Vol. 18, No. 7
August 17, 2018

In This Issue: Office visit fees | short-term insurance | the revival of risk adjustment payments | essential health benefits | White House Medicaid battle | Kentucky’s work requirement waiver | North Carolina and Maine’s separate Medicaid paths | hospices in the OIG’s crosshairs | SNF ratings take a hit | a groundbreaking Alzheimer’s law in Massachusetts | raised hopes for an Alzheimer’s drug | PCORI’s big transitional care study | low utilization for Medicare’s TCM benefit | patient safety in the home | HCBS bundled payments | the opioid crisis’ collateral damage | an Obamacare repeal scorecard | the trouble with Medicaid work requirements | red and blue American health care | palliative sedation | and President Trump’s health plan: Don’t get sick. Ever.
CMS Proposal to Change Physician Payments
Comments are due September 10 on a far-reaching CMS proposal to alter how physicians will be paid for office visits. As described by Kaiser Health News’ Martha Bebinger, the plan “combines four levels of paperwork required for reimbursement, and four levels of payments, into one form and one flat fee for each doctor’s appointment (although there would still be separate filing systems for new and established patients). In a letter previewing the plan to doctors earlier this month, CMS administrator Seema Verma said that physicians waste too much time on mindless administrative tasks to take time away from patients. ‘We believe you should be able to focus on delivering care to patients,’ she wrote, ‘not sitting in front of the computer screen.’” But as the New York Times’ Robert Pear reported , “Critics say the proposal would underpay doctors who care for patients with the greatest medical needs and the most complicated ailments—and could discourage some physicians from taking Medicare patients. They also say it would increase the risk of erroneous and fraudulent payments because doctors will submit less information to document the services provided. ‘Medicare would pay the same amount for evaluating a patient with sniffles and a head cold and a patient with complicated stage IV metastatic breast cancer,’ said Ted Okon, the executive director of the Community Oncology Alliance, an advocacy group for cancer doctors and patients. He called that ‘simply crazy.’ Added Dr. Angus B. Worthing, a rheumatologist, ‘(while) doctors did not go to medical school to type on the computer all day, this proposal is setting up a potential disaster. Doctors will be less likely to see Medicare patients and to go into our specialty. Patients with arthritis and osteoporosis may have to wait longer to see the right specialists.’” As Pear explained, “evaluation and management services are the foundation of an office visit. Medicare now recognizes five levels of office visits, with level five involving the most comprehensive medical history and physical examination of the patient, and the most complex decision-making by the doctor. A level five visit could include a thorough hour-long evaluation of the patient with heart failure, chronic obstructive pulmonary disease, high blood pressure and diabetes with blood sugar out of control. Medicare payment rates for patients now range from $76 for a level II office visit to $211 for a level V visit. The Trump administration proposal would establish a single new rate of about $135. That could mean gains for doctors who specialize in routine care, but a huge hit for those who deal mainly with complicated patients, such as rheumatologists and oncologists. For established patients, the proposal calls for a payment rate of about $93, in place of current rates ranging from $45 to $248 for the four different levels of office visits.”
Short-Term Health Plans Move Forward
Meanwhile the Trump administration has issued a final rule that clears the way for the sale of many more health insurance policies that do not comply with the Affordable Care Act and do not have to cover prescription drugs, maternity care or people with pre-existing conditions. As the New York Times’ Robert Pear reports , “President Trump has said that he believes that the new short-term, limited duration insurance could help millions of people who do not want or need comprehensive health insurance providing the full range of benefits required by the ACA. Under the rule issued in late 2016 by the Obama administration, short-term insurance could not last for more than three months, as it was meant to be a stopgap. Under the new rule the limit will be 364 days, and insurers will be allowed, but not required, to extend policies. The maximum duration, including any extensions, would be 36 months. Consumer advocates, doctors, hospitals and some insurance companies have expressed concern about the new plans, saying they would not adequately protect people who develop serious illnesses and could further destabilize insurance markets by drawing away healthy people. People who buy new policies and develop cancer ‘could face astronomical costs and may be forced to forgo treatment entirely because of costs,’ said Chris Hansen, the president of the American Cancer Society Cancer Action Network.’” As Modern Healthcare’s Harris Meyer pointed out , four states—Massachusetts New Jersey, New York and Rhode Island—essentially bar sales of short-term plans, while others, including California, Hawaii, Illinois, Maryland and Minnesota are considering or have passed restrictions on these plans. Observed Health Affairs blogger Katie Keith, “This new policy is expected to siphon off healthy enrollees from the ACA-compliant marketplace. Allowing longer-term enrollment in non-ACA policies that are medically underwritten could leave the ACA-compliant market with a higher-risk population that will drive up premiums for those who remain in the market and depend on comprehensive coverage. This concern has been raised by insurers, consumer advocates, and federal regulators alike.”
