KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Lack Of Medicaid Expansion Hurts Rural Hospitals More Than Urban Facilities

KFF Health News, September 8, 2016

Rural hospitals have long argued they were hurt by the lack of Medicaid expansion, A study published in Health Affairs suggests they have a point.

This article first appeared September 7, 2016 on Kaiser Health News

By Shefali Luthra

It isn't news that in rural parts of the country, people have a harder time accessing good health care. But new evidence suggests opposition to a key part of the 2010 health overhaul could be adding to the gap.

The finding comes from a study published Wednesday in the journal Health Affairs, which analyzes how the states' decisions on implementing the federal health law's expansion of Medicaid, a federal-state insurance program for low-income people, may be influencing rural hospitals' financial stability. Nineteen states opted not to join the expansion.

Rural hospitals have long argued they were hurt by the lack of Medicaid expansion, which leaves many of their patients without insurance coverage and strains the hospitals' ability to better serve the public. The study suggests they have a point.

Specifically, the researchers, from the University of North Carolina Chapel Hill, found that rural hospitals saw an improved chance of turning a profit if they were in a state that expanded Medicaid — while in city-based hospitals, there was no improvement to overall profitability. Across the board, hospitals earned more if they were in a state where more people had coverage and saw declines in the level of uncompensated care they gave.

To put it another way: All hospitals generally fared better under the larger Medicaid program, but there's more at stake for rural hospitals when the state expands coverage.

The study looked at how expanding Medicaid affected hospital revenue, how many Medicaid patients they discharged, levels of uncompensated care the hospitals provided and how well the institutions did financially overall. It compared those effects in rural versus urban areas, across more than 14,000 annual cost reports from hospitals between January 2011 and December 2014, or a year after eligible states could have expanded their Medicaid programs.

In states expanding Medicaid, rural hospitals saw a greater increase in Medicaid revenue than urban hospitals did. City-based facilities save a higher percentage than rural hospitals with the reduction in uncompensated care, though that change "did not translate into improved operating margins for urban hospitals," the study notes.

How much these differences matter, though, remains up in the air.

"There is a disparity in the impact of Medicaid expansion, and probably the [law] overall," said Brystana Kaufman, a doctoral candidate at the university's department of health policy and management and the study's first author. "There needs to be more exploration into why we're seeing this."

One likely factor: Rural hospitals serve more low-income people — who weren't eligible for insurance before, but who got covered after the health law took effect. And rural hospitals are historically more likely to operate at a loss than are urban ones. So the chance to see increased revenue is greater than in a city-based hospital.

That said, these are preliminary figures, looking at barely a year's worth of evidence when it comes to the Medicaid expansion. But the effect merits further scrutiny, experts said.

It's important because hospital finances matter for consumers, too. In rural communities, hospitals are often among the largest employers, and the main source of health care. Financial duress can affect what kind of services the facility offers.

"If you're [a hospital] in a state that did expand Medicaid, obviously you're going to be experiencing lower amounts of uninsured. Your bad debts and charity care have gone down," said Brock Slabach, senior vice president at the National Rural Health Association. He was not involved in the study, although he is familiar with the research team's work. "Has [that expense] gone to nothing? No. But it has helped."

That's especially true for rural hospitals, Kaufman said, because they have narrower profit margins than do urban ones. Any squeeze on the budget "is going to be more influential" and may limit a hospital's offerings or quality.

Hospitals are "still really trying to anticipate and assess the shakeout from all the changes that are happening," said Kristin Reiter, an associate professor at UNC-Chapel Hill's Department of Health Policy and Management and another study author.

Meanwhile, rural hospitals are already facing financial strains, Slabach said. More than 70 have shut down since 2010. Still more are at risk of closure. Many endangered hospitals are in non-expansion states.

How Medicaid affects rural and urban hospitals could influence other debates, the study authors said. For instance, the health law also is expected to cut so-called disproportionate health spending payments – cash infusions that support hospitals that treat low-income people, often in rural areas.

Those cuts haven't taken effect yet, but the researchers suggest, the paper could make a case for indefinitely postponing them.

"The hospitals rely on that funding to address uncompensated care," Kaufman said. In rural states that declined the expansion, uncompensated medical treatment poses a significant financial hurdle for hospitals.

But others cautioned against drawing hard conclusions yet. It's unclear how meaningful the rural-urban difference will be, especially over time, said Doug Staiger, a professor of economics at Dartmouth who has researched rural health access but was not involved with this study.

"I'd be really cautious interpreting," he said.

Plus, Slabach added, researchers must examine how the findings actually affect consumers.

And, it's possible the effects seen here aren't just thanks to Medicaid, said George "Mark" Holmes, an associate professor at UNC and director of the university's North Carolina Rural Health Research and Policy Analysis Program. Expansion states may have taken other steps meant to help hospitals and consumers. If so, it's worth figuring out what those are.

"Medicaid expansion is not a random event. That's very important to consider here," said Holmes, another author of the study. "These are states that have decided to do it. There could be other elements" at play.

Getting Doctor Lists Right

KFF Health News, September 6, 2016

Under a new California law, insurance companies — and health care providers — must comply with requirements to keep physician directories updated at least every quarter.

This article first appeared September 6, 2016 on Kaiser Health News

By Emily Bazar

SACRAMENTO, Calif. — State Sen. Ed Hernandez and his wife, Diane, are optometrists.

Diane handles some insurance matters for their practice, and she recently told him that a health plan had emailed to request more information: It wanted confirmation that they were both participating providers, he says.

