Thursday, December 12, 2013

#GetCovered & Obamacare Enrollment Numbers

This one from Alphacat sampling Snoop Dogg hits ya RIGHT in the health policy nerd. Right guys? Right??? Where'd everyone go????

Part of a campaign called Tell a Friend - Get Covered, from Covered California and Enroll America to spread the word on your new health coverage options.

Best move is, of course, the Bernie at 2:55:

To date, over 1.2 million individuals have selected a plan in the state and federal exchanges or have qualified for Medicaid. California leads the way in total enrolled...

 ...but there is still a long way to go to cover those eligible:

Nevertheless, per the recent numbers from the feds, cumulative enrollment is escalating:

Wednesday, December 4, 2013

Why American Health Care Costs So Much

An ongoing New York Times series delves into the uniquely-expensive American health care system, and its latest installment As Hospital Prices Soar, a Stitch Tops $500 tackles one of the biggest culprits: hospital care.

The United States now spends over $2.7 trillion on health care every year, averaging $8,400 per person, thousands more per capita than any other country on the planet. Roughly a third of those costs come from hospital care, and hospitals account for the biggest driver of medical inflation (which has unsustainably outpaced market inflation for decades). The whole series is worth a read, but here is a summary of the main points of this important article, which features many California hospitals:

- Hospital mergers have consolidated the market over the last several years, allowing a small number of hospital chains to dominate the market and demand higher prices from private and public insurance. 

- The ever-elusive 'chargemaster' of each hospital lists prices for each and every facet of a hospital admission (IV bags, aspirin, physical therapy visit, x-rays, procedures), that are largely arbitrary and far above the actual market price. Every effort is made by hospitals to keep these lists secret from the public. 

- Growing armies of costly non-clinical administrators are employed by these hospital systems to maximize revenue through billing and coding processes.

- Rates and charges for identical procedures vary widely across regions independent of cost of living, even at hospitals within the same community.

- When the largest health systems are able to charge more, smaller hospitals will soon follow suit causing a ripple effect of inflated costs. 

- While the actual payment to hospitals is usually less than what is charged because of negotiated discounts, these payments are still far higher than fair market prices. 

Government spending as a proportion of American health expenditure has increased substantially over the last 20 years, and now represents almost half of total health spending. This trend will continue to rise as more individuals enter Medicare and through implementation of the Affordable Care Act, specifically through Medicaid expansion and subsidies for individuals to purchase private insurance. The onus will fall on deciding how best to maximize these tax dollars, while creating structural change to allow better cost-consciousness for individuals in a competitive marketplace.

As I have discussed in the past, the Independent Payment Advisory Board (IPAB) may have a significant role to play in reducing unnecessary costs and maximizing efficiency in our health care system. This may be even more true now, for our leaders in the political arena have essentially removed a long-standing line in the sand: The Filibuster. Over recent years Presidential nominees have faced an increasingly entrenched need for sixty votes in the Senate to begin working, effectively crippling the appointment process and leaving vital leadership posts unfilled. As a result of the new reform, appointments now only require a simple majority for approval. The yet-to-be-formed IPAB is a Presidentially-appointed board that has stalled because of this political reality, but with this new development may now come to fruition.

Sunday, November 17, 2013

Q: Where is Obamacare Working? A: Covered California and Medi-Cal, and the Health Care Team Must Keep Leading

                                      As seen in Sierra Sacramento Valley Medicine Vol. 64 / No. 6 - Nov/Dec 2013  

The Final Countdown to
a Covered California

By Adam Dougherty, MS IV

THE CLOSING MONTHS OF 2013 bring a slew
of activity in the implementation of the
Affordable Care Act in California, and it is
impressive to see just how far the state has come
since the law was passed. While there have been
some unfortunate delays announced from the
feds, the main pillars of the law remain intact.
Notable delays include the postponement of the
annual and lifetime caps on out-of-pocket
insurance costs to 2015, and deferral of the rule
requiring large companies to provide
comprehensive coverage to full-time employees.
The following are what’s happening with the big
pillars, which go live beginning in 2014.