Risk Adjustment Payments: They’re Back for Now
Now you don’t see them, now you do—risk adjustment payments, that is, to insurers that enroll higher risk people such as those with chronic conditions. Less than three weeks after suspending the program CMS announced an abrupt resumption because, as the New York Times’ Robert Pear reported , “taking immediate action to allow for the continued operation of the risk adjustment program is imperative, the Trump administration stated, to maintain stability and predictability in the individual and small group health insurance markets.” The initial decision to halt the payments had followed a New Mexico federal district court decision voiding the risk adjustment formula used to calculate the payments; CMS is reopening the spigots while awaiting a final judicial resolution of the matter. 
Minimum Essential Health Benefits: Two States’ Proposals Reveal Disparities
Earlier this year CMS issued final regulations allowing states to determine the minimum essential health benefits that individual and small business health plans operating in the state are required to cover, beginning in 2020. Now as reported by Modern Healthcare’s Shelby Livingston, the first two states to take up the offer—Alabama and Illinois—have provided a look at how the flexibility is being used. “Policy experts,” Livingston writes, “had warned that the rule could lead to skimpier coverage if states chipped away at benefit requirements. Alabama appears to be doing just that by proposing to significantly reduce the number of prescription drugs that health insurers must cover, in the hopes that will reduce costs and address the opioid epidemic. On the flipside Illinois said it wants to require insurers to cover alternative chronic pain treatments and expand access to mental health services through telemedicine, among other services. Alabama and Illinois’ distinct approaches are an example of the growing disparities in individual insurance coverage between states, as some state lawmakers and regulators seek to bolster ACA markets and others attempt to weaken them. The short timeframe between the CMS’ April rule and the early July deadline is likely one reason only two states have so far proposed changes to their essential health benefit requirements. But there will be other changes inasmuch as CMS is allowing states to update the benchmark plan annually.”  
State Efforts to Increase Medicaid Coverage Halted Till After Midterm Amid Administration Battle
The Medicaid expansion debates continue unabated. In a detailed account of recent White House deliberations, the New York Times’ Robert Pear reports that an internal battle over whether to support state efforts to increase Medicaid coverage ended with President Trump’s decision to defer decisions until after the midterm elections. The debate, writes Pear, “divided the administration between top officials at the Department of Health and Human Services and hardliners, mainly at the White House, who were determined to snuff out the Affordable Care Act. Pushing for limited expansion support were HHS Secretary Alex Azar and CMS Administrator Seema Verma; pushing back: Mike Mulvaney, the director of the Office of Management and Budget, Treasury Secretary Steven Mnuchin, Kevin Hassett, the chairman of the President’s Council of Economic Advisers, and Larry Kudlow, the director of the National Economic Council. Under the Azar-Verma proposal the Trump administration would have offered more waivers to states, so they could devise and run their own health programs with federal money that would otherwise be available under the Affordable Care Act. Funds provided in this way could function as a block grant to states, the proponents argued. Paradoxically, in aborting the debate, Mr. Trump reached the same conclusion as President Barack Obama, but for a completely different reason. Mr. Obama refused to allow partial expansion of Medicaid because he wanted states to go for the full federal expansion envisioned in the Affordable Care Act. Mr. Trump opposed any expansion of Obamacare, even a partial one.”
Medicaid Work Requirements: Azar Pushing Ahead
While urging a limited Medicaid expansion option, HHS Secretary Azar signaled no retreat in the administration’s move to allow states to institute Medicaid work requirements. As Roll Call’s Mary Ellen Mcintire reported , “Azar told a Heritage Foundation meeting that the administration ‘will continue litigating the Kentucky case’ and is ‘fully committed to work requirements in the Medicaid program. We suffered one blow in the District Court in litigation. We are undeterred. We will continue to approve plans.’ Azar’s remarks came a week after CMS reopened public debate over Kentucky’s Medicaid work requirements proposal. A federal district court judge ruled June 29 that the administration ‘never adequately considered’ how the state’s plan would affect access to medical care for 95,000 low-income Kentuckians. The new CMS comment period could pave the way for federal officials to improve Kentucky’s controversial plan, which experts say would likely lead to more legal challenges from consumer advocates.” 
