Contesting Depression

Social disagreement about the medicalization of experience is intensifying. Psychiatrist Allen Frances complains that the draft DSM is too quick to pathologize grief:

A startling suggestion is buried in the fine print describing proposed changes for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders — perhaps better known as the D.S.M. 5, the book that will set the new boundary between mental disorder and normality. If this suggestion is adopted, many people who experience completely normal grief could be mislabeled as having a psychiatric problem.

Suppose your spouse or child died two weeks ago and now you feel sad, take less interest and pleasure in things, have little appetite or energy, can’t sleep well and don’t feel like going to work. In the proposal for the D.S.M. 5, your condition would be diagnosed as a major depressive disorder. . . .[This change] would give mentally healthy people the ominous-sounding diagnosis of a major depressive disorder, which in turn could make it harder for them to get a job or health insurance. . . .

Grieving is an unavoidable part of life — the necessary price we all pay for having the ability to love other people. Our lives consist of a series of attachments and inevitable losses, and evolution has given us the emotional tools to handle both.

Moving from the end of life to the beginning, another commentary mentions worries that quiet and listless preschoolers may be pigeonholed as depressed:

Today a number of child psychiatrists and developmental psychologists say depression can surface in children as young as 2 or 3. . . . [But c]lassifying preschool depression as a medical disorder carries a risk of disease-mongering. “Given the influence of Big Pharma, we have to be sure that every time a child’s ice cream falls off the cone and he cries, we don’t label him depressed,” cautions Rahil Briggs, an infant-toddler psychologist at Children’s Hospital at Montefiore in New York.

Though research does not support the use of antidepressants in children this young, medication of preschoolers, often off label, is on the rise. One child psychologist told me about a conference he attended where he met frustrated drug-industry representatives. “They want to give these kids medicines, but we can’t figure out the diagnoses.” As Daniel Klein warns, “Right now the problem may be underdiagnosis, but these things can flip completely.”

Both stories foreshadow larger struggles over the meaning of “health” in risk societies where there is less margin for error or “underperformance” at work or school. Virtually any wealthy New Yorker with small children has a story about the crucial “pre-school interviewing process,” where elite schools can use an hour-long interaction with a child to decide whether or not to accept him or her as a student. On the other end of the income scale, high unemployment means that at-will employees who can’t keep up an adequate reserve of chipper and helpful “can-do” spirit are always at risk of being sacrificed in favor of some member of the reserve corps of unemployed. Business can’t survive if it’s culture is “too nice.” And hiring may end up being driven by whether an “analysis by an organizational psychologist can tell the hirer whether an applicant will have a problem with the manager or team.”

Larger social currents are feeding anxieties about these trends. Some corporate mottos appear to be “get healthy, or else:”

“We have this notion that you can gorge on hot dogs, be in a pie-eating contest, and drink every day, and society will take care of you,” says Harvard Business School Professor Michael E. Porter, who co-authored Redefining Health Care. “We can’t afford to let individuals drive up costs because they’re not willing to address their health problems.”

Hence the wellness fixation at companies as varied as IBM, Microsoft, Harrah’s Entertainment, and Scotts. Employees who voluntarily sign up for such programs often receive discounts on health-care premiums, free weight-loss and smoking-cessation programs, gratis gym memberships, counseling for emotional problems, and prizes like vacations or points that can be redeemed for gift cards.

M. Todd Henderson assures us that “corporate nannies are superior to their state analogs in some cases,” in part because “corporate policies are subjected to more instantaneous feedback from labor markets, which reduces overreaching.” As unemployment climbs and benefits end, that “feedback from labor markets” gets weaker and weaker: employees take whatever job they can find.

What’s the end result of these trends? I can’t predict, but I think Gary Shteyngart’s recent satirical novel provides one template for the workplace of the future. His protagonist, Lenny Abramov, finds that his employer has placed “five gigantic Solari schedule boards” in the office. The boards:

[D]isplayed the names of . . . employees, along with the results of our latest physicals . . . our fasting insulin and triglycerides, and, most important, our ‘mood + stress indicators,’ which were always supposed to read ‘positive/playful/ready to contribute,’ but which, with enough input from competitive co-workers, could be changed to ‘one moody betch today” or ‘not a team playa this month.’ On this particular day . . . one unfortunate Aiden M. was lowered from ‘overcoming the loss of loved one’ to ‘letting personal life interfere with job.’ (57-58)

Ultimately, moods become health problems when they seriously interfere with activities of daily living, including family, work, spirituality, and play. What Shteyngart reminds us is that the demands of work are quite flexible, and always-evolving. Without a robust societal sense of the proper claims of grief and other emotions, economic imperatives are likely to shrink them inexorably. Unlike the film Gattaca, where extant social structures somehow persist in the wake of massive changes in enhancement technology, Shteyngart’s novel describes a world where relatively small changes in self-concept, media use, and aspiration in an elite can fundamentally destabilize societal expectations.

