Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: Affordable Care Act

An advocate gets busy while every politician and “talking head” takes credit for healthcare model ideas published long ago.

Reconciling data in my six health portals

Reconciling data in my six health portals

I watched Barbara Starfield again last night. She passed away in 2011 but it seamed as though she was sitting in my living room telling me everything will be alright but many of us will never get our way. Barbara spent several decades studying the characteristics of health systems all over the world. Her final conclusions were simple and easy to implement as long as social agreements were made between consumers of healthcare services and their providers. The contract (sort of) is that my primary care doctor will be available when needed if I promise to contact his or her office before going to the ER for an earache or other non-emergent condition; my doctor also agrees to follow my care as I transition through life stages and address all mental and physical health conditions as they arise by assuring I connect with the correct specialist if required. The specialists in return are in constant contact with my primary care doctor so the primary care clinic is coordinating continuous and comprehensive care and reviewing all interactions between myself and other medical environments. Like I said earlier this week. Someone to watch over me. I first learned of Dr. Starfield in 2001 and followed her publications. Funny, she was never accepted to sit on any best-practice boards but the scientific community considered her work to be spectacular in terms of statistical approach and quality. In other words, she looked for the null hypothesis also.

Again…concerns over repeal and replace.

Some more diatribe with hope at sarcastic humor is written for you below. Please follow through to the end as I pasted a really cool graphic pointing you to a new society of consumers and professionals that might fix the system over the long run.

The conversation doesn’t stop at my dinner table, on my phone, through IM or Facebook. It seems as though my popularity index took a healthy bump after November 8th, 2016. I wish I could be happy about the reasons for the traffic.
“Jeff, you are on Medicare are you concerned?”

Well yes; you see, as we become older the likelihood of needing assistance from case managers, specialists, short stays in skilled nursing or rehabilitation facilities increases. Same with home health services which is always the preferred place to recover from the self-inflicted fractured hip that occurred while my masculine ego informed me of my capacity to clean out my gutters.
One of the most important changes to the clinical language coming from Obamacare is the right for all patients cared for by primary care doctors with Medicare contracts to receive “Coordinated, Comprehensive Care”. Lately you might have heard the terms: “Patient Centered Care” or “Medical Home”. You probably heard President Elect Trump mention “Patient Centered” or a new commercial by Humana presented by a handsome young doctor stating that Humana’s system of Patient Centered Care is superior because of their capacity to coordinate your care within their “medical community”. Then you will watch a local conservative pundit state: “those stupid narrow networks tried through Obamacare didn’t work: here is a toast to repeal and replace.
This stuff cracks me up for the same proponents of patient centered care realize that closely collaborating narrow networks can provide you with clinical personnel that understand your needs better than anyone else! In fact, they have the same attributes of a Patient Centered Care Team using a single medical record and plan of care to increase safety and minimize mistakes. Yet you will hear no one (perhaps save me and a few of us that are tired of scraping the poop off our boots) tell you that the words Patient Centered, Narrow Network, Accountable Outcomes, Value Added Payment, Medical Homes, and all other terms implying a tightly coordinated, error free clinical team surrounding all patients are not original concepts. In fact, they are in place in many of our successful neighbor nations who provide universal enrollment and have always demonstrated lower reliance on emergency room services for basic medicine, better health outcomes and no difference in treatment effectiveness for cancer, diabetes, cardiovascular disease and other leading causes of premature mortality. Our own CMS (The Centers for Medicare and Medicaid Services) have published the policy here July 2016:
So all of a sudden the administration of 2017 will be using terminology invented by others to describe care models that work after years of academic surveillance by healthcare policy analysists and already written into The Patient Protection Affordable Care Act or what the opponents call “Obama-Care”.
My prediction is we will keep the new payment systems for coordinated care and chronic disease care management. However, the credit for the success will fall under a new Trump label. My fears is that the same three insurance companies comprising the oligopoly of payers for American Healthcare will recoup their lost profits of mandated care without premium inflation for the chronically ill by shifting the premiums higher for those with pre-existing conditions. So here is another question from the week:
“Jeff, what will I do now I couldn’t get covered because of my history of cancer before the ACA?” “What if “Trump-care” requires coverage for pre-existing illnesses but allows insurance companies to include the illness in the premium pricing model? “ My response to this question was “not sure, my cost in the NC High Risk Insurance Pool for my diabetes prior to Obamacare was $1200.00 per month not including co-pays. Today it is $350.00.
More on Patient Centered Care AKA Medical Homes AKA Integrated Care AKA Chronic Illness Care.
I discussed the integrated care model and its payment adjustments to my Men’s group on Thursday night as they requested a primer on planning for their last ten years of life. Their hope was that our system of care had evolved and they would not have to lose their homes to cover the long-term care charges. Many of the guys in my group neglected to buy long term care insurance when they were young and healthy, had since suffered a chronic disease diagnosis and episode of treatment and no longer qualified for long term care insurance. They could however place $10 K per month into an account to pre-pay up to one year of long term care. This is what my father did: In 2006 he entered into a contract with a transitional care organization. He paid them $350,000 for full access to assisted living and long term care until his death. They also allowed him to live in the attached apartment complex for independent seniors for an additional rent of $3200 per month including one meal per day. Not a bad deal eh? Oh yeah…one more oversight: My friends ; all retired upper middle class professionals had no idea that Medicare didn’t pay for long term custodial care either in home or inpatient facility.
Now, like I said the other day, I am a bit tired of shouting the truth to those who were unfortunate enough to buy into the following promise: “Oh we will have the most wonderful healthcare system in the world” and “We promise to repeal the expensive policies and replace with something better.
We were on our way folks: The biggest mistake, President Obama’s team was denied the necessary Medicaid expansion for ALL not SOME States by our supreme courts. If you don’t understand the math I will be pleased to describe it in another column. Basically when the folks that would have had access to Medicaid don’t receive the insurance they still consume services. The loss of revenue winds up on the balance sheets of hospitals and providers and they respond by increasing their cost per service. The insurance companies pay more and your premiums increase. So… my neighbors policy (55 year old male) in NC costs $11,000 per year. The very same policy in New Hampshire where they expanded Medicaid costs $5,500 per year. As Mr. Obama leaves keep in mind that the rate of increase in health costs since the inception of Obama Care is the lowest it has been in 40 years.
Somehow, someway; we need to cover everybody. If we do not we cannot cover the losses incurred in the private sector without the Magical Thinking that has been sold you for so many decade. Hide the losses, get others to pay for the losses through modest increases in cost of living and blame the doctors, and hospitals who give away more free care than you could ever imagine.
What would happen if our incredible consumer driven internet harnessed the decision support technology that we use daily on Amazon and instantly brings the right service to you when needed should you or a loved one become ill? What if we harnessed IBM Watson to make the diagnosis thereby reducing error rates and reducing unnecessary utilization of expensive diagnostic procedures?
What if we didn’t need insurance companies any more to assess population risk and perform preauthorization services while we waited for our new medication?
Since we have all of the data connecting lifestyle, culture, nutrition, infection and the human genome can anyone appreciate where we are headed with our capacity to discover the cause of disease and effect of treatment? This is not decades from now my friends; it is within the reach of our children’s lifetime. I have wonderful friends with incredible scientific minds that are creating open source technologies to accomplish human collaboration like humankind has never witnessed. The only barrier to their success is a loss of priority to cure disease, increase well-being and expand the functional-years of human life.
Or…we can keep these technologies secret, forget those we have developed through the natural sequestration of competing private enterprise and traditional silo thinking. If this is where we are headed then the best investment to assure a painless end of life if you are not surrounded by humanitarian friends is my undying support for the second amendment. If you catch my drift.