"I didn't say anything because I was afraid she'd be mad at me," says Hernandez, D-West Covina.

That's because the additional paperwork was probably his doing.

Hernandez, who chairs the California Senate Health Committee, is author of a newly enacted state law that aims to improve provider directories, long riddled with out-of-date and inaccurate information.

Under the law, insurance companies — and health care providers like the Hernandezes — must comply with new requirements to keep directories updated at least every quarter.

The law, which took effect July 1, also provides patients with some firepower to fight surprise medical bills that result from directory errors.

The law's reach is broad: It applies to Covered California and private market plans, as well as Medi-Cal managed care and most job-based insurance policies.

The inaccuracy of directories, Hernandez says, "has been and … seems to continue to be a problem that needs to be rectified."

Several other states, from Georgia to Maryland, have passed similar legislation or are considering doing so, says Claire McAndrew, private insurance program director for Families USA, a national health care consumer advocacy group. In some states, insurance commissioners have adopted new rules through the regulatory process.

But California's law "is the most comprehensive," she says. "The level of detail in California goes beyond any other state." Federal officials also instituted a rule this year requiring directories be updated monthly for all plans sold on the 37 state marketplaces run by the federal government.

And they set new rules for Medicare Advantage plans, requiring that the companies contact doctors every three months and update their online directories within 30 days. A recent study in the journal Health Affairs found that provider directories for some health plans sold through Covered California and in the private market are so inaccurate that they create a "disheartening" situation for consumers trying to find doctors.

That finding was confirmed this month when the state Department of Managed Health Care (DMHC) announced that Anthem Blue Cross and Blue Shield of California — which were previously fined for inaccuracies in their Covered California provider directories — still had "disappointing" directory problems.

"We are optimistic and hopeful that the law … will help," says department director Shelley Rouillard.

Among the law's new rules:

Health plans must update their printed directories at least every quarter and their online directories at least every week if providers report changes.
Provider directories must be posted online and be available to anyone, not just enrollees. Print directories must be available upon request.
The directories must "prominently" display directions for consumers who want to report inaccuracies. Upon receiving complaints, plans have 30 business days to makes changes, if necessary.
Providers must inform plans within five business days if they are no longer accepting new patients — or, alternately, if they will start accepting them.
Health plans can delay payments to providers who fail to respond to attempts to verify information.

The California law also gives consumers recourse. Let's say you use a provider directory to find a doctor but you're billed the out-of-network price because the directory was wrong. In that case, health plans must reimburse you the amount beyond what you would have paid to see an in-network doctor.

If you find yourself in this situation, first take your complaint to your plan, advises DMHC's Rouillard. You will have at least 180 days from the date you received the bill to file a grievance.

"You'll probably have to make a case" to the plan, Rouillard says. "You should explain what you did, when you looked at the directory, and that you relied on that information."

Documentation could help your case.

That's something to consider when you're searching for a provider in the first place. It wouldn't hurt to save a screen shot from the online directory showing the doctor is in-network, or take detailed notes if you call your plan's customer service line.

"Keep copies of everything, and note the date, time and name of anyone you speak to," says Nancy Kincaid, spokeswoman for the state Department of Insurance.

Plans have 30 days to investigate and respond to your complaint. If the situation isn't resolved to your satisfaction, your next step is to take your grievance to your health plan's regulator.

Since the law went into effect, the DMHC has helped one consumer get reimbursed as a result of this law.

But, "I'm hoping consumers don't have to go through process. I'm hoping the directories are accurate," Hernandez says.

It might take time to get there, as health plans implement the new requirements — as well as others that will take effect in the coming months — and work with providers to update the information.

"This is so early and there are so many errors," Rouillard says.

Attending To The 'Human Element' Is Key To Keeping Patients Healthy

KFF Health News, September 2, 2016

Paper suggests that "implicit bias"—doctors and nurses subtly or subconsciously treating some patients differently than others—or patients' perception of it could have consequences for patients' health.

This article first appeared September 2, 2016 on Kaiser Health News

By Shefali Luthra

Racial minorities and lower-income people typically fare far worse when it comes to health outcomes. And figuring out why has long been one of health care's black boxes. Forthcoming research may help shed light on what's driving those inequities — and how the system can fix them.

What is needed? Better bedside manner, so patients actually trust their doctors. Communication that is easily understood by everyday people. And transparency about what medical care costs, plus a willingness to discuss how price points fit into consumers' health decisions.

Those ideas were highlighted in a white paper presented last week at a health communication conference sponsored by the Centers for Disease Control and Prevention. The findings, which will be published in full later this fall, are based on interviews with 100 health professionals and 65 "disadvantaged patients," along with a nationally representative survey of 4,000 consumers. The examination is part of a larger project funded by the Robert Wood Johnson Foundation, a health-focused nonprofit. It was conducted by the Altarum Institute, a research and consulting organization.

The paper suggests that "implicit bias" — doctors and nurses subtly or subconsciously treating some patients differently than others — or patients' perception of it could have consequences for people's health. Patients who felt that they had experienced bias based on factors like race, income or insurance were less likely to follow advice about medication, for instance, and ended up sicker in the long run.

"We for a long time have neglected the human element," said Chris Duke, director of Altarum's Center for Consumer Choice in Health Care, and the white paper's author. "The number one predictor of patient satisfaction is if your nurse listened to you. We neglect this at our great peril."