Given the current balance of power between labor and employers, the disciplinary impact of new technology is likely to rise. As Hannah Pitkin puts it, if we are not careful, the very tools invented to reduce suffering may end up increasing it, by making authorities less tolerant of human need:

We have developed astonishing techniques of communication, persuasion, indoctrination, organization. . . . Yet these extraordinary capacities somehow have not made people happy or free or even powerful. . . . We do not direct these, our alleged powers; if anything, they direct us and determine the conditions of our lives, developing with a momentum of their own in ways we cannot foresee and that are often obviously harmful to human life and civilization

The contestation of pre-school and post-death depression concerns fundamental questions about what it means to be human. Circumstances need to be better engineered to accommodate the normal range of human experience. Otherwise a Procrustean drift will result in humans better engineered to to accommodate their circumstances. As Jaron Lanier has written, “When people are told that a computer is intelligent, they become prone to changing themselves in order to make the computer appear to work better, instead of demanding that the computer be changed to become more useful” (36). Perhaps employers without “grief leave” policies should be changed more quickly than employees in search of non-medical solace.

Good News for Health Care Reform Implementation

HCR implementation is steaming ahead. Jonathan Cohn lays out some of the key issues in a recent article in The American Prospect. A restrictive definition of “grandfathered plans” (which are not subject to the Affordable Care Act (ACA)) was an early victory for consumer advocates. Coverage appeal rules will soon be hotly contested during the rulemaking process:

Even if insurers are required to take all comers at relatively nondiscriminatory prices — “relatively” since age can be a rough proxy for medical condition — they’ll still have financial incentives to restrict care. This isn’t entirely a bad thing: Given the evidence of rampant overtreatment in American medicine, insurers should exercise some check on the use of technology, drugs, and other resources, for the sake of the patients as well as the insurers’ bottom line. But because insurers sometimes deny even necessary care, just to increase profit margins, the law seeks to limit the insurers’ authority — most obviously, by opening up treatment denials to outside appeal.

The idea sounds simple enough: Allow patients convinced they’ve been wrongly denied care to make their case to independent experts with authority to overrule the insurer. But who are the experts? How quickly must they rule? And what’s to stop insurers from ignoring the recommendations? The Obama administration has to write regulations answering all of those questions. A viable, working model exists: The National Association of State Insurance Commissioners has a framework, similar to what’s already in place in several states. HHS will consult those guidelines in devising a new scheme. The model is not perfect, but with sufficiently strong regulations it could give consumers significant new leverage.

Cohn also notes some important appointments at HHS. Having examined her work in the past, I was encouraged by the appointment of Karen Pollitz to “set up an Internet portal to provide basic information about different insurance policies.”

Nevertheless, Tim Jost warns that there are many possible obstacles ahead:
Read more

New Interim Federal External Review Process for Health Insurance Appeals Announced

As reported earlier in New Rules for Insurance Appeals, the departments of Health and Human Services, Treasury, and Labor issued interim final rules on July 23, allowing patient appeals of health insurance coverage.  On August 23, the U.S. Department of Labor, Employee Benefits Security Administration (EBSA) issued Technical Release 2010-01, regarding “Interim Procedures for Federal External Review Relating to Internal Claims and Appeals and External Review” under PPACA.

Looking back at the interim final rules, as they relate to the interim procedures (from New Rules for Insurance Appeals):

Under the rules, new health plans beginning on or after Sept. 23, 2010, must have an internal appeals process for beneficiaries to challenge “adverse benefits decisions” — a “denial, reduction, or termination of, or a failure to provide or make a payment (in whole or in part) for a benefit.”

If the internal appeal is denied, patients may choose to have the claim reviewed by an independent reviewer.  According to Appealing Health Plan Decisions, States are encouraged to adopt the National Association of Insurance Commissioners (NAIC) standards in “their external appeals laws to adopt these standards before July 1, 2011.”  If State laws don’t meet these standards, consumers in those States will be protected by comparable Federal external appeals standards.

The EBSA release “sets forth an interim enforcement safe harbor for non-grandfathered self-insured group health plans not subject to a State external review process, and therefore subject to the Federal external review process.”  The Federal process will apply to plan years beginning on or after Sept. 23, 2010 and will continue until the interim period is over.

The issuer of the “non-grandfathered self-insured group health plans” (hereinafter, “health plans”) is primarily responsible for compliance with the interim final regulations.  During the interim enforcement safe harbor, the Internal Revenue Service (IRS) will not take enforcement action against health plans that comply with either of the two interim methods provided by the EBSA.

1.      Compliance with State external review processes

Health plans may voluntary comply with the provisions of their State’s external review processes.  However, the State must first choose to expand access to their external review processes to health plans that are not subject to relevant State laws.

2.      Compliance with the procedures set forth in the technical release

A health plan may also adopt the external review procedure outlined in Technical Release 2010-01.  The release sets forth procedures based on the Unified Health Carrier External Review Model Act promulgated by the National Association of Insurance Commissioners (NAIC Model Act).  The EBSA procedure requires that an external review may be standard or expedited.

A. Standard Review

Health plans must allow a claimant’s request for external review if filed within four months of the adverse benefit determination.  A preliminary review must be completed by the health plan within five days of the claimant’s request and must determine whether:

a.       The claimant was covered under the plan at the time the service was requested or provided

b.      The adverse benefit determination was related to a failure to meet eligibility requirements

c.       The internal appeals process has been exhausted or is not required

d.      All information and forms required for the external review have been provided

Within one business day of completion, the health plan must provide written notice to the claimant of the health plan’s determination.  If the claimant is not eligible for external review, the health plan must provide the reason for ineligibility.  If the request is incomplete, the health plan must notify the claimant that further information or materials are required and provide the claimant with an opportunity to complete the request.  Health plans must allow the claimant until the end of the four-month filing period or forty-eight hours from the receipt of the notification, whichever is later, to perfect the request.

