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MGH Community News |
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MGH Community News |
| September 2014 | Volume 18 • Issue 9 |
Highlights
Sections Social Service staff may direct resource questions to the Community Resource Center, Lindsey Streahle, x6-8182. Questions, comments about the newsletter? Contact Ellen Forman, x6-5807. |
Free Monthly Boston Immigration Clinics The Mayor’s Office of New Bostonians offers free immigration clinics where constituents meet privately with immigration attorneys to discuss their concerns regarding any aspect of the immigration process. Location & Times
First and third Wednesdays of every month from 12-2pm
Please note: volunteer attorneys can only offer advice. If an individual needs legal representation after having attended the consultation, the attorneys have been asked to provide a 15%-30% discount based on the constituent's income. Additional Referrals The U.S. Department of Justice publishes this list of legal service providers that provide free and low-cost immigration legal services in Massachusetts. Flyer/Upcoming Dates: http://www.cityofboston.gov/images_documents/ImmigrationClinic_July-Dec2014_tcm3-35448.pdf The Office of New Bostonians: http://www.cityofboston.gov/NEWBOSTONIANS/ |
New Federal and State Mandates for Autism Coverage New Federal Coverage Guidelines In July, the Centers for Medicare & Medicaid Services announced that comprehensive autism services must be covered for children under all state Medicaid and Children’s Health Insurance Program plans, another federal-state program that provide health coverage to lower-income children. Although coverage of Applied Behavioral Analysis, which uses positive reinforcement and other techniques to encourage behavior change, isn't explicitly required, advocates expect it will be covered. "Since ABA is the most accepted, effective treatment that isn't experimental and investigational, you can't just exclude it entirely," says Daniel Unumb, executive director of Autism Speaks' legal resource center. Some states previously provided limited coverage before to certain age groups, for example, or up to a specified dollar amount. But the new policy is important because it requires mandatory coverage for everybody under 21, says Kristin Jacobson, co-founder and president of Autism Deserves Equal Coverage, a Burlingame, Calif.-based advocacy group. The new coverage guidelines apply to children with autism spectrum disorder, a group of developmental conditions including autistic disorder and Asperger syndrome. The Association Of Maternal Child Health Programs estimates that just over a third of them get coverage through Medicaid or CHIP. The new coverage rules went into effect July 7 when the CMS guidance was issued, although many states are still setting up procedures. Advocates across the country in recent years have been working to build support for better insurance coverage of autism services, including Medicaid coverage. The federal government’s announcement followed a number of recent court cases, including federal circuit decisions in Florida and Ohio, affirming that applied behavioral analysis services were required under the Medicaid EPSTD benefit. Those decisions bolstered advocates’ long campaign to get such services covered, Unumb says. In addition, 37 states and the District of Columbia have passed laws that require private plans to cover autism treatment, according to Autism Speaks. “It reached that boiling point where CMS had to step in and issue this guidance,” says Unumb. Advocates argue that early intervention, even pricey applied behavioral analysis that may cost more than $50,000 annually, can save money in the long run. Nearly half of children who receive early interventions such as applied behavioral analysis can achieve mainstream status, according to a 2005 study published in the American Journal of Mental Retardation. This section adapted from Medscape.com. See the full article. New State Law On August 6, 2014, the Governor signed the Autism Omnibus Bill into law as Ch. 226 of the Acts of 2014. The law includes the following key provisions:
State Law and Fact Sheet -This section adapted from http://massadvocates.org/legislation/ Social Security Reverses Decision to Stop Sending Verification Letters by Postal Mail Social Security is backpedaling on its decision to require most people to download their own Social Security verification letters, required for things like mortgage approvals and applications for government assistance. The agency had announced that beginning Aug. 1, those in need of these letters would have to sign up for a personal My Social Security account and have access to a computer and a printer, things that many people living in retirement don't have. As reported in June (Social Security Closes Offices as Demand is on Upswing), budget cuts have forced the Social Security Administration to close dozens of field offices as millions of baby boomers approach retirement, swamping the agency with applications for benefits, a senior agency official told Congress this month. A recent report by the U.S. Senate Special Committee on Aging, critical of Social Security's decisions to close 64 field offices and 533 mobile offices, points out that in 2013, 5 million people visited Social Security offices to get verification letters to corroborate such things as their income or retirement status. While public access to computers is available in many community libraries, some libraries and Microsoft itself warn against entering sensitive information into a publicly available computer. Response from those most concerned about the issue was positive. "I'm glad the Social Security Administration has listened to our seniors' concerns," Sen. Bill Nelson, D-Fla., chairman of the Senate aging committee, told the Associated Press. "As the agency pushes more people online to conduct their business, we need to make sure our most vulnerable citizens are not being left high and dry." -See the full Bankrate.com story... Elder Advocates Raise Concerns on Assisted Living In Stoughton, an elderly woman walked out of a locked dementia unit at an assisted living residence in May, wandered into another room and fell from a second-story window. That same month, at a Framingham assisted living facility, two staffers were arrested for allegedly slapping and pinching two elderly residents who have Alzheimer’s, and filming a third who was partly undressed. In July, an 88-year-old man with a history of falling, and who had a tube in his chest for dialysis treatment, apparently tripped in the bathroom of his Revere assisted living residence and bled to death before staffers reached him. Residents in Massachusetts assisted living facilities are