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Liberty Mutual: A Blow to Health Care Transparency

By CHARLES ORNSTEIN

Charles OrnsteinThe U.S. Supreme Court dealt a blow this week to nascent efforts to track the quality and cost of health care, ruling that a 1974 law precludes states from requiring that every health care claim involving their residents be submitted to a massive database.

The arguments were arcane, but the effect is clear: We’re a long way off from having a true picture of the country’s health care spending, especially differences in the way hospitals treat patients and doctors practice medicine.

It also means that, for the time being at least, we’ll remain heavily reliant on data being released by Medicare, the federal health insurance program for the elderly and disabled, to study variations in health care. ProPublica has used Medicare data to study differences in medication prescribing, surgeons’ complication rates and use of services by doctors, but it’s still not clear that Medicare is representative of all health care in the country.

The court’s decision involves a case from Vermont, one of 18 states that created so-called all-payer claims databases. Vermont’s law called for health insurers, health providers, medical facilities and government agencies to report data on health care costs, prices, quality and use of services to the state. That included employers who pay the costs of their workers’ treatments themselves, and not through an insurance contract. (Self insurance is common for large companies.)

But Liberty Mutual Insurance Co. objected, saying the Employee Retirement Income Security Act of 1974, or ERISA, prevents states from imposing such a requirement on self-funded plans. The idea is that companies that have operations across the country shouldn’t be subjected to 50 different state laws, but instead should only have to abide by rules from one agency, namely the U.S. Department of Labor.

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Are Patient Privacy Laws Being Abused to Protect Medical Centers?

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By CHARLES ORNSTEIN

Optimized-Ornstein

This story was co-published with NPR’s “Shots” blog.

In the name of patient privacy, a security guard at a hospital in Springfield, Missouri, threatened a mother with jail for trying to take a photograph of her own son. In the name of patient privacy , a Daytona Beach, Florida, nursing home said it couldn’t cooperate with police investigating allegations of a possible rape against one of its residents.

In the name of patient privacy, the U.S. Department of Veterans Affairs allegedly threatened or retaliated against employees who were trying to blow the whistle on agency wrongdoing.When the federal Health Insurance Portability and Accountability Act passed in 1996, its laudable provisions included preventing patients’ medical information from being shared without their consent and other important privacy assurances.But as the litany of recent examples show, HIPAA, as the law is commonly known, is open to misinterpretation – and sometimes provides cover for health institutions that are protecting their own interests, not patients’.

“Sometimes it’s really hard to tell whether people are just genuinely confused or misinformed, or whether they’re intentionally obfuscating,” said Deven McGraw, partner in the healthcare practice of Manatt, Phelps & Phillips and former director of the Health Privacy Project at the Center for Democracy & Technology.For example, McGraw said, a frequent health privacy complaint to the U.S. Department of Health and Human Services Office of Civil Rights is that health providers have denied patients access to their medical records, citing HIPAA. In fact, this is one of the law’s signature guarantees.”Often they’re told [by hospitals that] HIPAA doesn’t allow you to have your records, when the exact opposite is true,” McGraw said.

I’ve seen firsthand how HIPAA can be incorrectly invoked.

In 2005, when I was a reporter at the Los Angeles Times, I was asked to help cover a train derailment in Glendale, California, by trying to talk to injured patients at local hospitals. Some hospitals refused to help arrange any interviews, citing federal patient privacy laws. Other hospitals were far more accommodating, offering to contact patients and ask if they were willing to talk to a reporter. Some did. It seemed to me that the hospitals that cited HIPAA simply didn’t want to ask patients for permission.

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Some Predictions on How Medicare Will Release Physician Payment Data

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By CHARLES ORNSTEIN

The federal government’s announcement last week that it would begin releasing data on physician payments in the Medicare program seems to have ticked off both supporters and opponents of broader transparency in medicine.

For their part, doctor groups are worried that the information to be released by the Centers for Medicare and Medicaid Services will lack context the public needs to understand it.

“The unfettered release of raw data will result in inaccurate and misleading information,” AMA President Ardis Dee Hoven, MD, said in a statement to MedPage Today. “Because of this, the AMA strongly urges HHS to ensure that physician payment information is released only for efforts aimed at improving the quality of healthcare services and with appropriate safeguards.”

On the other hand, healthcare hacker Fred Trotter has raised concerns about CMS’ plan to evaluate requests for the data on a case-by-case basis. That isn’t much of a policy at all, he wrote, giving federal officials too much discretion about what to release.

So, how is this all going to shake out?

