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A COVID-19 vaccine exemption letter

BY ANISH KOKA

I recently saw a young man who came to see me because his place of future employment, a large health system was requiring him to complete the 1º series of his COVID-19 vaccination. He was concerned because he had chest pain after his first mRNA vaccine and was uncomfortable with the risks of a second mRNA dose. He attempted to get a Johnson and Johnson vaccine and was told by pharmacists he was not allowed to mix and match this particular vaccine as he had already received an mRNA dose. With no other option, he came to ask me whether I thought a vaccine exemption was reasonable in his case. He already had a family medicine physician sign an exemption that had been denied by his future employer’s vaccine exemption committee. The young man works on the “back end” of the health system remotely from home and he has no patient contact. The entire process has caused him to lose his health insurance from his former employer, and he was now paying out of pocket for an expensive COBRA health insurance plan. What follows is my letter to the vaccine exemption review committee regarding his case. (Published with permission, only the relevant names have been changed/redacted)


Dear Vaccine Exemption Review Committee,

I am writing this letter on behalf of John Smith DOB: xx/xx/xx in regard to a mandate from xxxx Health that Mr. Smith receive a second dose of an mRNA vaccine to complete his primary COVID-19 vaccine series.

Mr. Smith has asked me to render an opinion specifically related to his cardiac risk of receiving a second dose of an mRNA vaccine. I am a board-certified cardiologist in Philadelphia, Pennsylvania, and have been in active clinical practice for 13 years.

After reviewing the details of his case, I have grave concerns about compelling him to receive a second dose of an mRNA vaccine and would like to outline the reasons for my conclusion in this letter. I am going to specifically discuss his risk of an important, now well-recognized, adverse event: vaccine myocarditis.

What follows is some important background information about vaccine myocarditis that has been gleaned over the last 2 years before I discuss the particulars of Mr. Smith’s case.

It is relevant to note here that as a physician active clinically in both the inpatient and outpatient arenas, I am an eyewitness to the severe toll COVID-19 took on my patients in the Spring or 2020. I was impressed enough with the initial mRNA vaccine data to acquire the vaccine available from the Philadelphia Department of Health (Moderna) and ran multiple vaccine clinics in order to vaccinate my mostly high-risk patients.

What follows is data produced since the vaccine rollout that is relevant to Mr. Smith’s case.

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Last in Line: Hospitals Brace for a Chilly 2023

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BY JEFF GOLDSMITH

As they emerge from the COVID pandemic, US hospitals have a terrible case of Long COVID.  They experienced the worst financial performance in 2022 in this analyst’s 47 year memory.  As the nation recovers from the worst inflation in forty years, hospitals will find themselves locked in conflict with health insurers over contract renewals that would reset their rates to the actual delivered cost of care.  “Last in line” in the US battle with inflation, hospitals will be exposed to public criticism when they attempt to recover from pandemic-induced financial losses. 

Hospital payment rates for commercial payers are backward looking. Commercial insurance contracts between hospitals and health insurers were multi-year contracts negotiated before the pandemic.  They continued in force during the pandemic, despite explosive rises in people and materials costs.    As a consequence, health costs were conspicuously missing from the main drivers of the 2021-22 inflation surge– food, housing, energy, durable goods, etc.    

Hospitals’ operating costs blew up during COVID due to a shortage of clinicians, the predations of temporary staff agencies, shortages of supplies and drugs and crippling cyberattacks that disabled their IT systems.   Hospital losses worsened during 2022 because they are unable to place patients who are no longer acutely ill but who cannot be placed in long term, psychiatric or home-based care (a problem shared by Britain’s disintegrating National Health Service).   Thousands of patients are stuck in limbo in hospital “observation” units, for which government and commercial payers do not compensate them adequately or at all.   

