Untangled Health

Consumers Unite To Drive The Changes We Need

Tag: #let’s talk cost

21st Century Cures Act Trusted Exchange Framework and Common Agreement Kick-Off Meeting

Listening to a Webinar produced by the ONC (Office of National Coordinator for HIT) today I was content to hear about the progress of SHIEC (Strategic Health Information Exchange Collaborative) and NATE  (National Association for Trusted Exchange) during the morning review of National Trust Frameworks and Network-to-Network Connectivity.

It is clear that consumer need is receiving attention: We are far behind the curve wherein we have vocalized our frustration with barriers to accessing our  personal health information  and the industry is listening.

Keep in mind that you are the “master of your destiny”  and “captain of your ship” when it comes to assuring you receive the Right Care, from the Right People in the Right Place at the Right Time. Self-knowledge and System-Knowledge are your keys to success.

Best summarized by Cynthia Fisher the founding angel of ViaCord at the end of the morning session: “Patients are bound to institutions that have the keys to their data and are expected to write a blank check for services with no visibility of cost”. Passionately reflecting on the plentiful gaps in the information used to make critical health care decisions during our encounters with providers throughout the healthcare system, she said; “Healthcare Data is like a Liquid Asset; it needs to flow!”

Keep your eye on the target friends: The day when you are trusted to exercise your right to control both ownership and flow of the information that your life depends on!

Jeffrey

ONC Patient’s and Families 

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

Community Care of North Carolina goes for the gold: Proving valid reduction in hospitalization among Medicaid enrollees with Chronic Disease

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

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

I have not been posting much lately due to activities with the Patient Centered Primary Care Collaborative. We are working on an analysis of accreditation standards which will ultimately be used to verify Medical Home processes, procedures and clinical outcomes. Check out their website as you consumer types will have a chance to see what others are doing for you to assure you access to the best in health care as we reform the system over the next few decades.

I am very enthusiastic these days as I am seeing the changes I have hoped for my entire life as person with diabetes since 1966. As a child my doctor was always available to teach how to master my illness and provide tips with mechanisms I could use to reduce my cost: especially when I entered college. My docs have been so cool, I can never adequately thank them. Purchasing a glucometer and testing reagents for me when I was uninsured; providing free laser therapy when my employer dumped the plan I had in favor of becoming self insured. If you want an interesting read see an old post of mine titled Physician heroes.

Today I call your attention to Community Care of NC. The organization that employed me as their clinical informatics lead back in 2002. These folks are using a model of population management and patient care that I had seen work in Massachusetts in the 1990s. To that end my wife and I moved here in 2001 to work for CCNC. They use a centralized partnership between private healthcare industry and public agencies including Medicaid, Public Health, Mental Health and Substance Abuse Services, the NC Medical Society and the local branch or thee Academy of Family Physicians.

The central teams keep improving patient targeting and clinical outcomes analysis using a variety of statistical sources and deliver regionalized community information from 12 different 501c3 Community Care Networks. The individual Networks then put care coordinators, case managers, pharmacists and administrative staff in place to create local flavors of patient centered care. All have guiding physician committees and other staff who collaborate with subspecialists as well as local hospitals. The net result is a care continuum surrounding the sickest individuals where the team focuses on goals set by the patient, their family and the team. They have been doing this for fifteen years now and I can attest to the fact that they are one of only a few Patient Centered Medical Home Networks in the country that are using a web-native care plan accessible to all on the patient team as well as multiple other physician practice improvement web apps totally focused on education, assessment of each doctors population and measurement of patient outcome.

This week they published the proof in the pudding. After long struggles against threats to defund the program they survived. They are now audited in full and have demonstrated hospital utilization rates falling at 10% per year in the chronic disease population. We are talking HUNDREDS of MILLIONS of DOLLARS in savings folks on top of hugely improved clinical outcomes and patient satisfaction with their sense of well-being.

I have always said that I needed a lot of help in my life. Since I knew how to assemble a care team for myself I figured I may as well help others do the same. Today, in 2015 we have the mechanisms in play to reconnect patients with their physicians. Please step up and teach your docs about your needs, wants and struggles as it will take us a while to walk out of the woods.

nc hospitalization trends under CCNC

Patient commits suicide faulting pharmaceutical prior authorization rules as the cause.