Three recent examples offer some clues.Continue reading…

A Small Paper Problem: The Health Exchanges Face An Avalanche of Paper Applications

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By CHARLES ORNSTEIN

When HealthCare.gov and some state-run insurance marketplaces ran into trouble with their websites in October and November, they urged consumers to submit paper applications for coverage.

Now, it’s time to process all that paper. And with the deadline to enroll in health plans less than two weeks away, there’s growing concern that some of these applications won’t be processed in time.

The Associated Press reported last week that federal officials are now advising navigators—groups paid to assist consumers with enrollment—not to use paper applications anymore, if they can help it.

“We received guidance from the feds recommending that folks apply online as opposed to paper,” said Mike Claffey, spokesman for the Illinois Department of Insurance.

After a conference call earlier this week with federal health officials, Illinois health officials sent a memo Thursday to their roughly 1,600 navigators saying there is no way to complete marketplace enrollment through a paper application. The memo, which Claffey said was based on guidance from federal officials, said paper applications should be used only if other means aren’t available.

Federal health officials also discussed the issue during a conference call Wednesday with navigators and certified counselors in several states.

“They’ve said do not use paper applications because they won’t be able to process them anywhere near in time,” said John Foley, attorney and certified counselor for Legal Aid Society of Palm Beach County, who was on the call.

According to an enrollment report released Wednesday by the U.S. Department of Health and Human Services, about 83 percent of the 1.8 million applications completed between Oct. 1-Nov. 30 were filled out online; the rest were on paper. The online figure was higher, 91 percent, in the 14 states running their own health exchanges, compared to 80 percent for Healthcare.gov, which processes enrollments for the other 36 states.  But even outside the federal exchange, paper is proving to be a problem.

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November is the New October

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By Charles Ornstein

Many health care experts and journalists, including me, felt that the month of October would be the key barometer of the success of Healthcare.gov, the online health insurance marketplace that is a cornerstone of the Affordable Care Act.

But as days became weeks, and the problems plaguing the website stubbornly went unfixed, the question now is whether the administration can make the website work well by the end of this month and salvage the president’s signature achievement. If Healthcare.gov, which handles health insurance enrollment for 36 states, is working well at the end of this month, it will leave consumers just two weeks to choose plans if they want them to take effect on Jan. 1, 2014.

In other words, November is the new October.

The din of partisan accusations and counter-accusations is deafening and only getting louder. But in the interest of finding out what’s really happening on the ground, I consulted Kip Piper, who advises large health care organizations on Medicare, Medicaid, and health reform policy, finance and business strategy.

Piper has served as senior advisor to the administrator of the Centers for Medicare and Medicaid Services (CMS), Wisconsin state health administrator, director of the Wisconsin Medicaid program, a senior Medicare budget officer at the White House Office of Management and Budget, among other roles. He is articulate and clear-headed.

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Questions for Secretary Sebelius

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By Charles Ornstein

Health and Human Services Secretary Kathleen Sebelius will testify before the House Energy and Commerce Committee this morning. Her testimony comes the week after Healthcare.gov contractors testified before the same committee and a day after the head of the Centers for Medicare and Medicaid Services testified before a different House committee.

Here’s what you need to know.

1. Where to watch the hearing, which began at 9 a.m. EST:

Live coverage via C-SPAN.

2. Read Sebelius’ prepared testimony. Politico calls it more of the same:

Sebelius’s eight pages of prepared testimony for the House Energy and Commerce Committee matches nearly word-for-word testimony delivered by CMS Administrator Marilyn Tavenner to Ways and Means on Tuesday.

In both written statements, the officials acknowledge that the website hasn’t met expectations but say the administration is taking major steps to improve it.

Neither testimony includes an apology for the bungled launch—but Tavenner verbally apologized at the hearing Tuesday morning.

Clay Johnson (@cjoh), who advocates for open source information in the federal government, annotated the testimony on Rap Genius, with questions and comments.

3. Get familiar with the background. Sebelius gave an interview to CNN’s Sanjay Gupta last week in which she had this memorable exchange:

Gupta: The president did say that he was angry about this. I mean do you know when he first knew that there was a problem?

Sebelius: Well, I think it became clear fairly early on. The first couple of days, that —

Gupta: So not before that, though? Not before October 1st?

Sebelius: No, sir.

Gupta: There was no concern at that point here in the White House or at HHS?