The health plan must contract with at least three independent review organizations (IRO) to conduct external reviews.  The IROs must be “accredited by URAC or by a similar nationally-recognized accrediting organization.”  An independent, unbiased method for claim assignments, such as rotation or random selection, must be used.  The IRO may not have a financial stake in the outcome of its decision.

The following must be provided in the contract between a health plan and an IRO:

a.       The IRO will utilize legal experts as appropriate.

b.      The IRO will provide the claimant with timely written notification including a statement of the request’s eligibility and acceptance for external review and a statement that claimant may submit additional information for consideration within ten business days of the receipt of notification.

c.       The IRO may choose to consider additional information received ten business days after the receipt of notification.

d.      The IRO must submit all additional information received by the claimant to the health plan within one business day.  The health plan may reconsider its adverse determination and terminate the external review if it decides to reverse its prior determination and provide coverage or payment.

e.       The health plan must provide all documents and information related to the adverse determination within five days; otherwise, the IRO may terminate the external review and reverse the adverse decision.

f.       The IRO will review the claim de novo based on all information and documents timely received.

g.      Within 45 days of the assignment, the IRO will provide written notice of its decision to the health plan and claimant. The decision notice will contain a description of the disputed claim, the date of assignment, and reference to the evidence relied upon and reasoning for its decision.  The notice must provide a statement that the decision is binding to the extent that other remedies may be available under the law and that judicial review is available to the claimant.

h.      The IRO will maintain all records related to a claim for six years and make them available for examination upon request by the claimant, health plan, or government oversight agency.

B. Expedited Review

A group health plan must allow a claimant to request an expedited review when a claimant receives:

(a) An adverse benefit determination if the adverse benefit determination involves a medical condition of the claimant for which the timeframe for completion of an expedited internal appeal under the interim final regulations would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function and the claimant has filed a request for an expedited internal appeal;

or

(b) A final internal adverse benefit determination, if the claimant has a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the claimant or would jeopardize the claimant’s ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay, or health care item or service for which the claimant received emergency services, but has not been discharged from a facility

The main difference between the expedited and standard review is the timeframe (unsurprisingly).  During an expedited review, the health plan must perform the preliminary review immediately and send notice of its determination immediately.  Upon assignment to the IRO, the health plan must transmit all documents and information related to the claim by any expeditious method.  The IRO must provide notice of the final external review decision as quickly as possible, but no later than 72 hours after assignment of the claim.

How Much Does PPACA Really Benefit Women?

A recent article by the Commonwealth Fund entitled Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010¸forecast that “over the next decade, the Affordable Care Act (ACA) is likely to stabilize and reverse women’s growing exposure to health care costs.”  However, a review of the claimed benefits shows that many are equally important to men and women.

Such claims of gender-specific benefits without statistical support are also available from the White house.  That being said, there are some provisions that will greatly benefit women — and to supporters’ detriment — have not received the focus that they should.

Intended Benefits

Several portions of PPACA are intended to benefit women.  The prohibitions against gender-based insurance denials or premium pricing are aimed at combating blatant gender-discrimination in the insurance market.  7.3 million women (38%) in the individual insurance market reported that they were turned down, charged a higher price, or had a preexisting condition excluded from coverage (see graphic below).  As the White House reports, “Right now, a healthy 22-year-old woman can be charged premiums 150 percent higher than a 22-year-old man.”  Such gender-based rating is allowed in 42 states, with some plans charging women as much as 84% more than men for the same age group.  As Secretary Sebelius phrased it, “[b]eing a woman is no longer a pre-existing condition!”

S. Collins, S. Rustgi, and M. Doty, Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010, The Commonwealth Fund, July 2010.

The essential benefits standards require insurers to cover maternity care, eliminating previously reported pregnancy-discrimination.  Only 13 percent of plans sold in the individual market provide maternity benefits and “in 22 states, no plan covered costs related to pregnancy.”  Other plans impede access to maternity benefits by placing severe limits on costs covered or implementing long waiting periods before coverage begins.

Other services that must be covered by all non-grandfathered health plans beginning September 2010 include:

• Breast cancer screening every one to two years for women age 40 and older
• Cervical cancer screening
• Genetic counseling for the breast cancer (BRCA) gene
• Osteoporosis screening for all women 65 and older, and 60 and older for those at high risk
• Aspirin to prevent cardiovascular disease in women ages 55 to 79

PPACA has several other provisions focused on breast cancer–including, “a special provision directed at raising awareness of, and increasing screening for, breast cancer in young women,” and a directive to pursue breast cancer prevention research in younger women.

Section 4207 of PPACA amends Section 7 of the Fair Labor Standards Act (”FLSA”) by requiring employers to provide “reasonable break time for an employee to express breast milk for her nursing child for 1 year after the child’s birth each time such employee has need to express the milk… [in] a place, other than a bathroom, that is shielded from view and free from intrusion from coworkers and the public…”  The Department of Labor Fact Sheet #73 further explains that a space temporarily converted or made available will be sufficient.

