Tag: Medicaid

Got Medicaid (Expansion) Virginia?

DSC00367_2My hometown of Richmond, Virginia is fond of putting large statues of white men on horses in the middle of its streets. Richmond is also the setting for a political and health care drama of Southern Gothic proportions. Virginia is an ACA non-Medicaid expansion state, but the state’s leaders have been debating Medicaid expansion over the past year. Earlier this month Phillip P. Puckett, a Virginia Democratic state senator, suddenly resigned to take a job on the Virginia tobacco commission. Curious circumstances surrounding his resignation have led to an investigation by the U.S. Department of Justice and the FBI, as reported in this recent Richmond Times Dispatch article. His resignation flipped control of the Virginia State Senate to Republicans intent on blocking Medicaid expansion efforts. Today Virginia Governor Terry McAuliffe announced his plan to bypass the recalcitrant Republican General Assembly and expand Medicaid to 400,000 low-income Virginia residents. (see: Modern Healthcare Va. Governor to Bypass Lawmakers, Expand Medicaid, 6-20-14). Governor McAuliffe also plans to block funding a $300 million facelift of the Capitol complex where many of the lawmakers have their offices. The bright and shiny Virginia State Capitol is shown in this photo I took about a year ago.

Medicaid plays vital roles in people’s lives and in our health care system. Medicaid improves access to basic health care services for millions of our children, low-income adults, the elderly (long-term care services), and people with disabilities. Medicaid saves lives. Medicaid funds large portions of our public hospitals, health centers, and nursing homes. Without Medicaid, most of our children’s hospitals would be forced to close.

Several of my struggling small business owner nieces and nephews who live in Virginia would benefit from Virginia’s Medicaid expansion. My elderly father who lives in Richmond would benefit from Medicaid expansion for long-term care services not covered by Medicare. My own son who lives in our Medicaid expansion state of Washington is about to get Apple Health, our version of Medicaid because the University of Washington has ended their student health insurance plan–or at least what was masquerading as a health insurance plan (see my previous post, “My Young Invincible, His Lost and Found Toe, and University Health Insurance that ‘Technically Isn’t'” 4-23-14).

Virginia and other Southern states have high ratios of physicians to the general population, yet have the worst poverty and shortest life spans of any region in the U.S. Virginia has the second highest number of free clinics in the country. North Carolina has the most and Georgia is close to Virginia’s number. Most of the free clinics are faith-based and pride themselves on not accepting any ‘government handouts.’ This generally includes the clinics not accepting Medicaid or Medicare reimbursements. These Southern states are part of the Black Belt of entrenched poverty and severe health inequities. Are free health clinics part of the solution or part of the problem?

The deeply entrenched American notion of charity care as the way to provide safety net services engenders stigma, shame, dependency, and resentment among recipients. Charity care is especially pronounced in the Bible Belt South. People do not want to have to depend on the kindness of strangers. Charity care further fragments an already fragmented, disorganized health care system. Charity care clinics have to compete for donations, grants, staff, and patients. Charity care further fragments and separates us as members of society—sorts us into the haves and the have nots, into worthy and unworthy citizens. Charity care perpetuates poverty. Despite compassionate staff and health care providers, charity care is always leftover care, afterthought care, second-rate care. Charity care gets discouraging, both to give and to receive. I know this first-hand, having been on both the giving and receiving ends of charity health care.

Medicaid and Medicare are both basic entitlements; they are not charity care. So Virginians, come down off your high horses and get Medicaid expansion.

Hospital Dirty Laundry Exposed

Laundry
Laundry (Photo credit: Bilal Kamoon)

Julie Creswell and Reed Abelson of the NYT are writing a series of fascinating articles exposing hospital giant HCA (Hospital Corporation of America), now the largest for-profit hospital chain in the US. Their NYT article today “A Giant Hospital Chain is Blazing a Profit Trail” finally explains to me the story behind the strange digital billboards I saw in June when I was visiting my father in Richmond, Virginia. They seemed to be everywhere along major roads, flashing obnoxious red-lighted wait times for the emergency rooms at two HCA hospitals–one being CJW, which the NYT article calls out as being one of the worst hospitals in the US in terms of bedsores (bedsores being a fairly good indicator of poor nursing care).