Many untold stories

 

Patient commits suicide claiming prior authorization pharmaceutical rules as the cause.

Melt down, do you ever have them?

Well I will share mine with the world in this very moment.

I have carried hepatitis c for thirty-eight years now. That is until two days ago when my blood work returned the result of no detectable virus.

My family’s cheer is magnificent as everyone had considered this diagnosis to be the reason for my premature demise.

The medication I am taking (Harvoni) was approved for 90 days by the Federal Blue Cross program and I am now completing the second month of therapy. The protocol calls for 12 weeks of therapy due to a history of viral re-emergence using an 8 week protocol. We were lucky to get the medication as one course of therapy is $100,000! That is in the USA of course. In Egypt it is $1000.

CVS Care Mark was denied my refill as the date of the prior authorization expiration is tomorrow. That’s right TOMORROW!!!

It turns out that the Blue Cross administered program has a 24 hour lead time required for refills. Their internal processes begin flagging patients for cancellation one day before the actual term date!

So here I sit, just another patient with a life threatening illness who was given the hope of cure one week ago and now is pedaling as fast as he can to get help from his physician to extend the authorization of a medicine that is –on paper- still authorized!

They tell us patients with chronic disease that we are subject to depression. Feelings of hopelessness, loss of energy, inability to concentrate, suicidal ideation: Well I have all of them now. After 48 years of chronic disease, a 33 year career in healthcare where I operated at executive levels high enough to find out some ‘very ugly truths’ regarding this sector of the free market I feel ready to throw in the towel.

So for the next generation of patients: know this…you are on your own. This means it is up to you to find the best team of physicians, nurses, employers, insurance companies and friends to respond to your needs. It will be up to you to command them. It is time to stop being a passenger in the system.

I am the captain of my vessel. I have a wonderful team who is trying their hardest to get me the final dose of medication needed to save my life. I have just been wounded brother and sister so I will lay here for a while and bleed. Then –with your help; I will stand-up and continue telling my truth.

The truth that spills forth in the form of factual events involving actual people making life and death decisions has been held back until this point. I still try to earn a few dollars in the industry and do not want to become one of the untouchables. Perhaps it is time to execute my right to free speech.

When I am done I will rest and figure out another strategy for supplemental income in retirement.  It might be time to close this chapter and dance.

NC Continues to brainwash its citizens

 

We are dropped from the universe into loving hands (unfortunately not for all though)

We are dropped from the universe into loving hands (unfortunately not for all though)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is a recent opinion from Brian Balfour of Raleigh’s Civitas Institute. My response follows.

From Raleigh News and Observer Saturday December 28, 2014

Last week, yet another study claiming that expanding Medicaid in North Carolina would create tens of thousands of jobs was released and dutifully reported by the media. The findings of such studies, however, are based upon a fatally flawed assumption that Medicaid coverage equates to access to medical care.

The latest report, produced by George Washington University researchers, declares that North Carolina will miss out on 43,000 jobs in the next five years, along with $21 billion in federal money, if it continues to refuse Medicaid expansion as prescribed in Obamacare. The study’s findings largely echo other recent reports, such as a January study produced by the North Carolina Institute of Medicine that came to similar conclusions.

The job growth claims are based on the state’s “drawing down” additional federal funds due to Medicaid expansion. As the GWU report describes, “Since most of the cost of a Medicaid expansion would be borne by the federal government, expansion would result in billions of dollars in additional federal funding flowing into North Carolina. These funds will initially be paid to health care providers, such as hospitals, clinics or pharmacies, as health care payments for Medicaid services.”

This income received by health care providers is then spent on suppliers (such as medicine, medical supplies) and in their community on goods and services such as groceries, clothes and movies.

The fatal flaw in this methodology, however, is that in order to “draw down” federal Medicaid dollars, actual medical services need to be provided to Medicaid patients. It is only when doctors actually treat Medicaid patients that the federal government pays those providers for the services.