Unintended Benefits

The ban on pre-existing conditions exclusions will remedy a number of  unfair and discriminatory insurance industry practices. It will benefit women in the eight states and District of Columbia where insurers may legally reject a woman’s application on the basis of her prior experience as a victim of domestic violence.  It will also benefit women who would have been previously denied, on the basis of a previous cesarean section, either future C-sections or health insurance as a whole.

Also, the phase-out of the “doughnut hole” coverage gap in the Medicare prescription drug benefit )Part D) will incidentally help more women than men.  Of the 16% of Medicare beneficiaries that reach the doughnut hole each year, women (along with Alzheimer’s and diabetes patients) are the most likely to reach the gap in coverage.

Benefits for Men

So how do men benefit from PPACA?  For starters more men will benefit from the extended health insurance coverage mandated by PPACA.  Although women comprise 60% of adult Medicaid beneficiaries (in 2006), 54.6% of all uninsured are men (in 2007-2008).  The Medicaid safety net has caught more women than men.  However, that is a completely different social discussion to be had another day.

*Note: uncited statistics can be found in the Commonwealth Fund article, S. Collins, S. Rustgi, and M. Doty, Realizing Health Reform’s Potential: Women and the Affordable Care Act of 2010, The Commonwealth Fund, July 2010.

Not So Fast With That Lipitor Johnny!

Having previously described my diet, proclivities, and the thoroughly reasonable fear I had regarding the battery of tests I would have to undergo this week at the Cardiologist’s, I am pleased to say that I did so well that my doctor no longer thinks I will need to take Lipitor. My valves seem to all flap when they’re supposed to (echocardiogram), and the nuclear stress test showed no obstructions whatsoever. But the clincher was that the calcium scan showed zero calcium. Yes, zero.

Given the high correlation between the presence of arterial calcium and propensity for heart disease in a country where heart disease is the number one killer (about every 25 seconds an American will have a coronary event) and a major medical expense, I wrote previously how it seemed penny wise and pound foolish for health insurers to not pay for calcium deposit screening. This test can offer actionable insight years  prior to the onset of ultimately costly symptoms. There is, reasonably speaking, savings of more than one kind to be had in this kind of knowledge: if  one knows, one can act in accord. I paid the $318 out of pocket. Now, it seems, despite the ostensible risk factors which may have counseled otherwise, I have spared my insurer the cost of a lifetime’s worth of Lipitor. And myself the burden of a lifetime’s worth of pharmaceutical dependence.

There’s a J.D. at the end of my name, not an MD, so I do not give medical advice. But I will say that the whole battery of tests was painless, congenial, and took about 4 1/2 hours spread over two visits– which is not a lot of time to invest in dispensing with the ominous unknown. Of those one every 25 seconds in America who have a coronary event, one every minute will die. Testing will help tell you where you stand, and you never know, you just might get some peace of mind.

A Trip to the Cardiologist, A Lipitor Future, and “Why Doesn’t My Health Insurer Want Me to Know if I’m Likely To Have a Heart Attack?”

I visited with a cardiologist last week. My inadvertent but no less harmful dalliance with two different kinds of drain cleaner having set off an entire chain of long past due check-ups. A little more than two years shy of fifty, I listened intently as I was told that although I had had a good run, a diet composed of grease, chocolate, quick carbs, coffee and unfiltereds was simply not going to cut it as I ventured into the last half of life (last third is more likely, but also more painful to consider– and I suppose for the doctor, harder to say).

I now look forward to a battery of tests. The first, done today, is designed to detect artery calcification: “Coronary calcium is specific for atherosclerotic plaque and can be detected with high sensitivity and accurately quantified by computed tomography (CT) to help predict future cardiac events related to coronary artery disease.” I had to pay for the test out of pocket as it seems my insurance company deems such screening unworthy of coverage– despite the tests highly vaunted predictive power. Quite a few people in this country die each year from heart disease–hard to understand how it wouldn’t be worth the $318 to know who was vulnerable–and if unchecked, destined for the very expensive Intensive Care Unit.

Tomorrow brings an echocardiogram and my first ever stress test. I readily assented to the tests as it is good, I suppose, to know where one stands. But in addition to testing and making dietary changes, the doctor also wants me to start taking Lipitor. A statin prescribed to lower cholesterol. I did not react well.  The prescription it seems is, in more than one sense, a life sentence.

And I am generally suspicious of the pharma zeitgeist. And terribly so as it concerns myself.

The prescription is not, in this instance, a treatment for an acute condition, it treats the endemic. If one has risk factors, it is prophylactic and is prescribed to reduce the risk of heart attack, stroke and other heart diseases. It is doubtful whether once I start taking this drug I will ever stop. There is no foreseeable time (while alive) that I will wish to stop reducing the risk of heart attack or stroke. And that I suppose is the essence of the onset of age– piling up prescriptions. A daily regimen that will follow one to the grave–only the dosages or the brand names changing as each day welcomes a regimen of pills. In short, this prescription feels like the onset of dependence. The forward guard, if you will. A harbinger of a pharmaceutical future.