Sebelius: I think that we talked about having — testing, going forward. And if we had an ideal situation and could have built the product in, you know, a five-year period of time, we probably would have taken five years. But we didn’t have five years. And certainly Americans who rely on health coverage didn’t have five years for us to wait. We wanted to make sure we made good on this final implementation of the law.

And, again, people can sign up. The call center is open for business. We’ve had 1,100,000 calls. We’ve had 19 million people visit the Web site, 500,000 accounts created. And people are shopping every day. So people are signing up and there’s help in neighborhoods around the country, that people can have a one-on-one visit with a trained navigator and figure out how to sign up. So people are able to sign up.

I wondered at the time if Sebelius’ answer left a little wiggle room. I expect Republicans on the committee will pursue this.

4. Digest media reports. You can definitely expect that Sebelius will be asked about a CNN report yesterday that Healthcare.gov’s lead contractor warned the administrator well before the Oct. 1 launch of major problems. Read the documents.

CNBC suggests these six questions for her:

—What did you know, when did you know it, and who told you?

—Did you ever consider not launching Oct. 1?

—Why has no one been fired?

—What does all this cost?

—What contingency plans do you have?

—What are the enrollment numbers?

TPM offers what it calls seven legitimate questions for her.

And the Washington Post says that “the embattled secretary of health and human services will submit to a quintessential station of the Washington deathwatch.” Gotta love Washington.

Charles Ornstein is a senior reporter at ProPublica and past president of AHCJ. An earlier version of this post originally appeared on his tumblr, Healthy buzz.

Round One of the Obamacare Exchange Hearings. Angry Republicans 6 Contractors 0.

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By Charles Ornstein

Today’s House Energy and Commerce Committee hearing/grilling of the contractors behind Healthcare.gov brought a lot of defenses and fingerpointing, but little clarity of when the website will be fixed.

Still, here are some of the more-memorable quotes. The sources are below each.

“I will not yield to this monkey court,” Rep. Frank Pallone (D-N.J.) said when Republican lawmakers tried to talk about online privacy fears. -Politico

“This is not about blame. It’s about accountability,” said Rep. Fred Upton (R., Mich.), chairman of the House Energy and Commerce Committee. “We still don’t know the real picture, as the administration appears allergic to transparency.” – WSJ.com

“CMS [the Centers for Medicare and Medicaid Services] had the ultimate decision to go live or not go live,” said Cheryl Campbell, senior vice president of CGI Federal, the lead federal contractor on the project. “At CGI we were not in position to make that decision. We were there to support the client. It’s not our position to tell clients whether to go live or not go live.” —  Washington Post

“Amazon and eBay don’t crash the week before Christmas,” said Rep. Anna Eshoo of California, a Democrat. “ProFlowers doesn’t crash on Valentine’s Day.” – NBC News

“Three weeks after the Web site went live, we are still hearing reports of significant problems. These problems need to be fixed, and they need to be fixed fast,” said Representative Diana DeGette, Democrat of Colorado. -New York Times

“We understand the frustration many people have felt since healthcare.gov was launched. We have been and remain accountable for the performance of our tools and our work product,” said Andrew Slavitt, the group executive vice president for Optum/QSSI, a contractor on the project.   – ABC News

Meanwhile, HHS officials may be regretting their decision to give Healthcare.gov visitors the ability to post comments to the site. ProPublica reporters reviewed over 500 comments posted at https://www.healthcare.gov/connect/.

A sampling:

Wrongly Listed As Jailed

“Website said my wife and I were ineligible due to current incarceration. We have never been arrested in our lives, both 63!!!!!!!!!!!!!!!!!!!!!!!,” Fred wrote on Oct. 21.

Health Problems Made Worse

“I have a pre-existing condition …. a-fib…..and actually had an attack after getting frustrated with this confusing mess,” Bill wrote on Oct. 22. (A-fib refers to atrial fibrillation, an abnormal heartbeat.)

Daughter is Not a Daughter Anymore

“I am having difficulty with my account,” Joanna wrote on Oct. 22. “It appears that my daughter was added twice so that I now have two daughters with the same name and social security number. I am unable to delete one of them.  Also, the drop down menu that relates to what relationship someone is to another is faulty. I choose that my husband is the father of our daughter and that my daughter is a dependant [sic] to me and my husband. What it actually shows though is that my daughter is a stepdaughter to her father and that my daughter is now both my husband and I’s parent. “

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Is Healthcare.gov the Future? I Ask a Futurist

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By Charles Ornstein

Ian Morrison is a health care futurist. Companies, trade groups and nonprofits call on him to speak about trends in health care and offer prognostications of what the future brings. I’ve heard him speak a few times and his knowledge and sense of humor drew me in right away.