Check out Right Care Folks!

Right Care Now

Right Care Now

From Obama to ObamaTrumpCare

someone-to-watch

Someone to watch over me…….
Dear Doctor, will you please make sure I receive the RIGHT CARE!
What do you know about me Doc?
Do you have time to spend with me today; perhaps discuss who I am in the world, what my goals are and what I think might help me feel better?
Are you interested in my Well-Being? Do you and your staff ever discuss Well-Being or is it all veiled in a pile of healthcare acronyms; where Well-Being is described by absence of symptoms and disease?
Do you have the opportunity to discuss my goals and interventions with my other doctors? Sometimes I am not sure you folks talk because my information: from religion and employment history to list of medicines varies between practices. I thought someone was fixing all of the electronic health record issues ten years ago?
I noticed that all of my personal physicians that I have chosen over the last fifteen years are selling their practice or merging into some sort of healthcare system that appears to be managed by the local hospital; is this a good thing? I am really not sure you see me because the person at the registration desk doesn’t recognize me and your Medical Assistant told me that you only had time for 10 a minute appointment today.
Actually, to be honest with you; I am concerned for your Well-Being Doc because you have dark circles below your eyes and tell me that you are up until 10:00 PM each night completing your records at home. I realize that the new electronic health records are cool but shouldn’t they increase your quality of life as opposed to drain any remaining discretionary time you have with your family?
Ya know Doc, I have learned allot about healthcare in my life: Yeah, some because of my training and work but mostly because I have these….”conditions”. The “conditions” have presented adequate challenge to require me to understand the “bits and pieces” that string this system together. I’ll bet you don’t learn much about being a patient in medical school. I am not sure how you could do it without adding another two years to your fourteen years of post-grad education.
Did you know that I have spent ten hours in the last month trying to get a prescription authorized? You know the prescription that makes living with RSD and diabetic neuropathy tolerable! It appears that someone didn’t install your e-prescribing system correctly; something to do with prescription received and filled acknowledgments? I don’t know Man; it seems like the fax machine and pharmacy calls worked better than this e-Rx stuff. The long and short of it is that between your practice, my insurance carrier, and my CVS pharmacy the most efficient transaction I can hope for when I am in pain is 48 hours. My “Well-Being” wasn’t so “Well” this month…..
BUT my A1c is 6.5, my blood pressure is 124/78, my immunizations and other measures of health process and management outcomes are all great. I am pleased to be one of the good data points on your quality report and certainly testify to CMS and Blue Cross that you deserve an extra 5% for your hard work. Might be nice though if I received a discount on my insulin copay for the snappy A1c that has kept my feet attached to my legs and my body out of the hospital these last 50 years.