The Mandate
The controversial individual mandate will go
into effect on New Year’s Day, where most
individuals will be required to have insurance
coverage or will pay a penalty on their taxes that
year if they don’t. In 2014, the penalty equals 1
percent of income or $95 (whichever is greater),
and in 2016 phases up to 2.5 percent of income
or $695. Groups exempt from this mandate
include individuals who would have to pay
more than 8 percent of their income for
insurance, undocumented immigrants, and
Native Americans.

The Exchange
For those with incomes above 138 percent
of the Federal Poverty Level (FPL), the state’s
health insurance exchange called Covered
California is expected to provide competitive
insurance rates in a regulated market, while tax
subsidies will help make coverage affordable for
individuals and families up to 400 percent FPL.
The exchange began pre-enrollment on October
1st, and will officially go live on the first of the
year. The $80 million Covered California media
blitz is in full swing, and Exchange officials hope
to enroll over 70 percent of the 2.4 million
Californians who are eligible for subsidies over
the next year.

California is moving full steam ahead to
expand Medi-Cal to every individual under 138
percent FPL or roughly a salary of $16,000 per
year for an individual and $27,000 for a family
of three. This equates to 1.4 million newly
eligible Californians, adding to the ranks of
today’s 8 million Medi-Cal beneficiaries. Here is
what that looks like:

Counties have been working feverishly to
bring many of these individuals into the
temporary Low Income Health Plans (LIHPs),
commonly known as the “Bridge to Health Care
Reform.” Over 615,000 Californians have
already enrolled in county LIHP programs since
2011, and nearly all will transfer automatically
to Medi-Cal on January 1st. Today, nearly 12,000
Sacramentans are benefitting from this program.

It’s not all good news for Sacramento
County, though, as the state plans to claw back
$9 million next year from the County health
budget since these traditionally county-financed,
low-income individuals will transition to statefinanced
coverage (even though expenditures
will remain, as the county will still be
responsible for care to those who remain
uninsured). County officials are devising how
best to streamline existing programs as any cuts
to benefits seem to be off the table.

While the expansion will have far-reaching
benefits for the health of the newly insured,
coverage does not simply equate to access.
California still has the lowest Medicaid spending
per enrollee in the nation, and the second
lowest share of physicians accepting new
Medicaid patients at 57 percent. More so, the 10
percent Medi-Cal rate cut proposed in the
Governor’s budget was indeed upheld in the
courts and is now actively being implemented.

Nevertheless, 150 primary care services in
Medi-Cal will still see a boost in payment to
Medicare level in 2013-2014, thanks to the ACA,
equating to a 136 percent increase in
reimbursement on average. It is imperative that
these services are taken full advantage of over
the next year, and significant effort be put in to
extend them past 2014, in order to bolster
primary care networks and adequately meet the
pent-up need for the newly insured. While
reimbursement is the most immediate priority,
the state and committed, forward thinking
stakeholders must buy in to more organized and
integrated payment and delivery models that
improve efficiency while reducing barriers to
care or risk further provider network

Public Awareness
Much of the public continues to remain in
the dark on most of these developments, and
often become more skeptical when they do hear
about it. A recent Kaiser Family Foundation
study conducted in August exemplifies this
phenomenon, where individuals were asked
who they would trust getting information from
vs. actual exposure:

The health care team tops the list of trusted
sources, yet only one-fifth of individuals have
received any information from a doctor or
nurse. While the entire political spectrum is,
indeed, represented in the medical profession,
this peer-reviewed fact should be emphasized:
Insurance coverage reduces mortality, improves
quality of life, and enhances productivity.

The reality is that many eligible individuals
will still lack coverage by the end of the decade
because they can’t afford it, they can’t properly
navigate the system, or have encountered any
number of barriers to outreach. Whatever our
preferred ideology, it would behoove all our
patients to benefit from these reforms, and as
stewards of health, we should be expected to
guide them.