Seeing my, shall we say, chagrin, the cardiologist told me that, like over 50% of the cardiologists he knows, he takes a statin. “We’ve seen the data.” Another recently told me  “Yeah, I take it. They should put it in the water.”

And so I will take this drug. But I am not happy. I am loath to think of myself in these terms. Only 12 or so years ago I played starting defensive tackle on a semi-pro football team. Soon I will be discussing my cholesterol numbers and God only knows what other numerical health indicators at cocktail parties.

The essence of good health is simply not having to think about it. It is not an issue. I have to think about it now. And I have a sneaking suspicion, that like when I first became a parent, the terms of my existence have just changed.

UPDATE

Photo credit to incurable_hippie.

Alliance for Health Issues Major Resource, “Covering Health Issues”

Amazing resource for health care and health care reform info over at Alliance for Health, “Covering Health Issues, 5th Edition, 2010 Update.” Made possible by the Robert Wood Johnson Foundation, it has 12 chapters and covers such issues as Health Reform, Cost of Health Care, Quality of Care, Mental Health & Substance Abuse, Long-Term Care, and Disparities. The collection is a veritable treasure trove of information presented in a readily accessible manner. Though the phrase is lacking because access is free, the Fast Facts alone are worth the price of admission. A few to think about (footnotes omitted):

• Two-thirds of people age 65 today will need some long-term care in their lifetimes.

• An estimated 22.3 million people were classified as substance dependent or substance abusers in 2007. Substances abused range from alcohol, pain relievers and tranquilizers to hallucinogens, cocaine and heroin.

• Each year, about one in four adults (26.2 percent) suffers from a diagnosable mental illness, according to National Institute of Mental Health.

• In a ranking of 19 industrialized countries, the U.S. had the highest number of unnecessary deaths.

• Among 37 nations, the U.S ranks 29th in terms of infant mortality with nearly twice as many infant deaths per capita than France.

• The United States spent $2.3 trillion on health care in 2008, or $7,681 per person. This amounted to 16.2 percent of the nation’s gross domestic product (GDP).

• Health care costs more than tripled from 1990 to 2008,² and are projected to rise to 19.3 percent of GDP in 2019.

• Nearly 82 percent of the uninsured in 2009 lived in families headed by workers.

• In 2008, 17.2 percent of full-time employees and 25.5 percent of part-time employees age 19-64 were uninsured all year.

Why Angela Braly, CEO of WellPoint Insurance, May Not Deserve a Raise After All

Earlier this year we discussed why Angela Braly, the CEO of WellPoint Insurance, deserved a raise. WellPoint, by number insured, is the nation’s largest health insurer.  Ms. Braly had been forced to make ends meet in 2008 with total compensation which amounted to $189,311.76 per week. This of course is less than half of what Aetna’s CEO, Ronald A. Williams, made that same year ($467,309.85 per week). For those of you keeping score at home, Ms. Braly commanded $9,844,212 in 2008. Mr. Williams made $24,300,112.

Considering this disparity, we wrote

So why does Angela Braly deserve a raise? …. Because WellPoint subsidiary Anthem Blue Cross of California has found the audacity to raise individual insurance premiums in that state 39%. That’s right, 39%. This, according to Secretary of Health and Human Services Kathleen Sebelius, “as WellPoint Incorporated has seen its profits soar, earning $2.7 billion in the last quarter of 2009 alone.”

Profits “soar,” raise rates. What more could Wall Street want?

The answer to that question, apparently, is both math skills and a public relations strategy.

In April, Wellpoint was forced to withdraw its California rate hike of 39%  because of math errors in the submission. Yes, math errors.

According to the Wall Street Journal, “WellPoint’s stock fell almost 10% on April 30, the day after the company disclosed mathematical errors in its California rate filing, and it hasn’t rebounded.”

As such, Ms. Braly is said to have faced staunch criticism as of late at WellPoint’s annual shareholder’s meeting and at meetings with the company’s managers and top brokers prior. The shareholder’s meeting, described as “testy” by the Associated Press, was cut short when William H.T. Bush, the brother of former President George H. W. Bush, and a member of WellPoint’s board of directors, collapsed. Although no one is said to have collapsed at her other meetings, no one has described them as cordial either.

Wellpoint faced criticism from the Obama administration in light of its noteworthy proposed rate hikes in California, including, but not limited to, the scathing letter quoted above from Secretary of Health and Human Services Kathleen Sebelius. The level of acrimony recently escalated when, according to the Wall St. Journal

A week ago, President Obama said his administration had recently asked an insurer to stop systematically dropping coverage of women with breast cancer. The president didn’t name the insurer, but WellPoint has been fending off accusations that it targets such women.

Ms. Braly denied the allegations and shot back at Mr. Obama for spreading “false information.” Health and Human Services Secretary Kathleen Sebelius has called on states to investigate WellPoint’s pricing practices. And last Thursday, the Senate Finance Committee asked Ms. Braly for a detailed account of how the errors occurred.

Perhaps the lady doth protest too much?

Either way, Ms. Braly is said to have later offered that: “The goal is to have a positive relationship with the government at all times.”

It is good to have goals.