So what is Right Care? How do we know if we get it? Is it through the Diabetes DM report? Is it through the patient satisfaction survey that I take at each and every service provider I see? They all are very similar, I wonder if anyone has ever considered a “whole system measure”; at least something better than the Service Excellence Survey that reminds me of the material sent to me by American Airlines after every business trip. By the way, I always give my providers 5 stars with the exception of the conglomerate that bought up the primary care practices; their employees seem miserable. I find it amusing that their employees all where buttons that say “Ask me about the “Name of Healthcare Institutions” WAY. I guess they all have some kind of culture that is supposed to make my experience less painful as a consumer? Perhaps more like Disney Land I suppose.
What I really long for is my diabetes pediatrician from 1965. Dr. Lipmann. He always asked me to discuss how I was feeling about school, whether I had enough to eat at home, did I have any dreams and whether or not my diabetes would prevent me from achieving my dreams. Heck, he called me on Sunday night to as how I was feeling when my urine sugars were running 4 plus. When I left his care at the age of thirteen he had illuminated an interest in human biology that has carried me through my life. On a darker side of my childhood life he also notified “Children’s Protective Services” when he discovered I was living in an alcoholic flop-house!
My friend Tony is from another country. His mom had a CVA last year. She was transported to the ER, hospitalized, transferred to a facility with real rehabilitation specialists and doctors on staff daily, discharged home with visiting nurses and therapists and returned to society as a healthy 75 year old woman who is now completely independent. Her cost? Well there was no cost to her and the average cost per person for health services in her country is 1/2 of what it is in the USA.
In meeting with my insurance adviser the other day I was informed that my healthcare cost will be more than $500,000 between now and my death; with my diabetes, RSD, neuropathy etc. I wonder how we will cover the services. I really don’t want to be one of those patients that I cared for early on in my career. You know….like the old man and WWII B17 Aviator that looked up at me shortly before he died and said “Ya know Jeff; I used to be somebody once”.
The end of his life was no different than my fathers. Dad died last year from pneumonia at the age of 87. We had just celebrated Memorial Day. He called me complaining of a chest cold and 48 hours later I found myself sitting at his bedside with new onset dementia, consolidated breath sounds, a temperature of 101 degrees and abdominal cramps. I asked the Nursing Assistant to get him a bed pan and she informed me that he “just got off the pan”. A few minutes later I overheard her complaining to her supervisor that she had no intention of getting my Pop out of bed because he was a difficult transfer due to his combativeness. Pop was angry for sure but not combative. Then I witnessed the IV nurse insert a 18 gauge catheter into my pops wrist. She never registered IV access and proceeded to deliver 500 cc of solution into the sub-cutaneous space. This was the only vein he had left since they had made the same error the night before in the opposite hand. By 6PM his hand was as large as a soft-ball and this was hours after I complained about her technique.
So the following day Pop got a PICC line. PICC lines are infection risks!

Three days later I took him to the SNF with his PICC line and met with the therapists. Dad was becoming more lucid but I had concerns. I met with the Charge Nurse and facility director to assure his good care. I was concerned about the additional risk for infection from his new PICC line. You see, this facility was part of his life-long $450,000 investment in a continuing care environment; supposedly the best available in Huntsville Alabama. I used to direct clinical services departments in these facilities earlier in my career and was aware of their financial strain as they attempted to deliver hospital level care for 1/3 the cost.
I saw Pop the next day while he was cycling on the recumbent bicycle in the rehabilitation department. He had 20 minutes of therapy to go but as soon as I showed up to watch his work-out the therapist terminated the session and quickly wheeled Pop to his room so we could chat. Dad looked horribly sad, I knelt down to say good-bye kissing him on the forehead I said “I love you Dad!”; he looked up and said “And I love you Jeff”. These were our last words.
Three days later I received a call at 3AM from a person who could not speak English. He mentioned my father’s name and I asked for someone who could speak more clearly. The second person I spoke with also could not speak English. Finally a paramedic picked up the phone…”Mr. Harris, your father is unresponsive and we are taking him to the hospital”.
After a quick dialog I was able to determine that Pop had explosive diarrhea several hours earlier and simply lost consciousness. I called ahead to the Emergency Department to inform them of my father’s forthcoming arrival and that I was worried he might be septic. I told the doctor that Pop was a DNR patient and he should call me when he arrived. When Pop was evaluated the ER Doctor called me with his lab results and it was quite evident that he was dying and most certainly had been allowed to dehydrate while at the Rehabilitation Hospital OOPS I mean Skilled Nursing Facility OOPS I am not sure what I mean. God did I weep as the ER doctor and I discussed his DNR.
I wrestle with the fact that I might have been able to save Pop if I had pushed for re-hydration, antibiotics and other therapy but I couldn’t help think about Pops state of well-being. You see my brother and I had spent years shuffling him around between neurosurgery in Birmingham and other clinical facilities. At one point I had imitated a physician to keep my father from being discharged prematurely after his brain tumor operation. He had been in the hospital for a week. The Medicare Prospective Payment was going to pay for eight days and the hospital was pushing him out to a skilled nursing facility. I watched my Pop eating and realized he had an aspiration problem. Fearful of aspiration pneumonia I asked to have him discharged to the rehabilitation beds at the University Medical Center. I wanted him to receive a speech language therapy evaluation for aspiration risk and rehabilitation services. To get the transfer to rehabilitation where a doctor and therapists would be available; I had to retrieve every clinical skill I had when meeting with the staff to justify his case. When they assumed I was a doctor, I let it ride. Feeling shame the next day I convinced myself that I would do whatever I needed to protect my father.
You know, to make sure he would receive the
Right Care.