Last week (8-6-12, “Hospital Chain Inquiry Cited Unnecessary Cardiac Work) they wrote about a whistleblower, C.T. Tomlinson, a traveling nurse, who in 2010 worked as a cardiac nurse at the Lawnwood Regional Medical Center in Florida. Tomlinson was present in the cardiac catheterization lab when an HCA cardiologist inserted a stent into a patient who did not need it. Tomlinson reported the incident to his nursing supervisor who supposedly told him to forget about it. So he wrote a letter to the chief ethics officer of HCA’s hospitals in Florida who investigated his complaints and found them to be substantiated. Soon after Tomlinson wrote the letter of complaint, his contract to work as a nurse with HCA was terminated. It is not clear from the article whether or not he has filed a lawsuit for wrongful termination under Whistleblower protection. The HCA chief ethics officer’s investigation found that about half of all the cardiac catheterizations at Lawnwood Regional Medical Center were unnecessary, but did not alert the patients involved. It is unclear how many patients may have been harmed by the unnecessary cardiac work they had done. HCA also did not alert Medicare, state Medicaid or private insurers who were charged for the expensive procedures.

 

God and Mary and Jesus Are Back…..And Coming to a Hospital Near You

I am referring to the increasing number of US hospital mergers between Catholic missions-driven not-for-profit hospitals and secular hospitals. This hospital merger phenomenon has been happening for years, but is picking up speed in large and small cities—and even rural communities—across the country. Most health policy wonks attribute this uptick in hospital mergers to health care reform measures, which have increased hospital accountability for Medicare and Medicaid expenditures. Hospital systems are under more pressure to perform well, and following basic economic principles, the hospitals want to gain larger and larger market share by gobbling up competitors. It has happened here in Seattle, with Providence Health and Services (Catholic) merging with Swedish Medical Center/Health Services (secular). In this case, Swedish was the smaller fish (pun intended), and is now a division of Providence. Swedish has agreed to stop performing abortions, but is trying to staunch the outcry by funding a new (and not needed) Planned Parenthood office near the hospital. My family doctor is a part of the Swedish Medical System. I’m going  elsewhere in protest.

There are close to 600 Catholic charity hospitals in the US and they are all explicitly Catholic missions. That means they ‘do’ hospital care as an extension of their Catholic faith, as a way to evangelize through the provision of health care.  In their book God Is Back: How the Global Revival of Faith is Changing the World, Micklethwait and Wooldrige point out that in a decidedly Protestant young America, Catholicism had to fight for its market share of the faithful. The Catholic Church did this by developing a private welfare state in the US, complete with hospitals and schools. There are other religiously affiliated hospitals in the US (New York-Presbyterian is perhaps at least historically), but Catholic hospitals account for close to 80% of all such hospitals. In addition, Catholic hospitals are alone in working under special “Religious and Ethical Directives for Health Care Services.” These directives include bans on the provision of contraceptives (including condoms), sterilization, infertility treatments, abortion services, or end-of-life decision-making by patients. These bans fall disproportionately on the backs of poor, uninsured women who rely on charity-care hospitals. When Catholic hospitals merge with secular hospitals, the Catholic hospitals insist on contract clauses whereby the secular hospital has to abide by the Catholic religious/ethical directives.

Catholic leaders take their Religious and Ethical Directives for Health Care Services very seriously, going so far as to excommunicate a nun, nurse Margaret McBride, for being part of a hospital decision to allow an abortion in order to save a mother’s life. This happened in Phoenix, Arizona in 2009 when McBride was an administrator at St. Joseph’s Hospital and Medical Center. It involved a young woman with life-threatening pulmonary hypertension who was 11 weeks pregnant. If she had not had an emergency pregnancy termination, the young woman would have died.