Duke stressed that the research isn't enough to draw conclusions about causality — that feeling disrespected causes worse health. But the study builds on years of investigation that suggests implicit bias and how patients perceive it could contribute to differences in health outcomes.

Insurance status was the largest predictor of how patients viewed their doctor-patient interaction, Duke said. People on Medicaid, the state-federal health insurance program for low-income people, or who were uninsured, were more likely to perceive disrespect than those with private insurance or Medicare, which provides coverage for senior citizens and some disabled people. Income was the next predictor for how well people felt they were treated. After that came race.

Meanwhile, racial minorities and low-income people also were more likely to be sensitive to concerns about a doctor's bedside manner, and to seek out someone they thought would treat them well, Duke noted.

Often, these patients cue in on subtle behaviors, such as the doctor not making eye contact or not asking questions about their symptoms and health conditions, their lifestyle or their preferences on how to manage a disease. But that can be enough, Duke said, to keep people from seeking care, or following through on medical advice.

He recalled one interviewee: a lower-income black woman with high blood pressure. She said her physician never asked her meaningful questions about her health, instead just writing her a prescription. She was so dissatisfied she ignored the recommendation, meaning her condition only worsened.

"There's a huge need for provider training in communication and warmth, and the understanding that how you interact with your patients can have an implication … on their health," he said.

That interaction could have major consequences for patients with chronic diseases, like diabetes or heart problems, noted Ben Handel, an assistant professor of economics at the University of California, Berkeley, who has researched health consumer decision-making. These patients need regular follow-up, but they are less likely to seek it out, because they aren't in significant pain. But if they don't get regular treatment, they could develop severe medical complications.

"If you feel like your doctor doesn't respect you, you're not going to go the doctor unless you have to — and preventive care is something you don't get unless you have to," he said. "And that kind of stuff is in some ways the most important."

To address that, both Duke and Handel said it's worth examining how Medicaid pays doctors, so that they see more value in treating low-income patients. Currently, Medicaid reimburses physicians at a lower rate than do other insurance programs.

Encouraging more diversity in medical professions — from a racial and a socioeconomic standpoint — could also help, they said. That idea tracks with other suggestions researchers have made when brainstorming ways to tackle gaps in health care and to make the system more responsive to people who are typically overlooked.

"If you are a lower-income racial minority, and you walk into a hospital and none of the pictures of people look like you, and none of the staff looks like you, you may not feel welcome," Duke said. "People need to feel welcome for them to trust information, and trust guidance."

The paper also highlighted consumers' concerns about understanding their medical recommendations and how much their care costs. Expense in particular "is a big sticking point," Duke said, and it's something doctors have long been discouraged from discussing. But for patients, avoiding the subject means they're more likely to go without.

That's true across the board, but likely even more so for lower-income people, Handel said. "That's basic economic theory. If you're low-income and the marginal value of income is higher, you're going to be more price sensitive," he said.

The findings underscore a need for inclusivity, Duke said. "We heard many patients say, 'The system is for them and not for us,'" he said. "The fact that we have large disparities along the lines of income and race — it shows there's a lot of ground to be covered."

'Simple Choice Plans' To Debut In 2017 Marketplace Enrollment

KFF Health News, September 2, 2016

Aiming to make picking a health plan easier, the federal government, which runs the marketplaces in roughly two-thirds of states, is encouraging insurers to offer "simple choice plans" as an option this fall.

This article first appeared September 2, 2016 on Kaiser Health News

By Michelle Andrews

Despite much hand-wringing about health insurers exiting the marketplaces where people buy individual coverage, in many areas consumers will likely still have a choice of plans when the 2017 open enrollment starts in November. Aiming to make picking a plan easier, the federal government, which runs the marketplaces in roughly two-thirds of states, is encouraging insurers to offer "simple choice plans" as an option this fall.

The six new standardized plan designs will eliminate many of the moving parts that have bedeviled consumers trying to make apples-to-apples comparisons between plans. The government is providing guidelines for a simple choice plan at each of the bronze, silver and gold levels, and three more silver options for people who qualify for cost-sharing reductions based on their income.

In these plans, the deductibles and annual limits on out-of-pocket spending will be standardized, as will many of the consumer payments for medical services.

In the simple choice silver plan, for example, the deductible will be $3,500 and the maximum amount that someone will owe out-of-pocket for the year will be $7,100. For many specific services, consumers will have flat dollar copayments for services up front rather than having to meet their deductible before the plan picks up any of the tab. Some of these include primary care visits ($30), specialist visits ($65), urgent care ($75) and generic drugs ($15).

Insurers won't be required to offer standardized plans on the federal marketplace, just as they aren't required to do so in most of the state-based marketplaces that offer such plans.

Offering both standardized and non-standardized plans can present a challenge for consumers, say experts. Both need to be clearly differentiated online or consumers will have no easier time comparison shopping than before, said Sabrina Corlette, research professor at Georgetown University's Center on Health Insurance Reforms who coauthored a recent report examining state efforts to offer standardized plans.

"It's really important to get the consumer shopping experience right, otherwise you might as well not bother" with standardized plans, she said.

When the administration announced the simple choice plans in April, Kevin Counihan, CEO of the healthcare.gov marketplace said the plans would "display prominently" on the website and have "clear visual cues" that would distinguish the simple choice plans from others.

A CMS official said there was no further information available at this time about how the plans will be displayed this fall.

