Of course, more women will get these benefits, simply because more women will be insured. Approximately one in five women of reproductive age is currently uninsured. Most of them will get coverage, including preventive services, starting in 2014 whether through Medicaid, through subsidized coverage in the exchanges or by buying coverage. Right now, coverage of maternity benefits is spotty on the individual insurance market, but the plans in the health exchanges will cover it.

The law also requires many other preventive services – some free – for men, women and children. They have not gotten much attention in the polarized birth control debate.

The conversation (and press coverage) about the contraceptive rules have included lots of misinformation about abortion. Politicians who misstate policy don’t help, but reporters need to know what the law does and does not do.

The health law does not mandate abortion coverage and this preventive health rule does not change that. In fact, states under health reform have the explicit ability to limit abortion coverage in policies sold in state exchanges and several have already taken action to do precisely that. Plans that do cover abortion in the exchange will have to wall that off in a way to keep it apart from the federal subsidies.

Joanne Kenen

Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.

A few more stray but relevant facts:

According to the Kaiser.edu materials, about two-thirds of women aged 15 to 44 use contraception – and do so for about 30 years.

Most employer-based insurance plans do cover contraception, though there are often co-pays. Among large employers, more than 80 percent cover contraception.

Federal Medicaid dollars do not cover abortion under the Hyde Amendment (except for rape, incest or when the life of the mother is in danger) – although some states use their own money to cover abortion in some circumstances. But Medicaid does cover contraception. In fact, Medicaid pays for more than 70 percent of publicly financed family planning services.

And Title X funds family planning clinics (created in 1970 under the Nixon presidency). According to HHS, about 5 million women and men get family planning services through more than 4,500 community-based clinics. Someone with religious objections to providing contraceptives for employees is indirectly paying for Medicaid birth control coverage – and indirectly for the tax subsidies of employer-sponsored insurance – just as we all pay taxes that fund some things we agree with and some we don’t.

Share your thoughts on database design for tracking pharma payments to doctors

Curtis Brainard of Columbia Journalism Review reminds reporters that their input is needed on the design of a federal database that will track payments from drug and device makers to doctors.

Investigations and databases, such as Dollars for Docs by Propublica, have revealed payments to doctors who had been accused of professional misconduct, had been disciplined or lacked credentials. Researchers have found evidence that payments can influence doctors’ treatment decisions (PDF).

Provisions in the Affordable Care Act mean that companies will have to report such payments to the Centers for Medicare & Medicaid Services, which will post the data on a public website. CMS has asked for “comments on how to structure this Web site for ultimate usability.”

There are a number of ways to submit your comments, detailed in this Federal Register announcement. Comments must be received by 5 p.m. EST on Feb. 17.

Reuters shows how shell companies hide Medicare fraud in plain sight

Reporting for Reuters, Brian Grow and Matthew Bigg used an analysis of public data to investigate the practice of using shell companies to defraud Medicare of millions while staying a step or two ahead of federal investigators.

While the specific damage inflicted by shell companies has not been tracked, “Last year, ‘improper payments’ resulted in $48 billion in losses to the Medicare program, nearly 10 percent of the $526 billion in payments the program made, according to a Government Accountability Office report last March.”

“Simply by reviewing the incorporation records of Medicare providers in two buildings” in Miami, they write, “reporters uncovered information that one government official said could prompt “a serious criminal investigation” of some of the companies.”

The fraud rings merge stolen doctor and patient data under the auspices of a shell company and then bill Medicare as rapidly as possible. Other shell companies are often layered on top to camouflage the fraud, law enforcement officials say.

Some of the shells purport to be billing companies; they form a buffer between the sham clinics and Medicare. Others pay kickbacks to doctors and patients who sign off on bogus medical claims or sell their Medicare ID numbers to enable the shell company to bill the government. Still other shells act as fronts to launder the profits.

The key to this kind of fraud, known as a “bust-out” scheme, is for each of the fake companies to bill as much as possible before authorities catch on. Shell companies become a tool that helps keep the crooks ahead of the cops.

The Armenian crime ring whose fraud made headlines last year used 118 shell companies in 25 states and bilked the feds out of at least $100 million. Varying incorporation rules make state-hopping and obfuscation “easy,” they write, especially since states don’t check to see if records are legit before they allow a company to incorporate. The reportes found that even a few simple safeguards would go a long way to detecting the boldest frauds.

In Florida, FBI agents say almost every Medicare fraud scheme involves shell companies. There, Reuters scrutinized incorporation documents for firms located in two buildings near the Miami International Airport. In a building with dimly lit corridors, a rickety elevator and almost no one in sight, a host of companies purport to provide services to Medicare recipients. But telltale signs of fraud abound.