 

For instance, the NCIOM study assumes that more than 500,000 North Carolinians will not only enroll in Medicaid under expansion, but each would receive on average roughly $4,300 in medical services each year. As these services are rendered, the doctors and hospitals are paid by the federal Medicaid program, which injects the money into the state’s economy and spurs the job creation, according to the studies.

But here’s where the studies’ jobs claims fall apart: North Carolina already suffers from a shortage of doctors.

According to federal guidelines, 78 counties in North Carolina qualify as Health Professional Shortage Areas because of shortages of primary medical care doctors. And the problem is getting worse. According to the Shep’s Center for Health Services Research at UNC-Chapel Hill, North Carolina’s supply of primary care physicians is dwindling, dropping from 9.4 per 10,000 people in 2010 to 7.9 doctors per 10,000 people in 2011.

Indeed, a 2011 survey by the Association of American Medical Colleges found that only 15 states have fewer primary care physicians per capita than North Carolina. The doctor shortage is especially pronounced in the state’s rural areas, where there is a greater concentration of Medicaid enrollees as a share of the population.

And more to the point, not only is there a general doctor shortage in North Carolina, there is a shortage of doctors accepting Medicaid patients.

Medicaid roles in North Carolina have ballooned from about 1 million in 2003 to roughly 1.7 million today. Adding another 500,000 would push the program over 2 million enrollees and mark more than a million new Medicaid patients in a dozen years.

All this would take place when the number of physicians accepting Medicaid patients is dwindling.

Imagine adding since 2003 the equivalent of the entire population of Wake County to a group of people fighting over a shrinking pool of doctors. Making matters worse, a 2012 article in Health Affairs found that one-fourth of North Carolina’s physicians will not take any new Medicaid patients.

In short, there simply is not nearly enough doctors to meet the demand, and things could get worse.

As reported recently by WRAL, “A survey this year by The Physicians Foundation found that 81 percent of doctors describe themselves as either over-extended or at full capacity, and 44 percent said they planned to cut back on the number of patients they see, retire, work part-time or close their practice to new patients.”

Such extreme supply constraints tells us that if North Carolina were to expand Medicaid, the newly enrolled would have great difficulty actually seeing a doctor. Coverage will not equal access.

If new enrollees in the already overcrowded Medicaid program don’t have access to care, then there won’t be any services provided. With no services provided, no federal dollars are “drawn down” to Medicaid providers. The whole premise behind the studies purporting to show job creation is unsupportable.

Brian Balfour is policy director of the Civitas Institute in Raleigh.

Read more here: http://www.newsobserver.com/2014/12/26/4427841/why-medicaid-expansion-wont-boost.html?sp=/99/108/#storylink=cpy

 

 

Untangled Health’s Response

Jeffrey Harris · Consultant Community Medical Home Implementation: PCPCC Co-Chair e-Health Group; Director Diabetes Eyesight Preservation Program Taylor Retina Center
I am writing In response to Brian Balfour’ opinion on the relationship between expanding Medicaid in NC and job growth on Saturday December 28, 2014.