Medicaid Status in North Carolina and Maine
Reports from two states—North Carolina and Maine—illustrate the variation of Medicaid’s status in the wake of the post-ACA repeal efforts. On the one hand, as Modern Healthcare’s Shelby Livingston reports , “North Carolina’s managed care organizations will be required to screen a Medicaid beneficiary for access to food, stable housing and transportation once the state transitions its fee-for-service Medicaid program to managed care in 2019, depending on regulatory approval. The requirement is just one of the ways the state is transforming its Medicaid program to focus on patients’ social determinants as the main drivers of health outcomes. North Carolina asked the federal government last year for permission to overhaul Medicaid and expects to hear an answer in the coming weeks. More than two million North Carolinians are on Medicaid. It is one of the 18 states that did not expand Medicaid under the Affordable Care Act, so the state’s health services department has limited tools and funds to work with. The department started off collecting and merging lots of data on food deserts, transportation access, housing, income levels and other health indicators to create a map showing communities needing the most help. Existing organizations already investing in healthcare can use the hotspot map to figure out where to focus their resources. Providers will be able to refer patients to the right community resources just like they would to a health care specialist, and then make sure the patient showed, and follow-up if the patient didn’t.”

In Maine, meanwhile, a different scenario has been playing out. “A vote expanded Medicaid in Maine. The governor is ignoring it.” As the New York Times’ Abby Goodnough reports , “Brandy Staples, a 39-year-old breast cancer survivor expected to become eligible for Medicaid coverage in July after Maine voters approved an expansion of the program last fall. Instead she has found herself in a courtroom watching the latest chapter unfold in a rancorous, drawn out battle over whether she and thousands of other poor people in the state will get government insurance after all. Ignoring the binding vote, Governor Paul Lepage has refused to expand the program, blasting it as a needless, budget busting form of welfare. He vetoed five expansion bills before the issue made the ballot, plus a spending bill in July that provided about $60 million in funding for the first year. Earlier this month he went so far as to say he will go to jail ‘before I put the state in red ink’ by adding at least 70,000 more low income adults to the state’s Medicaid population of 264,000. Mr. LePage often points back to earlier state decisions to expand Medicaid, over a decade ago. Afterward, Maine struggled with budget shortfalls and fell behind on Medicaid payments to hospitals. After Mr. LePage took office, he paid hospitals $200 million they were still owed and reduced Medicaid eligibility. For Staples, however, the way forward is clear, ‘we shouldn’t have to be fighting this right now,’ she said. ‘We have 70,000 lives on the line here.’ Her friend Lynnea Hawkins relished the prospect of Mr. LePage going to jail over Medicaid expansion, however unlikely that might be. ‘I want to be outside the jail with a nice chair and some popcorn, waving to him—bye have fun!’”
Hospices to See Medicare Raise While Missing the Mark for Care
Modern Healthcare’s Virgil Dixon reports that “CMS plans to give hospices a 1.8% or $340 million reimbursement bump next year, up from the 1%, $180 million, pay hike they got last year. CMS also finalized new standards to help determine what measures hospices will no longer have to report under its meaningful measures initiative. While hospices were observing the good news of their Medicare raise, they fared much less well in a biting report issued by HHS’s Office of Inspector General. As summarized by Kaiser Health News’ Melissa Bailey, “Elderly patients spent over two weeks in uncontrolled pain or acute respiratory distress. Acute care was rare on weekends. And recruiters went door-to-door pitching fraudulent schemes, luring healthy patients to sign up for hospice in exchange for free housecleaning or medicine. The OIG report sums up over 10 years of research into inadequate care, inappropriate billing and outright fraud by hospices, which took in $16.7 billion in Medicare payments in 2016. A KHN investigation last year revealed that while many of the nations 4000+ hospices earn high satisfaction rates on family surveys, hundreds of them fell short of their obligations, abandoning families at the brink of death or skipping other services they had pledged to provide. Regardless of how often their staff members visit, hospices collect the same daily flat rate from Medicare for each patient receiving routine care: $193 for the first 60 days, then $151 thereafter, with geographic adjustments as well as extra payments in a patient’s last week of life. ‘Hospice is quite different than it used to be,’ the OIG report’s lead author Nancy Harrison observed. ‘When it started out there were faith-based nonprofits, and most patients had cancer. As of 2016, 4,374 hospices received Medicare money, about two thirds of which were for-profit.’”  