As the ACA (Obamacare) was implemented I began to have hope. You see, this year 2017 is the beginning of Medicare’s observation of how well inpatient hospitals and post-acute care facilities integrate. One important measure they are watching is the frequency of readmission to acute care for the same diagnosis. This combined measure of how well institutions, nursing homes, home health networks and primary care communicate regarding a patient’s process as they are handed off between facilities is to prevent patients from becoming ill and requiring re-hospitalization. Trust me folks, it used to be horrible: I can remember turning patients around as they arrived at our rehabilitation hospital and sending them straight back to the Medical Center that had just discharged them. You see, some were still in heart failure and semi-conscious; not only could they not participate in rehabilitation; to attempt rehabilitation might have killed them. But you see, the hospitals were not linked to the rehabilitation and skilled nursing facilities through a common therapeutic goal and reimbursement mechanism. The hospital in Boston just wanted to discharge the patient prior to exceeding their Medicare reimbursement allotment. We however had marketing nurses out in the field accepting any warm body with a heartbeat that just might survive a 21 day Medicare stay in a Skilled Nursing Environment.
My friends had no idea why I never lost my job by reversing the trajectory of these patients. What they did not know was that I had a compassionate family owned corporation employing me who trusted my clinical intuition.
Alas… as of today….Obamacare is being repealed and we have yet to be informed about “TrumpCare”. My guess us that we will return to the past with the exception of mandatory care for persons with pre-existing conditions. Then we will see just how much our policies cost and what our end of year out of pocket expense will be.
For my wife and I,
We are searching once more for our peeps. This week I have looked at my well-being through the end of my life if we ex-patriate to Canada. My cost will be $0.00 for healthcare. My waiting time for a CAT scan will double but Canada’s outcomes for Cancer and Cardiovascular Disease and diabetes are slightly better than in the USA. So what do we have to lose? In fact, Canada doesn’t amputate many diabetic limbs. You know why? Because all of their diabetics have access to care!

Fondly thinking of you fellow patients and consumers;
Jeffrey Halbstein-Harris
• An advocate for those who feel lost
• Always watching
• Harnessing the compassion that surrounds you in a time of crisis
• Connecting you with the best science available
• Minding your pocketbook
• Working to return you home safely

What is important! Life, Death and Taxes

Hopeful

Hopeful

The most important messages I carry are personally empowering. They are seldom original but channeled through the “bright spirits” I encounter in life.

To be empowered in this confusing world requires a grasp on reality. I will be 60 next week, a milestone I never cherished; even less so today with recent memory of the loss of my father, mother, brother and best friend of 30 plus years.
I was so freaking sad today when I woke that I found it hard to make a cup of coffee. I preferred to sit in my armchair (nicknamed the neurotic’s spaceship) and discuss the meaning of life with Bodi my loyal canine friend.
When I opened my social portal into the virtual world I discovered a friend’s post. A warm soul I met in a business conference two years ago, April Koontz had posted an important message; another piece of wisdom that I find to be a blessing for all of us.
I have chosen to teach about how to survive in America if one is ill perhaps it is time to focus on the ultimate reality for my lifetime. I will not witness a fix. We are far from agreement on the definition of health and well-being and human rights in American Society to imagine anything close to a satisfactory solution in my generation.

 

So perhaps I will continue to post interesting tidbits and ideas with hope of enlightening those who did not work 35 years in healthcare; but most importantly I will re-state my agreement with the video below; a presentation by @Michael Hebb, the founder of Death Over Dinner’s Ted Talk below – a must see!

A great thanks to April for bringing this to my breakfast table this morning.

Hooray Humana for providing useful tools to family caregivers.

Yikes!!

Yikes!!

