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.

Toe Saga Enters Health Insurance Maze

toes
toes (Photo credit: ribarnica)

The first bill of sorts came today for my young not-so-invincible son for his recent torn off big toe (previous post). The letter is in reference to a $17 radiology charge from the emergency department of the university-affiliated hospital where he was seen. I assume this charge was for flipping the switch to warm up the X-ray machine, but it doesn’t specify what it was for.

The letter came from his student health insurance company. They are requesting documentation that my son’s missing toe was not a preexisting condition. Their specific wording: “Has (dearest son of mine) received any medical care or medicine for diagnosis code 729.5–pain in limb (for the three months preceding the X-ray)?”  Like what, he’s been running around for the past three months with his
toe in the refrigerator just waiting for his health insurance to kick in
so he can have his toe reattached?

Do U.S. health insurance companies purposefully hire stupid people so they can spend even more on administrative overhead and pass those charges on to us, the mostly overwhelmed and confused health care consumers? At least 15% of our country’s total healthcare expenditures is spent on this sort of inept health insurance administration. That’s over $360 billion annually just for paper pushing. Medicare’s administrative costs are less than 2% of total Medicare expenditures. Meaning: that paper pushing can be done a lot more efficiently.

As Jeffrey Pfeffer wrote in his Bloomberg Business Week News article (4-10-13), “Because insurers are paid a fixed percentage of the claims they administer, they have no incentive to hold down costs. Worse than that, they have no incentives to do their jobs with even a modicum of competence.”

A good overview of the obstacles to reducing administrative costs within our healthcare system is included in this brief NEJM article. The authors point out that Obamacare/ACA has some provisions to address these problems. Here’s hoping.

Into the Sunset

dadatbeachIn October 2010 I first wrote about the journey of my elderly father through declining health and the healthcare maze. In my blog post titled A Practical Man and Modern Medicine this is how I started his/our story:

Today on the phone, my 87-year-old father asked me to be his patient advocate. He is facing tough health care decisions over the condition of his heart, and is scheduled for surgery in a week. He is a practical man, bright, charming, and articulate, with no cognitive deficits that I can detect. He told me where his Living Will and Advanced Directives are, where he wants his body donated for medical research, and what to do when his CD matures (he’ll be in surgery) so that he can roll it over to a money market account. He says he needs access to the money for his after-hospital care, in case he survives surgery. I am thinking about the health policy issues within all of this: 1) heart failure accounts for the largest portion of Medicare expenditures, 2) none of his doctors have talked with him about what all is involved with this surgery, or what quality and quantity of life he can hope for afterward, and 3) home care provided by family members is not well supported (financially and otherwise) in our country. As his daughter and as a family member embedded in the health care system, what do I do with this information?

Almost three years later I still don’t know what to do with this information. I have discovered the healthcare system to be even more bewildering and capricious than I had imagined. I last wrote about my father this past fall in the post Transitions (October 22, 2012), when I was back in Virginia helping him survive the rough crossings between four different health care settings in six weeks—the last one being the calmest and sanest of all—home hospice. My father was weak, oxygen-dependent, and had advanced wasting from end-stage congestive heart failure. His cardiologist didn’t expect him to live much past Christmas. The day after hospice started my father used his walker to get from his hospital bed in the living room to the studio in the back of the house. Once there he strapped himself into his recumbent exercise bicycle and started “getting back into shape again.” We all thought he was nuts, but decided if he wanted to die while riding his bike off into the sunset of the studio that was his choice.

Since then he has confounded his cardiologists who say that by all objective measures my father should be so physically disabled as to be bed bound. Instead, he once again ‘graduated’ out of home hospice and as I write this he is riding his ‘real’ bicycle off into the ‘real’ sunset on a beach in Florida to meet up with friends for Happy Hour, sans alcohol for my teetotaler father. The photo to prove it was taken by my niece who is his caregiver for a few weeks.

Clearly my father’s story is not over, even though he has finished writing his memoir in barely decipherable handwriting on ten legal pads, which are in the mail to me. My father wants me to transcribe them and make into a book. “After all, this whole memoir business was your idea,” he said to me. He wants to proofread the final draft to make sure I didn’t change any of his words.

Last fall I wrote an essay titled Home Death about my experiences with the healthcare system, as I tried to uphold my role as health care advocate and proxy for my father. It was published recently in Johns Hopkins Public Health: The Magazine of the Johns Hopkins Bloomberg School of Public Health, Special Issue 2013. You can read it here.

Transitions

Road cones
Road cones (Photo credit: Christchurch City Libraries)

Transitional care: part of care coordination across time and settings, specifically for patient populations at high risk for poor and costly outcomes as they cross health care settings.

There is the ideal (smooth, patient and family-centric) transitional care and then there is reality.

Case in point is my elderly father with congestive heart failure—the diagnosis associated with the highest Medicare health care costs. My father has been in four different health care settings over the past six weeks. These include an inpatient acute care hospital, a skilled nursing care/rehab facility, home nursing care, and as of today, home hospice. I have worked as a nurse in three out of four of the specific health care systems he has moved through. I know something about how they work—the key people to contact—the questions to ask—the code words to use to get things done. In spite of all that—plus flying cross-country to do much of this care coordination in person—it has been more than just difficult. As my father says, “There’s been a mix-up everywhere I go—it’s as if none of them communicate with each other.” Indeed, it shouldn’t be this hard. I keep wondering: how do people with fewer resources do this?