In addition to potentially helping consumers wade through a bewildering array of options, standardized plans make it harder for insurers to design plans to be less attractive to people with expensive health care conditions, said Corlette. Insurers may be limited in their ability to make certain types of specialist care or drugs more expensive, for example.

Behavioral economics research tells us that simplifying consumer choices helps people make better ones. It makes sense that it will work with marketplace plans, too, but at this time that's an unknown.

"We don't yet know that standardized benefit design will help people make better choices and get into the plan that's right for them," Corlette said.

Baltimore Draws 10-Year Blueprint To Cut Racial Health Disparities

KFF Health News, August 31, 2016

Tentative targets of the population health plan are to reduce disparities in obesity, smoking and heart-disease deaths by 15% by 2020.

This article first appeared August 31, 2016 on Kaiser Health News

By Jay Hancock

Baltimore officials presented a 10-year plan Tuesday that sharply highlights the poor health status of African-Americans and aims to bring black rates of lead poisoning, heart disease, obesity, smoking and overdoses more in line with those of whites.

"We wanted to specifically call out disparities" in racial health, said Dr. Leana Wen, who became the city's health commissioner early last year. "And we have a moonshot. Our moonshot is we want to cut health disparities by half in the next 10 years."

Black Baltimore leaders praised Wen for putting disparities squarely in the conversation even as they acknowledged the difficulty of achieving the plan's goals.

"It's a big challenge. There's no debating that," said Diane Bell-McKoy, CEO of Associated Black Charities, a Maryland nonprofit. "She takes a step forward more so than anybody else I've seen because she calls it out. Most of the time we find code words for it. We don't call it out."

Violence last year following the death of Freddie Gray, a black man who died after being injured in police custody, exposed Baltimore's health divide as well as its criminal justice differences, officials said. Gray's family had won a settlement for alleged lead-paint poisoning, which is blamed for low test scores and cognitive challenges among thousands of Baltimore children.

"What happened last year with Freddie Gray put Baltimore in the national media spotlight," said Helen Holton, a Baltimore councilwoman who represents a portion of the city's west side. "That made people stop and take notice of what had been going on and stop treating it as business as usual."

The health plan, called Healthy Baltimore 2020, was first reported by the Baltimore Sun. Officials plan to track blood-lead levels, overdose deaths, child fatalities, healthy-food availability and other indicators year by year. It's called Healthy Baltimore 2020 because officials have set ambitious goals to achieve before 10 years is up, Wen said.

Tentative targets include cutting youth homicides by 10 percent and disparities in obesity, smoking and heart-disease deaths by 15 percent — all by 2020.

Tactics include more programs to reduce street violence, expanded anti-smoking campaigns, more home visits for pregnant women and increased access to naloxone, which blocks the effects of heroin.

The blueprint is "an ongoing document" that will be amended with community participation and results closely scored, Wen said.

"Our community is sick of us overpromising and underdelivering," she said.

Baltimore officials have made substantial progress in reducing lead poisoning, lowering teen pregnancy and cutting infant mortality.

But as in many other areas, Baltimore is still divided by health. Residents of Gray's west-side neighborhood of Sandtown-Winchester live 10 years less on average than Marylanders in general. Poor neighborhoods have far higher rates of heart disease, diabetes, addiction, HIV infection and other illness than more prosperous parts of the city.

Black leaders emphasized that Baltimore's health won't improve unless policymakers address deeper causes of illness such as poverty, unemployment and poor housing.

"It is affirming to see someone in Dr. Wen's role address the uncomfortable truths behind health inequities," said Debbie Rock, CEO of LIGHT Health and Wellness, which offers health and other community services on Baltimore's west side. "This is a great platform to also address upstream factors" such as low incomes, she said.

Holton compared the health blueprint to a Justice Department report this month alleging a pattern of excessive force and violation of constitutional rights by the Baltimore Police Department.

Both documents address racial differences and offer challenges for improvement, she said.

"You can travel 5 miles from one neighborhood to another and it's like you are in two different communities" in health levels, Holton said. "Freddie Gray was like the tipping point. Let's take this and make it a teachable moment of how to be better moving forward."

'America's Other Drug Problem': Copious Prescriptions For Hospitalized Elderly

KFF Health News, August 30, 2016

The polypharmacy problem "is huge," says the director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica.

This article first appeared August 30, 2016 on Kaiser Health News

By Anna Gorman | Photos by Heidi de Marco

SANTA MONICA, Calif. — Dominick Bailey sat at his computer, scrutinizing the medication lists of patients in the geriatric unit.

A doctor had prescribed blood pressure medication for a 99-year-old woman at a dose that could cause her to faint or fall. An 84-year-old woman hospitalized for knee surgery was taking several drugs that were not meant for older patients because of their severe potential side effects.

And then there was 74-year-old Lola Cal. She had a long history of health problems, including high blood pressure and respiratory disease. She was in the hospital with pneumonia and had difficulty breathing. Her medical records showed she was on 36 medications.

"This is actually a little bit alarming," Bailey said.

He was concerned about the sheer number of drugs, but even more worried that several of them — including ones to treat insomnia and pain — could suppress Cal's breathing.

An increasing number of elderly patients nationwide are on multiple medications to treat chronic diseases, raising their chances of dangerous drug interactions and serious side effects. Often the drugs are prescribed by different specialists who don't communicate with each other. If those patients are hospitalized, doctors making the rounds add to the list — and some of the drugs they prescribe may be unnecessary or unsuitable.