Lately I have complained about the lack of utility if not barriers created by various e- communication tools that seem to complicate the process of educating consumers on the topics within the domain of self-mastery.
After losing my poa agreement with my father, Humana finally
Let me know that I am now Pop’s designated healthcare proxy.
I find the letter engaging with plenty of contact info content and a promise to send me a care-advocates guidebook with accompanying educational material for visit preparation, medication reconciliation and financial management.
I will let you know how useful it is when received.

For now, a gratuitous thank you to a payer stepping into the medical home care team role with both patient and family!

NC Senate : While the rest of the country profits from North Carolina’s success in Medicaid, you throw the baby out with the bathwater.

 

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

cmis_use

 

 

The graphic report (above right) comes from the CCNC data systems developed by the Community Care of North Carolina Program. It allows communities to identify and assist people in need of support or locate systemic problems such as high utilization rates in local emergency rooms. All of this stuff combined fits into the Medical Home Model that out senate suggests purging CCNC; Yet, as you will note below, this program is a locally managed;public-private joint venture that is used throughout the US to achieve cost reductions in health systems. Please read on:

Yet another testimony to the capability of a Medical Home framework to decrease cost and improve health outcomes was published in today’s NY Times.   Here are the data:

  • The payer: Care First Blue Cross Blue Shield
  • The population size: 1.1 Million!
  • The model: Medical Homes (Community Care of North Carolina an early adopter of this strategy)
  • The savings: $130 Million

The article goes on to explain that results have been mixed in Medical Home Evaluations, demonstrating a need to identify the components that are required to achieve such results.   However, The Patient Centered Primary Care Collaborative Chief Executive Marci Neilson noted that the studies are showing promise as Blue Cross Blue Shield of Michigan demonstrated a $155 Million savings in Emergency Room Visits and Hospitalization through their Medical Home Program last year.   So here’s what I have to say to the Senate: WAKE UP… the people providing the knowledge and structure to the programs now receiving accolades from the media cut their teeth in North Carolina through a fifteen year joint effort between public and private industry. Then, after receiving national recognition they were asked to teach other States the basics of the Medical Home that will reduce cost and improve health outcomes.

  1. Local control with State support
  2. Physician directed care
  3. ACCURATE DATA published frequently, reviewed frequently, converted to focused interventions
  4. Care Coordination and patient education from within the physicians practice
  5. Frequent regional meetings to review success and make adjustments to work-flow and design.

Here is an example from years ago in Greensboro (CCNC ORAL REHYDRATION PROGRAM)  

  • The local Community Care Network discovered that many emergency room admissions were attributed to children experiencing dehydration when they had GI Flu.
  • The CCNC Network (Partnership 4 Health) created an oral rehydration program where they reached out to the community of working mothers who would come home to a child experiencing diarrhea and vomiting.
  • As they engaged the family they taught the mothers to rehydrate their children using pedialyte.
  • They distrusted the rehydration kits to physician practices, public health departments and elsewhere.
  • The people started treating their children at home as opposed to the emergency room.
  • The Medicaid emergency department visit rate for GI distress fell and the tax-payers saved money.
  • All of this with happier children as the most important outcome in my opinion.

So what do you think NC Senate?   How about we keep what works!!! If you need further illustration there are a few thousand of us who would be pleased to teach you: Republicans, Democrats, and Independents alike. 

From the front lines in North Carolina’s debate over human equality

I am so sad to see the level of intentional prejudice in this State.

Here is todays local television coverage of the closure of a critical access hospital (CAH). CAH’s are placed in rural areas throughout the USA and exist strictly to provide life saving healthcare to sparsely populated areas (usually agricultural).

This event is blamed on a corporation “Vidant Health”

In reality, it is not the fault of a corporation; or the pharmaceutical industry, or publicly funded healthcare, or the insurance industry; or the doctors; or your dog.

This is a collapse of civilization. In NC, we have decided to stop caring for those in the lower socioeconomic classes. We have proven this through our elected officials. So the fault lies with us and every life that is lost in transit to hospitals 45 minutes away is our responsibility.

You see:

The Affordable Care Act found the money to expand Medicaid and provide coverage for those with incomes less than 200% of Federal Poverty Level (about $28,000). In doing this, the cost of insurance polices through exchanges decreases. This has been proven in States that accepted Medicaid expansion funding. North Carolina did not.

The money for expanding Medicaid is partially funded by eliminating the large disproportionate share payments to critical access hospitals. You see, they would now bill Medicaid.

Well, NC did not accept the money as a “Statement of our conservative believe in small government”.

Now the hospitals are closing.

Here are my comments to our State Health News today, and more will come of this situation as you watch it play out on the national front. You will note that the good people are here. They are just under-represented.

  1. Very sad indeed. Within the last week the following has occurred in my personal world of chronic disease management: 1) the endocrinology group that fills the diabetes management subspecialty role for many Medicaid diabetics in the RTP area has stopped taking these patients and (according to my personal MD) they plan to discontinue services for existing patients on Medicaid. 2) The behavioral health group that treats many of the same diabetics for depression has dropped away from their care-team roll as they too are no longer accepting payment from Medicaid.