in harm’s way too often, and the Executive Office of Elder Affairs, the state agency charged with overseeing the 224 residences, is ill-equipped to protect these increasingly frail residents, elder advocates say. Among the most glaring shortcomings, advocates say: outdated rules that fail to address the need for adequate staffing levels and training, and guidelines that fall short of ensuring safety during emergencies. Also troubling, they say, are lax rules for monitoring medications, especially among residents with dementia. Even a key staffer at the agency is worried. Peter Antonellis, compliance officer at Elder Affairs who inspects the facilities, said the agency has just two ombudsmen to handle the thousands of complaints that pour in each year involving assisted living residences. State data show that Elder Affairs has suspended just three assisted living residences for serious infractions since 2008 — an action that merely prevents the facilities from accepting new residents until they fix identified problems. “I think most elders and their families think this is a regulated industry, but we don’t have the staff to regulate it,” Antonellis said. The Boston Globe recently reported that roughly 100 incidents at assisted-living residences are reported each week to the Office of Elder Affairs and that an agency staff member has repeatedly alerted his superiors that reports of serious incidents are languishing for weeks or months. He also told the Globe that no one seemed to be analyzing the incidents for patterns that may point to larger issues. A department spokeswoman quoted in that report disputed the allegation of a backlog, but did not address whether the agency was analyzing the incident reports. State regulators said this month that they continue working out bugs in a year-old computerized data-collection system that does not yet record the consequence of incidents at the state’s 222 assisted-living residences, nor actions taken by the facilities or state regulators to correct problems. “In general, we think the system we have for monitoring the incidents is getting better,” Elder Affairs Secretary Ann Hartstein told members of the Assisted Living Advisory Council, an appointed board of Patrick administration officials, industry leaders, and consumer representatives. Hartstein was unable to answer council members’ questions about the extent of follow-up for reported incidents and whether the system is able to distinguish isolated cases from systemic problems at specific facilities, or track trends. The agency has not updated its regulations since 2006, while the percentage of residents with dementia and in need of assistance with everyday activities such as eating, dressing, and walking has increased. A national referral service funded by the assisted-living industry, a Place for Mom, recently ranked Massachusetts last for the amount and type of information it makes readily available to consumers about services, such as inspection reports about facilities. States that got high marks, including Missouri and Washington, allow consumers to search on their websites for residences by community or ZIP code and make inspection reports of the facilities available online, including information on corrective actions and fines. This type of information is not available on the Massachusetts Elder Affairs website. Department spokeswoman Martina Jackson told advisory council members that the agency is open to suggestions about how to improve its website. But Jackson said adding data or more reports may not be feasible because the agency’s computer system does not have the capacity to handle the load. -See the full Boston Globe articles:
Martha’s Vineyard Cancer Support Group Offers Financial Assistance The Martha’s Vineyard Cancer Support Group (MVCSG) is a nonprofit organization that provides resources, support services, and financial assistance to Martha’s Vineyard residents who have a diagnosis of cancer and are in need. Financial assistance specifically is awarded to year-round Martha’s Vineyard residents to help them meet emergency and temporary needs resulting from their cancer related illness and treatment. A patient is eligible to apply for financial assistance twice each calendar year. The MVCSG website: http://www.mvcancersupport.org/#. To apply for financial assistance: (Application and Instructions):
Applications can be filled out online and e-mailed to annmarie@vineyard.net or mail to: MV Cancer Support Group Inc. P.O. Box 2214, Vineyard Haven, MA 02568. justice Americorps- New Program to Provide Legal Services to Unaccompanied Child Immigrants On September 12, at the 20th anniversary celebration of the AmeriCorps network, President Obama announced the launch of "justice AmeriCorps," a new public service program that will provide legal services to unaccompanied children in immigration courts across the country. This week, the Massachusetts Immigrant and Refugee Advocacy Coalition (MIRA) was informed that it has received a $298,350 grant to create and implement that program in Massachusetts. Working in partnership with the Greater Boston Legal Services (GBLS), which will provide technical assistance, MIRA will recruit, train and place 12 AmeriCorps attorneys and three AmeriCorps paralegals at legal service organizations across the state, to provide legal assistance to unaccompanied children under the age of 16 who will appear before the Boston immigration court in Fiscal Year 2015. There are an estimated 1,115 children who were released to sponsors in Massachusetts between January 1 and August 31, according to the Administration for Children and Families. MIRA sought to extend its experience with AmeriCorps in response to the dramatic increase of unaccompanied children who have crossed the U.S. border fleeing violence in Central America. These children are temporarily resettled with friends and families by the U.S. Office of Refugee Resettlement, with cases heard in regional immigration courts. In Greater Boston and statewide, the region’s pro bono legal system has been strained by the influx of children who are staying with friends or family while their cases are processed in the Boston court. This justice AmeriCorps grant will increase the effective and efficient adjudication of their immigration proceedings. "Can you imagine being a 12 or 13-year-old child who's gone through a violent ordeal having to explain your story to an immigration court, with a government lawyer opposing you?" MIRA Executive Director Eva Millona said in a prepared statement. "We are greatly heartened that this grant will allow us to place 12 AmeriCorps attorneys and 3 paralegals in Massachusetts legal services organizations to work exclusively with these children, so they can have their cases justly heard."
