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MGH Community News |
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MGH Community News |
| January 2014 | Volume 18 • Issue 1 |
Highlights
Sections
Social Service staff may direct resource questions to the Community Resource Center, Lindsey Streahle, x6-8182. Questions, comments about the newsletter? Contact Ellen Forman, x6-5807. |
Thousands Exhausting Heating Aid as Temperatures Plunge With temperatures falling into the single digits, some 50,000 low-income heating oil customers in Massachusetts have exhausted fuel assistance for the winter, leaving many in danger of losing heat even as millions in additional funding for the benefits remain tied up in Washington. The release of an estimated $13.5 million in federal fuel assistance due the state is still awaiting approval from the Obama administration. Meanwhile, advocates for the poor are pressing the state to provide additional money to help meet the growing need. Fuel assistance tended to last longer into the winter in the past, but the combination of reduced funding and high energy prices has resulted in the money being depleted sooner. The amount of money appropriated by Congress for fuel assistance has declined to $3.4 billion this winter from $5.1 billion in 2010. While the assistance applies to all types of fuel, oil customers are most at risk because when their oil tanks run dry there is no heat, unlike gas customers, whose utility service cannot be shut off during the winter under state law. In Massachusetts, oil heat customers go through about four tanks of oil a winter. At one time, fuel assistance could cover about two of those tanks, said John Drew, president of Action for Boston Community Development, an antipoverty group serving Boston, Brookline, and Newton. But with heating oil prices above $4 a gallon this year, fuel assistance generally covers less than a tank, Drew said. As a result, Drew and other advocates are pressing Governor Deval Patrick and his administration to make $20 million in state funds available for heating assistance. -See the full Boston Globe article... |
SSA Removes Hold On Some Same Sex Couple SSI Applications In December, The National Senior Citizens Law Center (NSCLC) learned that all Supplemental Security Income (SSI) applications from people in a same sex marriage had been placed on an indefinite hold following last summer's Supreme Court decision in United States v. Windsor. Individual cases in California, Maine and New York were brought to our attention by Gay & Lesbian Advocates & Defenders (GLAD), the American Civil Liberties Union (ACLU) and the Empire Justice Center. All of the individuals had applied for benefits prior to Windsor. In each case, they had been determined to meet the disability standard and would satisfy the SSI financial eligibility standard, whether they were regarded as married or not. As a result of the delays, one individual was facing eviction, another had already been evicted. Another person had a terminal diagnosis with only six months left to live. NSCLC, along with GLAD and the ACLU then raised the "hold" issue with the Social Security Administration (SSA) and the U.S. Department of Justice, stressing the urgency of the situation in which SSI applicants often find themselves. We emphasized that people eligible for SSI are a group who, by definition, have no resources to fall back on. Individual cases were also brought to SSA's attention. As a result, SSA issued instructions earlier this month that provide for processing SSI applications from individuals in a same sex marriage who reside in a marriage recognition state and were married on or after the date that the state first happened to recognize an out of state marriages. They have also now paid each of the four hardship cases that were specifically brought to their attention. NSCLC appreciates that SSA has responded favorably on these cases. However, further steps need to be taken without delay. SSI claims are still not being processed for the following groups:
While the number of SSI applications still being held under these instructions is believed to be small, the impact of holding applications is significant for these individuals and could lead to homelessness, hunger and more. In some states Medicaid eligibility may depend on it. NSCLC believes that there is no justification for not processing all of these applications now. This is a group of people whose eligibility is not the result of Windsor. They would have been eligible before Windsor and for the most part will continue to be eligible after Windsor. SSA began processing some applications for spousal benefits based on a same sex marriage in late August and started to process applications for survivor benefits and lump sum death benefits based on a same sex marriage in December. However, the same categories of SSI applications that are on hold remain on hold for OASDI applications as well. If you have a client who is waiting to have an SSI application processed because the applicant is in a same-sex legal relationship, please contact Gerald McIntyre at gmcintyre@nsclc.org. -Excerpted from: SSA Removes Hold on Some SSI Same Sex Applications, The National Senior Citizens Law Center, January 29, 2014.
Scammers Take Aim at Aging Population In about one third of reports to Massachusetts Protective Services last year, the concern involved financial exploitation, according to state officials, a problem that is expected to grow significantly as the population ages and the number of older adults left vulnerable by Alzheimer’s disease nationwide is projected to double, and perhaps triple, by 2050. With a potential tsunami of elder financial abuse on the horizon, researchers, health care leaders, lawyers, and lawmakers have launched a number of initiatives to better understand the size and scope of the issue and craft strategies to minimize harm. “My expectation is that exploitation will be a growth industry,” said State Representative Paul Brodeur, a Melrose Democrat and former general counsel to the Massachusetts Executive Office of Elder Affairs. Brodeur successfully lobbied for the creation of a special state commission to investigate and make recommendations to Governor Deval Patrick’s administration for beefing up elder protective services. Brodeur said the panel’s report, expected in January, will likely include a proposal to establish volunteer teams of financial experts, such as financial planners and bankers, who can be tapped to help overwhelmed protective services staffers untangle increasingly sophisticated financial scams against the elderly. Amid this rising tide, a group of brain specialists and legal experts have collaborated at Massachusetts General Hospital to form the Center for Law, Brain, and Behavior. Among the goals of collaborators is to research and better understand the changes that are believed to occur in the brains of those with early, often subtle signs of dementia, which can expose elders to undue influence in financial decision making. For instance, patients in the early stages of Alzheimer’s disease often are depressed, apathetic, and anxious, symptoms that could make them vulnerable to exploitation. The center’s team also aims to devise standardized methods to help lawyers and judges assess the capacity of impaired elders to make financial decisions, such as in executing wills and signing over the deed to a home. While there have been many advances in brain science in recent years, including high-tech brain scans, and a number of verbal and written tests designed to assess competence, there has been little consensus between researchers and legal experts about how these tools should be reliably used in courtrooms to measure an elder’s ability to understand complex legal matters. -See the full Boston Globe article...
