BLOG Medicine

Dirigo Health: Con Artists, Liars, and Thieves?

With no new enrollment as of July 1 and stated savings estimates and membership numbers gyrating up and down faster than a turkey trot, one has to wonder if Maine's Dirigo Health is made up of con artists, liars, and thieves or if they actually believe their mathmagical accounting.

On 8 July 2007, Dirigo Health released a 2006 estimated savings amount of $92.7 million.  By Friday, 27 July Maine's Dirigo Health Board of Directors had reduced the amount they claim the Dirigo Health program has saved the state's healthcare system in 2006 to $78 million, still more than twice the amount determined in 2005 that required a ruling by the State Supreme Court to be settled.  The recently reduced $78 million figure will now be submitted to the state superintendent of insurance, who has historically reached a lower number than the board, for final determination.

Karynlee Harrington, executive director of the Dirigo Health Agency, was quoted in the Portland Press Herald stating that the agency has refined the methodology used to determine the savings amount based on past decisions of the superintendent seemingly oblivious as to why it should be objectionable that Dirigo's accounting methodologies are changeable, year-to-year and seem to conveniently eliminate Dirigo's earlier cost concerns.  However, not only do Dirigo's accounting methodologies change based on the needs of the day, but the membership numbers experience dramatic unexplained leaps, as well.

On 1 July 2007, when Dirigo stopped accepting new enrollees stating cost concerns, they quoted membership of 14,400, many of whom already had insurance and less than half of the 31,000 Dirigo said they would cover in 2003 and nowhere near the 130,000 Dirigo forecast for coverage by 2009.  By 28 July 2007, only 27-days after halting enrollment, Dirigo mathmagically claims 26,000 Maine residents have been helped.

For their part, as expected, Maine insurance carriers plan to dispute the board's figures, adding that it's a conflict of interest for the Dirigo board to make a determination on savings that will translate into income for its program.

Dirigo's annual attempt to be more than just another failed attempt at healthcare reform with lingering delusions of grandeur is similar, in its own way, to the frivolousness, fantasy, and mathmagical fiction that might be found in a Harry Potter book -- too bad, unlike JK Rowling, Dirigo doesn't know when to end the fairy tale.■ 

Lifespan and Care New England Plan Monopoly (Again)

For the second time in ten years, Lifespan and Care New England, Rhode Island's two large health systems, plan to merge into a single entity to be called Lifespan.

In 1998, the two entities applied for regulatory approvals needed to merge, but pulled their applications in 2000.  If allowed to combine, the resulting entity will control nearly three-fourths of Rhode Island's hospital system.

Lifespan President and CEO George Vecchione expects this regulatory process to only take six to nine months and for the merger to result in some efficiencies, specifically in central-office operations and alignment of system-wide services, but without substantial job cuts.

According to Lifespan, clinical enhancements that would occur under the merger include:

• Butler Hospital will create the state’s first Brain Sciences Institute, which will support research, education and behavioral health treatment. In addition, the Butler campus would be sold or otherwise developed to fund a new Butler Hospital facility on or near the RIH campus
• Kent Hospital will apply to become a level II trauma center and will also seek to create an emergency medicine residency program. Together, these improvements will enhance statewide disaster responsiveness
• Women & Infants will retain its leadership role in neonatal and women’s reproductive health. There will also be a greater opportunity to develop services for conditions that disproportionately affect women and to maximize Women & Infants’ referral network and strong regional presence
• Continuation of Care New England’s VNA under the Lifespan system

Mixed responses to the merger plans include Rhode Island Governor Donald L. Carcieri (R-RI) who notes that the creation "of such a dominant healthcare network" raises "a number of important concerns" and  Lt. Governor Elizabeth H. Roberts, who states that she will "advocate for a focus on the core mission of hospitals to serve the public and recognize the importance of this proposal’s potential for economic growth in the state.”■

Mass Governor Asks Blue Cross to Keep Higher Employer Contribution

At the request of Governor Deval L. Patrick (D-MA), the state's largest health insurer, Blue Cross and Blue Shield of Massachusetts, scrapped a new policy that would have allowed owners of small businesses to contribute just one-third of the cost of their employees' health plan premiums.  Blue Cross is the state's largest health insurer with about 3 million members.

Prior to 1 July, Blue Cross required a minimum 50 percent contribution to premiums from employers with 50 or fewer workers.  The average contribution by Massachusetts employers is about 75 percent.

On 1 July, Massachusetts's healthcare reform law took effect, under which, if a company does not offer health insurance, low income works can receive subsidized coverage under the state's Commonwealth Care plan.  They are ineligible for assistance, however, if their employer offers a company health plan, regardless of the company's contribution to premiums.

