Monday, September 28, 2015

Uninsured Rate Drops in All 50 States, Texas Still Last

The number of Americans without health insurance fell in all 50 states and Washington D.C. from 2013 to 2014, according to the United States Census Bureau. The biggest changes occurred in states that chose to expand Medicaid ― including Kentucky, Nevada, and West Virginia ― whose uninsured rates each fell by more than 5 percent.

Texas, however, remains in last place. The Lone Star State saw a modest decrease of 3 percent in its uninsured rate, putting the state at 19.1 percent uninsured ― a far cry from the U.S. average of 11.7 percent.

Click to enlarge.

Read the full report.

Thursday, September 17, 2015

Accountable Care Organizations, Explained

By Jenny Gold
Kaiser Health News

Content provided by Kaiser Health News



One of the main ways the Affordable Care Act seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently. 

The law takes a carrot-and-stick approach by encouraging the formation of accountable care organizations (ACOs) in the Medicare program. Providers make more if they keep their patients healthy. About 6 million Medicare beneficiaries are now in an ACO, and, combined with the private sector, at least 744 organizations have become ACOs since 2011. An estimated 23.5 million Americans are now being served by an ACO. You may even be in one and not know it.

 While ACOs are touted as a way to help fix an inefficient payment system that rewards more, not better, care, some economists warn they could lead to greater consolidation in the health care industry, which could allow some providers to charge more if they’re the only game in town.

 ACOs have become one of the most talked about new ideas in Obamacare. Here are answers to some common questions about how they work:

What is an accountable care organization?

An ACO is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. At the heart of each patient’s care is a primary care physician.

In Obamacare, each ACO has to manage the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years.

Think of it as buying a television, says Harold Miller, president and CEO of the Center for Healthcare Quality & Payment Reform in Pittsburgh, Pa. A TV manufacturer like Sony may contract with many suppliers to build sets. Like Sony does for TVs, Miller says, an ACO brings together the different component parts of care for the patient – primary care, specialists, hospitals, home health care, etc. – and ensures that all of the “parts work well together.”

The problem with most health systems today, Miller says, is that patients are getting each part of their health care separately. “People want to buy individual circuit boards, not a whole TV,” he says. “If we can show them that the TV works better, maybe they’ll buy it,” rather than assembling a patchwork of services themselves.

Why did Congress include ACOs in the law?

As lawmakers searched for ways to reduce the national deficit, Medicare became a prime target. With baby boomers entering retirement age, the costs of caring for elderly and disabled Americans are expected to soar.

The health law created the Medicare Shared Savings Program. In it, ACOs make providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work, they have to seamlessly share information. Those that save money while also meeting quality targets keep a portion of the savings. Providers can choose to be at risk of losing money if they want to aim for a bigger reward, or they can enter the program with no risk at all.

In addition, the Centers for Medicare & Medicaid Services (CMS) created a second strategy, called the Pioneer Program, for high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk.

In 2014, the 20 ACOs in the Medicare Pioneer Program and 333 in the Medicare Shared Savings generated $411 million in total savings but after paying bonuses, the program resulted in a net loss of $2.6 million to the Medicare trust fund. That’s far less than 1 percent of Medicare spending during that period.

Still the program is expected to be expanded and Health and Human Services Secretary Sylvia Burwell has set a goal of tying 50 percent of all traditional Medicare payments to quality or value by 2018 through new payment models, including ACOs.

How are ACOs paid?

In Medicare’s traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. That drives up costs, experts say, by rewarding providers for doing more, even when it’s not needed. ACOs don’t do away with fee for service, but they create an incentive to be more efficient by offering bonuses when providers keep costs down. Doctors and hospitals have to meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers get paid more for keeping their patients healthy and out of the hospital.

If an ACO is unable to save money, it could be stuck with the costs of investments made to improve care, such as adding new nurse care managers. An ACO also may have to pay a penalty if it doesn’t meet performance and savings benchmarks, although few have opted into that program yet. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help them build the infrastructure necessary for coordinated care – a concession the Obama administration made after complaints from rural hospitals.

In 2014, the third year of the Medicare ACO program, 97 ACOs qualified for shared savings payments of more than $422 million.

How do ACOs work for patients?

Doctors and hospitals will likely refer patients to hospitals and specialists within the ACO network. But patients are usually still free to see doctors of their choice outside the network without paying more. Providers who are part of an ACO are required to alert their patients, who can choose to go to another doctor if they are uncomfortable participating. The patient can decline to have his data shared within the ACO.