The metaphor for ‘good enough’ healthcare transitions that has occurred to me are those orange safety cones lined up re-directing traffic. Knowing the more ideal freshly paved road of smooth health care transitions is a ways off in the future, all I’ve yearned for are orange safety cones. I did finally see one bright orange safety cone today. It came in the form of a wonderfully compassionate male hospice nurse who spent over an hour patiently and respectfully talking to my father about quality of life–about what matters most to him and how hospice can help support him to pursue those things. Finally! Sanity and clear, direct communication from someone in the health care system. I thanked this nurse and asked him how long he’d been in nursing–14 years–and what he did before nursing–he owned/operated a bar. There are many paths to becoming a really great nurse.

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.

 

Hospital and Doctor Compare: Patient Beware

Patient Recognition Month Poster
Patient Recognition Month Poster (Photo credit: Army Medicine)

Nurse and NYT’s Well Blog contributor Theresa Brown has a NYT Op-ed piece today entitled “Hospitals Aren’t Hotels,” in which she states “…the growing focus on measuring ‘patient satisfaction’ as a way to judge the quality of a hospital’s care is worrisomely off the mark.” She points to the patient satisfaction section of The Centers for Medicare and Medicaid’s Hospital Compare website, where consumers can look up individual hospital quality of care information. Based on Medicare patient data and hospital reporting mechanisms, Hospital Compare includes process and outcome of medical care measures, use of medical imaging, patient safety measures, Medicare payment/volume, as well as a 10-item survey of patient’s hospital experiences.

It is instructive to note that patient satisfaction is only one of six categories of quality of care data on Hospital Compare from which consumers can make more informed medical care decisions. Obviously it is only useful for planned procedures and hospitalizations, since patients having a heart attack aren’t likely to stop and look up Hospital Compare data on their iPads. I used Hospital Compare several years ago when my sister asked my advice as to Seattle-area hospital choices for her planned abdominal hernia repair. At the time, Swedish Hospital had the highest volumes and best patient outcomes (including patient safety) for this surgical procedure, so my sister then picked a surgeon from their list. She had a decent hospital experience. Today for grins I pretended I needed to have laparoscopic gallbladder removal (I don’t) and ‘shopped’ for Seattle-area hospitals based on this specific procedure. Of the three geographically closest hospitals—Group Health Central, Northwest, and University of Washington Medical Center (UWMC), Group Health came out the clear winner overall for quality of care measures that are most meaningful to me: patient safety (UWMC is worse than national average for hospital acquired conditions such as infections and things besides vital organs left in after surgery—and for the ominous sounding “accidental cuts and tears from medical treatment”), having medications explained to me before they are given, nurses and doctors who communicate with patients well, and the area around patient rooms being quiet at night.

It can be and is argued that patient satisfaction with care is not a valid measure of outcome of medical care. I know from teaching that I can make my students happy and get high ‘student satisfaction’ with teaching scores, and still not have done my job of actually teaching them anything of importance. In her NYT Op-ed piece today, Ms. Brown uses an example of an elderly cancer patient who was told by the hospital oncologist that he was basically too old to qualify for treatment and was sent home. He may have not scored that hospital very high on his Medicare hospital survey, since he didn’t get what he wanted. Ms. Brown links to a recent study by Joshua Fenton at UC Davis showing that higher patient satisfaction scores with individual doctors was linked with greater use of hospital services (higher medical cost) and increased mortality. To me that’s a no-brainer and points to the danger of overuse of health care—more health care is not better health care, and health care can be dangerous to your health.

US doctors have been fighting consumer ratings of individual doctors. (see Ron Lieber’s “The Web is awash in reviews, but not for doctors. Here’s why.” NYT, 3-9-12) The developer of the online RateMyProfessors.com site created RateMDs.com. RateMDs.com now includes ratings of close to 1.4 million physicians in the US and Canada. The founder of RateMDs.com gets at least one lawsuit threat a week from physicians who don’t like what’s been posted about them. A physician reputation management service, Medical Justice, set up a system whereby physicians had patients sign a “no web posting opinions of the doctor” agreement in exchange for enhanced patient privacy protections. That’s almost like a restaurant owner asking you to sign an agreement not to post a review on Yelp in exchange for not putting flies in your soup. The Medical Justice system collapsed after a complaint was filed with the Federal Trade Commission.

Insurance companies and health plans collect consumer ratings and medical outcomes data for individual doctors and other providers, but they don’t make these data available to consumers. With the Affordable Care Act/health care reform, starting January 1, 2013, Medicare will be required to provide consumers more information on doctors as well as on hospitals. (As of this writing, they have a “Physician Compare” site, but it only allows searches to find physicians who accept Medicare.) I disagree with Theresa Brown on this issue. I think that patient satisfaction as one aspect of judging the quality of hospital or other medical care is essential for improving our health care system. It is an essential component of patient-centered care.

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….)