"This is America's other drug problem — polypharmacy," said Dr. Maristela Garcia, director of the inpatient geriatric unit at UCLA Medical Center in Santa Monica. "And the problem is huge."

The medical center, where Bailey also works, is intended specifically for treating older people. One of its goals is to ensure that elderly patients are not harmed by drugs meant to heal them.

That work falls largely to Bailey, a clinical pharmacist specializing in geriatric care.

Some drugs can cause confusion, falling, excessive bleeding, low blood pressure and respiratory complications in older patients, according to research and experts.

Older adults account for about 35 percent of all hospital stays but more than half of the visits that are marred by drug-related complications, according to a 2014 action plan by the U.S. Department of Health and Human Services. Such complications add about three days to the average stay, the agency said.

Data on financial losses linked to medication problems among elderly hospital patients is limited. But the Institute of Medicine determined in 2006 that at least 400,000 preventable "adverse drug events" occur each year in American hospitals. Such events, which can result from the wrong prescription or the wrong dosage, push health care costs up annually by about $3.5 billion (in 2006 dollars).

And even if a drug doesn't cause an adverse reaction, that doesn't mean the patient necessarily needs it. A study of Veterans Affairs hospitals showed that 44 percent of frail elderly patients were given at least one unnecessary drug at discharge.

"There are a lot of souvenirs from being in the hospital: medicines they may not need," said David Reuben, chief of the geriatrics division at UCLA School of Medicine.

Some drugs prescribed in the hospital are intended to treat the acute illnesses for which the patients were admitted; others are to prevent problems such as nausea or blood clots. Still others are meant to control side effects of the original medications.

University of California, San Francisco researcher and physician Ken Covinsky said many doctors who prescribe drugs in hospitals don't consider how long those medications might be needed. "There's a tendency in medicine every time we start a medicine to never stop it," Covinsky said.

When doctors in the hospital change or add to the list of medications, patients often return home uncertain about what to take. If patients have dementia or are unclear about their medications, and they don't have a family member or a caregiver to help, the consequences can be disastrous.

One 2013 study found that nearly a fifth of patients discharged had prescription-related medical complications during their first 45 days at home. About 35 percent of those complications were preventable, and 5 percent were life-threatening.

UCLA hired Bailey about three years ago, after he completed a residency at University of California, Davis. The idea was to bring a pharmacist into the hospital's geriatric unit to improve care and reduce readmissions among older patients.

Speaking from his hospital bed at UCLA's Santa Monica hospital, 79-year-old Will Carter said that before he was admitted with intense leg pain, he had been taking about a dozen different drugs for diabetes, high blood pressure and arthritis.

Doctors in the hospital lowered the doses of his blood pressure and diabetes medications and added a drug to help him urinate. Bailey carefully explained the changes to him. Still, Carter said he was worried he might take the drugs incorrectly at home and end up back in the hospital.

"I'm very confused about it, to tell you the truth," he said after talking to Bailey. "It's complicated. And if the pills are not right, you are in trouble."

Having a pharmacist like Bailey on the team caring for older patients can reduce drug complications and hospitalizations, according to a 2013 analysis of several studies published in the Journal of the American Geriatrics Society.

Over a six-month stretch after Bailey started working in UCLA's Santa Monica geriatric unit, readmissions related to drug problems declined from 22 to three. At the time, patients on the unit were taking an average of about 14 different medications each.

Bailey is energetic and constantly on the go. He started one morning recently with a short lecture to medical residents in which he reminded them that many drugs act differently in older patients than in younger ones.

"As you know, our elderly are already at risk for an accumulation of drugs in their body," he told the group. "If you put a drug that has a really long half-life, it is going to last even longer in our elderly."

The geriatric unit has limited beds, so older patients are spread throughout the hospital. Bailey's services are in demand. He gets paged throughout the day by doctors with questions about which medications are best for older patients or how different drugs interact. And he quickly moves from room to room, reviewing drug lists with patients.

Bailey said he tries to answer several questions in order to determine what's best for a patient. Is the drug needed? Is the dose right? Is it going to cause a problem?

One of his go-to references is known as the Beers list — a compilation of medications that are potentially harmful for older patients. The list, named for the doctor who created it and produced by the American Geriatrics Society, includes dozens of medications, including some antidepressants and antipsychotics.

When he's not talking to other doctors at the hospital, Bailey is often on the line with other pharmacists, physicians and relatives to make sure his patients' medication lists are accurate and up to date. He also monitors patients' new drugs, counsels patients about their prescriptions before they are discharged and calls them afterward to make sure they are taking the medications properly.

"Medications only work if you take them," Bailey said dryly. "If they sit on the shelf, they don't work."

That was one of his main worries about Cal, the 74-year old with chronic obstructive pulmonary disease. Standing at her bedside, Bailey pored over the list of 36 drugs. Cal told him she only took the medications that she thought seemed important.

Bailey explained to Cal that he and the doctors were going to make some changes. They would eliminate unnecessary and duplicate drugs, including some that could inhibit her breathing. Then she should take as prescribed all of the medications that remained on the list.

Bailey said he's constantly weighing the risks versus the benefits of medications for elderly patients like Cal.

"It is figuring out what they need," he said, "versus what they can survive without."

Teaching Medical Teamwork Right From The Start

KFF Health News, August 29, 2016

The new Case Western Reserve University Health Education campus will eventually include Case Western's medical, dental, and nursing schools, as well as Cleveland Clinic's in-house medical school. "The idea is to create a 'mini campus' that gives each school its own identity but fosters collaboration," says one of the architects.