The man standing next to me in Church in Four Oaks NC in 2011 said; “you must have sugar”; as he observed me checking my blood with a finger stick. “Sure do brother I said, since the age of 10, this is my 44th year with diabetes, I assume you have the disease also.” “Sure do, runs in my family: I am scheduled to have several toes amputated next week.” I could not help but notice the soft cast and bandage on his leg and told him I was sorry that he had to be the victim of such an avoidable circumstance. “Avoidable?” he said; this happens to everyone in my family; we all assume it is par for the course.”
These are the people who would receive coverage under Medicaid expansion should NC decide to follow the recommendation of the Federal Government under the Affordable Care Act. In fact, more than 400,000 of these people who are presently uninsured would have a source of payment for Medical Care. I know them well as I was one and if not for the generosity of friends would have gone without insulin on several occasions in my life.
On Saturday, Brian Balfour, policy director of the Civitas Institute in Raleigh demonstrated a common misunderstanding of health economics. He states NC will not expand Jobs through accepting Federal Medicaid expansion money because we historically have underserved areas with few physicians who cannot expand their caseloads. I guess this means that in a free market society if a geographical area in need of services receives funding and resources to increase their supply of services that the suppliers of such services (Community Clinics, Medical Schools) will not increase the capacity of the delivery system?
Mr. Balfour further fails to recognize that these patients are already receiving treatment often for free in local emergency departments, further inflating the cost of healthcare to the insured.
By the way, Mr. Balfour fails to recognize that North Carolina wrote the book on how to provide Medicaid coordinated care through a Primary Care Medical home which has served as the ‘how-to’ guide for numerous other states (Community Care of NC).
Let’s see: Where Mr. Balfour is correct with regard to our need to expand the number of primary care physicians we have multiple mechanisms in place through ACA that are making the profession of primary care medicine much more attractive. I point the reader to one of many publications demonstrating the return on investment for engaging individuals in patient centered primary care Profiles in interprofessional health training. Since President Bush called for the adoption of electronic health record technology we are now well passed the early adopter stage of connected information systems that allow us to find large segments of our population that require access to specialty care thereby prospectively catching the crisis before it occurs and saving all stakeholders time and money; but more importantly mitigating the risk for the permanent suffering that arises from poorly managed chronic disease. Telemedicine is now a recognized intervention and carries a reasonable fee for patients and doctors to feel as though they receive a fair exchange in value (wellness for the patient and salary’s for the doctor’s practice). One thing any student of economics learns is that investments in technology and advancements in process favor a positive shift in the supply demand curve and its derivative…productivity. Let me recap: New tech, new care coordinating jobs, new analysts’ jobs = MORE JOBS!
In my work I spend a great deal of time assisting the public with the interpretation of so-called facts and opinions arising through think-tanks and praised by the media. I am confident in my judgment that NC Medicaid should expand in accordance with ACA policy. So are the Vice President of the IBM Global Health Initiative, our Governor and every other well versed healthcare economist regardless of political party affiliation. I suggest you do some of your own reading (reports vs opinions like mine). Good luck to my 400000 friends that are deprived of fair health care services when they are ill.
One more thing:
Physicians are willing to treat Medicaid patients. I spend my time looking for specialty care. And have located retina surgeons willing to treat diabetics regardless of funding: Simply to preserve eyesight.
Jeffrey Harris
Consulting Program Manager Taylor Retinal Center
Co-Chair Patient Centered Primary Care Collaborative Washington DC

A Chronic Disease Patient Reports On e-HR and p-HR utility

 

Reconciling data in my six health portals

Reconciling data in my six health portals

I will be attending the PCPCC annual conference next week and moderating a session on Do It Yourself Primary Care Medical Homes.

Most of my time of late has been attending to my ‘case’ as the demands of self-management are now more complex with the advent of new tools which were to lighten our load. Nowadays I spend at lease two hours each week keeping my 4 p-HRs up to date across four specialty physicians.

Why you ask? Well it appears that someone forgot to turn on the ‘interoperability switch’. I am sure it is here somewhere, I just can’t find it. I know the standards were written for certification purposes, I even have a copy of them. For some reason, here in metropolitan RTP North Carolina: Duke, Wake Med and UNC have all established contracts with Epic. The physicians that I use are independent and they have all chosen AllSCRIPTS and this is my patient experience.

NOTHING CONNECTS

I HAVE AN EPIC MY CHART PORTAL AT UNC

I HAVE ANOTHER EPIC MYCHART PORTAL AT DUKE

I HAVE AN ALLSCRIPTS-MEDFUSION PORTAl AT GARNER INTERNAL MEDICINE

I HAVE AN ALLSCRIPTS MEDFUSION PORTAL AT SOUTHERN DERMATOLOGY

I HAVE AN ALLSCRIPTS PORTAL WITH NO MED FUSION AT NC CARDIOLOGY

I HAVE AN ALLSCRIPTS PORTAL WITH NO MED FUSION AT MY ENDOCRINOLOGIST

I HAVE A HEALTHVAULT PORTAL ATTACHED TO LABCORP AND SURESCRIPTS

 I AM UNABLE TO TRANSFER CCR S BETWEEN RECORDS

THE FACILITIES ARE NOT TRANSFERRING THE RECORDS

OUR TAXPAYERS SUPPOSEDLY BUILT THE NCHIE TO CONNECT TO ALL PROVIDERS

I started out on this journey to reduce errors in medicine in 1997. Why are we still here? Please don’t blame it on Obama, Bush, Clinton; well you get the picture.