Many of the 26 companies in the buildings had replaced corporate officers at least once in the last four years. Some had changed ownership, or their corporate executives represented more than one medical-related company. Law enforcement officials consider such activities to be red flags for fraud.

For its part, CMS told the reporters it simply didn’t have the resources necessary to conduct the widespread audits needed to catch fraud, though the $350 million allocated to such efforts under the 2010 health reform law should help.

Health journalists who will certainly want to review the “methodology” subheading at the end of the story.

Growth of for-profit hospices ripe for coverage

Given the recent spate – some good, some pretty muddy, and one I think pretty eye-opening – of articles about the growth of for-profit hospices, it’s probably worth taking a look at the issue, particularly for those of you who live in communities (such as the south and west) where the for-profits are most dominant. I think it’s also important to note some of the context that some of these articles omitted. And, yes, there’s a health reform angle. Several, in fact.

MedPAC started looking into the for-profits several years ago, as the sector started growing very rapidly. It became clear that the Medicare hospice “caps” and penalties meant to discourage too many long stays weren’t working.  MedPAC  has made a number of payment recommendations, including one that would revamp how all hospices are paid (which would make long stays less profitable) and another focusing more narrowly on creating a separate payment scale for hospice care in nursing homes.

MedPAC advises Congress but doesn’t set policy. And Congress has not acted on the recommendations to date – except that it did include in the 2010 health reform law a requirement that HHS review (and gives it a pathway to revamp) the hospice payment system in 2013. In addition, hospice faces about $7 billion of Medicare payment reductions over a decade under the Affordable Care Act. On top of that is the 2 percent Medicare provider cuts that will be “triggered” next year now that the supercommittee failed to agree on an alternative deficit-reduction steps.

All that being said, the recent Bloomberg piece by Peter Waldman on sales and marketing tactics by the for-profit chains was a hefty piece of reporting. It documents things like “Summer Sizzle” promotions, “Christmas Cash Blitz” and “Fall Frenzy” admission drives. The focus was pretty squarely on the business and sales practices. That is an important issue (and I haven’t seen it as well reported elsewhere ). But for those of you who may want to write about hospice, it’s not the only issue.

If you write about the growth of for-profit hospices – and some communities are now dominated by them – a few things to keep in mind.

  • Don’t conflate quality and quantity. A flawed government payment system, and overly aggressive/inappropriate sales tactics (or even outright fraud) by some players isn’t always the same thing as a quality-of-care problem. A nursing home resident who ends up getting hospice care longer than he or she really should isn’t necessarily getting bad care – although they may well be getting care that Medicare shouldn’t be paying for.
  • There’s a difference between large publicly-traded, investor-owned hospice chains and smaller, local for-profit hospices, which can be quite mission-driven (and low margin.) A hospice’s tax status doesn’t automatically define whether it provides good or bad patient care. (Remember the ongoing debate about which nonprofit hospitals are really “non” profit).
  • Prognosis is really, really hard – particularly for the frail elderly nursing home population. It is hard to know whether a dementia patient is going to die within six months – even when there are some tell-tale danger signs of decline and deterioration. CMS did add some recertification and quality rules two or three years ago that are supposed refine the eligibility criteria – but they still aren’t a crystal ball.
  • Long hospice stays may be a poor use of taxpayer/Medicare money but potentially so are very short stays. If people are only in hospice a couple of days, that often means that they got very aggressive care – which usually means very costly care  until close to the end. That’s one thing if such care was what the patient/family chose. It’s another if the doctors never explained to the patient/family the likely prognosis, the likely outcome, the relative burdens and benefits of such care (and by “burdens” I don’t mean purely financial burdens). If Medicare paid for all that and then there is a mad dash for hospice to try to get pain and symptoms (physical and emotional) under control in the last few days, it’s neither good for Medicare’s bottom line nor does it give hospice the optimal circumstances for providing really good end-of-life care. Those last few days of life can be intensive for the hospice and a hospice with only very short-stay patients would be hard pressed to survive financially.
  • How would small community and rural hospitals survive under some of the new payment models being discussed? Would they close? Get swallowed up by big chains? Both – i.e., first get swallowed up and then be closed because they aren’t as profitable?
  • There have been several studies suggesting that patients who receive hospice care may live longer than similar terminally ill patients who do not. There was a whole spate of articles on this phenomenon back when Art Buchwald was dying – or rather when he was not dying. Most of the research I’m familiar with was on hospice care for specific cancers and heart diseases, not necessarily dementia, and not necessarily in the context of for profit hospice care for nursing home patients. But seriously ill people who get expert, interdisciplinary end-of-life care may bounce back, temporarily, and no longer fall in that six-month life expectancy category. If they really rebound, they should leave hospice care, as Buchwald did, with the right to resume it when the time comes.
  • When asking whether there’s “too much” hospice care in nursing homes – don’t forget to ask what happens when there is not enough. This is the one area where I thought the Bloomberg story was incomplete – or even slightly misleading – by quoting a physician in Kansas as saying there should “never” be hospice in nursing homes. There is a lot of data – in peer-reviewed journals and medical conferences produced by academics and palliative care experts and nonprofits, not by the “industry” – that pain is poorly controlled in nursing homes, that there is overtreatment (feeding tubes being a prime example) of late-stage dementia patients in nursing homes, and that nursing home patients who could benefit from hospice/palliative care are instead sent repeatedly – often via costly ambulance-to the hospital. I met one doctor who called this care model “Our Lady of Perpetual Hospitalization.” This is a piece of the readmission issue that the health care reform law aims to address. There’s no room here to go into the convoluted mismatched incentives regarding nursing home care, but suffice it to say the revolving door won’t stop without quality end-of-life care in nursing homes – and nursing homes are often surprisingly ill-equipped to provide quality end of life care. Accountable Care Organizations, advanced medical homes, home and community based alternatives to institutional care, all part of health reform, may play a role here in coming years but it’s not going to be an overnight change.
  • Hospice was not designed to be a substitute for, or side door to, Medicare-financed long-term care and it’s not the right way to pay for long-term care. Unfortunately, we don’t have a good way of paying for long-term care, nor for helping family caregivers.
  • I’ve heard some rumblings – and it’s not a story I’m in a position to chase right now but may be worth looking into locally – that some groups or individuals are starting small nonprofits, specifically to flip them fast in sales to the big chains and make a lot of money. The Bloomberg piece reported on the recent uptick in acquisition of nonprofits.
  • Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.