HomeStart Court Intervention Project – Preventing Eviction and Homelessness The state reduces homelessness and saves millions by finding ways to prevent evictions from public and subsidized housing, according to a report by a nonprofit housing group. HomeStart Inc., in coordination with the Boston Housing Authority, used its report to track its efforts to intervene in evictions from public housing and to provide financial counseling to poor families. The report said HomeStart, through its Court Intervention Project (CIP), has prevented more than 500 evictions from the authority’s properties since 2010, not only saving families from homelessness but saving taxpayers thousands of dollars. In the first year alone, the program saved the Boston Housing Authority $365,000 in eviction-related costs, according to the report. Each eviction can cost the Boston Housing Authority as much as $10,000, including the expense of hiring a constable and preparing the apartment to be rented again. HomeStart paid an average of $800 per household to cover back rent and keep families in their apartments. The agency helped 99 households in 2010, 141 in 2011, 144 in 2012, and 166 in 2013, preventing nearly 200 children from becoming homeless each year. Linda Wood-Boyle, executive director of HomeStart said none of these families has faced eviction since HomeStart intervened. As part of the program, HomeStart provides post-crisis stabilization services for at least one year to those households whose tenancy was preserved. Once the tenancy is preserved, the client and their HomeStart advocate focus on stabilization goals related to maximizing their income, stabilizing their finances and creating job opportunities. These services are made available to clients for one full year after they preserved their tenancy.
-See the full Boston Globe article...
The Sisters Wish: Wish-Granting Agency Serving Young Adults The Sisters Wish is a non-profit organization that provides wishes to terminally or chronically ill young adults (ages 18-30) living in Massachusetts, New Hampshire, and Maine. So far, the Sisters Wish has granted 25 wishes intended to improve the recipient’s quality of life. Past wishes include laptops, trips, a new bathroom, makeovers, and more. Wishes are considered on a case-by-case basis. To apply, complete the application online. The Sisters Wish also requires a letter from the treating physician/social worker that states the diagnosis and prognosis before a wish can be granted. All medical information is considered confidential and is not discussed with outside parties unless it is required for the wish and the young adult has given his/her consent. For more information and an application: Drug Disposal Kiosks Installed at Boston Police Stations Unused or expired medication can be disposed of at newly-installed kiosks in each of the 11 district police stations in Boston, city health officials said in a recent announcement. The MedReturn Drug Collection kiosks are free, safe, confidential and available 24 hours a day, seven days a week, officials said. No questions will be asked of people who use the kiosks. The kiosks were installed through a partnership between the Boston Police Department, the Boston Public Health Commission, the Massachusetts Department of Environmental Protection, and the Massachusetts Department of Public Health’s Bureau of Substance Abuse Services, which bought for the kiosks. “Unused or expired medication can pose a risk to children, family members, and the environment,” the city’s public health commission said in a statement. “It can also be misused or abused, leading to serious complications, overdose, even death.” To learn more about how to properly use the kiosks and for an interactive map of kiosk locations, visit www.bphc.org/DrugTakeBack.
-See the full Boston.com article...
Health Connector Fraught with Uncertainty The Massachusetts Health exchange is known as “The Connector”. The Connector’s new website has performed so poorly that Connector officials last month said they would forgo trying to fix it before the end of the year and instead focus on processing applications without it. Without a functioning website, the state has put most applicants for subsidized coverage into temporary insurance through the state’s Medicaid program and jury-rigged a system for processing others’ applications on paper and with simple software tools. The workaround has kept tens of thousands of people from losing coverage, despite the website woes, and provided new assistance to more than 24,000 people. But Connector spokesman Jason Lefferts acknowledged the workaround has spawned misinformation, leaving some consumers confused about the status of their coverage. “The Health Connector is working on these isolated situations as soon as they come to our attention, ensuring people have coverage,” he said. An untold number of people, however, who applied for Connector plans without financial assistance have not gotten coverage, because their payments were lost or somehow never linked to their accounts. Nearly 7,000 people have succeeded in signing up for unsubsidized health plans through the new Connector. But Connector officials acknowledged Thursday that others have completed applications and paid for their preferred health plan but still have not been granted coverage. Connector executive director Jean Yang said Thursday that the manual systems created to bypass the malfunctioning website are complicated. The agency has been working to identify stalled enrollments, so that a crisis management team can address them. The team was working on between 40 and 50 cases Thursday, Yang said, though she could not say how many were related to premium payments that were not properly processed. She said the Connector is planning to improve customer service with better training. While the federal site is largely fixed, major components of the state site still do not work, including those that process payments, determine whether people are eligible for subsidies, and transfer information automatically to health insurers. The Legislature’s Joint Committee on Health Care Financing has scheduled a Feb. 12 hearing on the Connector woes. Advocacy Tip: Some who have signed up through the Connector may not realize that their insurer has not received their information, so they are not actually enrolled. Applicants should ideally keep documentation of their enrollment and then are advised to watch for communications from the insurer. If they don’t receive any communication after a reasonable period of time they should check with the plan directly to confirm that they are in fact signed-up. -See the full Boston Globe articles... Also see related story: State to aid new health coverage, The Boston Globe, January 1, 2014.