Here is my ‘secure message’ to my Medical Home

My recent note to my PCMH

My recent note to my PCMH

 

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.

Not an insurance company, just an empowered consumer.

Hopeful

Hopeful

My report for today:

Helped one more person register his family for an affordable insurance product using Healthcare.gov

Sequence

Met friend at 4:00 for dinner prior to our club meeting. Turn’s out he is lost in acronyms and asked for help.

Over the course of the next four hours we improved his ability to self-advocate, submitted an application and lessened his anger and fear of OBAMACARE.

My objective was met by my friends eloquent ability to inform his teacher of the many reasons OBAMACARE should have never been named OBAMACARE and his understanding of healthcare as it differed from earlier in the day when he could only think of it as “the monthly premium “or the cost of a subspecialists co-pay”; or “a communist scam”.

We ended the night with one happy conservative family man receiving a quote for his silver policy for a family of three. The monthly premium is $200 less than last years and his services have increased.

As we concluded the evening he asked if I ever thought of inventing a software program that would track all important health information for patients.  He had evidently been responsible for a $4000 co-pay on an $18,000 ER visit for chest-pain. This was mostly due to his inability to articulate a thorough history to the doctors on staff.

I described to him the importance of maintaining a relationship with a primary care physician and then logged on to MyHealthRecord at Duke and MS Health-Vault to demonstrate the rather rough but much better communication I had with my physicians and interoperability of pharmacy and EMR systems. Then I described how these data could be used to empower a person in an emergency with timely and acurate information. His conclusion: Jeesh, I probably would not have needed the expensive work-up if the doctors had access to all these studies!

One more convert.

So little time….

But one more convert.

Tomorrow’s agenda: Meet with ophthalmology practice to organize diabetic eyesight preservation program for non-Medicaid, uninsured folks in NC. So far, I have the cost of a vitrectomy reduced from $12000 at a local hospital to $4800. Not bad for a days work!

Jeff Harris

Not an insurance company, just an empowered consumer.

Duke Medicine offers to ‘show interest in my life-goals’ for $1500.00 per year!

 

My medical stuff for a 3 day trip!

My medical stuff for a 3 day trip!

February 2013

Last month my father called and complained of being ‘dumped by his primary care physician of 25 years unless he was able to pay an additional $2000.00 per year for concierge services. He said: “Jeff, Dr. Xxx’s nurse called and said that this new program would assure 30 minute follow-up appointments and 60 minute annual evaluations along with a 24 hour, 7 day per week personal communication with the primary care physicians in the practice. I told dad to pay the fee since he could afford it. With disgust, my 84 year-old father and former career NASA aerospace engineer told his Dr. to stick it where the sun doesn’t shine.

Then; on a personal level: I started visiting the Duke Integrative Primary Care program. They have made wonderful changes to my treatment after uncovering several unknown nutritional and biochemical deficiencies. Unfortunately, they tell me today that they will be pleased to accept my commercial insurance but no Medicaid and no Medicare. They also now require that I pay $1500 per year in addition as a membership to the practice as they are limiting the practice size to 600 patients. The administrative RN tells me that this is the only way I can get the services one would expect from a ‘medical home’ such as appointments of sufficient length to “ADDRESS MY LIFE GOALS”. With a smile, the RN says: “Well, with your background Jeff, you know that it is impossible to do without additional funding”. My response was to illuminate (with colorful words) the purpose and methodology of practice re-design when implementing Medical Homes. I find it hysterical that Duke itself claims to be a leader in their own primary care system in the evolution of Medical Home concepts and adherence to Meaningful Use Criteria. I find it disgusting that their ‘offering’ of this concierge service is really nothing more than what over 3000 physicians have been providing through NC Medicaid’s Community Care of North Carolina contract for a decade. I find it nauseating that we are continuing to squeeze profit from a dwindling consumer base and refusing services which are noted to be ‘best practice’ to the poor. People are people I suppose…and subject to greed.
I am writing this as I leave the Duke Integrative Primary Care clinic today, probably for the last time. These folks diagnosed my metabolic issues and low testosterone: I feel better. If I did not ask for the appointment with my “10 minute visit primary care doctor” she would have never referred me to the clinic. I will now return to her and when I am able to afford it I will return for further investigation and treatment of the many factors that decrease my health related quality of life.