Finally, for now at least, remember that most hospice care takes place at home, with family members as caregivers. But not all terminally ill people have family members alive, or living nearby, or hale and hearty enough themselves to provide that care at home. For them, at least for some of them, the nursing home IS “home,” and that’s where they will access hospice.

Update: Just after I finished writing this blog post, Bloomberg and Kaiser Health News wrote about a big fraud case against a hospice chain based in Arkansas, and updated the status of other investigations.

CLASS Act is gone but long-term care problem remains

The ill-fated CLASS Act is gone.

What’s not gone is the problem of how to provide long-term care to the millions of disabled and/or elderly people who need it – numbers that will only grow as the baby boomers age.

What, if anything, does the Affordable Care Act do to address the problem?

What questions do you have about health reform and how to cover it?

Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.

The health reform law did not solve the long-term care problem. Not today’s problem, not the growing problem of the future. Even the most ardent backers of the CLASS Act (Community Living Assistance and Services and Supports), which was part of the health care law, did not see it as a complete answer. CLASS was designed to ameliorate, but not eliminate, long-term care costs, which can easily run $70,000 or more a year. Had CLASS been implemented, it would have given families who chose to participate about $18,000 (the finances were never finalized) a year that could pay a piece of a nursing home bill, or for assistance at home, or to build or a wheelchair ramp or accessible-bathroom etc to enable someone to stay at home.

But CLASS sank in an actuarial/legal/political swamp.

Is there anything else in the ACA to help family caregivers?

The law does have dozens of provisions that – depending on how well they are funded and implemented, how widely they are adopted and, quite frankly, how well some of the new care models turn out to work in the real world – can at least nibble around the edges of the long-term care needs.

New models of care

Some of you have started reporting on hospital readmissions. If we’re going to keep older people out of that revolving hospital door, they are going to need to be taken care of – well – outside the hospital. And that’s where a lot of the new models step in – community health teams to support primary care practices, the independence at home act, medication reconciliation programs, transition teams etc. A part of the legislation called “rebalancing” addresses some of the requirements and obstacles that up until now have led states to put institutional/nursing home care ahead of home and community based services.

The AARP just put out a report on how health reform addresses aspects of long-term care and family caregivers. It’s just nine pages, and some of the programs are going into effect this fall, or early next year. There are lots of good local angles for stories there. (The SCAN Foundation is also a good resource on these issues, and I wrote a while back about some of the relevant care models here.) We tend to think of the elderly when we think about long-term care but remember families of the disabled, whether adults or children, and some of people with serious mental disabilities also have these needs.

The report from the AARP Public Policy Institute by Lynn Feinberg and Allison Reamy notes that the health reform law explicitly includes both individuals and their caregivers in shared decision making an in quality assessment. What the family thinks and experiences matters; the family is a partner in care. The law includes family caregivers in some of the programs to improve caregiver training. The AARP report notes, in fact, that “The law explicitly mentions the term ‘caregiver’ 46 times and ‘family caregiver’ 11 times.”