Leading the way in this regard are the
California Academy of Family Physicians, the
California Chapter of the American College of
Physicians, the California Academy of Physician
Assistants and the Osteopathic Physicians and
Surgeons of California, whose partnership was
awarded an $865,000 grant from Covered
California to develop educational programs for
physicians and materials for patients in order to
increase the number of Californians with health
care coverage.

Wednesday, October 9, 2013

The Government Shutdown Affects National Health, But Not Obamacare

Heading into Week 2 of the shutdown, we are already seeing the effects of the government shutdown on federally-funded programs that effect American's health. Here are a few of the big ones:

- 92% of the Agency for Health Care Research and Quality (AHRQ) staff members have been furloughed, effectively freezing the $400 million operation. The AHRQ provides crucial grants, research and recommendations for consumers and health care professionals in order to improve health care delivery and quality. 

- The Center for Disease Control and Prevention (CDC) has suspended its seasonal influenza program, resulting in reduced outbreak detection efforts and halting efforts to assist states with infectious disease monitoring. Just in time for flu season when these programs are needed most!

- The Center for Medicare and Medicaid Services (CMS) has suspended certain health care fraud and abuse detection efforts, halting ongoing investigations and leaving the programs more vulnerable to new attacks. 

- The Department of Agriculture has furloughed more than a thousand food safety and inspection workers. Lo and behold, a Salmonella outbreak emerged this week that has sickened 300 people in 18 states and rages on, while a barebones staff of officials attempt to coordinate already delayed interstate investigations.   

- The FDA has furloughed roughly half of its employees, halting numerous safety activities, including routine inspections, import monitoring and laboratory research needed to inform public health decision-making.

- The National Institutes of Health (NIH) is not accepting new clinical care patients or awarding new grants, stifling groundbreaking medical research.

In light of these delays, the mandatory spending established for implementation of the Affordable Care Act, aka Obamacare, has not been effected. Enrollment efforts are moving full steam ahead since last week's launch, as thousands of individuals are already pre-enrolling for health care coverage through and Covered California here at the state level. While a few opponents are continuing their last gasp effort to defund or delay the law, this marks the beginning of the end of the 'repeal' rhetoric. 

Tuesday, September 17, 2013

3 Reasons Why Gov't Shouldn't Be Run Like a Business

A great video from the folks over at OnlineMBA, explaining the inherent differences between corporations and government. The hard part, of course, is defining just what qualifies as the common good. This is especially relevant in health care, where public spending continues to outpace the private sector as a percentage of total national health expenditure.

Created by

Wednesday, May 29, 2013

We Care for California on June 4, 2013

Funding for Medi-Cal, the California Medicaid program for the poor and disabled, has been under fire since the early days of the Great Recession. Meanwhile, the Golden State is leading the way to fully expand Medi-Cal as authorized in the Affordable Care Act (ACA). While millions will gain health insurance as a result, the threat of inadequate state funding will severely restrict health care access for those who need it the most. Join with thousands of hospital workers, hospital administrators, physicians, dentists, insurers, elected leaders and others across the state on June 4th in Sacramento to call on State lawmakers to restore a $1 billion cut in funding for quality healthcare in California.

Visit We Care for California to learn more!

Saturday, May 18, 2013

Controlling Health Care Costs and the Independent Payment Advisory Board (IPAB)

As seen in Sierra Sacramento Valley Medicine Vol. 64 / No. 3 - May/June 2013  

Getting Serious about Cost Containment

Understanding the ACA’s Independent Payment Advisory Board (IPAB) 

THE PATIENT PROTECTION AND Affordable Care Act (ACA) brings unprecedented changes to the American health care system. Through the individual mandate, health insurance exchanges, and the expansion of Medicaid, the nation may finally shed its dubious title as the sole Western nation without universal coverage. 