MassHealth Revised Regulations Released At the beginning of January MassHealth released revised regulations to conform to the requirements of the Affordable Care Act (ACA). MassHealth Eligibility Letter 213 dated January 1, 2014 is available at http://www.mass.gov/eohhs/docs/masshealth/el2013/el-213.pdf.
Confusion and Cost Create Barriers to Children’s Dental Coverage Plans For years advocates have worked to share the message that oral health is critical to overall health, and dental insurance is health insurance. Dental coverage for children was mandated by the ACA as one of 10 Essential Health Benefits that must be offered by compliant insurance plans. However, as illustrated by this NPR story, the route to expanded access to quality, affordable children’s dental coverage is not as foolproof as one would hope. First, families aren’t required to buy dental coverage for their children when shopping through states’ health care marketplace exchanges. Though the coverage is technically mandated, there are no penalties for families who do not purchase it. Because some plans in the marketplace include embedded pediatric dental coverage, while other plans require that coverage be purchased separately, there exists an underlying confusion and inconsistency. (Adult dental benefits always have to be purchased separately — because they're optional, under the law.) Lastly, because stand-alone dental plans are not eligible for federally-sponsored subsidies, families face an economic disincentive to buy such plans—and the most vulnerable families (namely those with particularly tight budgets) may not be able to afford them at all. With 1 in 10 children from low-income families suffering from untreated dental problems, the issue of access to dental care is both immediate and widespread. Though the ACA has laid a strong foundation by declaring children’s dental coverage one of its 10 essential benefits, there remains much to be done to ensure that the oral health needs of children across the state and nation are equitably met. -See the full A Healthy Blog post from Health Care for All – Massachusetts. Insurance Costs to Fall for Many College Students Thousands of low- and moderate-income college students are about to get a break on the cost of health insurance, thanks to new rules to bring the state into compliance with the national health care law. Until now, Massachusetts denied most full-time college students free or subsidized state health insurance through Commonwealth Care or MassHealth, forcing them to buy insurance directly from their colleges if they are not on their parents’ plan. That meant many students who otherwise might have had free or low-cost health insurance were instead charged thousands of dollars. Premiums vary widely, but the annual premiums at the University of Massachusetts’ Boston and Dartmouth campuses are about $2,100 this year. While some students received financial aid to cover their health insurance, several advocates said they heard from students forced to take out more loans to cover their insurance, drop to part-time studies, or even take time off from school. The Affordable Care Act has changed the ground rules. The state is no longer allowed to exclude from subsidized programs those who can get insurance elsewhere, and that includes college students, according to Suzanne Curry, senior health policy manager with Health Care For All, a Massachusetts advocacy group. At the same time, she said, the law’s Medicaid expansion means that young people won’t lose MassHealth at age 19, as many have in the past. The Massachusetts Health Connector issued rules in December requiring colleges to accept plans from the Connector or MassHealth, with a few rare exceptions. State officials did not have an estimate for the number of students who will benefit from the changes. Most college students are covered by their parents’ private health insurance, but more than 108,000 students were enrolled in health insurance through their colleges in the 2009-2010 academic year, according to state data. It is not clear how many of them will now qualify for subsidized state plans. -See the full Boston Globe article... Medicare Outpatient Mental Health Parity Due to the Mental Health Parity Act, for the first time in 2014, Medicare will cover outpatient mental health care in the same way it covers other outpatient health services. If you have Original Medicare and see a mental health provider that accepts the Medicare amount, Original Medicare will cover 80 percent of the cost, and you or your supplemental insurance will cover the remaining 20 percent. If you have a Medicare Advantage plan, contact your plan to find out its mental health cost and coverage rules. Before 2010, When a claim was for mental health services, Medicare made an initial deduction of 37.5 % before paying 80% of the charge. As a result, the Part B reimbursement was on average, about 50% of the charge. The coinsurance for mental health claims was therefore 50 percent, which was more than for other Part B-covered services (usually 20%). Beginning in 2010 Medicare began to increase the percentage that it covers for mental health services as follows: 55 percent of expenses incurred in 2010 or 2011; 60% in 2012; 65% in 2013; 80% (the amount reimbursed for other Part B claims) in 2014 or in any subsequent calendar year. The services Medicare covers include:
-Adapted from Medicare Watch, Volume 5, Issue 1, Medicare Rights Center, January 9, 2014, and Medicare Coverage of Mental Health Services, Center for Medicare Advocacy, Inc.