This article first appeared August 29, 2016 on Kaiser Health News

By Julie Rovner

CLEVELAND — There's a new building going up on the campus of the Cleveland Clinic. A very big building.

The structure will house the new Case Western Reserve University Health Education campus, eventually including Case Western's medical, dental and nursing schools, as well as Cleveland Clinic's in-house medical school.

"The idea is to create a 'mini campus' that gives each school its own identity but fosters collaboration," said Chris Connell, one of the architects.

The building, which will cost almost half a billion dollars, will provide an estimated 8.5 football-fields' worth of space and enough concrete to build a 75-mile-long sidewalk. It is expected to be open to the first classes of students in 2019.

But this part of the project is less the beginning and more the culmination of a long-running effort at Case to train different types of health professionals how to work together. Health care in the 21^st century is increasingly being provided by teams, say the projects' advocates, yet most health care professionals don't encounter their "teammates" until they are well along in their training.

"Health care is no longer a gladiatorial sport, where you had the one health care provider; you know mano a mano, one on one, battling a disease," said James Young, a cardiologist who heads the Cleveland Clinic Lerner College of Medicine. "I'm involved with heart transplantation and mechanical devices for the heart," he said. "Boy, you can't do it by yourself."

On this particular day, about a mile away from the construction site, a small group of students from the medical, dental, nursing, and social work schools were gathered on Case's main campus around a conference table. Every student in every health professions school is required to attend a seminar like this twice a year — one of the ways in which the training programs are already encouraging collaboration.

At this particular session, the students are tasked with figuring out how to best treat a (hypothetical) patient — a 35-year-old woman with hypertension, obesity and diabetes. She has come to the (fictitious) clinic with a series of injuries she said she got falling down a flight of stairs. Meanwhile, her boyfriend is in the lobby acting disruptively.

The students discuss and argue about which of the patient's problems to address first, and what to do about the boyfriend. They don't end up reaching a consensus, but faculty overseeing the group say that's OK.

"I think that's fabulous," said Kristin Victoroff, an associate dean at the dental school. "It is actually an indicator of a functioning group, where's there enough trust in the group where you can say what you really are thinking."

But that's not the only way the university is trying to foster "interprofessional" education. For example, at a free oral health clinic elsewhere in Cleveland, dental students and nurses collaborate to treat real patients. Other activities bring students together to discuss problems that cross professional lines, like obesity or pain.

"We all have to deal with pain whether it's dentists or social workers or nurses," said Carol Savrin, an administrator at the Case nursing school.

Efforts such as these to train doctors, nurses and other health professionals together have been tried for years. And they haven't always been successful.

"I think they come in with some preconceived or stereotyped notions of what a doctor [or] a social worker is," said Scott Wilkes, an assistant dean at the Case social work school.

Yet getting everyone on the same page is critical to preventing medical mistakes, said Patricia Thomas, a vice dean at the Case medical school.

In studying the problem, she added, "the root of many of our errors had to do with the fact that our professions were not working effectively together for patient care."

Administrators say that is why the new building is so important.

It's not just the formal training together, said Victoroff of the dental school, "I'm excited about the informal interactions that are going to happen."

Doctors Raise Concerns For Small Practices In Medicare's New Payment System

KFF Health News, August 25, 2016

"The ways it's structured now, the large practices will do well and the small practices will do badly," says Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.

This article first appeared August 25, 2016 on Kaiser Health News

By Steven Findlay

Dr. Lee Gross is worried. He has practiced family medicine in North Port, Florida, near Sarasota, for 14 years. But he and two partners are the last small, independent practice in the town of 62,000. Everyone else has moved away, joined larger groups, or become salaried employees of hospitals or health companies.

"We're struggling to survive," Gross, 47, said. "Our kind of practice is dying in this country, and medicine itself is changing so rapidly that doctors everywhere seem to be burning out."

Indeed, in their professional journals, at conferences, on social media and health care blogs, and in comments to federal regulators, the nation's doctors are expressing growing anger and frustration.

The focal point of their angst is a 2015 federal law that changes the way Medicare pays doctors.

The Medicare Access & CHIP Reauthorization Act — is Congress' boldest step since the 2010 Affordable Care Act to push the health care system to reward quality over quantity. It replaces a reimbursement system that was widely criticized by doctors and regularly ran into budget problems on Capitol Hill.

"This is a big change, we know," said Tim Gronniger, deputy chief of staff at the Centers for Medicare & Medicaid Services. But, he added, "the current way we pay doctors incentivizes them in bad ways — to waste resources, for example."

The law has bipartisan support and does not come with the political tension of the ACA. Still, the Obamacare battles have shown that broadly reshaping health care is no easy task.

Poor and wasteful care accounts for a quarter to a third of all health care spending, according to the National Academy of Sciences' Institute of Medicine.

That would total between $875 billion to $1.1 trillion of the $3.5 trillion expected to be spent on health care in the U.S. in 2016.

The law sets up two payment tracks. All doctors must choose one, except for those who see too few Medicare patients or whose income from Medicare is too low.

On one track, doctors whose performance and quality of care exceeds benchmarks get bonuses up to 4 percent of their total Medicare reimbursements. Those will start in 2019, based on evaluations of care delivered in 2017, and will rise a maximum of 9 percent by 2022. By the same token, physicians who score poorly on quality benchmarks — which include requirements for the use of electronic health records — face penalties at the same levels.