MassHealth Increases Bed-Hold Days to 20 Effective September 1, 2014, the MassHealth allowable MLOA (Medical Leave of Absence) days, also known as Bed Hold days, was increased to up to 20 days. The prior to this date, the maximum was 10 days. During a MLOA, MassHealth pays the SNF to hold a bed for the patient at the facility. If a patient’s medical stay exceeds the MLOA limit, the SNF must offer the next available bed in a semiprivate room to the patient (unless the patient no longer requires the services provided by the nursing facility.). Any existing MLOA events that commenced prior to September 1 will fall under the previous policy of ten (10) MLOA days. MLOA applies to admissions to Acute, Chronic Disease, Psychiatric and Rehabilitation hospitals. MassHealth will also pay for non-medical leaves of absence for up to 10 days per year. This limit has not changed. For more information see the regulations 130 CMR 456. 425 through 456. 433 at http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-nursingfac.pdf -Adapted in part fromMA Health Care Training Forum, e-mail correspondence, September 08, 2014.
Each year, Medicare members have a chance to make changes to their Medicare Advantage or Medicare prescription drug coverage for the following year. There are 2 separate enrollment periods each year. Open Enrollment Period for Medicare Advantage and the Medicare prescription drug coverage This open enrollment period runs from October 15–December 7 each year. During this open enrollment period members may:
Those with a Medicare Advantage plan or a stand-alone Part D plan should receive an Annual Notice of Change (ANOC) and/or Evidence of Coverage (EOC) from their plan by the end of September. They will explain any changes that the plan will be making in 2015. This includes information about changes to the plan’s list of covered drugs (formulary), health benefits, and/or premium costs. Plans are allowed to change their cost and coverage rules from year to year, so it’s important for members to read mail from their plan to see if there are any changes that might make it worthwhile to take advantage of other options during open enrollment. Medicare Advantage Disenrollment Period During this second, limited, open enrollment period that runs from January 1–February 14, Medicare Advantage Plan members can switch to Original Medicare. Members who switch to Original Medicare during this period will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Coverage will begin the first day of the month after the plan gets the enrollment form. This Disenrollment period is strictly for the purpose of Medicare Advantage Disenrollment. So switching from Original Medicare to a Medicare Advantage Plan, switching between Medicare Advantage Plans or between Medicare Prescription Drug Plans is not allowed. -More at Medicare.gov -Adapted in part from Medicare Watch, Volume 5, Issue 35, Medicare Rights Center, September 11, 2014. Affordable Care Act (ACA) Lingering Questions Now that the federal health law forbids denial of insurance for pre-existing condition, some people have wondered if they can wait until they get sick to buy health coverage. Let's say an uninsured person is in a car accident, has emergency surgery and is hospitalized, and after awaking from surgery asks to purchase insurance right away. Under the health law, would his medical costs be covered since he can't be denied insurance because of a pre-existing medical condition? An article I saw said the hospital would even enroll people and pay their premiums. Is that correct? It's unlikely that this hypothetical person would be able to sign up for coverage after being injured, says Judith Solomon, a vice president for health policy at the Center on Budget and Policy Priorities. "It's true that you can't be denied because you have a pre-existing medical condition, but you generally have to sign up during an open enrollment period," says Solomon. Employers generally offer insurance through an enrollment period in the fall. People buying coverage individually on or off the online marketplaces set up under the health law can sign up during open enrollment starting Nov. 15. But there's a lag between when a person signs up and when coverage begins. The reason for open enrollment is clear: If people could sign up anytime, chances are they would wait until they got sick to do so, wreaking havoc on the health insurance market that relies on spreading the insurance risk among sicker and healthier people. Hospitals may sometimes pay premiums for patients' existing policies or enroll people before they get sick. But in general it's not possible to purchase coverage after you've already been injured and admitted to the hospital, says Solomon. There is one important exception, however. Enrollment in a state's Medicaid program for low-income people is open year-round. If someone lives in a state that has expanded Medicaid coverage to people with incomes up to 138 percent of the poverty level (currently $16,105 for an individual), enrollment would generally be retroactive to the first day of the month that the person applied for coverage. In addition, if someone was eligible for Medicaid during the three months preceding the application, medical care received