A lesser-known piece of the law has the potential to tackle an even greater challenge: the unsustainable growth in health care spending. National health care costs are now an all too familiar problem. In 2009, the U.S. topped $2.5 trillion in health care expenditures, or 17.6 percent of GDP. This equates to $8,086 per person, more than twice the average of the highest spending countries.1,2 The unyielding growth in federal health program costs, most notably Medicare and Medicaid, remains the single greatest threat to our nation’s fiscal health and long-term deficits. 

Extended life expectancy and an aging baby boomer population means spending will continue to accelerate, and the CBO projects that direct federal health costs will total 9.7 percent of GDP by 2030 and 13.7 percent by 2050, with national health expenditures nearing 50 percent  of GDP by 2080.3

The ACA begins to take important steps to combat these trends and improve the value of the health care dollar through accountable care organizations, comparative effectiveness research, and value-based purchasing. Arguably the most significant effort to contain costs, though, can be found in Section 3403 of the ACA and is known as the Independent Payment Advisory Board (IPAB).4

Consisting of a 15-member panel of presidential appointees, IPAB’s task is to produce recommendations to hold down Medicare spending, if the program’s per capita growth exceeds established limits. Beginning in 2015, IPAB will make recommendations with the spending target tied to the Consumer Price Index (CPI), better known as inflation. After 2020, the target will be tied to GDP plus one percent, a historically less-restricting trend. Most importantly, the IPAB recommendations offered to Congress are binding, for legislators must either approve the proposals or find equally effective alternatives to offset the costs.

As the federal government has an increasing stake in future health care spending through Medicare, Medicaid and the ACA’s low-income subsidies, an effort to address the underlying costs is imperative for public programs, payers, and employers. IPAB is in a unique position to fast-track successful cost-saving models, mobilize the leverage of the nation’s largest purchaser, and truly effect health system change.  Yet the IPAB itself is on life support, as both the House and Senate rescind $10 million of the $15 million allocated by the ACA in their proposed FY2013 budgets.

The highly politicized nature of reigning in Medicare costs and the failure of Congress to take action in the last several decades justifies new approaches to real cost containment. Nevertheless, the inability to adopt serious cost control measures has created skepticism and has cast IPAB as a controversial body comprised of unelected bureaucrats who are accountable to few. These concerns are probably overblown, since Congress has the ability to override IPAB recommendations by enacting comparable cost controls. Efforts to repeal IPAB are commonplace in the House, where it is referred to as a “rationing board” and “the real death panel,” yet little is being done to address long term costs containment.5

This picture offers further justification for IPAB’s necessity. The mere presence of the board requires recognition of the need for a Congressional plan to control Medicare costs, something vehemently avoided in the current age of political polarization and special interest influence. Additionally, concerns about restricting access to care are addressed in the ACA itself, as IPAB is unable to make any recommendations that would alter plan benefits or eligibility levels, and has explicit language against the notion of “rationing” care.6

Organizations such as the American Hospital Association (AHA) and the American Medical Association (AMA) fear that IPAB will simply cut provider reimbursements in order to meet spending targets, and are also pushing for its repeal. Their concerns are valid, but too generalized, as IPAB would be able to propose smarter changes than blunt across-the-board payment reductions as seen in the Sequester. Including strategies similar to those offered by organizations like the Medicare Payment Advisory Committee (MedPAC) into IPAB recommendations is a more realistic scenario.

At present, Congress routinely ignores MedPAC recommendations. Examples of MedPAC strategies include targeted reductions to areas of overpayment and high-cost procedures, coupled with a greater investment in primary care. Moreover, IPAB would be able to look at bold new strategies to ensure the future stability of Medicare. For example, given the increasing use of pharmaceutical therapies, recommendations could include Medicare Part D amendments like additional drug manufacturer rebates, negotiated rates, or even a Medicare-operated plan to compete with private drug plans.7

IPAB will indeed have broad-reaching implications, as Medicare arguably sets the bar for health coverage, price, quality measurement, and workforce training and distribution. Not only is IPAB commissioned to make recommendations for Medicare, but is also instructed to produce non-binding advisory recommendations for non-federal programs, national health expenditure, and health policy issues that affect both public and private health care systems.8 Such recommendations could have lasting effects on the health care system, particularly in the federally subsidized state-based health insurance exchanges.