MassHealth - Long Term Care Insurance May Protect Assets in MA Massachusetts is unique in having an exception to some of its MassHealth rules for individuals who own qualifying long-term care insurance (LTCI) policies. Under Massachusetts law, the home of a MassHealth resident with such a policy will not be counted in determining eligibility for benefits and the estate -- which usually consists of the home -- will not be subject to claim for reimbursement by MassHealth upon the death of the beneficiary (often referred to as "estate recovery"). There is a potential gap in this rule, however, if LTCI coverage has been exhausted providing care in the home or an assisted living facility before admission to a long-term care facility. To qualify for these protections, the LTCI policy must provide a benefit of at least $125 a day for at least two years. Until this year, MassHealth required that the policy be qualifying at the time the applicant moved to a nursing home, meaning that at least two years of coverage remained at that time. This meant that some seniors and their families felt compelled to move to nursing homes earlier than they might have otherwise done in order not to lose the estate recovery protection. If they used up their policies paying for care at home or in assisted living, under the MassHealth policy they would no longer qualify for the estate recovery exemption. Many advocates felt that this policy was perverse, since it both reduced the incentive for seniors to purchase LTCI and encouraged them to move to nursing homes and seek MassHealth coverage sooner than they might have done otherwise. After significant advocacy, earlier this year the legislature passed a law (M.G.L. c. 118E, sec. 33) permitting qualified policies to be spent down paying for home and assisted living prior to the beneficiary entering a nursing home and still qualify for the estate recovery exemption. However, even this left a gray area. While the MassHealth applicant would no longer have to have two years of coverage remaining on the policy when she entered the nursing home, the statute wasn't totally clear on whether the policy still had to be in force at that time. In other words, what if the policy holder used all of her benefits before moving to the nursing home? MassHealth issued a letter in June 2013 stating that the policy may not have been exhausted prior to the MassHealth applicant moving to a nursing home. There must be at least one day of benefits remaining. While this is a much better result than the prior rule, it still could compel seniors to nursing homes earlier than they might have moved otherwise. Important note: Seniors and their families hoping to take advantage of the LTCI exclusion on the countability of their former home and the estate recovery exemption need to be aware of another perverse rule and be careful when they complete their application for MassHealth. Normally, applicants who own homes are counseled to check off the box saying that they do intend to return home in order for the property to be treated as their personal residence and be noncountable. However, in order to take advantage the LTCI exclusions, they must instead check off the box stating that they do not intend to return home. Even though the house would no longer qualify for the exemption as a personal residence, it will qualify for the LTCI exemption for which there is no $802,000 limit on the equity value. -See the full Margolis & Bloom article. -See related story: State Cost Protections Still Awaited for Long-Term Care
New Issue Brief: SSA's Failure to Process SSI Appeals Requests A new issue brief, Why SSI Needs an Appeal Process That Works, from the National Senior Citizens Law Center says recipients who have a legitimate basis for challenging the Social Security Administration’s decision to stop or decrease their Supplemental Security Income (SSI) benefits are harmed when they have no effective means of presenting their side of the case. Social Security regulations establish an administrative appeal process on paper that protects the due process rights of SSI recipients who face a reduction or loss of benefits. However, in practice, SSI recipients too often face roadblocks at reconsideration, the first stage of the appeal process. A big contributor to due process violations that hurt recipients is the lack of a way for SSA local office staff to log in appeals upon receipt. As a result, SSA regularly fails to process appeals or may lose reconsideration requests and supporting material. This happens whether requests are filed in person at the local office or sent via certified mail, even when an SSA employee signs the return receipt. As a result, these appeals tend to not receive the serious attention required by law. The problem is compounded by understaffing at SSA’s local offices nationwide which is the direct result of tight federal budgets. An SSI recipient’s benefits will only continue unchanged if she files a request for reconsideration within 10 days (plus five days for mailing) of Social Security’s notice of planned action. Therefore, the loss or delay in processing an appeal request can permanently affect an individual’s rights. Plus, if a request for reconsideration is not filed within the 60-day statute of limitations, the recipient loses her right to appeal entirely. The overwhelming majority of people are unrepresented by counsel at this stage of the appeal process. They are also not likely to get the necessary proof to show that they filed their appeal by the deadline. SSA's failure to process appeal requests can leave SSI recipients without the subsistence income they rely on to pay for food, housing and medical care. -See the full issue brief: SSA’s Failure to Process SSI Appeal Requests, National Senior Citizens Law Center, January 2014.