during that time could be covered as well. My work offers health insurance, but I opted to go into the marketplace last winter and buy it individually instead. Was this not allowed? Should I terminate my coverage and get on my boss's plan even though I don't want that coverage? The answer depends on your circumstances. Most people can opt to buy a marketplace plan during open enrollment rather than sign up for employer coverage if they want; there's nothing in the health law that prohibits it. The real question is whether you're eligible for subsidies to make coverage more affordable if you do so. If you have good, affordable employer coverage available — meaning it costs less than 9.5 percent of your income and covers at least 60 percent of your medical costs — you won't be eligible for subsidies. Nor will you qualify for subsidies if your income is more than 400 percent of the federal poverty level ($46,680 for an individual next year). If you take subsidies out of the equation, however, there's no reason not to buy a plan on the state marketplace if you prefer it over your on-the-job coverage, says Solomon. My employer is telling me that an excise tax will be assessed if our company pays more than 80 percent of the cost of our health insurance premium. I thought it was based on the value of the plans, that if individual coverage exceeds $10,250 and family coverage $27,500 our company would be taxed. Can you tell me when the excise tax will be assessed and who pays the tax? The excise tax that will be assessed on so-called Cadillac health plans with very generous benefits starts in 2018. It isn't related to how much the employer or employee pay in premiums. The tax will be charged based on the total value of a plan, including both employer and employee premium contributions. Under the health law, if the total value is more than $10,200 for individual coverage or $27,500 for family coverage, the employer or insurer will be responsible for paying a 40 percent tax on amounts over those thresholds. "There's nothing to preclude an employer from passing along some or all of that tax to an employee," says Amy Bergner, managing director at tax and human resources consultant PwC. By the time the tax takes effect in 2018, expect the thresholds to be higher, says Bergner, because of consumer price index adjustments, among other things. -From NPR blogs. See the original post. State Requests Extension for Expiring Health Insurance Programs Massachusetts is requesting another federal extension for its existing health care program and an extension of temporary Medicaid, saying the addition would help the state better accommodate a rush of enrollees into the new health insurance system, and give members more time to switch to the new program. In a Health Connector meeting on this month, Maydad Cohen, special assistant to the governor for project delivery, reiterated that the state is expecting approximately 450,000 people to have to re-enroll in health insurance through the health connector website. Of those, 34,000 are on qualified health plans, or unsubsidized health insurance purchased through the state through the old program, 100,000 are on Commonwealth Care – the subsidized state health insurance plan, and another 300,000 are on temporary Medicaid – established when the health connector website wasn’t working and couldn’t determine Medicaid eligibility last year. Each of those plans was set to expire come Dec. 31, but state officials have asked the Centers for Medicare and Medicaid Services to extend coverage for approximately 400,000 members to stagger coverage end dates. Under the proposal, Commonwealth Care programs would be extended to Jan. 31, a plan that would require extensions to existing health plan contracts and revised partnerships with managed care organizations, Connector staff said in a PowerPoint presentation. For temporary Medicaid members, coverage would be extended in three waves based on when the member initially enrolled in coverage. The first group of 100,000 people would be extended to Jan. 15. The second group of 100,000 would have coverage through the program through Jan. 31, and the third group of 100,000 would have coverage extended until Feb. 15. All groups, as well as those interested in purchasing insurance on the open market, will be able to apply for new health insurance through the state’s revamped website come open enrollment on Nov. 15, a period that will end on Feb. 15. Cohen said that the state would extend insurance to the end of the month for the temporary Medicaid members whose coverage expires mid-month and who enroll in new insurance by their deadline. As new health insurance doesn’t begin until the first of the month, those members would otherwise enroll by their deadlines, and then have a two-week gap in coverage. Though Connector officials said the revamped website is designed to handle the volume of all 450,000 re-enrollees, the extension would give people more time to switch to the new system and to allow time to allow aids and volunteers to help people enroll. If the extension request is approved, the end dates for different types of coverage will be as shown in the chart below (indicated by Red diamonds). -See the full Boston Business Journal article...