Future challenges will include how best to parallel IPAB’s work with the efforts of the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). Maximizing collaboration and information flow through public-private partnerships will be vital, as well. Concurrent investigations through ACA-established bodies like the Patient-Centered Outcomes Research Institute (PCORI) and Center for Medicare and Medicaid Innovation (CMMI) will glean novel models of evidence-based health care delivery and financing that IPAB could accelerate.

Pending its survival in the political arena, IPAB will not only be an effective backstop to impose Congressional discipline, but more importantly will be a vehicle to efficiently translate this research into practice.

1 Squires D.A., The U.S. Health System in Perspective: A Comparison of Twelve Industrialized Nations, The Commonwealth Fund, July 2011.
2 California Health Care Foundation, Health Care Costs 101: US Health Care Spending, 2011 Edition.
3 The Long Term Outlook on Health Care Spending, CBO, November 2007.
4 Public Law 111-148, Section 3403: Independent Payment Advisory Board.
5 HR 452, The “Medicare Decisions Accountability Act of 2011,” House Energy and Commerce Health Subcommittee, Feb. 29, 2012.
6 Aaron H, The Independent Payment Advisory Board — Congress's “Good Deed,” N England Journal of Medicine, June 2011.
7,8  Ebeler J, Neuman T, Cubanski J. The Independent Payment Advisory Board: a new approach to controlling Medicare spending. Kaiser Family Foundation Program on Medicare Policy, April 2011.

Thursday, March 14, 2013

Improving Mental Health Access for the Desperate with Laura's Law

Laura’s Law – Time to
Bring it to Your County?
By Adam Dougherty, MPH, MS III

in some way − be it a personal struggle, a loved
one’s troubles, a news story of mass murder, or
simply witnessing a disturbed soul on the street
corner. Fortunately, there is growing recognition
of the importance of mental health services as a
mainstay of comprehensive medical care.

But what if an individual is too ill and
disorganized to even seek out care? Tragically,
people with the greatest need are the same ones
with the most trouble navigating the system.
If these people are lucky enough to find some
mental health services, it is usually limited to
acute short-term hospitalization or care within
the criminal justice system after a crime has
been committed.

Our patients with mental illness are forever
in a revolving door between the emergency
department, county mental health clinics,
and jail psychiatric services. With no ability to
provide sufficient follow up, doctors are forced
to discharge these patients back to the streets
until they fall into the cycle again.

This was the case in 2001 when Scott Thorpe,
an untreated schizophrenic, made headlines for
gunning down 19-year-old Laura Wilcox and
two other employees in a Nevada City clinic.
Following the tragedy, the California Legislature
passed Laura’s Law. It expands services to
severely ill, often-untreated individuals. The law
allows counties to require Assisted Outpatient
Treatment (AOT) for needy people who have a
history of violence and repeated hospitalization
and have failed voluntary treatment.

More specifically, AOT is court-ordered
therapy that is designed to intervene before an
individual further deteriorates into the vicious
cycle. Unlike high-cost acute hospitalization,
AOT includes a menu of options tailored to an
individual’s unique needs and circumstances.
It focuses on outpatient services such as
psychotherapy, medication management, crisis
intervention, in-home nursing and social

Counties have the prerogative to decide
whether to implement the law or not; and
unfortunately for most of California’s severely
mentally ill, only one county − Nevada County
− has done so. Local government has been
hesitant to implement the law, given a sense that
it limits people’s autonomy. However, many of
us would argue for a greater good to promote
public safety and a moral responsibility to help
those who truly can’t help themselves.