    Meanwhile, back in the grass roots of Johnston County we have been blessed by three Raleigh Retina Specialists who are willing to continue treating Medicaid patients. This includes visits, laser procedures, vitreal injections for macular edema etc. I begged them not to drop the Diabetes Eyesight Preservation program at Taylor Retina Center and their response was clear: Are you kidding Jeff, we will turn no-one away, this is a serious disease and far too many preventable vision related disability cases are missed.
    A Heart-Felt Hooray for the Good Guys.

    I wish the NC voters could understand the magnitude of dishonesty between legislators and their constituents. I have worked directly with past external review actuaries including Mercer when determining the return or loss associated with NC Managed Care through their CCNC program. The level of detail, down to the adjustment for illness burden and months of enrollment in Medicaid proved to me the sincerity and accuracy of the folks charged with program evaluation. Later (2006-2010) the program and its outcome data were modeled in many States around the country.

    Yet when attending a Medicaid public forum I witnessed a NC employee from the budget office explain away all cost efficiencies by pointing to differences in the percentage of the NC population that are children in contrast with other States. Such an illinformed if not ignorant piece of information to share with the GA. This comment was made as I sat next to a former legislator who is a surgeon. I described the inaccuracy to him and said they may want to get some help with interpreting the data reported on Medicaid estimates. After a few more minutes discussing evaluation methodologies he looked at me and admitted ” We really do not know what questions to ask”.
    I testify to the truth of this statement further acknowledge that it is mine alone.

More on the land of Oz (North Carolina)

Heck! With health insurance we can afford a cup of coffee!

Heck! With health insurance we can afford a cup of coffee!

It is so unfortunate that the Senate has demonstrated such ignorance of the systems in NC that have provided frequently cited information on the cost benefit associated with Medical Homes.

I came here in 2001 to work with Community Care of NC following the sale of my company to Aetna Health. The technology we sold allowed Medicare Advantage Programs to identify, target and engage at-risk seniors through referral to primary care case management. It was clear at that time that the lessons learned from the world of HMO managed care had reached the end of their useful life as physicians had learned about the concepts of cost control through limiting redundant procedures and using evidence based guidelines in the 1980’s. The 1990’s brought us minimal returns in Disease Management which was the initial model deployed by Carolina Access’s efforts in Asthma and Diabetes population management activities. Those in the US that were on the cusp of ‘the next big thing’ were organizing for Primary Care Case Management through regional networks. I had spent 1999-2001 making presentations to the likes of Aetna, United Health Care, PACE and Empire Blue Cross to sell our intellectual property. If the commercial insurance industry understood the value of the marriage of technology with Medical Homes in 2001 it was a sure bet that our entire delivery system was on the verge of major payment reform.

Having had these successes in the private sector, my wife and I moved to NC after learning about the evolving Medicaid program which ultimately was titled Community Care of NC. We had a sincere desire to see a replication of a successful private industry venture through the public systems of care.

Since I was from the ‘evil private sector ‘I often heard ridicule from folks working in public programs here in NC. However; the willingness of these people to adopt information technologies that would increase their understanding of the Medicaid population and facilitate the design of delivery systems to tackle specific risks for the State of NC and separate regionally-managed community centered action plans for twelve regional networks was undoubtedly supported by the experts and General Assembly alike. Since that time it has become clear to all who work in the field of population health and disease management that the involvement of local providers, patients, payers and institutions in the creation of these programs is critical to the success in terms of both return on investment and quality of care.

So here we are: Those of us fortunate enough to work with these teams learned many lessons. When I left CCNC in 2006 I worked nationally, implementing similar programs across multiple states. I frequently heard how impressed various leaders in healthcare were with North Carolina’s success at improving the health of persons with diabetes and asthma as well as making a significant dent in the inflation rate in NC Medicaid when compared with other States.

So why would the Senate disband a working solution. I witnessed the reports from various budget experts at the public forums held last spring and noted a general lack of proper methodology when reporting cost data. For example: There was no evidence of proper control group selection and illness burden adjustment. When I stated to a former Senate member who happened to be a surgeon the errors in the reports used by the committee to compare cost benefit he agreed with me and stated “We really are not sure what questions to ask”: Yet the citizens of NC place their trust in this group to reform Medicaid.

Of course, when the public was asked for input, the decision was made to keep the existing program. Obviously many became clearer on the benefits. Then, out of left field comes enough controversy and distrust to once again, throw out the baby with the bath water.

Now that I am retired the muzzle of political correctness is no longer relevant. So here is some more feedback that is based on actual happenings in my life since working in NC.

I returned two weeks ago from the Patient Centered Primary Care Collaborative, a 10 year old group spawned from the private sector in response to the escalating costs of care in this country along with the fact that we are rated far down the line in healthcare outcomes when compared with at least seven other industrialized nations; few of whom conform to what we like to think of as traditional socialist thinking. I hold a co-chair position with this group and have gratitude for hearing the current thinking of the ‘best and brightest’   a club of economists and CEOs which I certainly do not qualify for membership.