State Cost Protections Still Awaited for Long-Term Care Insurance More than a year after Massachusetts passed legislation aimed at curbing the rapidly rising cost of insurance for long-term care, regulators have yet to adopt new rules that would help protect consumers as they buy products to cover nursing homes and similar services. Regulations were scheduled to be in place by Oct. 31, but the Division of Insurance missed the deadline and recently extended the process to July 1. The state’s insurance commissioner, Joseph G. Murphy, said he does not plan to approve premium increases while his agency finalizes rules, but other protections, such as making it harder for companies to deny coverage, will be further delayed. Massachusetts regulators have in recent years allowed insurers to raise premiums by about 10 percent annually. Several companies over the past two years have submitted requests to raise premiums by as much as 100 percent, or double, Murphy said. Among the undecided issues is whether controls that would limit annual increases over multiple years should apply only to new policies sold in Massachusetts, Murphy said. Insurance companies have indicated that if older policies are included in the cost controls, they may have to ask for even bigger rate increases, Murphy said. Rates have risen rapidly, in part because of an aging population and rising health care costs. But insurers also made mistaken assumptions when they launched the product, leading them to set prices too low. They expected more policyholders to stop paying or drop their plans before they collected benefits. Also, insurance companies have not generated the investment income they anticipated from the premiums because of low interest rates. As a result, insurers are seeking annual double-digit increases from regulators across the country. Several have stopped selling new plans. -See the full Boston Globe article... -Also see accompanying story: MassHealth - Long Term Care Insurance May Protect Assets in MA
Federal Spending Bill Reverses Some Sequester Cuts A compromise spending bill was passed earlier this month and signed by President Obama that funds the government through September. The omnibus appropriations bill calls for an additional $45 billion in military and domestic spending that partially makes up for across-the-board budget cuts called sequestration. These annual cuts, mandated by the Budget Control Act of 2011, were widely denounced as indiscriminate and harmful to vital government functions. It was a compromise bill, however, so the reversal of cuts was not uniform and some programs fared better than others. Key provisions follow. Health and Health Care While key provisions of the Affordable Care Act (ACA) weren’t touched, in a concession to Republicans, the bill contains no new funding for the law. Rather, it trimmed spending in 2 places. The ACA's Prevention and Public Health Fund will lose $1 billion. The GOP call it a "slush fund" that the federal government can raid to pay for the health insurance marketplaces struggling to get off the ground. The spending bill also takes $1 million away from the Independent Payment Advisory Board (IPAB). The ACA created IPAB as a means to curb the growth in Medicare spending if it surpasses certain targets. Supporters say the powerful board, which has no appointees almost 4 years after the law's passage, will make the hard decisions on Medicare spending that lawmakers under the sway of healthcare industry lobbyists won't. Most of organized medicine opposes the IPAB, fearing that it will drive physicians out of Medicare by driving down payment rates. Republicans view the board as a mechanism to ration healthcare. Spending for the Centers for Disease Control and Prevention in 2014 comes to $6.9 billion, $369 million more than its presequester budget in 2013. The National Institutes of Health did not fare as well. The research agency received $29.9 billion in fiscal 2014, roughly $1 billion more than in 2013 after sequestration took its toll, but $714 million less than its original 2013 allotment. Human Services
Veterans and Federal Workers
Other Federal Agencies
Sources and for More Information:
Partners Defends Plan to Expand Partners HealthCare, under growing pressure from regulators to abandon expansion plans, recently filed a forceful rebuttal arguing that its proposed merger with South Shore Hospital and a related doctors’ group would save about $27 million a year in health care costs. The largest Massachusetts hospital and physician network contends that a state commission’s preliminary report criticizing the deal as costly and anticompetitive uses flawed reasoning and contains “inexplicable omissions.’’ The commission’s analysis concluding that the merger would give Partners too much market power is absurd, the rebuttal charges. The Massachusetts Health Policy Commission, a new watchdog agency charged with restraining the growth of health spending, released its review of the proposed merger last month. Partners and South Shore Hospital project a strikingly different financial impact than the commission, which said the acquisition of South Shore and Harbor Medical Group would boost the state’s three largest health insurers’ spending by a projected $23 million to $26 million annually. That increase, it said, would overwhelm potential savings from more efficient operations. Partners said the commission misinterpreted its physician contracts with insurers and ignored savings from improving the coordination and quality of care for privately insured patients on the South Shore. For example, South Shore Hospital admitted 79 patients for every 1,000 commercially insured people in its service area in 2010, considerably more than Newton-Wellesley Hospital, a similar community hospital in the Partners network. By investing more heavily in primary care and mental health services and using information technology to target patients for preventive care, Partners argues, it would reduce admissions at South Shore. Newton-Wellesley’s rate that year was 56 admissions per 1,000 people. The commission is scheduled to vote Feb. 19 on a final report on the merger. It is also pressing forward with a review of Partners’ plans to take over a pair of community hospitals north of Boston. The commission, created last year to help bring health cost increases in line with the state’s economic growth, will refer its report on Partners’ proposed South Shore expansion to Attorney General Martha Coakley’s office for further review, it has said. The Health Policy Commission does not have authority to block any of the deals, but state and federal antitrust regulators could sue to prevent the