Company's not offering health insurance to their employees or contributing less than what the state deems "fair and reasonable" toward their employees' health plan premiums are required to pay an annual fee of $295 per employee.

Harvard Pilgrim Health Care, the state's second largest health insurer with about 1 million members, has said that the insurer will retain its 50 percent contribution after earlier reviewing its policies as a result of Blue Cross's lowering its minimum contribution to 33 percent.■

AMA Sounds the Alarm, Medicare Making Yet Another Attempt to Cut Reimbursement

The American Medical Association (AMA) must once again don its armor, this time preparing to go to battle on behalf of its approximately 240,000 members over pending cuts to Medicare reimbursement.  Physicians received below-inflation updates in 2004 and 2005 and zero percent updates in 2006 and 2007.

Without congressional action, Medicare physician payment rates will be reduced 10 percent effective 1 January 2008.  By 2016, the cuts will total about 40 percent, while practice costs are expected to increase by 20 percent.

In addition to steep pay cuts, the AMA charges that the Medicare physician payment update formula:

• has kept average 2007 Medicare physician payment rates about the same as they were in 2001
• prevents physicians from making needed investments in staff and health information technology to support quality measurement
• punishes physicians for participating in initiatives that encourage greater use of preventive care in order to reduce hospitalizations
• has led to a severe shortfalls in Medicare’s budget for physician services that have driven Congress to enact short-term interventions with funding methods that have increased both the duration of cuts, as well as the cost of a long-term solution
• hurts access to care for America’s military families, has payment rates in the Department of Defense’s TRICARE program are tied to Medicare rates

An AMA Physician Payment Action Kit is available for more information and the AMA Physician Grassroots Network to receive updates on physician payment rate legislation.

The impacts of Medicare physician payment cuts in New England are significant:

• New England physicians will lose $306 million for the care of elderly and disabled patients in 2008 due to the 10 percent cut in Medicare payments beginning 1 January.  The region's physicians will lose $12.1 billion for the care of elderly and disabled patient by 2016 due to eight years of cuts
• 149,461 employees, 2,007,382 Medicare patients and 234,343 TRICARE patients in New England will be affected by these cuts
• 42 percent of New England's practicing physicians are over 50, an age at which surveys have shown many physicians consider reducing their patient care activities

	CT	ME	MA	NH	RI	VT
Losses in 2008	$92 million	$27 million	$137 million	$22 million	$18 million	$10 million
Losses by 2016	$3.7 billion	$1 billion	$5.4 billion	$860 million	$720 million	$380 million
Affected:
Employees	39,803	13,671	63,187	14,144	11,613	7,043
Medicare Patients	485,970	220,081	884,894	170,937	155,540	89,960
TRICARE Patients	51,403	46,849	70,159	28,786	24,818	12,328
Physicians Aged 50+	42%	46%	38%	43%	37%	43%

• Compared to the rest of the country, Connecticut, Massachusetts, Rhode Island, and Vermont, each at 14%, has an above-average proportion of Medicare patients
• Compared to the rest of the country, Maine, at 17%, has the second highest proportion of Medicare patients and, at 17 practicing physicians per 1,000 beneficiaries, has a below-average ratio of physicians to Medicare beneficiaries, even before the cuts take effect
• In 2008, on top of the 10 percent cuts across the country, the "Southern Maine" Medicare payment area faces cuts of an additional 1.1 percent, the "Rest of Maine" Medicare payment area faces cuts of 2.1 percent; New Hampshire faces cuts of an additional 1 percent; and, Vermont faces cuts of an additional 1.7 percent

Countering the congressional inaction and the resulting 10 percent rate cut, the AMA is advocating a 1.7 percent increase in reimbursement in 2008, in line with the estimated practice cost increase; long-term, the AMA wants Congress to create a new reimbursement formula.

Over-stepping their role as a payment mechanism and forgetting that they're not actually providers of medical care, the talking-heads of the health insurance industry charge that physicians are partly to blame, contributing to costs by ordering unnecessary and expensive services.  Mohite Ghose, spokesman for the insurance trade association, America's Health Insurance Plans, was even disingenuous enough to question whether physicians are always providing "appropriate services at the right setting at the right time."

BLOG Medicine must concur with the AMA's statement that, "utilization of physician services is not the cause of the Medicare program's financial predicament, and cuts in physician payment rates are not the way to improve Medicare's financial sustainability."  Congress needs to bring up the house-lights and call a close to this "annual dance of death" -- it's time to pay the piper.■

Pollyanna With a Pen: Maine Governor Signs 18 New Health Care Bills into Law

On Tuesday, 17 July, Governor John Baldacci (D-ME), joined by the state's legislative Democrats, signed into law 18 new health care bills meant to protect the health and welfare of the people of Maine.