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There Is Something About Trains, Indeed

BY KIM BELLARD

Like many of you, when I heard about the Norfolk Southern train derailment in East Palestine (OH) on February 3, my heart went out to the people in that community. The train was carrying some hazardous materials, and no one was quite sure what was vented, especially when officials did a “controlled burn.”  Still, though, I didn’t think much about it; although I live in Ohio, I’m about as far away as one can be within the state.

Yesterday my local water company shut off access to water from the Ohio River. “We are taking this preventative step to ensure the health, safety, and confidence of residents,” said Cincinnati Mayor Aftab.  (Note: it reopened access today).

East Palestine isn’t all that close to the Ohio River, but whatever chemicals got into the local streams eventually started reaching it, and a “plume” of them slowly meandered the 400 miles downstream to here. Initially, the water company noted how small the particulate levels were – well below any danger – and that normal filtering processes would take care of them. Then they announced that they’d add a second filtering step, just in case.  I guess people weren’t reassured, because they still closed the intakes, if only for a day.

I can only imagine how worried the people in East Palestine must be.

The scary thing is that this derailment was not a freak occurrence.  There are about 1,000 derailments every year. Fortunately, most don’t involve either hazardous materials or result in deaths. If it’s any consolation – and it shouldn’t be – most hazardous material spills come from trucks, not trains (but, then again, trucks carry the most freight).   The odds are against bad things happening. But, with 1.7 trillion ton-miles of freight carried by train every year, the odds eventually result in an East Palestine (and there were train derailments with hazardous materials in both Houston and Detroit since East Palestine’s). 

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Matthew’s health care tidbits: Medicare Advantage is now a provider fracking contest

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Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Yes it’s time to talk Medicare Advantage (MA). It’s been a huge couple of weeks for the world of MA. On the commercial side, CVS bought the biggest pure play MA provider, Oak Street Health for $10bn. This pissed me off as if they paid $2 a share more I’d have made a profit on the stock I foolishly bought “on a dip” in 2021.

But this amazed many of us on THCB Gang, as they paid a huge premium and it works out to some $60k per patient. Now health care organizations have been overpaying for patient “lives” as long as I can remember–going at least as far back as Aetna nearly going out of business when it bought US Healthcare in 1996. So why is today’s incarnation of Aetna buying providers?

Well that’s to do with the regulatory side of MA. I have been on record since the very first post of THCB that Medicare FFS is an inefficient and expensive program–even if 80% of American hospitals say they lose money on it and have to charge commercial insurers more to make up for it. But while it’s possible to agree with George Halvorson that MA delivers better care at a lower cost than FFS Medicare, it is simultaneously possible to believe that MA costs more than it should. That’s because of aggressive RAF upcoding that’s been built both into home visits from companies like Signify and also into the EMRs doctors have been using to code MA members’ health status.

There are lots of proposals on how to fix this–including this one from Chenmed on how to change MA from paying for inputs (i.e how sick people are when they join MA) to outputs (how much better they got while in MA). But it’s clear that CMS is now officially coming after upcoding including full cross plan audits back to 2018. Even if not back to 2011. The MA plans will grumble about those past audits and tie CMS up in court but they know going forward the game is up

To make more money in MA they need to get hold and shake loose or frack some of the 85% of the premium that goes to provider organizations. Hence they are all getting into bed with them or buying them outright. UHG, Humana & now Aetna/CVS have been buying physician groups that serve MA populations at a quickening rate, and their goal is to put more of the 50% of seniors already into MA into those groups.

Will this save any money?  Well probably not, at least not yet. Humana has been reporting on the costs in its full risk capitated MA groups versus its FFS ones for a couple of years, and the difference is a rounding error. But the point is that the next war in Medicare Advantage is going to be what happens inside these plan-owned medical groups. So expect a lot more scrutiny of both costs, outcomes and patient experience within MA focused medical groups starting about now. 

All Three Legs of the Obamacare Stool Are Working Well – Part 2

BY GEORGE HALVORSON

2022 Medicare Advantage data gathering process change made last year just made upcoding for plans irrelevant and impossible, but the critics do not accept that it happened. 