acquisitions. Coakley’s office and the US Department of Justice are also examining Partners’ planned acquisition of 378-bed South Shore Hospital in Weymouth as part of a broader investigation into allegedly anticompetitive practices by the Boston-based health care system. The commission acknowledged that Partners’ merger with South Shore has the potential to save $6.6 million by improving care for Medicare patients. The analysis is based on Partners’ success at lowering medical costs for chronically ill elderly patients through home visits and other intensive preventive services. Partners said such measures, broadly called “population health management,” will become even more widely used as hospitals and doctors take on financial risk for the health of their patients. But the commission said it could not project similar savings for commercially insured patients based on this program, because Medicare recipients are older and sicker, and therefore the opportunity for savings is greater. Nancy Kane, a professor at Harvard School of Public Health, said “there are a lot of unknowns,’’ but that research has shown that, in the long run, market consolidation causes “prices to go up and it’s not measurably better quality. Often community hospitals get more expensive.’’ The savings Partners and South Shore are projecting from improving the coordination and quality of care are possible, but unproven, Kane said. “It’s great if they can do it . . . but the evidence is not there yet. The whole industry is struggling to achieve that.’’ -See the full Boston Globe article... Opinion: Medicare Advantage and the ‘Theft’ of $156 Billion In a Dec. 27 lead editorial, “Government Advantage,” the editorial writers of The Wall Street Journal wrote: Amid the larger ObamaCare meltdown, seniors are discovering their choices are fewer, costs higher and coverage poorer too. Liberals fear the increasing popularity of Medicare Advantage, and they’re starting to gut this market alternative to their original health care entitlement before the sand runs out on President Obama’s second term. About 14 million people or 28 percent of Medicare beneficiaries choose Advantage over the government option, which is why the Affordable Care Act steals about $156 billion from the program – even as enrollment has surged 30 percent since 2010. What the Affordable Care Act has done to the Medicare Advantage plans lies, like beauty, in the eyes of the beholder. The story begins with the Medicare Prescription Drug Improvement and Modernization Act of 2003, which revamped the manner in which Medicare paid private health plans for Medicare beneficiaries who chose them in lieu of traditional Medicare. On average, the payment method prescribed by the 2003 law, which took effect in 2006, has cost taxpayers substantially more per Medicare beneficiary who enrolled in a Medicare Advantage plan than these beneficiaries would have cost taxpayers in traditional Medicare. That is because Medicare has paid private plans more per beneficiary than these beneficiaries would have cost in traditional Medicare. For the most part, these extra payments have not landed in the private plans’ profits. Instead, the plans have been required to offer Medicare beneficiaries either added benefits for those extra payments or reduced premiums for the Part B and Part D coverage that Medicare beneficiaries are required to buy under Medicare Advantage plans or traditional Medicare. But the extra payments and the added benefits did give the private plans a competitive advantage compared with traditional Medicare in the market for enrollees. In effect, the 2003 law rewarded Medicare beneficiaries opting for a private health plan with more tax-financed benefits than were available to similar beneficiaries choosing to stay in traditional Medicare and even forced the latter to help finance the bonus granted the Medicare Advantage enrollees through higher out-of-pocket Part B premiums. The Medpac commissioners – a group of savvy policy analysts and private stakeholders in American health care – have deemed this payment method unfair. As they noted (see Page 252) in their March 2009 report, referring to Medicare Advantage as M.A. and traditional Medicare as F.F.S.: In 2009, payments to M.A. plans continue to exceed what Medicare would spend for similar beneficiaries in F.F.S. M.A. payments per enrollee are projected to be 114 percent of comparable F.F.S. spending in 2009, compared with 113 percent in 2008. This added cost contributes to the worsening long-range financial sustainability of the Medicare program. … In aggregate, enhanced benefits [offered by the M.A. plans] are funded by the taxpayers and all beneficiaries (whether they belong to M.A. plans or not), rather than being funded through savings achieved as a result of plan cost efficiencies. In addition, a portion of the value of enhanced benefits consists of funds for plan administration and profits and not direct health care services for beneficiaries. The Commission supports financial neutrality between F.F.S. and the M.A. program. Prompted no doubt by these repeated recommendations from the nonpartisan Medpac, the drafters of the Affordable Care Act introduced the following changes in the payment formula for Medicare Advantage: (a) Gradually moving the overall average (risk-adjusted) payments per beneficiary to the Medicare Advantage plans toward neutrality with traditional Medicare; (b) Gradually reducing payments to the plans in counties with high per-beneficiary costs under traditional Medicare (on the theory that economies there should be more easily achievable for the private plans), but lifting the payments above per-beneficiary costs under traditional Medicare in low-cost counties; (c) Within those constraints, rewarding the plans explicitly with higher payments for higher, measured quality. Now, one can easily understand why The Wall Street Journal editorial writers, given their ideological predilections and the point they sought to make, would not mention the extra payments hitherto made to Medicare Advantage plans and simply portray the payment change under the Affordable Care Act as theft. On the other hand, one can also easily see why designers of the Affordable Care Act saw in their new payment formula not a theft from the Medicare Advantage plans nor their destruction through “fiscal starvation,” as The Wall Street Journal portrays it, but, like the commissioners on Medpac, a leveling of the playing field in that competitive market. -See the full New York Times blog entry... Cited in/Linked from: HEALTH CARE WEEKLY UPDATE, Barbara Roop & John Goodson, Health Care for Massachusetts, January 03, 2014.