The amount the government spends on the bonuses — estimated at $833 million for 2019 — must be balanced by the penalties, keeping the program "budget neutral." However, Congress also authorized an extra $500 million a year bonus pool through 2024 for doctors judged "exceptional."

On the other path, doctors choose to join larger practices or organizations — called "alternative payment models" — that would be held accountable for the quality of care delivered by all the doctors in the organization.

Congress' intent, experts say, was to push doctors to join such larger organizations, which generally are considered better equipped to manage and coordinate care, improve quality and lower costs than are solo or small groups of doctors.

Doctors get a 5 percent annual bonus between 2019 and 2024 if they join an alternative payment organization, along with any bonuses or penalties the organization chooses to mete out. Starting in 2026, doctors in such organizations will continue to get a small annual payment adjustment from Medicare that's larger than doctors who don't choose the alternative path — 0.75 percent versus 0.25 percent.

Physicians' concern is that the new payment system — laid out in a 962-page proposed regulation in April — will put doctors in solo or small practices at high risk of incurring payment penalties and will push thousands into larger practices and alternative payment organizations.

"The ways it's structured now, the large practices will do well and the small practices will do badly," said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution.

During a public comment period, the American Medical Association and dozens of other physician trade organizations and every state medical association said the system needs to be simplified and must "accommodate the needs of physicians in rural, solo, or small practices in order to enhance their opportunities for success and avoid unintended consequences."

One of those unintended consequences, the AMA says, is that penalized doctors would limit the number of Medicare patients they see, or drop Medicare.

"I have no idea what I'm going to do yet," says Dr. Jean Antonucci, a primary care physician who has a solo practice in Farmington, Maine. Half her patients are covered by Medicare. "If I'm going to lose money, I'll have to see what my options are. I don't want to limit how many Medicare patients I see."

Antonucci and Gross say they want to preserve their small practices. "I don't want to spend the bulk of my time doing paperwork or collecting data on my patients," said Antonucci. "That's what the doctors in my community who are employed [in larger groups] seem to spend most of their time doing."

Some experts agree that the burden to report quality-of-care to the government is significant.

"We don't yet have a good system to measure the performance of individual physicians," says Robert Berenson, a physician and fellow at the Urban Institute and former director of Medicare payment policy for the federal government. "And yet we are going to peg billions of dollars in payment to such measurement. It's a little crazy."

A study published in March in the journal Health Affairs calculated the scope of that data collection now. It found physicians and their staffs spend $40,000 per doctor per year — $15.4 billion nationwide — collecting and reporting information about their care to Medicare, private insurers and others.

Gronniger says CMS has, in the proposed rule, scaled back the number of measures doctors must report. "We are eager to work through the issues doctors' groups have raised," Gronniger said.

Even so, the AMA and other physician groups are pushing CMS to delay the start for collecting quality-of-care information from next January until at least July. Medicare administrators have pledged to issue final regulations by Nov. 1.

"This is all very complex," said AMA President Andrew Gurman. "A lot of doctors are very frustrated … but we are committed to trying to make the new law work."

CMS Identifies Hospitals Paid Nearly $1.5B In 2015 Medicare Billing Settlement

KFF Health News, August 24, 2016

NewYork-Presbyterian Hospital, one of the nation’s largest academic medical centers, received nearly $16 million, more than any other hospital, according to data released by the Centers for Medicare & Medicaid Services.

This article first appeared August 23, 2016 on Kaiser Health News

By Phil Galewitz

A year after paying nearly $1.5 billion to more than a third of U.S. hospitals to resolve longstanding Medicare billing disputes, the Obama administration has disclosed who got paid.

NewYork-Presbyterian Hospital, one of the nation's largest academic medical centers, received nearly $16 million, more than any other hospital, according to data released by the Centers for Medicare & Medicaid Services.

The second largest amount went to North Shore University Hospital in Manhasset, N.Y., which received $14.5 million. CHI Memorial Hospital in Chattanooga, Tenn., ranked third — $10.9 million — but two other New York-area hospitals rounded out the top five. Long Island Jewish Medical Center received $10.8 million and NYU Langone Medical Center was paid $10.5 million, the CMS data show.

In total, 2,022 hospitals shared in the government payout, which settled 346,000 claims for reimbursement for treating Medicare patients admitted on or before Oct. 1, 2013. The largest payments resolved thousands of claims at once. Memorial Hospital's settlement covered nearly 3,000 claims.

The settlements were a compromise to reduce a swollen backlog of disputes over what hospitals argued they were owed. At one time, pending cases under appeal stretched more than two years.

The resolutions followed the government's offer in 2014 to pay the hospitals 68 percent of the value of inpatient claims that had been caught in Medicare's hearings and appeals process, some for years.

The new CMS data show 35 hospitals received more than $5 million each, but most were paid far less. The median payment — meaning half the hospitals got more and half got less — was $307,642, according to a Kaiser Health News analysis. The data was released in response to a Freedom of Information Act request made last year by KHN.

Medicare pays private contractors known as recovery audit contractors, or RACs, to review hospital claims for improper payments. If hospitals disagree with RACs' decisions, they can appeal. Most RAC reviews have focused on costly inpatient-status claims, questioning whether certain patients should have been admitted to hospitals. Many audits determine that short patient stays should have been billed at less-costly outpatient rates.

Last year's settlement indicated that many hospitals preferred to settle quickly for a discounted amount rather than keep claims tied up in appeals for what could have been months or even years. Hospitals that declined to settle with Medicare still had the option to continue their appeal.