You couldn't see the rose-colored glasses on his face, but Baldacci's "Pollyanna" was definitely showing in his prepared statement: "What all these have in common is that they provide further evidence that Maine is the leader in health care reform and in efforts to expand access to quality, affordable health care."

Maine, already heavily burdened with healthcare legislation, has added laws that require health insurers to extend coverage to policy-holder's adult children until age 25, to require health insurers to cover hearing aides, to prohibit advertising of prescription drugs on software sold in Maine, to ensure sterile supplies for needle exchange programs, and to regulate access and screening for HIV and cancer.

Increasing health care costs, postpartum depression, eating disorders, and the role of dental hygienists are all to be reviewed by study groups.  November will be Lung Awareness Month, Free Health Clinics will have lower taxes and, disturbingly, despite widely being viewed as an expensive failure and having stopped accepting new enrollees as of 1 July due to cost concerns, Dirigo Health will now be allowed the even more expensive proposition of self-insurance.

Noticeably absent from Tuesday's "Glad Game" shenanigans was a resolution for the much-needed reform to MaineCare, Maine's overloaded and very broken Medicaid program and a new, functional, self-supporting funding-mechanism for Dirigo Health.

The Maine Legislative Documents signed into new law include:

LD 4 -- An Act to Amend the Prescription Privacy Law

LD 101 -- An Act to Enhance Screening for Breast Cancer

LD 144 -- An Act to Support Maine's Free Clinics

LD 243 -- An Act to Establish November as Lung Cancer Awareness Month

LD 429 -- An Act to Improve Access to HIV Testing in Health Care Settings

LD 431 -- An Act to Enable the Dirigo Health Program to be Self-Administered

LD 792 -- An Act Concerning Postpartum Mental Health Education

LD 807 -- An Act to Prevent Overcharging for Prescription Drug Copayments

LD 839 -- An Act to Establish a Prescription Drug Academic Detailing Program

LD 841 -- An Act to Extend Health Insurance Coverage for Dependent Children up to 25-Years of Age

LD 995 -- An Act to Reduce the Expense of Health Care Treatment and Protect the Health of Maine Citizens by Providing Early Screening, Detection and Prevention of Cancer

LD 1044 -- An Act to Address Eating Disorders in Maine

LD 1129 -- An Act to Increase Access to Oral Health Care

LD 1440 -- An Act to Prohibit Inappropriate Software Advertising of Prescription Drugs

LD 1514 -- An Act to Require Health Insurance Coverage for Hearing Aides

LD 1786 -- An Act to Reduce the Spread of Infectious Disease through Shared Hypodermic Apparatuses

LD 1812 -- Resolve, Regarding the Role of Local Regions in Maine's Emerging Public Health Infrastructure

LD 1849 -- An Act to Protect Consumers from Rising Health Care Costs.■

For an Operator, Please Press...

We've all experienced it -- calling customer service only to be put on never-ending hold, or, worse, having to listen to the numerous prompts, pressing all the appropriate keys only to be disconnected.

Paul English, founder of Gethuman.com, figured out a better way.  He and his core group of supporters tracked down and have published the shortcuts that cut out the computerized telephone middle-man and get you to a human operator.

English's site allows you to jump to specific categories (e.g., Insurance) as well as sort individually through the more than 500 companies to find both toll-free telephone numbers and the shortcuts that get you off hold and connected to a live person.  The site also has a link if you prefer a printer-friendly format rather than electronic version of the information.

In a corporate world dominated by impersonal, unhelpful, computerized interactive voice response, English's site is much-needed relief for an all-too-human frustration.■

Health Insurance Benefit Costs by Region

According to March 2007 data released by the U.S. Bureau of Labor and Statistics, among the four regions of the United States, the average cost per hour to employers for health insurance benefits ranges from $1.59 to $2.04.

The Compensation Cost Trends program reports that the proportion of total compensation represented by health benefits was 6.7 percent in the West, 6.9 percent in the South and Northeast, and 7.8 percent in the Midwest.

Nationwide, the average cost for health benefits was $1.83 per hour worked, accounting for 7.1 percent of total compensation.■

America's Doctor, President's Puppet

Dr. Richard Carmona, the 17th U.S. Surgeon General testified, last week, before the House Committee on Oversight and Government Reform that while he was the nation's top doctor from 2002 to 2006, politics overrode science and belief was more important than fact.