March 2013

Note: I returned to my PCP yesterday March 15th, 2013:

She was angry that I had been placed on testosterone since she had worked me up last year for prostatitis. Had she read the notes in the wonderful e-HR that inter-operates with only duke physicians she would have noted that prostatitis is now ruled out, neurogenic bladder is the new dx and that Dukes own specialty physicians had started testosterone replacement with the intention of having primary care pick up the prescription writing responsibility.

She stated she would not write the prescription.

My next move was to walk her through the notes of the physicians she had referred my case to. I then told her that the Duke Integrative Medical practice would charge me $1500 per year if I needed to return to them for the prescription and that I would leave Duke and her primary care practice if she couldn’t address this with the other doctors on my health team.
My doctor says: “Well why would you leave, what is it that you expect?”
I followed with: “Dr. XXX; I would expect that you would have read the consulting notes prior to entering the exam room so we would not wind up in this tense situation where you are asking me to run all over the locality to describe your directions to my specialists as far as who prescribes what” ”Beyond that, I find your employer ‘Duke Primary Care’ attempting to drive my SSDI money as a private payment to their concierge doctors by not allowing the consulting physician to prescribe medications. In other words, he finds the chronic disease which is treatable with integrative techniques and then refers the patient to the front desk to get them enrolled with the two new primary care physicians in the concierge program.” “Furthermore, not only has this new system of care created a barrier to me getting the medications I need but it has done this by not addressing the educational issues that are clearly needed among their own medical staff.” “Oh yeah, one more thing I realize this is not your fault with the exception that you neglected to read the consult results. I believe this is due to the fact that you carry a case load of 2500 patients and become overwhelmed at times.” “Actually Duke has insulted both you and I. You call me whenever I need you and that is why I choose to be treated by your practice. In my view you have a nice start with your Medical Home right here. But your employer is selling a package wherein they differentiate the offering by noting that the concierge physicians are 1) more available and 2) interested in my ‘life goals’. I realize nothing will happen as a result of this discussion today because it relates to Duke Politics. However, if you think about it we have just touched on: Cost of Care, Quality of Care, Patient Satisfaction, Provider Satisfaction and reputation.”

She nodded, said nothing else; spent ten minutes reading my chart and looked up at me with a sad expression. She apologized for “not getting it right”: I responded with “You did not have enough information, you were not educated as to the changes in program marketing and none of this is your fault.” “I promise you that I will only take medications that are prescribed by you for chronic conditions once I return from the specialty consults. I count on you to interact with my other doctors and resolve conflicts on my medication list; but I need to trust the system of care.”
Dr. XXX of Duke and me are still together, we have agreed to how we will relate in the future and how we will survive in a patient-primary care relationship within the context of the Duke System. I think that what transpired over this last month models patient participation in medical decision making, cost control and providing feedback. I hope that my doctor stays with Duke, it seems their turn-over is quite high. Perhaps they should look at those data!

Dear Brother and Sister Patients,

You will find many physicians not agreeing with me when I state that all should have access to 100% of my health record, care plans and prescriptions. They might further disagree (for legal issues) with owning the responsibility of taking into consideration 100% of available information so may be less supportive of data exchange between electronic medical records. 

Please understand: We, that is you and I paid for a seamless ‘inter-operative healths record through ARRA-HITECH funding. Our purpose in asking for this feature was to make sure we did not fall victim to therapeutic misadventure e.g. a physician prescribing a medication that could interfere with your ‘well-being’. YOU NEED THIS as it is one issue, which we call poly-pharmacy that is responsible for well over 100,000 errors in medical practice per year. 

When your doctor gives you your visit summary which should include a problem list and medication list make sure that it correlates with other doctors in your treating team. You might just save your own life!