Last Friday, I tweeted a story written by Anna Gorman and Julie Appleby,friends at Kaiser Health News about hundreds of thousands of consumers receiving cancellation notices from their insurance companies on account of the Affordable Care Act. I was surprised to learn that Morrison was one of them.

I emailed him to find out more. This is what he told me: Until 2011, Morrison paid for his health coverage from a company on whose board of directors he served. The company was sold and he was insured through COBRA until this March. As he tells it, Blue Shield of California “didn’t want a badly behaved 60 year old Scotsman,” so he got coverage through a preferred-provider organization offered by the insurance company Health Net through a Farm Bureau program.

“No kidding,” he says, he’s no farmer.

Two weeks ago, he received a letter canceling that plan for reasons similar to those cited in the Kaiser story. He subsequently applied for coverage—not through Covered California, the state’s new health insurance marketplace, but directly through Blue Shield. Because of the Affordable Care Act’s ban on discriminating based on pre-existing conditions, the insurer must take him.

Here’s a Q&A I had with Morrison by email (edited for clarity with his approval).

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Why You Should Care About the Drugs Your Doctor Prescribes

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By Charles Ornstein & Tracy Weber

The following column appears today on THCB, in the op-ed pages of the Los Angeles Times and at ProPublica.

Your doctor hands you a prescription for a blood pressure drug. But is it the right one for you?

You’re searching for a new primary care physician or a specialist. Is there a way you can know whether the doctor is more partial to expensive, brand-name drugs than his peers?

Or say you’ve got to find a nursing home for a loved one. Wouldn’t you want to know if the staff doctor regularly prescribes drugs known to be risky for seniors or overuses psychiatric drugs to sedate residents?

For most of us, evaluating a doctor’s prescribing habits is just about impossible. Even doctors themselves have little way of knowing whether their drug choices fall in line with those of their peers.

Once they graduate from medical schools, physicians often have a tough time keeping up with the latest clinical trials and sorting through the hype on new drugs. Seldom are they monitored to see if they are prescribing appropriately — and there isn’t even universal agreement on what good prescribing is.

This dearth of knowledge and insight matters for both patients and doctors. Drugs are complicated. Most come with side effects and risk-benefit calculations. What may work for one person may be absolutely inappropriate, or even harmful, for someone else.

Antipsychotics, for example, are invaluable to treat severe psychiatric conditions. But they are too often used to sedate older patients suffering from dementia — despite a “black-box” warning accompanying the drugs that they increase the risk of death in such patients.
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How My Parents’ Death Changed My Thinking About End-Of-Life Care

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By Charles Ornstein

My sister and I took our positions in the funeral home’s family room and greeted hundreds of mourners who had come to pay their respects. Everything seemed as it had four months earlier at our mother’s funeral. The ubiquitous tissue boxes. My navy pinstriped suit. The ripped black ribbon, a Jewish tradition, affixed to my lapel.

But this time, we were accepting condolences after the death of our dad, who stood next to us such a short time before.

It’s hard enough to lose one parent. Losing two within months is incomprehensible. When I left my parents’ Michigan apartment last month, I couldn’t believe it would be for the last time. I’ve replayed phone messages so that I could hear their voices again. And each morning, I look at Dad’s watch on my wrist, thinking it should be on his.

Two days before my dad died, I celebrated the first Mother’s Day without my mom. Now, I’m marking the first Father’s Day without my dad.

As I’ve mourned my parents, I’ve been struck by how many stories I’ve heard about husbands and wives dying soon after their spouses. One of my high school teachers lost both parents within a year; so did a journalist friend in Los Angeles. My rabbi told me his parents died only months apart.

My mom buried both of her parents within the same week in April 1979, when I was 5. My zaydee died first, unable to fathom life without his wife, who lay dying in the hospital. My bubbe died during his funeral two days later.

I wondered whether there was more to this than coincidence, and sure enough, there’s a well-documented “widowhood effect.” Those who lose a spouse are about 40 percent more likely to die within six months than those with living spouses. The effect has been found in a host of countries, across a range of ages, in widows and in widowers – though men are more likely to die soon after losing spouses than women are.

S.V. Subramanian, a professor of population health and geography at Harvard University, co-wrote a review published in 2011 that looked at more than a dozen studies on the effect. “We never say that grief is a disease,” he told me. “But what some of this research is showing is that at older ages, grief can make you more vulnerable to mortality.”

Subramanian said his uncle’s parents died within days of one another.

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