CMS Lowers Star Ratings on Skilled Nursing Facilities’ Staffing Levels
A recent Kaiser Health News analysis of many skilled nursing facilities’ lack of adequate staff has now prompted CMS, as Jordan Rau and Elizabeth Lucas report in the New York Times, “to lower star ratings for staffing levels in one out of 11 of the nations’ nursing homes—almost 1,400 of them—because they were inadequately staffed with registered nurses or failed to provide payroll data to prove they had the required nursing coverage. Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes, as required by the Affordable Care Act, rather than relying as it had before on nursing homes’ own unverified reports. ‘It’s a real positive that they actually are taking the payroll basis seriously, that they’re using it to punish those nursing homes that either aren’t reporting staffing or those that are below the federal limit,’ said David Grabowski, a professor of healthcare policy at Harvard Medical School. ‘Could they do more? Sure, but I think it’s a really good start.’ For roughly half the homes, the downgrades lowered their overall star ratings, which are the measures displayed most prominently on the site. But some of the homes saw their overall ratings stay the same or even rise, buoyed by their scores on other quality measures. Seventy-nine are still rated with a coveted five stars.”
New Massachusetts Law to Improve Diagnosis and Treatment of Alzheimer’s
Massachusetts has enacted a groundbreaking law aimed at improving the diagnosis and treatment of the state’s 120,000 residents living with Alzheimer’s disease. The law’s advocates and sponsors have pointed to the added burden that ignorance and lack of training pose for Alzheimer’s caregivers. The legislation, the Boston Globe’s Felice J. Freyer reports , “requires physicians, physician assistants, and nurses to undergo training in diagnosis, treatment, and care of patients with Alzheimer’s and other forms of dementia, before they can obtain or renew their licenses. It also requires physicians who have diagnosed Alzheimer’s in a patient to inform a family member or legal representative about the diagnosis. And it mandates that all hospitals, no later than October 1, 2021, develop and put into practice a plan for recognizing and managing patients with dementia. ‘No other state in the country has something like this,’ said Daniel C. Zotos of the Alzheimer’s Association. Dr. Brent P. Forester, chief of McLean Hospital’s division of geriatric psychiatry, observed that ‘it’s often very hard to tease out what may be normal aging and what might be early signs of Alzheimer’s disease. Primary care doctors don’t necessarily have the tools or comfort level with giving a diagnosis that is today a death sentence. And when they know or suspect Alzheimer’s, doctors are often hesitant to talk about it, feeling there’s nothing to be done. But patients and their families need to know soon as possible,’ Forrester said. ‘In the early stages, patients can take medications that in some people slow the disease’s progress, or enroll in clinical trials of experimental drugs. Relatives can ensure that the affected person is kept safe and isn’t left with inappropriate responsibilities, such as managing finances. And most critically, the family can set about making the patient as comfortable as possible during an illness that could easily last a decade or more.’”
Clinical Trial for Alzheimer’s Drug BAN2401 Offers Hope and Skepticism
For individuals with Alzheimer’s disease and their beleaguered caregivers, July brought a whiff of hopeful drug research news, but whether the ensuing media blitz will turn out to have been justified remains to be seen. The New York Times’ Pam Belluck summarized the development: “For the first time in a large clinical trial, a drug was able to both reduce the plaques in the brains of patients and slow the progression of dementia. More extensive trials will be needed to know if the drug is truly effective, but if the results pan out, the drug may be the first to successfully attack both brain changes and the symptoms of Alzheimer’s. ‘This trial shows you can both clear plaque and change cognition,’ said Dr. Reisa Sperling, director of the Center for Alzheimer’s Research and Treatment at Brigham and Women’s Hospital in Boston. ‘I don’t know that we’ve hit a home run yet. It’s important not to over-conclude on the data. But as a proof of concept, I feel like this is very encouraging.’ Many drugs have managed to reduce amyloid levels but they did not ease memory decline or other cognitive difficulties. In the data presented Wednesday, the highest of the five doses of the drug—BAN2401—an injection every two weeks of 10 mg per kilogram of a patient’s weight, both reduced amyloid levels and slowed cognitive decline compared to patients who received placebo.”