The Wall Street Journal notes that

Jay Nogueira, vice president at one of the company’s top 10 shareholders, T. Rowe Price, said the stock won’t bounce back until investors were convinced that there isn’t another chapter in the hostility with the government. “These guys are not dealing well with the public limelight,” said Mr. Noguiera.

High Risk Pools: Then and Now

By Christine Davis

For medically uninsurable people, or people with pre-existing conditions who cannot find coverage, coverage may soon materialize.   Even before President Obama signed the PPACA, CMS had provided “Qualified High Risk Pool” grants to qualifying states, in order to cover these higher risk people since 2007.  (45 CFR Part 148)  Thirty-five states participated.  Before health care reform passed in 2010, states could qualify for operational or seed grants, which they could use to cover eligible individuals.  (Federal Register, v 73, no 81).  PPACA authorizes the development of  a temporary national high risk pool, which will operate similar to what is happening now with the state grants and will function as a temporary fix until the insurances exchanges kick in after 2014 and insurance companies are mandated to cover all individuals with pre-existing conditions. This is a unique part of the new bill because it seems to be something both Republicans and Democrats can agree on.    Previously, the majority of these state high risk pools had lifetime maximum payouts, usually around $1 million, (three states had lifetime maximums of $500,000). Once these individuals reached that amount, they had no other way to be insured. (http://www.federalgrantswire.com/seed-grants-to-states-for-qualified-highrisk-pools.html).

The goal of the national risk pool is to transition the uninsurable until health care exchanges are established in 2014.  Once that happens, there will no longer be lifetime or annual limitations on coverage.  The idea here is that an individual will never reach a point where there is absolutely nowhere else to go for coverage.

By 2014, eligible individuals will be people “who have not had creditable coverage for the previous six months and now have a pre-existing condition.”   As of now, most state pools require those seeking coverage to (a) submit proof that they have been denied coverage due to a pre-existing condition, or (b) show that they have applied recently for coverage and were a victim of “adverse underwriting actions,” such as limiting benefits or charging extraordinary premiums (for example, diabetics). (Coverage: Creating a Temporary National High Risk Pool: the New Health Dialogue Jan 12, 2010). One concern of these eligibility requirements is that they might discriminate against those who only recently lost coverage, because they are making every individual prove they have not had coverage in the past.

An advantage to a national high risk pool as opposed to a state high risk pool is that it will be more balanced and less costly, because the premiums charged won’t be as high.  Although, if annual or lifetime limits aren’t capped once these exchanges kick in, these costs could skyrocket. However, a downside is that in some states, these high risk pools have limited eligibility and low enrollment, and for example, monthly premiums costing an individual well over $1,000/month.  However, the news is not all bleak. States like Minnesota have been doing it right all along, even with broad eligibility, by finding additional streams of revenue, such as tobacco settlement funds, with which to support the pool.  In order to  be successful, the national pool, should model itself after successful states like Minnesota.

First Step in the Expansion of Medicare? Feds Assist Employer Health Plans for Retirees Age 55 +

During the Health Care reform debate, one of the many plans promulgated was to expand Medicare availability to persons aged 55 and up who are not otherwise insured. The argument on behalf of the initiative was simply that Medicare works, people like it, and it would not require the reinvention of the wheel. The system is already in place, we would just need to expand what is already there. In addition, even people who rail against “socialized medicine” seem to have an ideological (if not personal) soft spot for Medicare.

The initiative did not gain sufficient traction. There is, however, more than one way to skin a cat. The White House announced the other day that it would commence in helping to pay the medical bills for early retirees (55 and up) who have medical insurance through their former employers and are not yet eligible for Medicare.

The New York Times reports:

Under the program, the federal government can reimburse employers for 80 percent of the cost of claims from $15,000 to $90,000 a year for a retired worker who is 55 or older and not eligible for Medicare.

The primary goal it seems is to incentivize private employers to continue insuring retirees.  The Times quotes Valerie Jarrett, a senior advisor to President Obama:

“In 1988,” Ms. Jarrett said, “66 percent of large firms provided health care coverage to their retirees. Twenty years later, in 2008, the percent of firms offering coverage to retirees plummeted to 31 percent.”

Obviously, if one can indirectly continue private coverage for those over 55, one need not expand Medicare coverage to do so. But of course there remains those over 55 who are not fortunate enough, at present, to be covered by an employer retiree plan.

80 per cent of up to $90,000 is a large subsidy–by anyone’s standards. But the money will go to business which, for some reason, attenuates the subsidy sufficiently for the largesse to not be “socialism.” And businesses which benefit from such subsidies are not likely to complain–having now cultivated a personal, and thus ideological, soft spot for the program. Like Medicare.

State Long-Term Care Partnership Programs

By Brian Seguin

Long-term care refers to end of life care where a person can no longer take care of themselves. These people require either the assistance of a trained professional, such as a home health aide, to help them care for themselves in their home, or they need to be housed in a nursing home and cared for there. Since Medicare does not cover long-term care, people who require it need to either pay for it themselves, or if they have almost no savings and get a low enough monthly income that they qualify, they can apply for Medicaid which does cover it. If someone pays for it themselves and winds up spending all of their savings and still needs care, they can then apply for Medicaid to cover it if their monthly income is under the threshold set by their state in order to qualify for the program.