Are No-Calorie Sweeteners Safe and Effective? While the American Heart Association recently concluded that replacing sugary foods and drinks with those containing no-calorie sweeteners is one way “to limit calories and achieve or maintain a healthy weight,” researchers have been unable to establish that such a swap promotes weight loss. A Johns Hopkins School of Public Health study earlier this month examined national dietary surveys from nearly 24,000 Americans and found that overweight folks who drank diet beverages actually consumed 88 more calories per day, on average, compared with those who drank sugary beverages; those at the obese end of the spectrum who drank diet drinks consumed a total of 194 extra calories per day more than their counterparts who drank beverages sweetened with sugar. “Simply switching to diet soda does not appear to be enough to promote long-term weight loss,” said study leader Sara Bleich. Dieters may compensate by eating more sweet snacks, she added, possibly because beverages sweetened with no-calorie substitutes fuel sugar cravings by reinforcing the body’s preference for sweets without providing calories to reduce the appetite. Partly for this reason, leading nutrition experts who spoke with the Globe said they not only limit their sugar intake but also make efforts to completely avoid artificial sweeteners like sucralose, aspartame (NutraSweet), and saccharin, and even the newer “natural” sweeteners made from plants like stevia and monk fruit extracts, which haven’t been well studied. While sugar also comes from a plant, its effects on the body are well known because it has been added to foods for centuries. Unknown safety risks have also made some researchers wary. Animal studies suggest an increased risk of tumors associated with large doses of aspartame and a potential for sucralose to wipe out beneficial bacteria in the gut and to interfere with how the body breaks down medications. Other sucralose research, published last year in the journal Diabetes Care, found that sucralose caused a more rapid spike in blood sugar and a bigger surge in the hormone insulin — mimicking the early stages of diabetes — among 17 obese volunteers who consumed the sweetener before a sugary beverage compared with when they consumed the beverage alone. With mounting safety questions, Dr. Walter Willett, chair of the department of nutrition at Harvard School of Public Health said it is a good idea for children in particular, to avoid no-calorie sweeteners. “What happens when kids consume them for 40 or 60 years?” he said. “Those who are will be participating in an uncontrolled experiment.” Beverage makers have been eagerly testing newly approved “natural” sweeteners like stevia (also called rebiana) and monk fruit extract in their sweetened drinks in a nod to consumers who are looking for products without artificial ingredients. “It’s not iron-clad logic,” Willett said. “There are many toxins that occur in nature, so natural isn’t necessarily proof of safety.” -See the full Boston Globe article...
Dementia- Are Gluten and/or Carbs the Culprit? Editor's Note: In his new book Grain Brain: The Surprising Truth About Wheat, Carbs, and Sugar -- Your Brain's Silent Killers, Dr. David Perlmutter, Associate Professor at the University of Miami School of Medicine, advocates that lifestyle modifications, starting with a high-fat, nearly carbohydrate-free diet, can prevent or greatly lower dementia risk and progression. While detractors say the evidence isn't quite there, Medscape spoke with Dr. Perlmutter about his thoughts on the impact of carbohydrates and gluten on the brain. Medscape: For those unfamiliar with your ideas, can you summarize the thesis behind your new book and how you arrived at it? Dr. Perlmutter: A study published in Neurology in 2005 pointed a finger squarely at the most powerful metric being glycated hemoglobin. Even back then, it was becoming clearer that there was something going on with blood sugar correlating with rate of brain atrophy, specifically hippocampal atrophy, and cognitive decline. When you now retrospectively evaluate that study, you begin to appreciate that glycated hemoglobin is more than just a metric of average blood sugar, which is typically how it's looked upon even today. Glycated hemoglobin is a glycated protein. This is a marker not just of average blood sugar, but more important, it's a marker of the degree of glycation that's going on in human physiology -- a process that increases inflammation and dramatically increases the production of free radicals and oxidative stress. So the idea that even subtle elevations of sugar, which is a dietary lifestyle choice, are related to risk for brain degeneration really began to crystallize. This notion has gained traction and, I think, is profoundly supported by a couple of more recent studies. A study published in August 2013 in the New England Journal of Medicine (NEJM)[2] was very supportive, indicating that even subtle elevations of fasting blood sugar translates to dramatically increased risk for dementia. This was a prospective analysis that measured fasting blood sugar and followed 839 men and 1228 women for a mean of 6.8 years. I'll quote the conclusion: "Our results suggest that higher glucose levels may be a risk factor for dementia, even among persons without diabetes." Why? These are levels of 105 and 110 mg/dL -- levels that most doctors are going to be satisfied with. However, according to the study, these numbers translated into a significantly increased risk for dementia in individuals who were not demented. Medscape: That is striking. However, I think it's important to point out that many of the studies you cite report associations between glucose and risk for dementia and don't necessarily prove causality, correct? Dr. Perlmutter: You are 100% correct. I'll stand and take my lumps from those individuals who want to make the argument that there's no smoking gun here. But when a prestigious journal like NEJM calls our attention to this relationship effect in glucose and cognitive decline, we've got to take notice, especially at a time when we have no other choice. It's the best thing that we have going. We know that a lower-carbohydrate diet is the right choice for the heart and the immune system. There's no downside to it. I offer it up as being supported by the current peer-reviewed literature. If that's as good as it gets, that's the best we have right now. -See the full Medscape interview...