Cautionary notes were sounded by a number of Alzheimer’s research experts, with emphasis on the early stage of the trial and the difficult matter of how to measure treatment effect. Fortune magazine’s editor Clifton Leaf, in a very incisive discussion of the state of Alzheimer’s research, addressed the reasons why some skepticism had accompanied reaction to the latest announcement. “In Alzheimer’s, neurons are seemingly choked to death by two types of normal central nervous system proteins that, for some reason, begin to accumulate in large quantities in the cerebral cortex. The first are beta-amyloid peptides that, when not cleared from the brain, begin to encircle neurons en masse, clogging their synapses, inflaming surrounding tissue and ultimately killing off critical brain cells. The second are twisted protein fibers or tangles called ‘tau,’ which aggregate within the neurons themselves and cause degeneration. Most efforts at stopping or reversing the disease focus only on the former phenomenon, the mysterious amyloid deposits. BAN2401 follows the same worn track. And in this latest trial, what no one doubts is that the targeted antibody does a bang up job of clearing beta-amyloid plaques from the brain. The higher the dose, in fact, the more it wipes it clean. But this approach doesn’t seem to flip the Alzheimer’s switch, causing many in the field to doubt whether the ancient and vaunted amyloid hypothesis is the right one. So far the failure rate for Alzheimer’s drugs is 99.6%. That’s right, virtually every time we’ve tried this strategy, it has failed. Maybe that’s why so many caregivers, Alzheimer’s advocates, research scientists—and perhaps even a few biotech investors—seem so befuddled about this latest, well-hyped drug study. Maybe they’re wondering why we’re not trying something else.”
Needed: Participants for Alzheimer’s Trials
As if Alzheimer’s researchers didn’t face enough challenges, the New York Times’ Gina Kolata tells readers about one other, namely, finding enough patients to enter a clinical trial to find a way to slow or stop memory loss. “The number of trials has exploded in recent years. There are more than 100 Alzheimer’s studies looking for a whopping 25,000 participants, according to the Global Alzheimer’s Platform Foundation President John Dwyer. The numbers make it clear: there’s no way scientists are going to find 25,000 participants for all the Alzheimer’s trials that have been approved. ‘The irony is that the science has never been more promising,’ Dwyer said. ‘How many promising drugs will be abandoned or their evaluation seriously delayed? Some good science is going to be left on the cutting room floors.’”
PCORI Care Transitions Study Near Completion
ACHIEVE, a $15 million study funded by PCORI and focusing on the effectiveness of interventions designed to improve care transitions, is nearing completion. “Despite millions of dollars of investment and thousands of hours of effort, the healthcare system still feels very hazardous, unsafe and stressful from the perspective of patients and caregivers,” said Dr. Suzanne Mitchell, assistant professor of family medicine at Boston University School of Medicine and lead author of the forthcoming report. Medscape’s Judith Graham offers a preview of the study results in a piece entitled “Why taking care in discharging a patient matters.” The project included asking more than 9,000 patients and 3,000 caregivers who underwent transitions about their experiences—what went well, what did not. “In May, Art Kornfield, 81, was admitted at 3 a.m. to a hospital near his home in Santa Clarita, California, with severe food poisoning and dehydration. Less than six hours later, after a sleepless night, a hospitalist he had never met walked into his room and told him she was sending him home because his situation has stabilized. ‘I wasn’t there,’ said Hedy Greenfield, 76, his wife, ‘and no one asked if there was somebody who could take care of him at home when he got there. Fortunately, he had the presence of mind to say I’m not ready. I need to stay another day.’ Over and over again,” Graham writes, “patients and caregivers told Project ACHIEVE researchers how important it was to feel that health professionals care about their well-being. Without a sense of caring, patients and caregivers often feel abandoned and lose trust in healthcare professionals. With it a patient is better able to handle concerns and act on the doctor’s recommendations. Such was the case with Kathy Rust of Glendale California, who panicked the first time her mother’s feeding tube came out, by accident. ‘I called the transition service of my hospital’s outpatient clinic, and they sent someone over in 30 minutes,’ she said. ‘They were very reassuring and said that I had done the right thing in calling them, very calming. It was such a positive experience that I wasn’t afraid to contact them with all kinds of questions that came up.’”