Who’s in charge — hospitals, doctors or insurers? 

ACOs can include hospitals, specialists, post-acute providers and even private companies like Walgreens. The only must-have element is primary care physicians, who serve as the linchpin of the program.

In private ACOs, insurers can also play a role, though they aren’t in charge of medical care. Some regions of the country, including parts of California, already had large multi-specialty physician groups that became ACOs on their own by networking with neighboring hospitals.

In other regions, large hospital systems are scrambling to buy up physician practices with the goal of becoming ACOs that directly employ the majority of their providers. Because hospitals usually have access to capital, they may have an easier time than doctors in financing the initial investment, for instance to create the electronic record system necessary to track patients.

Some of the largest health insurers in the country, including Humana, UnitedHealth and Aetna, have formed their own ACOs for the private market. Insurers say they are essential to the success of an ACO because they track and collect the data on patients that allow systems to evaluate patient care and report on the results.

If I don’t like HMOs, why should I consider an ACO?

ACOs may sound a lot like health maintenance organizations. “Some people say ACOs are HMOs in drag,” says Kelly Devers, a senior fellow at the Urban Institute. But there are some critical differences – notably, an ACO patient is not required to stay in the network.

Steve Lieberman, a consultant and senior adviser to the Health Policy Project at the Bipartisan Policy Center in Washington, D.C., explains that ACOs aim to replicate “the performance of an HMO” in holding down the cost of care while avoiding “the structural features that give the HMO control over [patient] referral patterns,” which limited patient options and created a consumer backlash in the 1990s.

In addition, unlike HMOs, the ACOs must meet a long list of quality measures to ensure they are not saving money by stinting on necessary care.

What could go wrong?

Many health care economists fear that the race to form ACOs could have a significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs and limit patient choice.

But Lieberman says while ACOs could accelerate the merger trend, consolidations are already “such a powerful and pervasive trend that it’s a little like worrying about the calories I get when I eat the maraschino cherry on top of my hot fudge sundae. It’s a serious public policy issue with or without ACOs.”

Are ACOs the future of health care?

ACOs are already becoming pervasive, but they may be just an interim step on the way to a more efficient American health care system. “ACOs aren’t the end game,” says Chas Roades, chief research officer at The Advisory Board Company in Washington.

One of the key challenges for hospitals and physicians is that the incentives in ACOs are to reduce hospital stays, emergency room visits and expensive specialist and testing services — all the ways that hospitals and physicians make money in the fee-for-service system, explains Roades.

He says the ultimate goal would be for providers to take on full financial responsibility for caring for a population of patients for a fixed payment, but that will require a transition beyond ACOs.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Sunday, September 13, 2015

Celebrate Grandparenting: Stay Healthy With Vaccinations

Grandparents are an important part of children’s lives. Even before grandbabies are born, grandparents can help protect them from disease by getting themselves vaccinated. For Grandparents Day on Sept. 13, Texas Medical Association (TMA) physicians urge grandparents to make sure their shots are up to date.

“Grandparents want what’s best for their grandchildren,” said Katharina Hathaway, MD, a family physician in Austin and a member of TMA’s Be Wise — Immunize Physician Advisory Panel. “Vaccinations can help in two very important ways: preventing grandparents from passing on a potentially deadly illness to a baby and keeping grandparents healthy to keep up with their grandkids.”

Adults may need as many as 10 vaccinations, but two in particular are recommended for seniors: pneumococcal, which prevents infections in the lungs and bloodstream, and meningitis; and zoster, which protects against shingles, a painful rash. Two others are recommended for all adults: a yearly flu shot and a vaccination for pertussis (whooping cough).

Babies under 1 year old are at high risk for catching whooping cough. It is so severe in infants that more than half of babies who get it end up in the hospital with complications like pneumonia. And many of whooping cough’s tiny victims die.

Babies require a series of pertussis vaccinations, so they’re not fully protected until close to 18 months of age. Dr. Hathaway said grandparents can avoid passing on the highly contagious yet preventable whooping cough to newborns by getting vaccinated.

A Tdap vaccination (a combination vaccination that protects against tetanus, diphtheria, and pertussis) is recommended for anyone who will be around a baby, including grandparents. Adolescents and adults should get the shot at least two weeks before visiting the baby to have full protection. Physicians call it “cocooning,” vaccinating those who will be near a vulnerable newborn to surround the infant in a vaccination “cocoon.”