Bracing for New Challenges in Year 2 of Health Care Law The first year of enrollment under the federal health care law was marred by the troubled start of HealthCare.gov, rampant confusion among consumers and a steep learning curve for insurers and government officials alike. Insurance executives and managers of the online marketplaces are already girding for the coming open enrollment period, saying they fear it could be even more difficult than the last. One challenge facing consumers will be wide swings in prices. Some insurers are seeking double-digit price increases, while others are hoping to snare more of the market by lowering premiums for the coming year. At the same time, the Obama administration is expected to try to persuade about five million more people to sign up while also trying to ensure that eight million people who now have coverage renew for another year. Adding to the complexity is the shorter time frame for choosing a new policy: three months instead of six. No one expects to face last year’s technological hurdles, in which consumers sometimes could not navigate the federal or state websites to buy a policy. HealthCare.gov is running relatively smoothly, and the states have been working to address technical problems with their marketplaces. But the upheaval in insurance markets, with new carriers entering and the price of plans changing significantly, may make the coming year no easier than the last. While federal rules allow people to renew their coverage automatically for the next year in the same plan, many customers, especially if they were eligible for federal tax credits, will want to resurvey the landscape. Just as there was an uproar when some people found out last year that their policies had been canceled, individuals this year may be surprised to find that they could be asked to pay much more for the same plan because their carrier is raising its prices or the amount of the federal tax credit they will receive is changing. People will be renewing at the same time that others are enrolling for the first time, starting a week and a half before Thanksgiving, on Nov. 15. To ensure that they have a new plan by the beginning of the year, those who renew will have to sign up by Dec. 15. Exactly how the renewal process will work has not yet been determined. Consumer advocates and others say nearly everyone with coverage should review their options, as well as whether their federal tax subsidy is likely to shift — either because their income may have changed or because the cost of the benchmark plan used to calculate the tax credit has changed. -See the full New York Times article... 115,000 immigrants to Lose Health Coverage by Sept. 30 Because of Lack of Status Data Federal health officials said recently that more than 100,000 immigrants who bought health-care plans through the federal insurance exchange will have their coverage cut off at the end of the September, because they failed to provide proof by the Sept. 5 deadline that their citizenship or immigration status makes them eligible for insurance on the marketplace. Those individuals can still send in the needed information to the federal exchange and if they are found eligible, they will be able to regain coverage, officials said. They will be considered under a special category reserved for people who have experienced a major life change, such as having a baby or getting divorced or losing a job with health insurance. Consumers who have submitted the requested documents but have not received confirmation by the deadline will remain covered while their application is being processed, said Health and Human Services spokesman Benjamin Wakana. Those who lose coverage may be liable for paying back at least part of any subsidy they received, up to a cap. Immigrant advocacy groups have criticized the Obama administration because, they say, some consumers have sought to upload their documentation numerous times, but they have been hindered by technical problems with the exchange. The government mailed letters in English and Spanish to those affected, but immigration advocates say the notices don’t take into account the wide variety of immigrant languages. They say many who received the letters already have filed the documents either by mail or via computer, but the paperwork was not processed. And they fear most who haven’t responded don’t understand the gravity of the situation or think they have already complied. A line at the bottom of the letter advises the recipients to call a phone number if they need the notice translated, said Amy Jones of the Southeast Asian Mutual Assistance Associations Coalition Inc. in Philadelphia. ‘‘People do not know what they say or that they’re important. Many have been putting them aside or throwing them away,’’ Jones said. Vicki Tucci, an attorney with Legal Aid in West Palm Beach, said she’s heard from fewer than 20 clients, despite meeting with thousands during open enrollment. A few thought the letter was a scam and ignored it, she said. But Andy Slavitt, principal deputy administrator at the Centers for Medicare and Medicaid Services, which manages HealthCare.gov, the federal exchange, said the administration has made repeated attempts to reach those consumers, often 10 to 12 times. The Affordable Care Act created insurance marketplaces that began providing coverage in January. The rules include who is eligible to buy a health-care plan and receive new federal subsidies. In addition to U.S. citizens, the marketplaces are open to people who are lawful permanent residents, refugees, foreigners who have been granted asylum and in a few other immigration categories. Separately, about 363,000 consumers who have coverage could lose financial subsidies for their insurance premiums unless they clear up information about their incomes that differs from that on federal tax records. If those individuals don’t provide updated income information by Sept. 30, federal health officials will adjust their premiums to “reflect what we have in our records,” said Slavitt. That means the federal government could reduce — or eliminate — those individuals’ federal insurance subsidies. It’s also possible that some consumers could get a bigger tax credit. The CMS is sending letters to those individuals, notifying them that if they do not send in supporting documents by Sept. 30, their costs may change.
-See the full Washington Post article...
'Dying in America' IOM Report Calls for Major Reform The US health system needs major reform to ensure high-quality, affordable, and sustainable end-of-life care for Americans, according to a new Institute of Medicine (IOM) report called Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The 507-page document was released on September 17, 2014, and reports recommendations developed during the past two years by a 21-member national committee. Victor Dzau, president of the Institute of Medicine, said in a press release that end-of-life care has changed "remarkably" since the IOM's previous report on this issue in 1997, with palliative care now "well-established" in medicine, nursing, and social work, but there is more than ample room for improvement. Americans hold "strong" views about the type of care they would like to receive at the end of life. They generally prefer to die at home and with the ability to maintain control over healthcare decisions, according to the report. But there is little, or no, planning put in place. Surveys have suggested that more than 25% of adults, including those aged 75 years and older, have given "no thought" to end-of-life care. "Even fewer" have written down their preferences or talked about them with family or providers, according to the report. In a system aimed at curative rather than supportive and comfort care, such discussions are crucial to honoring the preferences of dying patients and their families. Challenges to delivering quality end-of-life care include the growing population of aging Americans, increased cultural diversity in the United States, barriers to accessing care among disadvantaged populations, mismatch between services that patients and families need and what they can actually obtain, growing demand that outpaces the availability of palliative care services, and a wasteful and costly healthcare system characterized by time pressures that interfere with communication and care coordination. Quality end-of-life care needs to be consistent with patients' values, goals, and preferences, the report maintains. To that end, the authors propose a model for advanced-care planning that would require overhauling and restructuring Medicare, Medicaid, and other health plans. The report offers recommendations for improving end-of-life care in five key fields. -See the full Medscape summary article...