In the early 1980’s, states began to worry that as the baby boomer generation got closer to retirement age and might start requiring long-term care, it could cause increases in their Medicaid expenditures and thus budget deficits. One possible solution forwarded for this impending problem, and eventually implemented by four states in 1993, was the idea of state long-term care partnership programs. Under these programs states would incentivize their citizens to purchase private health insurance to cover at least part of the long-term care they may eventually require and thus spare Medicaid from covering some of the costs. Insurance companies who participated in the programs had to meet certain regulations of what type of care was provided and had to report certain data back to the states so they could effectively monitor the impact the programs were having.

Proponents hoped these plans would cause people to buy their own long-term care insurance coverage and hopefully never need to turn to Medicaid to pay for it. They also hoped this would stop the perceived threat of people transferring their assets (savings) to family members early in order to appear qualified for Medicaid. Of the four original states, California and Connecticut incentivized their citizens by allowing them to disregard assets they had above the threshold allowed to qualify for Medicaid in the amount that the partnership plan had paid towards their long-term care. In other words if a person purchased a partnership plan and it paid out $200,000 towards their long-term care, that person would still qualify for Medicaid even if they had up to $200,000 in assets over the amount usually allowed to qualify. This was called the “dollar for dollar approach.” New York required citizens to purchase more comprehensive plans that had higher lifetime benefits, and if they did they could disregard all of their assets in determining if they qualified for Medicaid, known as the “total assets approach.” Indiana allowed a “dollar for dollar” disregard if the person purchased a plan covering less than four years of care and a “total asset” disregard if they purchased a plan covering more than four years.

Opponents of this idea worried that these public partnerships would inappropriately promote private plans with limited values, and that they could lead to increases in Medicaid expenditures by allowing wealthier people who would purchase private long-term care plans anyway keep their assets and now have access to Medicaid that they wouldn’t have otherwise had. As a result of these fears part of the Omnibus Budget Reconciliation Act of 1993 (OBRA) required any state that started a partnership program after 1993 to recover any disregarded assets of a deceased Medicaid recipient from their estate. Although this Federal law did not apply to the four states already operating partnership programs and did not ban other states from starting their own programs, it effectively eliminated any other states from trying to start their own programs by removing the incentives for citizens to join. This is because although a person could keep some of their assets while still alive, and still qualify for Medicaid, the state would now have to take those assets from their estate. So there was no longer any incentive for a person to purchase a partnership plan which they may never need, and thus shift some of the potential costs of long-term care on private insurers rather than Medicaid.

The Federal government finally decided to give long-term care partnership programs another chance in 2005 with the passage of the Deficit Reduction Act (DRA). Parts of that bill removed the estate recovery requirement of OBRA and allowed states (other than the original four who have continued their programs and are again not subject to this bill) to start their own partnership programs provided they use the “dollar for dollar” approach. Insurance companies participating in these new programs will have to be certified by the state, using new federal guidelines, and will have specific data reporting requirements. The “dollar for dollar” approach is mandated to avoid the grant of Medicaid benefits to those who do not need or deserve them. This approach only allows beneficiaries to keep the amount of assets they would have presumably spent for long-term care themselves and then qualified for Medicaid anyway, had their partnership plans not paid that amount. The federal government has finalized its rule of what data needs to be submitted by partnership insurers after consulting with the National Association of Insurance Companies, insurance companies who issue long-term care plans, the four original states with programs, and consumers who purchase long-term care plans. The data collected is meant to cost insurers as little as possible while still allowing the federal government to accurately track the effectiveness of these programs. While no states or private insurers are required to participate in these partnership programs, as of August 2008, 13 states (in addition to the original four) are now offering partnership plans and 12 more are in the process of implementing them.

Reform Rodeo: A Sick Wellpoint; Performance; EHRs; and More

1. Really?: Reuters released an exclusive story about Wellpoint’s recent push to rescind contracts for those suffering from breast cancer.

2. Specialists: The New England Journal of Medicine has a piece on the role of specialists in performance-incentive programs.

3. EeeeekHR: In the New York Times, Pauline Chen describes her experiences as a physician attempting to come to grips with the unforeseen changes that EHR-based health care delivery has introduced into the doctor-patient relationship.

4. Myths of Health Reform: On The Health Care Blog, Maggie Mahar discusses the myths of health reform, including the belief that the reform measure was a hand out to industry.

4. When Skepticism Becomes Quackery: Steven Novella at Science-Based Medicine calls attention to the often hyperbolic demonization of the pharmaceutical industry.

5. That’s Just Your Opinion: Kaiser Health News gathers the latest opinions and editorials about health care, including pieces about children’s health care, RomneyCare, and the nursing shortage.

6. Resources: For those studying PPACA, George Washington University has released, among other things, a thorough provision-by-provision comparison of PPACA and subsequent reconciliation.

Consumer Watchdog Spots Health Reform Loopholes

Consumer Watchdog has authored an important letter to HHS Secretary Kathleen Sebelius on loopoholes in PPACA. The letter highlights the importance of rapid and forceful rulemaking at HHS to ensure that the framework set up by legislation actually promotes affordable access to care. Here are some highlights.