“As we get older, our immune systems tend to weaken,” said Dr. Hathaway. “That means adults need a vaccine boost because they are more prone to catching certain diseases, several of which you can prevent through vaccination.”

Pneumococcal pneumonia, an infection of the lungs, affects about 1 million Americans each year, and sends about half of them to the hospital, according to the Centers for Disease Control and Prevention (CDC). Experts recommend a pneumococcal shot for adults over 65 years and for younger adults with certain health conditions.

A yearly influenza vaccination is recommended for anyone over six months of age. Influenza, or seasonal flu, is especially serious for adults over 65. The CDC says nearly three-quarters of people hospitalized with flu-related illness are 65 or older, and most flu deaths are among elderly people. Two flu vaccines are available for that age group: the regular flu shot or a high-dose version with four times the protection. Ask your doctor which is right for you.

People who have had chickenpox are at risk for getting shingles because the same virus causes both illnesses. Anyone can get shingles after having chickenpox, but the risk increases with age. About half of the 1 million cases each year are in adults age 60 or older, reports the CDC. The zoster vaccine is recommended for adults in this age group to help prevent shingles.

Physicians suggest you check with your doctor to see if your vaccinations are up to date. TMA has published a fact sheet about vaccinations for adults, in English and Spanish.

Wednesday, September 9, 2015

Infographic: Flu Facts

Flu season is just around the corner, and Texas physicians want to remind everyone that your best defense is getting vaccinated. The following TMA infographic illustrates top “flu facts” everyone should know, including the dangers of influenza (it hospitalizes 200,000 people each year), who should get vaccinated (nearly everyone), and what types of vaccines are available (not all include needles!). The graphic also dispels the belief that a flu shot can give you the flu.

Check it out:

See a Spanish language version of this infographic.

Friday, September 4, 2015

Avoid Tragedy – Watch Kids Near Water This Weekend

Labor Day Weekend… summer’s last hurrah. For many Texans the holiday will involve dipping in the lake or pool to cool off and play. But sadly, that’s where most children drown, according to a Texas government agency.  Parents, keep an eye on children around water at all times. Too quickly and easily they can slip beneath the water’s surface before anyone notices. It’s already happened 68 times so far this year.
The state says most kids drown here:
  • Swimming pools (33 child/teen drownings so far in 2015)
  • Natural water bodies like lakes, ponds, etc. (22 drownings)
Don’t let tragedy spoil a fun outing and ruin lives. Read the Texas Department of Family and Protective Services news release, and learn more about protecting kids around water at WatchKidsAroundWater.org.

Thursday, September 3, 2015

Jimmy Carter's Cancer Revelation

By Sid Roberts, MD
Lufkin Radiation Oncologist

This blog post was originally published at the Lufkin Daily News and on Dr. Roberts’ blog.

When a current or former President of the United States has a major health problem, it is international news. And when a former president has cancer, we all take in a collective gasp. Especially when that former President is 90 years old. On August 12, 2015, Jimmy Carter announced that he had cancer.

As an oncologist, I read such announcements with particular interest. I look for certain words or phrases that carry a lot of meaning. According to the New York Times coverage that day, Mr. Carter has a diagnosis of “a spreading cancer that was detected by recent liver surgery.” Already, my antennae went up. No cancer in a 90 year old is good news, but a few are potentially more benign acting – not likely to be fatal – than others. For example, prostate cancer in the elderly may not even need to be treated. But just about any cancer in the liver is extremely serious, no matter what one’s age. The New York Times goes on to say that “a small mass” was removed, as if “small” is any more comforting.

But the next statement attributed to the former president’s office blew me away: “(T)he prognosis is excellent for a full recovery.” Full recovery, in my mind, means cure. What sort of propaganda is this, I wondered.

The Times noted that Mr. Carter has a strong family history of pancreatic cancer; his father and three siblings all died of pancreatic cancer, and his mother had it as well. If he had pancreatic cancer that spread to his liver, prognosis is likely months, with a chance for “full recovery” being zero. Most other metastatic cancers also have a poor prognosis, although time frames can vary. How could I reconcile what I presume medically to be a near zero chance of “full recovery” to a press release predicting an excellent prognosis?

What bothered me in the early discussion was not so much that the news media refused to speculate; that is understandable. But Mr. Carter’s team did a disservice to those who have cancer – and to those of us who treat cancer – by overly reassuring and misleading the public about his condition rather than owning up to it.