Medication Noncompliance – Why and What Can We Do About it? The number of patients who are noncompliant has reached epidemic proportions, and doctors' inability to provide optimal care as a result has mushroomed into one of the most pressing problems in healthcare today. The Problem
Why Don’t Patients Take Their Medications? One reason noncompliance has been such a tough nut to crack is its daunting complexity. Patients don't take their medications for a multitude of reasons, many of them emanating from the murky depths of human psychology, and which the patients (not to mention medical researchers) may not fully understand. To complicate matters, these reasons vary from patient to patient. A major reason why many patients go off-regimen is the cost of drugs. But even when patients are given drugs gratis, compliance improves only slightly. One much-discussed study looked at 2845 Aetna health plan members discharged from the hospital after an acute MI episode who were given all of their drugs -- statins, beta-blockers, ACE inhibitors, ARBs -- for free, comparing them with 3020 Aetna enrollees who had the usual prescription coverage. In the usual-coverage group, compliance rates were 36%-49%. But without the cost barrier, the rates were only 4%-6% higher. Medicine regimen complexity is a factor. Compliance, it turns out, is inversely proportional to the number of times a patient must take medication each day. For medication taken only once daily, the average compliance rate is nearly 80%; for medication that must be taken 4 times a day, the average rate drops to about 50%. "We're asking patients to adopt obsessive-compulsive behavior," admits internist Edmund Pezalla, MD, MPH, National Medical Director of Pharmacy Policy & Strategy for the health insurer Aetna. Unfortunately, the ocean of data on the subject of medication compliance has stubbornly resisted attempts at synthesis into a statistically compelling, evidence-based, systematized plan or plans of action for overcoming barriers to compliance across a range of patients, drugs, and diseases. A 2007 Cochrane review of interventions for enhancing medication compliance didn't mince words: "With the astonishing advances in medical therapeutics during the past two decades, one would think that studies of the nature of non-adherence and the effectiveness of strategies to help patients overcome it would flourish," the authors wrote. "On the contrary, the literature concerning interventions to improve adherence with medications remains surprisingly weak." Identifying patients who stop taking or fail to fill their prescriptions is useless without effective ways to get them back on track. The most advanced integrated delivery systems are finding ways to intervene that are showing promise. They use predictive modeling to identify patients who are noncompliant; bundled payments for acute care procedures; pay-for-performance incentives; enhanced support for primary doctors and their care teams; improved chronic disease management; and improved transitions of care between primary doctors, specialists, hospitals, and other care facilities. Take the Geisinger Health System based in Danville, Pennsylvania. It serves more than 2.6 million patients in 44 counties in central and northeastern Pennsylvania, a population that is poorer, older, and sicker than the national average. Consider the 25,000 patients with diabetes in Geisinger's care. Their prescription activity is monitored at Geisinger pharmacies, and if a patient goes off-regimen, fails to fill an electronically sent prescription, or misses a doctor's appointment, a care team, generally composed of nurse practitioners, promptly intervenes. Patients who need additional help with compliance are referred to health coaches who specialize in disease-specific education for conditions like diabetes and chronic obstructive pulmonary disease. A separate care team may monitor the patient several times a month, week, or day via phone, texting, email, videoconferencing, or the use of wireless devices that remotely send team members data on the patient's vital signs. As a result of such measures, since 2006, when Geisinger's care was "fragmented" and not focused on patients with chronic disease, the percentage of patients with diabetes whose hemoglobin A1c measurements were at goal rose from 2.4% to 12.9%. Those whose blood pressure was under control (< 130/180 mm Hg) rose from 39% to 54%. Similar gains were achieved with other chronic diseases. But most doctors and patients aren't part of integrated systems like this, with their extensive resources and mission to address noncompliance -- at least not yet. Editor’s note: And despite these improvements, the final numbers are still lower than we’d hope. -See the full Medscape articles: Why Are So Many Patients Noncompliant? and Can We Get Patients to Be More Compliant?
Illicit Drug Users More Likely to Seriously Consider Suicide Illicit drug users are significantly more likely to consider suicide compared with the general population, new research shows. A new report from the Substance Abuse and Mental Health Services Administration (SAMHSA) shows that the rate of suicidal thoughts among illicit drugs users in the United States was 9.4% compared with a rate of 3.9% in the general population. In addition, the study revealed that the percentage of adults who had serious thoughts of suicide varied by the type of illicit substance used. For example, although 9.6% of adults who had used marijuana in the past year had seriously considered suicide, the highest rate was 20.9% for their counterparts who had engaged in illicit use of sedatives. The report is based on findings from SAMHSA's 2012 National Survey on Drug Use and Health (NSDUH), which is a scientifically conducted annual survey of approximately 70,000 people aged 12 years and older in the United States. -See the full Medscape summary article...
Renegotiating Sex and Intimacy After Cancer: Resisting the Coital Imperative There is a growing body of research demonstrating that cancer can result in significant disruption to sexuality and intimacy. These sexual changes can lead to significant distress and can be among the most negative influences on the social well-being of people with cancer. There are, however, a number of limitations in existing research about sexuality in the context of cancer. The focus has been on embodied aspects of sexual changes, in particular changes to sexual or genital "functioning." This includes a focus on erectile performance in men and vaginal dryness or elasticity, sexual dysfunction, or body image changes in women. Although there is a growing body of research examining psychosocial correlates of changes to sexuality after cancer, including the influence of relational context, little attention has been given to renegotiation of sexual practice or intimacy, which has led to a plea for research examining "successful strategies used by couples to maintain sexual intimacy" in the context of cancer. The biomedical model of sex positions sex as a physiologically driven act, and heterosexual penis-vagina intercourse as "natural" or "real" sex, with other forms of sexual activity deemed to be preliminary "foreplay," an optional extra, or simply a substitute if the "real thing" is not possible. Described as the "coital imperative, this biomedical model of sex is enshrined in definitions of "sexual dysfunction" in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, used to diagnose inability to perform coital heterosexual sex as pathological, in both cancer and noncancer contexts. The coital imperative is not confined to the biomedical domain; it is also reflected in discursive representations of "real" or "normal" sex within popular culture, reinforced by advertisements for Viagra, that promise sexual fitness and "functionality" across the life span and the restoration of premorbid coital abilities if dysfunction is experienced. Resistance of the coital imperative, through redefining noncoital genital practices as sex or exploring nongenital forms of intimacy, was the primary strategy of successful sexual renegotiation reported by participants. -See the full Medscape article... |