During the conference a lead executive in a fortune 100 company along with several others from other organizations respected by all who read the Wall Street Journal told me that he had been asked to consult with the Governor’s office after the GA changed its mind about Medicaid outsourcing. He asked me what I thought and I gave him feedback on my personal observations of the successes achieved by Community Care of NC and told him a story about a similar plan assembled in Chicago in 2007 where I had a consulting contract. The Chicago plan failed since the commercial HMO and technology vendor had not developed succinct written requirements. I recall the meetings as if they were yesterday: Especially the frustration I exhibited in public when I found out that the HMO had not connected with the Medicaid primary care providers in Chicago prior to submitting their proposal. So here I had evidence of a public –private partnership success story in NC and private failure in Chicago.

My business friends that had reviewed the politics and business cases in NC for our Governor had all recommended that the State keep CCNC and the Accountable Care Organization models that had been promised only two months ago. Unfortunately their actual comment to me was: “Sorry Jeff, we do not understand the logic, the drivers appear to be something other than cost and quality. Perhaps it is time for you to leave.

What more can I say. The Senate’s budget is counter-intuitive yet those who are emotionally trapped by their opinions concerning the ACA seem unwilling to discuss the details as to why it makes no sense.

Does the GA realize that the Triad had a huge problem with mothers using the emergency room when their children became dehydrated from GI influenza and that the local CCNC network assembled a clinic to educate mothers to master the task of orally rehydrating their kids when they were sick which brought down the ER visit rate to almost nil?  How do they think an HMO will be able to address local needs with such specific detail and provide educational resources?

I have had diabetes for 48 years. I remember when Blue Cross sent my refrigerator magnets to remind me to have tests performed and monitor my blood-sugar. I have no idea how much my employer paid for that Disease Management Service but I do know that I had to argue for my insulin pump in 1984: The one tool that I attribute my lifespan to today.

I will close with this:

For the last six months I have been working with some private practice ophthalmologists who are willing to treat Medicaid diabetics. Many specialists will not treat Medicaid patients due to the lower reimbursement but these folks are a dream team. I assembled a program description and took it to the NC Medicaid Medical Home leadership to get their feedback. They were very pleased to see local people getting involved with creating specialty networks that would treat their patients. Why? Well we have a problem with diabetics becoming blind if they are on Medicaid due to inadequate access to specialty care. So here I was offering a bundled service at ½ the commercial rate charged by the hospital next door.

Unfortunately, I have had to place the project on hold. One of our major criteria for inclusion in the retina service for diabetics is that they are tethered to a Medical Home. As of a few weeks ago I can no longer assume we will have a relationship with a Medical Home enterprise.

NC Legislature Let-Down

cmis_use“I thought we were going to keep what worked?”

The NC General Assembly, as an independent move regardless of feedback from their electorate, physicians, Medicaid program evaluation programs is moving forward with plans to throw the baby out with the bath water. www.NC Health News May 30, 2014.

It is a sad moment indeed to see the citizens of NC exploited by their General Assembly. As a person who has had diabetes for 47 of 57 years. As a person who spent 15 years traveling the US assisting “the hired guns of the assembly” win bids for population care management under capitation I can attest to the trickery in numbers, computer vapor-ware and conveniently forgotten success of in-place efforts between 1990 and now.

The GA will find data to back their claims of NC Medicaid efforts failure to improve quality and decrease cost. When I attended the Medicaid reform meeting in Raleigh, I sat next to a former legislator who was also an MD. The NC Budget office had just finished describing that NC Medicaid’s claimed savings was a result of unfair comparison to other States with a different % of children in the program. I informed the man that the approach used was inaccurate and that the Office of Rural Health had gone to the extremes of analyzing differences in utilization between the States CCNC Medical Home program and Fee for Service basic Medicaid. These extremes included using well-recognized illness burden modeling tools that are commonly used by the best healthcare economists in the US. There has never been any doubt that the program in place through CCNC was effective.

My wife and I moved here in 2001 after the sales of our company to a commercial insurance disease management vendor. The vendor “Active Health Management” then sold itself to Aetna. Aetna insures over 20 million individuals. I had read about the pioneering efforts of Mr. James Bernstein’s Community Care of NC program (then called Access 2 now called CCNC): A program which challenges each region to self-determine areas needing improvement in healthcare processes by carefully examining their own data. Then the CCNC program aligns State DHHS resources with local providers to work together to accomplish documented goals as guided by industry standard project plans. I moved here to work with CCNC as the opportunity to learn from the best and take part in the reform we need was enticing. These were the people that had been trained in the Nation’s best public health graduate education programs. Many of the from our own UNC.

NC was one of a few States that knew of the few simple aspects of care necessary to reduce the rate of inflation in health spending. While the rest of the country was wasting money on Disease Management Programs sold by private industry CCNC and DMA had the foresight to understand that you can only make these improvements through local partnership. The basis of change is multi-pronged including these objectives: 1) Patients receive incentive to contact their primary care docs before going to an emergency room, 2) care managers to assist the 20% of the population spending 80% of the resources choose the correct care and engage in self – management and the creation of patient centered care plans that addresses all barriers to health including transportation issues to and from medical appointments and compliance with medication use for chronic conditions.