Amended Partners Deal Would Impose Stricter Price Caps; Judge Delays Decision Attorney General Martha Coakley is asking a judge to approve an amended deal with Partners HealthCare that imposes stricter price caps before allowing the state’s biggest health system to acquire three more hospitals. Coakley filed the amended settlement in Suffolk Superior Court on September 25th, where it awaits the approval of Judge Janet L. Sanders. Partners has sought to acquire South Shore Hospital in Weymouth and Hallmark Health System’s hospitals in Medford and Melrose. While critics concerned about Partners’ high prices and formidable market power wanted Coakley to sue to block the mergers, she reached a settlement to allow the takeovers to go through. Coakley, the Democratic nominee for governor, said the amended settlement puts sufficient limits on Partners to protect consumers while allowing its expansion. “These additional concessions will mitigate the potential for higher prices related to this transaction,” Coakley said in a news release. Coakley began renegotiating a portion of the original deal with Partners after the Health Policy Commission, a state watchdog group, said Partners’ acquisition of Hallmark would raise health care costs as much as $23 million a year without necessarily improving the quality of care. The amended deal caps prices at Hallmark to the rate of inflation for 6½ years, similar to a provision in the agreement capping price increases at South Shore Hospital. Partners also agreed to preserve psychiatric and behavioral health services at its North Shore facilities for five years. Stuart Altman, chairman of the Health Policy Commission, praised the new restrictions. “I commend the attorney general for pushing Partners to mitigate the price impact of the Hallmark transaction, one of the major concerns identified in our report,” he said in a prepared statement. The agreement would include restrictions on how Partners contracts with insurers and gives the insurers more choice over which Partners facilities to include in their plans. It would also limit Partners’ expansion over the next seven years and require the health system to pay for a monitor to track its progress for a decade. Superior Court judge Janet L. Sanders raised serious concerns at the September 29 hearing about the deal, and she moved her decision on the transaction until after the November election. Judge scheduled the next hearing for Nov. 10, meaning Partners’ nearly three-year effort to merge with South Shore Hospital in Weymouth and its subsequent move to take over hospitals in Medford and Melrose could be delayed for months. At the November 10 hearing, the judge will ask lawyers from Coakley’s office and Partners to explain why they believe the settlement is in the public interest. Sanders is not expected to make a decision the same day. The court process could continue through a political changing of the guard. A new governor and attorney general will be elected on Nov. 4 and take office in January. The state’s new top lawyer would oversee the settlement, if it were ultimately approved. Sources and for More Information One Way Insurers Are Shifting Costs to the Sick- Higher Co-Pays for Generic Drugs Health insurance companies are no longer allowed to turn away patients because of their pre-existing conditions or charge them more because of those conditions. But some health policy experts say insurers may be doing so in a more subtle way: by forcing people with a variety of illnesses - including Parkinson’s disease, diabetes and epilepsy - to pay more for their drugs. Insurers have long tried to steer their members away from more expensive brand name drugs, labeling them as “non-preferred” and charging higher co-payments. But according to an editorial published this month in the American Journal of Managed Care, several prominent health plans have taken it a step further, applying that same concept even to generic drugs. The Affordable Care Act bans insurance companies from discriminating against patients with health problems, but that hasn’t stopped them from seeking new and creative ways to shift costs to consumers. In the process, the plans effectively may be rendering a variety of ailments “non-preferred,” according to the editorial. “It is sometimes argued that patients should have ‘skin in the game’ to motivate them to become more prudent consumers,” the editorial said. “One must ask, however, what sort of consumer behavior is encouraged when all generic medicines for particular diseases are ‘non-preferred’ and subject to higher co-pays.” The editorial comes several months after two advocacy groups filed a complaint with the Office of Civil Rights of the United States Department of Health and Human Services claiming that several Florida health plans sold in the Affordable Care Act marketplace discriminated against H.I.V. patients by charging them more for drugs. Specifically, the complaint contended that the plans placed all of their H.I.V. medications, including generics, in their highest of five cost tiers, meaning that patients had to pay 40 percent of the cost after paying a deductible. The complaint is pending. In July, more than 300 patient groups, covering a range of diseases, wrote to Sylvia Mathews Burwell, the secretary of health and human services, saying they were worried that health plans were trying to skirt the spirit of the law, including how they handled co-pays for drugs. Generics, which come to the market after a name-brand drug loses its patent protection, used to have one low price in many insurance plans, typically $5 or $10. But as their prices have increased, sometimes sharply, many insurers have split the drugs into two cost groupings as they have long done with name-brand drugs. “Non-preferred” generic drugs have higher co-pays, though they are still cheaper than brand-name drugs. With brand names, there’s usually at least one preferred option in each disease category. Not so for generics, the authors of the editorial found. One of the authors, Gerry Oster, a vice president at the consulting firm Policy Analysis, said he stumbled upon the issue when he went to his pharmacy to pick up a medication he had been taking for a couple of years. The prior month it cost him $5, but this time it was $20. As he looked into it, he came to the conclusion that this phenomenon was unknown even to health policy experts. “It’s completely stealth,” he said. In some cases, the difference in price between a preferred and non-preferred generic drug is a few dollars per prescription. In others, the difference in co-pay is $10, $15 or more. Even small differences in price can make a difference, though, the authors said. Previous research has found that consumers are less likely to take drugs that cost more out of pocket. “There’s very strong evidence for quite some time that even a $1 difference in out-of-pocket expenditures changes Americans’ behavior” regarding their use of medical services, said the other co-author, Dr. A. Mark Fendrick, a physician and director of the University of Michigan Center for Value-Based Insurance Design. Dr. Fendrick said the strategy also ran counter to efforts by insurance companies to tie physicians’ pay to their patients’ outcomes. “I am benchmarked on what my diabetic patients’ blood sugar control is,” he said. “I am benchmarked on whether my patients’ hypertension or angina” is under control, he said. Charging more for generic drugs to treat these conditions “flies directly in the face of a national movement to move from volume to value.” If there are no cheaper drugs offered, patients might just skip taking their pills, Dr. Fendrick said. -See the full New York Times article...