Thankfully, that misdirection did not last long. It was announced on August 20, 2015 that Mr. Carter, in fact, had metastatic melanoma. Surely that was known on August 12 (the liver surgery was August 3, after all). At a videotaped news conference on August 20, Mr. Carter explained that the melanoma in his liver had been completely removed, but that four small tumors were found in his brain. He started radiation treatment that afternoon and famously taught his Sunday School class three days later.

To Mr. Carter’s credit, he admitted on August 20 that his cancer is “likely to show up other places” in the future. And being the man of faith that he is, he is quoted as saying that his life was in God’s hands and that he was perfectly at ease with whatever comes. It was reported that when he first learned that the cancer was in his brain, he believed he “had just a few weeks left.” After radiation, he will pursue several courses of a brand new drug pembrolizumab – also known as Keytruda – over a period of several months, depending on how he is doing.

Regardless of how Mr. Carter responds to treatment or how long he lives, what started as obfuscation on the part of a press machine ultimately turned into an amazingly vulnerable self-revelation by a man of deep faith. I hope and pray President Carter responds well to treatment. I also hope that as he confronts treatment and end of life decisions he will spark an honest and open discussion of the role of palliative (comfort) care and hospice care. That would be as great a humanitarian legacy as any he has yet left behind.

Wednesday, September 2, 2015

Red Tape Kills Venerable Medical Practice

Bureaucratic red tape has killed a decades-old medical practice.

After 40 years of service and more than 20 years together, the physicians at Austin Internal Medicine Associates (AIMA) will be closing their doors for good Sept. 4. The physicians cited burdensome regulations ― including electronic health record (EHR) requirements and the looming switch to a new medical billing and coding system called ICD-10 ― as factors in their decision to close.

“It’s gotten a lot harder to run a small personal practice, and that’s because of all the regulatory and EHR requirements and things like ICD-10 and new HIPAA (Health Insurance Portability and Accountability Act) regulations,” AIMA physician R. Scott Ream, MD, said. “I mean, you could just go on and on about what we have to really worry about all the time.”

The four physicians of AIMA will retire after the practice closes its doors Sept. 4. From left to right: Ace Alsup, MD; Isabel Hoverman, MD; R. Scott Ream, MD; and Frank Robinson, MD. Photo by Jim Lincoln.
He and his colleagues prefer to worry about patients, not red tape. But medicine was a different profession when the doctors at AIMA began their practice four decades ago. Physicians Ace Alsup, MD; Isabel Hoverman, MD; Frank Robinson, MD; and Dr. Ream told Texas Medicine magazine being a doctor now is less about patient care and more about navigating an avalanche of health records, government technological requirements, and administrative red tape.

Admittedly, there’s more to AIMA’s closure. All four physicians are retiring, and about a year after closing the practice’s doors, three of them will be 70 years old. However, in recent years, circumstances of the modern medical landscape made AIMA’s closure inevitable.

The practice holds a meeting each year to evaluate its current situation. Dr. Hoverman says the physicians began thinking about closing AIMA last year, “But at our meeting [this year], it really became obvious that the administrative burden had really escalated even further, to the point that it had gotten just overwhelming,” she said.

One big factor was the increasing prevalence of the widely maligned EHRs.

AIMA never adopted an EHR system, citing limited resources. This year, for the first time, foregoing an EHR hurts medical practices’ Medicare bottom line. Beginning on Jan. 1, 2015, the Centers for Medicare & Medicaid Services docked Medicare physicians’ pay 1 percent for not meeting EHR requirements. That number increases to 2 percent in 2016 and 3 percent in 2017.

Another factor contributing to the physicians’ decision to retire was the federally mandated switch to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems, or ICD-10, to document all patient diagnoses. Adoption is required by Oct. 1.

The Austin physicians’ concerns over ICD-10 are not unique: Nearly half of Texas doctors over age 61 might retire early due to anticipated cash-flow problems from ICD-10, according to a Texas Medical Association survey released last month.

“Of all the hassle factors, [ICD-10] is down the list a ways, but it’s definitely why we chose [Sept. 4],” Dr. Ream said.

The decision to close was a difficult one for Dr. Ream, and he told TMA’s Texas Medicine getting to know his patients is one of the aspects he will miss the most.

“They’re much more like family and friends, and that’s going to be difficult,” he said. “On the other hand, everywhere I look tells me it’s time to retire.”


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