AOT shouldn’t be construed as “forced
treatment,” but rather it is an opportunity to
bring relief to a vulnerable, high-risk and costly
group, providing services to those who have
been unable to benefit from the medical system
other than re-hospitalization or incarceration.
For every Scott Thorpe, there are hundreds more
who don’t make headlines, but continue to suffer
in the community − many with malnutrition,
medical illness and treatable mental health
conditions that severely limit their ability to
become a functioning member of society.

Governor Jerry Brown recently signed
legislation extending Laura’s Law to 2017, and
it is time for Sacramento and surrounding
counties to take a closer look at the benefits of
implementation. Not only would it save lives,
but AOT also makes fiscal sense. In a recent
study of the law’s implementation, the Nevada
County Behavioral Health Department found 
that AOT significantly reduced hospitalization
and incarcerations rates, resulting in savings of
$1.81 for every $1.00 invested in the program.
For these efforts, Nevada County was bestowed
the 2011 National Association of Counties
Achievement Award.

Laura’s Law would be a promising patch to
help mend our fragmented local mental health
system, reduce disparities for the neediest among
us, provide rehabilitation and prevent tragedy.
Sacramento and its neighboring counties could
lead the way by enabling funding streams
available through the Medi-Cal program, the
Prop. 63 Mental Health Services Act, and the
recently unveiled bipartisan federal legislation,
The Excellence in Mental Health Act, introduced
by our very own Congresswoman Doris Matsui.

Local law enforcement, county health
services and their affiliates, and patient
advocates also all have a part to play in making
this program a reality. 

Adam Dougherty is a third year medical student
at the UC Davis School of Medicine and sits on the
Sacramento County Public Health Advisory Board

Thursday, March 7, 2013

The Future of Medicine

A couple years old, but a great TED overview of what's on the horizon in the next few decades from Dr. Daniel Kraft, Executive Director of FutureMed.

Some of the concepts:

P4 Medicine

Stage Zero Medicine
-Curing disease before even getting sick.

Quantified Wellness/Quantified Self
-Biometric monitoring of health

Yay future!

Wednesday, January 30, 2013

Special Session to Implement Health Reform Underway in California

Last week, Governor Brown announced a Special Legislative Session so that California can continue to lead the way in implementing the Affordable Care Act. Under this special session, bills signed into law can be deemed effective withing 91 days, as opposed to the traditional process where they would have to wait until next January to become effective. With enrollment into our new insurance exchange Covered California beginning in October, and the individual mandate and Medi-Cal expansion going live on Jan. 1 2014, this session will maximize preparation state-wide.

The session began this week, with focus on how best to carry out the Medi-Cal expansion to those making up to roughly $14,000 a year. Below is the text of the Governor's Proclamation proclamation outlining the major priorities, and a news spot on the session featuring UC Davis pediatrician Assemblyman Richard Pan:


WHEREAS, an extraordinary circumstance has arisen and now exists requiring that the Legislature of the State of California be convened in extraordinary session;

NOW, THEREFORE, I, EDMUND G. BROWN JR., Governor of the State of California, in accordance with Section 3(b) of Article IV of the Constitution of the State of California, hereby convene the Legislature of the State of California to meet in extraordinary session in Sacramento, California, on the 28th day of January, 2013, at a time to be determined, for the following purpose:

To consider and act upon legislation necessary to implement the federal Patient Protection and Affordable Care Act (Public Law 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152), in the following areas: ‪

a. California’s private health coverage market, and rules and regulations governing the individual and small group markets related to guaranteed issue of coverage, pre-existing condition exclusions, rating restrictions, and any other requirements necessary to conform state law to federal rules.

‪b. California’s Medi-Cal program and changes that are necessary to implement federal law, including requirements for eligibility, enrollment, and retention.

‪c. Options that allow low-cost health coverage to be provided to individuals who have income up to 200 percent of the federal poverty level within the California Health Benefit Exchange, to the extent allowed by federal law or regulations.

IN WITNESS WHEREOF, I have hereunto set my hand and caused the Great Seal of the State of California to be affixed this 24th day of January 2013.

Governor of California