Shopping and Checkbook Balancing Help Discriminate Between Normal Cognitive Function and Mild Cognitive Impairment Early detection of patients with cognitive impairment is extremely challenging. Now a team of investigators from the University of Pittsburgh, Pennsylvania, have studied whether preclinical disability in the performance of cognitively focused daily living tasks can discriminate between older adults with normal cognitive function and those with mild cognitive impairment (MCI). The researchers performed secondary analyses of cross-sectional data from a cohort of individuals diagnosed with normal cognitive function or MCI and found that 2 tasks -- shopping and checkbook balancing -- were the most discriminating. They concluded that this is the first demonstration of the discriminative ability of preclinical disability tests to distinguish older adults with MCI from cognitively normal older adults, and suggested that such tasks may be considered when attempting to diagnose MCI or mild neurocognitive disorder in clinical practice and research. From a clinical perspective, this is important and should make us take a careful history of shopping and checkbook balancing in our patients who have suspected dementia.
-From Medscape Best Evidence, Medscape.com
Commonly Held Myths About End-Of-Life Issues Some people don't have a health care power of attorney or living will because they don't realize how important these documents are. Others worry that such documents mean they are signing their lives away. Not so. These powerful documents make sure that you get the treatment you would want for yourself if you couldn't communicate your wishes. Here are a few myths that shouldn't get in the way of creating a health care power of attorney or living will: Myth: More care is always better. Truth: Not necessarily. Sometimes more care prolongs the dying process without respect for quality of life or comfort. It's important to know what interventions are truly important. It's often impossible to know that in advance. That's where the advice of a healthcare team is invaluable. Myth: Refusing life support invalidates your life insurance, because you are committing suicide. Truth: Refusing life support does not mean that you are committing suicide. Instead, the underlying medical problem is considered to be the cause of death. Myth: If medical treatment is started, it cannot be stopped. Truth: Not starting a medical treatment and stopping a treatment are the same in the eyes of the law. So you or your health care agent can approve a treatment for a trial period that you think may be helpful without fear that you can’t change your mind later. However, be aware that stopping treatment can be more emotionally difficult than not starting it in the first place. Myth: If you refuse life-extending treatments, you’re refusing all treatments. Truth: No matter what treatments you refuse, you should still expect to receive any other care you need or want — especially the pain and symptom management sometimes called intensive comfort care. Myth: Stopping or refusing artificial nutrition and hydration causes pain for someone who is dying. Truth: Unlike keeping food or water from a healthy person, for someone who is dying, declining artificial nutrition or intravenous hydration does not cause pain. For more on setting goals for end-of-life care and avoiding common pitfalls, Living Wills: A guide to advance directives, health care power of attorney, and other key documents, a Special Health Report from Harvard Medical School is available for purchase. -From HEALTHbeat, Harvard Medical School, September 13, 2014. (See the archive.)