Medicare Transitional Care Management: Good Results, Low Participation
As the Project ACHIEVE final report approaches publication, a new study raises some concerns over just how rapidly transition care services are being put into place. Since 2013 Medicare has attempted to improve transitional care management services by offering specific payment for performing them. To bill for the thirty-day service, a care team member must communicate with a beneficiary or caregiver within two business days after discharge, and the clinician must provide an office visit within 14 days. Researchers have now looked at the impact of the payments and found that, on the one hand, when utilized, the covered service has produced positive cost and mortality incomes outcomes; on the other hand, unfortunately, the service payment offer has been too seldom accepted. “Medicare beneficiaries who receive TCM services have lower total Medicare costs and mortality in the subsequent month compared with beneficiaries who do not receive these services. These effects persist after adjusting for beneficiaries’ demographic and health status as well as the type of discharge and whether it included home healthcare. We observed a stepwise benefit with the provision of an office visit with in 14 days of an eligible discharge, which was enhanced when an office visit also included TCM services. Despite the apparent benefits of TCM services, the use of the service remains very low and it is growing slowly.” Of more than 18 million eligible Medicare beneficiaries during the study period, transitional care management services were billed in 3.1 percent of cases in 2013. 5.5 percent in 2014 and 7 percent in 2015.”
Report on Challenge to Improve Home Care Safety
The Institute for Healthcare Improvement and the National Patient Safety Foundation have jointly published an extensive report on the challenge of improving patient safety at home as care migrates increasingly to that setting. “Patient safety issues in the home are multifaceted; we use four dimensions to organize them. The physical dimension involves the physical attributes of the home care setting, including environmental hazards such as home layout and infrastructure, clutter, and unsanitary conditions. Key processes of care that affect home safety—medication management, infection control, nutrition, fall prevention, complex clinical care, and care coordination—are also discussed in this category. The emotional dimension of home care safety involves stress, trauma, and discomfort related to receiving and providing care. Finally, the social and functional dimensions of home care safety involve the community and the network of support, and the effects of health conditions on activities of daily living.”
Milbank Memorial Fund Report on Bundled Payments for HCBS
In another report related to care in the home, the Milbank Memorial Fund has issued a report on “Bundling, Benchmarking, and Beyond: Paying for Value in Home- and Community-Based Services.” “Bundled payments are a package of healthcare services that are paid for as a set. Although bundled payments have been in development for clinical procedures for several years and continue to be explored, they are now just being developed for HCBS. While few examples exist, bundled payments are being used in the Arkansas Medicaid Living Choices Waiver and the Colorado Medicaid Brain Injury Waiver, in which assisted-living facilities or contracted home health agencies receive a daily rate to provide a bundle of HCBS to beneficiaries. The beneficiaries receive different levels of services in their plans of care, based on their assessed severity of need, and providers receive a different daily rate based on the level services provided.”
Opioid Epidemic Leaves Those in Need Seeking Relief
As the nation continues to cope with its growing opioid addiction and overdose crises, two reporters delve into some “unintended consequences” aspects of how legislative and regulatory agencies are responding to the challenge. The Washington Post’s Sarah Vander Shaaff profiles the story of an Oregon resident, Julie Ann Feinstein, “for whom opioids have provided some relief from a lifetime of severe pain caused by multiple triggers, but who now faces growing obstacles to obtaining her medications. ‘The opioid epidemic is scooping up and confusing the lives of people who have a real need for medication with those who are abusing, and that is tragic and that is wrong,’ said Feinstein’s daughter, Amanda Feinstein. She has a degenerative disease. Without pain medication, everything stops.’ During the six-month search for pain specialists, Feinstein’s family turned to Myra Christopher, recently retired as the director of the Center for Practical Bioethics in Kansas City, Missouri. Christopher is agnostic on the use of opioids for chronic pain but concerned that patients such as Feinstein are ‘collateral damage’ in the effort to combat the opioid crisis. ‘I want people with chronic pain to have access to comprehensive chronic pain care, which may or may not include opioids therapy, interventional procedures, surgery, acupuncture, physical therapy, massage, biofeedback and behavioral health.’ Doctors are in the middle of a turnabout, added Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado Anshutz Medical Campus. ‘For 20 years physicians were told, by bioethicist and patient empowerment groups, to believe patients when they said they were in pain and to do what the patients wanted. Now,’ he said, ‘the bioethicists and others have a new role: to help one side understand where the other side is coming from, that the opposing force isn’t evil but coming at this with a set of values and preferences and priorities that need to be understood to find some sort of common ground.”