I am all for religious freedom, and I even support—to a point—conscience exclusions for health care providers. But I also believe that the separation of church and state goes both ways—not only protecting the church/religion from the bully-power of the state, but also the state (government and civil society) from the bully-power of the church. Medicare and Medicaid account for over half of the total funding for Catholic hospitals. In addition, they (the Catholic hospitals) enjoy benefits such as tax-exempt status and low-cost financing through government bonds programs. In some cases they even enjoy free use of municipal buildings. Perhaps it is time to re-think those arrangements.

(The statue of Jesus included in this post is Christ the Divine Healer, an 11 foot marble statue in the foyer of the original hospital building at Johns Hopkins (a Quaker). When I went there it was still a ritual for patients, family members and students to touch Jesus’ big toe for luck, blessing, whatever you wanted to call it. It was a well-worn toe….)

No More Free (drug) Lunches or Pens

As part of the Affordable Care Act (ACA) health care reform, drug companies will soon be required to report payments and free lunches/dinners/cruises/vacations/gifts to physicians or payments to teaching hospitals. It includes any free ‘educational’ service for physicians or teaching hospitals. This is section 6002 of the ACA and is known as the Physician Payment Sunshine Act (sunshine, as in shedding light on or transparency). As part of the mandatory reporting, individual physicians and hospitals will be named, along with what items of monetary value they received and by which companies. This information will be publically available and easily searchable. Companies will be assessed hefty fines of up to $1 million for failing to report the information. This Sunshine Act was supposed to have already been implemented, but has been delayed while government officials at the Centers for Medicaid and Medicare sift through public comment and iron out final details.

I read through the proposed Physician Payment Sunshine Act (vol 76,no. 243/12-19-11 Federal Register), and found that they define “physician” as a doctor of medicine or osteopathy, dentists, podiatrists, optometrists and licensed chiropractors. Teaching hospitals are defined as hospitals having graduate medical education. And here is their rationale for the Sunshine Act:

“2. Transparency Overview

Collaboration among physicians, teaching hospitals, and industry manufacturers may contribute to the design and delivery of life-saving drugs and devices. However, while some collaboration is beneficial to the continued innovation and improvement of our health care system, payments from manufacturers to physicians and teaching hospitals can also introduce conflicts of interests that may influence research, education, and clinical decision-making in ways that compromise clinical integrity and patient care, and may lead to increased health care costs.” (p. 7)

(The NYT has a recent article on this, as does Kaiser Health News–older but good.)

Several states including Vermont have already implemented similar reporting requirements. Some physicians are complaining that drug companies are now wooing more nurse practitioners as a way around the reporting requirements. I saw that in action at this past fall’s regional nurse practitioner conference. It was overrun by aggressive pharmaceutical reps waiving tons of swag (including the ubiquitous drug pens), as well as signing NPs up for free lunches/dinners/talks, etc.

In the community health clinics where I’ve worked, most all of the family physicians were rabidly anti-drug company marketing and influence. One physician in particular would go on a tirade if she discovered one of her medical residents writing with a drug company pen. They—and everyone else in the building—would get a lecture in the evils of drug company influence on physician prescribing practices and health care costs. So I thought I had long ago purged myself of all drug company free stuff. While preparing to write this blog post I engaged in some late winter housecleaning searching for hidden drug company subliminal influences. I found six drug company pens, four of which were for drugs that have been pulled from the market as unsafe. I threw them all away. On a popular blog lamenting the Sunshine Act, one physician complained that he has to buy pens for the first time since he graduated from medical school in 1986.

The only drug company swag I found that I am keeping is a funky glass sun catcher given to me by a retired pharmacist who lives on my street. It has elemental alchemy symbols for strange things like lead and vinegar and talc—but is really an advertisement for a nasal decongestant hidden in small type at the bottom. See if you can find it on the attached photo—but don’t buy the stuff!