Benzodiazepine Withdrawal Little Discussed While rampant abuse of heroin and prescription opiates dominates public attention, dependency on benzodiazepines - a group of tranquilizers that includes drugs such as Ativan, Klonopin, and Xanax – may be less widely acknowledged or understood. Doctors say benzodiazepines are effective for short-term stress, as in the days following the death of a loved one or another emotionally difficult event. But problems can arise when use continues for more than a few weeks. The federal Food and Drug Administration requires warning labels that describe dependency risks — the Ativan label lists 35 reported withdrawal symptoms, including anxiety, depression, hallucinations, panic attacks, and seizures. But doctors and patients say physicians often prescribe benzodiazepines with no discussion of the dangers and the drugs’ declining effectiveness over time. “People get used to prescribing these drugs and they forget what they’re dealing with,” said John Kelly, associate director of the Center for Addiction Medicine at Massachusetts General Hospital. Kelly said patients can feel a false sense of security when taking any drugs prescribed by their doctors. “With benzos and stimulants and opiates, because they’re prescribed, people do have this perception that they’re safe, or much safer than illicit drugs you’d obtain on the street,” he said. Dr. James Berry of the Mercy Recovery Center in Westbrook, Maine, estimated that a third of those who are prescribed benzodiazepines experience dependency and painful withdrawal, but there is no sure way to predict who will have those reactions, though the dangers increase with prolonged use. “Generally, withdrawal symptoms . . . are the opposite of what a drug does,” he said. “If a drug relieves anxiety, the drug causes anxiety” during withdrawal. Berry recommends that those who have become dependent reduce their doses gradually over a six-month period before they cease using the medication, but some doctors advise patients to stop taking the drugs over just a few weeks, he said. Even a six-month tapering process isn’t sufficient for some, according to Berry. For a small percentage, it can take years for withdrawal symptoms to recede. The risks remain little discussed, some patients say. Colin Moran, co-founder of the online support group Benzo Buddies said in an e-mail “We still hear from members [in the United States] that their doctors claim there is no potential for dependency or addiction with this class of drug...Some doctors even sometimes ‘cold turkey’ their patients off large doses of benzodiazepines, even after protracted use. This is extremely dangerous.” -See the full Boston Globe article... Mythbusters: Complementary and Alternative Treatments in Cancer Over the past decade, complementary and alternative medicine (CAM) has grown into a multi-billion-dollar industry in the United States, with the use of CAM interventions becoming increasingly popular among cancer patients. Studies estimate that at least half of cancer patients use some type of complementary intervention,[1] though the reported range varies from less than 10% to more than 60%.[2] The number of patients who seek out alternative therapies is quite low, with experts estimating that the percentage falls in the single digits. Although the term "CAM" combines complementary and alternative medicine, distinguishing the two is important. Complementary interventions are only intended to supplement mainstream care and are used primarily to control symptoms and bolster physical and emotional well-being throughout treatment. "Although we can't rely on complementary therapies to shrink a tumor, if given together with chemotherapy or radiation therapy, such interventions may improve quality of life and possibly survival as well," said Gary Deng, MD, PhD, interim Chief of Integrative Medicine at Memorial Sloan Kettering Cancer Center in New York City. "It's a common misconception that cancer treatment is all about shrinking the tumor. Reducing anxiety or pain can make an enormous impact on a patient's day-to-day quality of life." Alternative therapies, however, are meant as a substitute for mainstream care. Both supporters and skeptics of complementary treatments agree that alternative modalities are not viable substitutes for mainstream care and that using any in lieu of conventional medicine is dangerous. "We discourage our patients from using alternative interventions instead of mainstream therapies because they will miss the opportunity for proper care," said Dr. Deng. That is why a growing number of oncologists and policy makers want to abandon the term "CAM" in favor of "integrative oncology," which focuses solely on combining mainstream and complementary care. These integrative services facilitate communication between oncologists and patients, providing an environment where patients can share their concerns and disclose any complementary interventions they already use or would like to try. Disclosing this information is particularly important because some complementary modalities can interact with chemotherapy drugs. "Many patients don't realize that herbs and supplements -- one of the most common complementary interventions -- are drugs, and that some have been shown to interact with chemotherapy and can be harmful to patients," said Steven Novella, MD, a neurologist and assistant professor at Yale University School of Medicine who is executive editor of the blog Science-Based Medicine. Still, many patients don't inform their doctors about their CAM use. One study found that only 58% of men with prostate cancer had told their physician about using CAM interventions, and even fewer asked their family physician (15%) or oncologist (7%) for guidance regarding CAM use. -See the full Medscape article for a review of the scientific validity of popular complementary interventions, from acupuncture to Reiki, exploring common myths about these modalities and examining what the scientific literature and experts in the field say about their safety and effectiveness. Additional topics include exercise, massage, a sugar-free diet, antioxidants, curcumin and meditation. Remember Statistics Class? Why Much of the Medical Literature Is Wrong John Ioannidis and others have argued that much of the medical literature is prone to bias and is, in fact, wrong. Given a statistical association between X and Y, most people make the assumption that X caused Y. However, we can easily come up with 5 other scenarios to explain the same situation. The Medscape.com article “It Ain't Necessarily So: Why Much of the Medical Literature Is Wrong” reviews and explains many research errors in readable terms. For example here’s the explanation of reverse causality Given the association between X and Y, it is actually equally likely that Y caused X as it is that X caused Y. In most cases, it is obvious which variable is the cause and which is the effect. If a study showed a statistical association between smoking and coronary heart disease (CHD), it would be clear that smoking causes CHD and not that CHD makes people smoke. Because smoking preceded CHD, reverse causality in this case is impossible. But the situation is not always that clear-cut. Consider a study published in the NEJM that showed an association between diabetes and pancreatic cancer. The casual reader might conclude that diabetes causes pancreatic cancer. However, further analysis showed that much of the diabetes was of recent onset. The pancreatic cancer preceded the diabetes, and the cancer subsequently destroyed the insulin-producing islet cells of the pancreas. Therefore, this was not a case of diabetes causing pancreatic cancer but of pancreatic cancer causing the diabetes. -See the full Medscape article... |