While some patients like Ms. Feinstein are seeking to maintain pain control regimens they have found beneficial, others, the New York Times Sheila Kaplan reports , are reaching out for even riskier solutions. “An injectable drug that the manufacturer says is too dangerous to use along the spine is growing in popularity for back pain as pain doctors turn away from opioids. The anti-inflammatory drug, called Depo-Medrol and made by Pfizer, is approved for injection into muscles and joints. Once the drug is approved, however, doctors may legally prescribe it however they see fit. And doctors have long given Depo-Medrol shots, or their generic equivalent, close to the spinal cord for painful backs, necks and conditions like spinal stenosis. What few doctors and patients know is that Pfizer, faced with hundreds of complaints about injuries and complications related to the shots, asked the FDA to ban that type of treatment five years ago. The company cited the risk of blindness, stroke, paralysis—a request that neither the agency nor Pfizer made public. The FDA declined to issue a ban, but toughened a label warning. The opioid epidemic, however, appears to be spurring the injections’ popularity. And in June, as part of legislation to tackle the opioid crisis, the House of Representatives approved an increase in Medicare reimbursement for the procedure.”
Scorecard on the ACA: Stuck in ‘Purgatory’
A major figure in the creation of Obamacare, University of North Carolina at Chapel Hill professor Dr. Jonathan Oberlander, offers a New England Journal of Medicine scorecard entitled “The Republican War on Obamacare—What Has It Achieved?” Oberlander, after recounting the 18-month saga of legislative and regulatory assaults on the Affordable Care Act, concludes that “the ACA is stuck in purgatory, beyond comprehensive repeal but subject to a war of attrition that jeopardizes its gains. Such a campaign poses risks for Republicans. The politics of healthcare have fundamentally changed. Tens of millions of Americans are ACA beneficiaries; taking away their coverage and consumer protections is difficult. And as the party in power, the Republicans are now responsible for Obamacare’s problems, which the Trump administration’s policies may worsen. Whereas resisting the ACA previously produced political benefits for the GOP, continued opposition could exact a price in coming years. The 2018 elections could further alter the political calculus, leading Republicans to either revive or retreat from repeal efforts. Yet the more the ACA is undermined, the further left U.S. health politics seem to shift. Threats to repeal Obamacare have increased Democrats’ support for single-payer health care and Medicare expansion. Thus, Republicans’ campaign against Obamacare could produce a transformation in U.S. health policy—just not the one that they envisioned.”
Andy Slavitt on Work Requirements and Compromise Solution in Montana
Among the ACA-related developments Jonathan Oberlander appraises is the move by states to condition Medicaid coverage expansion on the imposition of work requirements. Adding to the already extensive commentary on this effort, former acting CMS Administrator Andy Slavitt argues that “there is a link between health and work, only it’s the reverse of how it is portrayed by work requirement proponents: Good health allows people to be productive, and losing access to care is a way to lose one’s ability to be productive. Proponents in the Trump administration talk about work requirements as a way of lifting people out of poverty. Saying that if you can work, you must do so to qualify for Medicaid benefits, appeals to some people on the surface. The implication is that some people with lower incomes need an incentive to work, and that access to medical services is such an incentive. This is an inference, even setting aside the moral value judgment, that is without the facts to back it up, however. The majority of Medicaid expansion beneficiaries already work in the increasing number of jobs that don’t offer benefits. Often these are in hourly wage or seasonal jobs. In practice, rather than increase the workforce by incentivizing lazy individuals, requirements would harm three groups of people: the many who work, but can’t maintain consistent hours to meet state standards; those with disabilities that aren’t recognized from the state; and many individuals who will be caught in a web of administrative paperwork under new systems being designed to monitor people’s work and other habits.” Slavitt points to Montana—a state which has a Democratic governor, a Republican legislature and a frontier culture—as having possibly arrived at a solution that “works for everyone. Instead of a work requirement they introduced a new set of job training resources. People gaining health coverage through expanded Medicaid are given the opportunity to meet a labor specialist to help them with job placement and advancement, including tips for improving skills and income. Rather than invest in expensive and intrusive monitoring system, Montana, in a bill written by a Republican state senator and signed by Democratic governor Steve Bullock, made investments in resources to help people work.”