These are the things that the most respected professionals in the USA teach states that need help. Funny that some of NCs current Medicaid CCNC leadership are invited to other states to educate their legislature on how to reform Medicaid to demonstrate methods to a) find, engage and treat the highest cost, sickest people in the insurance pool; b) engage patients in managing their own illness as Greensboro did when it taught mothers how to hydrate their children instead of visiting the ER and c) reduce the threat to the States economy.

All of this published by the National Institute for Health Improvement Triple Aim measures to improve our Nations Health, our satisfaction with the system in general and lower the cost per person/year.

So here you are NC, years of recognized success; national awards for design; a web-native care coordination platform which allows any professional to view the patients history of treatment, list of problems and medications along with the published, evidenced based goals that the patient and treating team are working toward; a physician portal allowing physicians to review their improvement success and areas where they can tighten up their practice; a portal allowing physicians to contrast their performance against their peers setting the stage for friendly competition: Virtually all of the tools that the supposed consultants will tell the legislature they need.

The IT infrastructure for N3CN’s data center which houses the web-applications noted above along with the support staff to address the needs of 14 networks caring for over 1 million North Carolina citizens has over 300 simultaneous users including case managers and physicians and meets HIPAA security standards. It allows the professional to access critical information in a time of acute need; something the States hospitals are just now implementing and still have not agreed to share information on the NCHIE. It was designed and implemented for a fraction of the cost of commercial systems using a public-private partnership model. Does anyone know about this?

So, we have a nationally recognized program, we have nationally recognized population health management information system architecture, we have healthier diabetics and asthmatics and those of us who worked in the system that actually know something about medicine and being a patient are asked to be panel speakers in regional US conferences on Patient Centered Care somehow get discounted by a General Assembly without the skills to understand the nature of the problem. I know this since the person sitting next to me in the Medicaid open forum told me “we do not understand the data” when I asked him if he needed some help to tease out fact from fiction.

The N3CN organization is positioned with others to take accountability for the population that the assembly is concerned about. Functioning as ACO for multiple commuted local networks is a dreamlike structure that many states would pay millions to introduce. You see, we not only have the knowledge and technology, we have the countless life years of experience in our native state: but instead, the GA wants to hire nurses to call me from California to discuss my diabetes management issues and send me a nice refrigerator magnet and new web-site to track my health. Unfortunately it wont talk to my Duke, UNC, Federal Blue Button website when I start Medicare this year.

Wow!!!!!!!!!

HIT at its best

Check out Telcare Cellular Enabled Diabetes Management Platform.

Now we have a example of a technology applied to address consumer and physician hassles.

One device for measuring, cloud storage, analysis and communication for the patient.

For the doctor: This could be the ultimate registry platform for diabetes specialists.

I am pumped…..well I use a pump but I was referring to something else.

Telcare.

Seeing the Invisible: Desperate for dental work, an all-night wait

Seeing the Invisible: Desperate for dental work, an all-night wait | Seeing the invisible | NewsObserver.com

 

The invisible North Carolinian waits in line for relief of pain

From Raleigh News and Observer Sunday August 25, 2013

 

I beg all to share this article on our dental care system in. North Carolina. This is only one example of a crumbling infrastructure as the policy makers in Raleigh decide to not accept solutions.

 

Since election of new state legislature and GOVERNOR MCCRORY

Highest unemployment rate:

  • Decision to end extended unemployment

Lowest teacher pay

  • No pay increase.
  • Yet. Pay to Governor Staff increased to $120K as he states “they need a livable wage”.

One of the most notable Medicaid Primary Care systems in the country with improvement in health quality and reduction in health cost for many years now.

  • Yet the legislature and Gov. decide to not accept sustainable Federal reimbursement for increasing enrollment in Medicaid, making healthcare unavailable to 500,000 people.

Reduction in substance abuse detoxification beds

  • Yet we have some of the highest rates of addiction and alcohol related teenage fatalities in the US.

Stipend for food stamps…..nah

Need so many papers to vote; it is as difficult as my Jewish relatives’ attempts to leave Germany in 1943.

Decision to not create a health exchange leaving a 3 company oligopoly to set insurance rates due to lack of competition.

The people standing in line for dental care in this photo are our neighbors. Can you imagine needing a root canal, being unable to eat, experiencing severe pain every time you had a drink of soda? Then being denied care?

Is this how it was in the 30’s Dad?

 HELP! The new Director of HHS has hired a 24 year-old with no experience in Public Health to be her policy adviser and his salary is $85,000; more than twice the pay of a teacher with a master’s degree.

Oh yeah, we won’t pay salary differential to teachers who achieve graduate level degree in education!

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Seeing the Invisible: Desperate for dental work, an all-night wait | Seeing the invisible | NewsObserver.com.