Hospitals and RACs have long battled over audits and appeals. RACs — which are paid a fee for every audit that recovers money for Medicare — argue they are protecting taxpayer dollars and ensuring that hospitals are paid for appropriate patient services. Hospitals criticize the RAC process as burdensome and liken contractors to bounty hunters focused on making money for themselves.

CMS has said 18 percent of appealed claims were overturned in favor of hospitals between Oct. 1, 2013 and Sept. 30, 2014, but the American Hospital Association reported in 2014 that self-reported data by its members showed hospitals had won 66 percent of appeals since 2010.

The $1.5 billion paid in last year's settlements contrast with more than $9.6 billion collected by RACs from 2010 through September 2015. More than 90 percent of collections by RACs were from hospitals.

Sydney Lupkin contributed to this report.

Public Health Officials Struggle To Identify Sepsis Before It Becomes Deadly

KFF Health News, August 23, 2016

A growing number of doctors, hospitals, patient advocates and state and federal policymakers are pushing to educate consumers and clinicians, and ensure procedures are followed that focus on prevention and early detection.

This article first appeared August 23, 2016 on Kaiser Health News

By Michelle Andrews

After Rory Staunton fell at the gym and cut his arm in March of 2012, the 12-year-old became feverish and vomited during the night, complaining of a sharp pain in his leg. When his parents called his pediatrician the next day, she wasn't worried. She said there was a stomach virus going around New York City, and his leg pain was likely due to his fall.

However, she advised his parents, Orlaith and Ciaran Staunton, to take the youngster to the emergency department because he might be dehydrated. There hospital workers did some blood work, gave him fluids and sent him home.

How Ohio Hospitals Are Tackling Sepsis

The next day Rory's pain and fever were worse. His skin was mottled and the tip of his nose turned blue. The Stauntons raced back to the hospital, where he was admitted to intensive care. The diagnosis: septic shock. Rory was fighting a system-wide infection that was turning his skin black and shutting down his organs. On Sunday, four days after he dove for the ball in gym class, Rory died.

"It was frightening to think that something could kill my son so fast and it would be something that I had never heard of," said Orlaith Staunton.

She's not alone. Sepsis kills more than 250,000 people every year. People at highest risk are those with weakened immune systems, the very young and elderly, patients with chronic diseases such as diabetes, cancer or kidney disease and those with illnesses such as pneumonia or who use catheters that can cause infections. But it can strike anyone, even a healthy child like Rory.

Sepsis is a body's overwhelming response to infection. It typically occurs when germs from an infection get into the bloodstream and spread throughout the body. To fight the infection, the body mounts an immune response that may trigger inflammation that damages tissues and interferes with blood flow. That can lead to a drop in blood pressure, potentially causing organ failure and death.

Yet many people don't know about sepsis. Meanwhile, health care providers struggle to identify it early. There's no simple diagnostic test and many symptoms — elevated heart and respiratory rates, fever or chills, pain — are common ones that are present in many conditions.

Now, a growing number of doctors, hospitals, patient advocates and state and federal policymakers are pushing to educate consumers and clinicians and ensure procedures are followed that focus on prevention and early detection.

The Stauntons established a foundation to raise awareness about the deadly infection, and in 2013 New York became the first state to require all hospitals to put in place procedures for its early recognition and treatment. This month, Illinois Governor Bruce Rauner signed a law requiring similar actions by hospitals in that state.

The federal Centers For Disease Control and Prevention Tuesday released a study about sepsis as part of an effort to draw attention to the importance of prevention and early detection of the disease.

"Early treatment is vital," said Dr. Anthony Fiore, chief of the epidemiology research and innovations branch at the CDC's Division of Healthcare Quality Promotion. "It's an emergency that you need to deal with, like heart attack and stroke."

When sepsis advances to septic shock, characterized by severely low blood pressure, each hour of delay in administering antibiotics decreases the odds of survival by an average of 7.6 percent, one study found.

In 2013, sepsis, or septicemia as it's sometimes called, accounted for nearly $24 billion in hospital costs, the most expensive condition treated. Up to half of people who get it die. Many cases are related to health care, such as catheter use or an infection acquired in the hospital. But contrary to the common perception, approximately 80 percent of cases develop outside the hospital or at a nursing home, according to the new CDC study.

As the front line in identifying these cases, emergency departments typically have sepsis protocols in place to screen for the disease.

"The work you do in those first three to six hours in the emergency department makes more difference in cost than the whole next several weeks in the ICU," said Dr. Todd L. Slesinger, emergency medicine residency program director at Aventura Hospital and Medical Center in Aventura, Fla., who co-chairs a task force on sepsis at the American College of Emergency Physicians, which has developed a tool to help emergency department staff screen and treat the condition.

Last fall, the federal Centers for Medicare & Medicaid Services started requiring hospitals to measure and report on efforts to screen for and treat the illness. In addition, Medicare sets penalties for a variety of hospital-acquired conditions, including high rates of post-operative sepsis.

Patient advocates and policymakers agree that patients themselves are key to improving its prevention and early detection. Good hygiene can help prevent sepsis, including cleaning wounds. If someone gets injured, look for signs of sepsis, including rapid breathing or heart rate, confusion, fever or chills and pale or discolored skin.

Don't assume health care providers have it covered, experts advise. If you or someone you're caring for has these symptoms, ask the health care provider directly: "Do you think it might be sepsis?"

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