Red and Blue: Disparities in Coverage
Slate’s Nisarg A.Patel comes at the impact of the Trump administration’s ACA actions by putting them into the context of “‘ The Fractured State of American Healthcare: The quality of your coverage increasing depends on whether you in a red blue state.’ Recent federal rollbacks and the subsequent response by states have amplified divisions in access, affordability and coverage of health insurance,” Patel writes. “Blue states are creating their own laws to both expand coverage and serve as stopgap measures to block the administration’s moves from destabilizing their own individual insurance markets. Red states, on the other hand, are falling in line with federal positions on health care policy that would both limit access to Medicaid and erode risk sharing, leaving sicker patients to pay higher premiums. People move for jobs, education, and family. They rarely move for affordable healthcare. But with health insurance premiums set to significantly rise again this fall, the compounding of state and federal action could make otherwise exceptional stories about moving for affordable care more commonplace.”
Palliative Sedation at the End of Life
While debate continues to simmer about whether to allow physician-assisted suicide, “palliative sedation,” the Washington Post’s Michael Ollove writes , “is legal and offers peace. Toward the end,” he recounts, “the pain had practically driven 66-year-old Elizabeth Martin mad. By then the cancer had spread everywhere, from her colon into her spine, liver, adrenal glands and one of her lungs. No medication made the pain bearable. A woman who had been generous and good-humored had turned into someone hardly recognizable to her family: paranoid, snarling, violent. Under palliative sedation, a doctor gives a terminally ill patient enough sedatives to induce unconsciousness. The goal is to reduce or eliminate suffering, but in many cases the patient dies without regaining consciousness. At the acute care center in Long Beach where Martin was a patient the medical staff gave her phenobarbital. Once they calibrated the dosage properly, she never woke up again. She died within a week, not the one or two months doctors had predicted before the sedation. ‘At least she got into that coma state versus four to eight weeks of torture,’ her sister Anita Freeman said. Palliative sedation has been administered since the hospice care movement began in the 1960s and is legal everywhere. The result, according to Dr. Timothy Quill, who teaches psychiatry, bioethics and palliative care medicine at the University of Rochester Medical Center in New York, is that the dilemma facing doctors is moral rather than legal. ‘Some doctors are hesitant about using it because it brings them right up to the edge of euthanasia.’ But any doctor who treats terminally ill patients has an obligation to consider palliative sedation because of the overwhelming physical suffering of some patients under your charge.”
Cheap, Short-Term Health Coverage: Don’t Get Sick
Finally, the Washington Post’s Catherine Rampell tells readers she has at last come to understand President Trump’s “grand plan for fixing healthcare. During his presidential campaign, then candidate Donald Trump promised to replace Obamacare with ‘something terrific.’ For a long time that ‘something terrific’ was left unspecified. Now, more than a year and a half into Trump’s presidency, we finally learned his grand plan for reducing Americans’ healthcare costs. It is: Don’t get sick. Ever.” Rampell’s epiphany stems from her blistering review of the administration’s endorsement of year-long, short-term insurance plans not subject to ACA protections. “Even care listed as ‘covered’ is often subject to ridiculously low or otherwise absurd payout limits. Think a policy term maximum of $3,000. Or no coverage for any hospital stay that begins on the weekend. The tiny print can be endless. Because these plans cover so little, cherry pick their enrollees, and pay out so infrequently, premiums tend to be dirt cheap. So what about those lucky, healthy people who might celebrate the greater availability of cheap plans They won’t be celebrating if their kid breaks a leg or they try to fill a prescription or (heaven forbid) they face a more serious health scare. That’s when they’ll discover the insurance that seemed so cheap is cheap only because it’s worthless—and that their ‘catastrophic’ coverage doesn’t even cover catastrophe. If they want to pay their catastrophic medical bills, they’d better luck into a job with decent insurance. Or join the hundreds of thousands who are begging strangers online for charity. Which brings us back to Trump’s real plan for American consumers: Stay healthy, or drop dead.”
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Editor: Alan K. Kaplan, (attorney and health policy consultant)
Contributor: Kathleen Kelly (executive director)
Layout: Francesca Pera (communications specialist)

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