Carmona described a number of topics deemed taboo by Bush administration officials while U.S. Surgeon General, including:

• embryonic stem cell research;
• Plan B, the emergency contraceptive;
• the dangers of secondhand smoke; and,
• the failings of abstinence-only programs

In his speeches, Carmona was ordered to mention President Bush three times for every page and was even discouraged from going to the Special Olympics because of the charitable event's close connection with the prominently-Democrat Kennedy family.

Carmona is quoted as saying, "anything that doesn't fit into the political appointee's ideological, theological or political agendas is ignored, marginalized, or simply buried."

When Carmona quit July 31, last year, public health advocates were critical of Carmona for having not acted more forcefully with an Arizona health department spokesman Michael Murphy sniping, "went out with a whimper, didn't he?", according to the Arizona Daily Star.

Testifying with Carmona were two predecessors, Dr. C. Everett Koop, who served under President Ronald Reagan, and Dr. David Satcher, name by Clinton but whose term ended under Bush.  Carmona told that committee that some of his predecessors had told him that, "we have never seen it as partisan, as malicious, as vindictive, as mean-spirited as it is today, and you clearly have worse than anyone's had."■

MassBay Nursing Program in Jeopardy

Massachusetts regulatory officials have barred the Massachusetts Bay Community College (MassBay) from accepting new nursing students pending correction of serious deficiencies in the Wellesley-based college's popular nursing program, one of the largest in the state.  A two-year school, the 432-student nursing program graduated 93 students last year.

Peter Schworm's Boston Globe article describes issues including the lack of a dean, nursing program administrator, and several nursing instructors as well as grade-tampering as the primary causes for the possible loss of the Massachusetts Board of Registration in Nursing's approval.  Nurses are required to graduate from a board-approved program to be licensed.

Schworm describes an unstable school with a nursing program already in disarray, suffering from the school's recent reorganization that resulted in the loss of a significant number of faculty and administrators.  Recruitment efforts have also been hurt by budget constraints that prevent the school from offering competitive salaries.

Problems with the MassBay nursing program couldn't come at a worser time.  An American Association of Colleges of Nurses (AACN) factsheet points to 118,000 vacant RN positions as of April 2006 and estimates more than 1.2 million new and replacement nurses needed by 2014.  Government analysts project that more than 703,000 new RN positions will be created through 2014, two-fifths of all new jobs in the health care sector.

The Massachusetts Center for Nursing (MCN) lists a number of profiles and reports on the Massachusetts nursing faculty shortage including a Massachusetts Association of Colleges of Nurses (MACN) assessment of the current nursing shortage and strategies for expanding educational capacity.

It's time for Carole Berotte Joseph, MassBay's President and the first Haitian to head a U.S. college, to step up and exhibit some much-needed leadership by taking expeditious and appropriate action to correct the nursing program deficiencies and fully address regulator's concerns.  If Berotte Joseph proves not up to the task, MassBay's Board of Trustees have actions of their own to take.  This program is too vital to the patient community and economic health of both the state and the region to be allowed to founder any longer.■

One Nation, Uninsured

Six times in the past century -- during World War I, during the Depression, during the Truman and Johnson administrations, in the Senate in the 70s, and during the Clinton administration -- efforts have been made to introduce some kind of universal health insurance, only to be rejected.  Each time, Americans have instead opted for a system of increasing complexity and dysfunction.

The above quote, found in Friday's BLOG Medicine, begs the question:  Why?

A good place to start when looking for an answer can be found in Jill Quadagno's, One Nation, Uninsured: Why the U.S. Has No National Health Insurance.  Quadagno is a sociology professor at Florida State University, where she holds the Mildred and Claude Pepper Eminent Scholar Chair in Social Gerontology.  One Nation, Uninsured shows how powerful stakeholders like the American Medical Association (AMA), the American Federation of Labor (AFL), and the Health Insurance Association of America (HIAA), at various times over the last 60 years, have acted to keep health care financing out of the government's hands, effectively preventing every attempt to enact national health insurance.

In light of Michael Moore's recent shockumentary Sicko, a quote from Jonathan Cohn's review in the Washington Post of Quadagno's book is especially relevant (and prescient -- the review was done in 2005):

Quadagno's ultimate message seems to be that politics are more important than policy -- that progressives won't achieve universal coverage unless they learn to operate like the special interests of the right. She's probably correct -- which is why her richly constructed history could prove so handy in the months and years to come.

Given the breadth and depth of the various coalitions that have formed to promote change, we have reason to be optimistic that we are, indeed, at a tipping point for healthcare reform.■