1) Vague “review” of insurance rate increases: The statute provides grants to assure that states “review” insurer rate increases, but does not provide adequate guidance on acceptable performance here. Without something like “all-payer rate setting” operating as background cost-control, the legislation’s prescribed “medical loss ratios” could even encourage insurers to increase rates:

the federal law’s requirement that insurers spend 80% or 85% of the premiums they collect on health care services will—absent strict rate regulation—perversely encourage insurers to raise their premium rates. In the same way that a Hollywood agent who gets a 20% cut of an actor’s salary has an incentive to seek the highest salary, insurers will have incentive to increase health care costs and raise premiums so that their 20% cut is a larger dollar amount.

2) Lack of real rescission reform: One of reform’s key selling points is preventing rescissions–an insurance company’s cancellations of policies for members just at the point they need them most. Consumer Watchdog worries the protections will turn out to be illusory:

A key rallying cry for federal reform was the insurer practice known as rescission—retroactive cancellation of coverage after a patient makes a claim for health care services. Insurers often argue that a rescission is warranted because the patient intentionally failed to report minor health problems when applying for coverage. Such rescissions are carried out unilaterally by the insurer and regardless of whether the patient even knew about, or understood the significance of, the health problem the insurer claims was intentionally omitted from the application. Since an applicant’s health condition is no longer relevant to determining insurability, coverage rescissions should be barred outright.

However, section 2712 of the Senate legislation allows for rescission of health policies on
the basis of fraud or the “intentional misrepresentation of material fact as prohibited by
the terms of the plan or coverage.” The insurers are left to define the terms of future coverage rescissions in the fine print of their policies. No new regulatory oversight of rescission is provided to ensure that omissions or errors are indeed fraudulent or intentional, rather than innocent mistakes.

3) Manipulating the Medical Loss Ratio: Here CW calls out Wellpoint, whose CEO enjoyed a massive pay increase last year while socking it to California insureds.

The new federal health reform law requires that insurers spend at least 80% of customers’ premiums on medical care in the individual insurance market, and 85% in the employer/group market. HHS must narrowly define what constitutes medical care to block gaming of the new medical loss ratio requirement by health insurers. [because insurers like Wellpoint have said they would] simply re-label administrative costs as “medical care” in response to the new health reform law.

4) Weak federal fallback. This is one of the most disturbing aspects of the Consumer Watchdog letter, and definitely bears watching as state governments hostile to reform begin implementing it:

The threat of strong federal fallback is the kind of carrot and stick approach that would encourage state regulators to act where they otherwise may not. However, federal enforcement fallback provisions are virtually absent from the bill. For example, under section1321(c) federal regulators shall step in to operate a state Exchange if (and only if) a state fails to implement one at all. . . . Medicaid, HIPPA, COBRA, and the CHIP program for children’s health insurance all provide minimum
federal standards and funding levels but allow states to fit the federal program to local needs,
provide enforcement, and adopt more robust regulations not envisioned by federal law.

Since the courts have not been very supportive of judicial interventions to enforce Medicaid beneficiaries’ legal rights (given Gonzaga v. Doe), it’s essential for the feds to develop a record of enforcement when wayward states fail to protect their citizens.

Image Credit: Linda Hirschman.

Reform Rodeo: Medicaid; Self-insurance; EBM; Gene Patent Smackdown; eRx; Cool stuff

1. PPACA & Medicaid: Kaiser Health News’ Maggie Mertens discusses PPACA’s affect on Medicaid, specifically the legislation’s increase in Medicaid reimbursement.

2. PPACA & Self-Insurance: Professor Tim Jost breaks down how PPACA will influence self-insured plans.

3.  Doc vs Doc: Maggie Mahar profiles two feuding medical organizations: The Association of American Physicians and Surgeons, and the newer National Physicians Alliance.

4. Preventive Problems: The New York Times’ Duff Wilson reports on the brewing controversy of the FDA’s decision to permit broader marketing of AstraZeneca’s blockbuster statin Crestor.

5. On Evidence-based Surgery: David Gorski at Science-based Medicine has a tome-of-a-piece on surgery and evidence-based medicine.

6. Patent Pending: David Post at the Volokh Conspiracy discusses the recent ruling that invalidated (for now) the patenting of a gene thought to be associated with breast and ovarian cancer.

7. E-Prescribing: John Halamka discusses the trials and tribulations of e-prescribing controlled substances.

8. Just plain interesting:

a. Parkinson’s patients who can’t walk but can ride bikes. Wow.

b. Transcranial Magnetic Stimulation appears (at least in the lab) to influence moral decision making.

c. TED Talk: The Future of Medicine — Taking health care off the mainframe.

Obama in Ohio, a Letter from Natoma Canfield

As the Health Care Reform debate winds to a frenzied conclusion, President Obama visited Ohio to reach out in favor of the bill’s passage. I’ll let the President speak for himself, but there’s a letter below this video that you should read. Natoma Canfield sent the letter to President Obama back in December; it epitomizes, I believe, the every day tragedy which is the current state of health care and health care finance. Since then, it’s gotten even worse. Facing the prospect of unaffordable increases in her insurance premiums, Ms. Canfield took, and lost, the gamble that no one wants to take. Unable to pay, she discontinued insurance coverage; she was just recently diagnosed with leukemia.

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