CMS just ended that upcoding debate for 2022 by completely killing the coding system for the plans, effective immediately. The plans can’t code risk levels up because the coding system was eliminated entirely for 2022.

RAPS is dead.

The payment approach for Medicare Advantage now has no upcoding components and the government just used their new and more accurate numbers to create the 2023 payment level for the plans.

The numbers went up a bit with the real risk levels because the plans actually seemed to have been undercoding in spite of their best efforts to have higher numbers in their RAPS data flow.

We should now be able to put that issue to bed and look at what has been accomplished overall by the Affordable Care Act.

The Medicare Payment component of the Affordable Care Act just evolved to a new level — and the entire Obamacare package should now be recognized for what it is now and what it has become. 

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THCB Gang Episode 116, Thursday February 16

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday February 16 were futurist Ian Morrison (@seccurve); delivery & platform expert Vince Kuraitis (@VinceKuraitis); and Olympic rower for 2 countries and all around dynamo Jennifer Goldsack, (@GoldsackJen). Sadly, fierce patient activist Casey Quinlan (@MightyCasey) had to cry off, and sadly never returned to THCBGang.

We really dug into distributed care and who was going to control the emerging virtual first conundrum.

You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.

Let’s Finish The Job

BY MIKE MAGEE

In President Biden’s State of the Union Address, the most oft repeated phrase was “Let’s Finish The Job!” This came as part of an appeal for partnership as well as an assertion that in his first two years as President much had been accomplished.

Several days later, as if on cue, U.S. Senator Amy Klobuchar (D-MN) and Senator Chuck Grassley (R-IA), joint chairs of the Senate Subcommittee on Competition Policy, Antitrust, and Consumer Rights, announced that two bipartisan pieces of legislation focused on reducing the price of drugs to consumers had passed the Senate Judiciary Committee.

Both bills focus on the range of shenanigans Pharma firms have engaged in to extend their 20 year patents on blockbuster brands and delay generic versions from coming on the market.

The first bill – the Preserving Access to Affordable Generics and Biosimilars Act – is designed to prevent Big Pharma firms from flooding the FDA with sham requests for patent extensions. In the process, opponents have popularized a new term – “patent thicket” to describe the barrage of skimpy patent extension tricks companies use to extend their original 20 years of exclusivity. 

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All Three Legs of the Obamacare Stool Are Working Well

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BY GEORGE HALVORSON

When the Affordable Care Act was passed, the politics were so intense and the debates were so filled with rhetoric in all directions that most people actually didn’t understand that there were three major component parts to the strategy and program that function very directly as a package, and should be looked at now in the context of several years of implementation to see how each part of that law is currently doing.

Medicaid was our first priority.

The first component part — and the one that had the highest need for passage when the law was passed because we were doing such a horrible job as a country in providing coverage to our children and to our low-income people — was Medicaid expansion.

We were the only country in the industrialized world that did not have health care available to our low-income children, and that deficiency damaged so many people and was so terrible as a reality that we needed to correct it as soon as we could.

That program is on the right track.

Most states have now used the full Medicaid package and we now have a total of 90 million people enrolled in Medicaid. About 41 million of the members are in the CHIPS program, and a majority of the births in a majority of the states are now Medicaid births.

The states have all used a number of modern care improvement tools to provide and deliver significantly better care than the old Medicaid programs that are far too often delivered to their beneficiaries.

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Give Him a Hand – No, Really

BY KIM BELLARD

When I read The Washington Post article about how a Tennessee high school student’s engineering class built him a prosthetic hand, my immediate reaction, of course, was to be touched, but my bigger reaction was, wait – high school students can now create prosthetics?

If you haven’t been paying attention, the world of prosthetics has been changing in amazing ways, and it’s not done.  

The student, Sergio Peralta, was born with his right hand not fully formed, and for much of his life it was a problem.  As he wrote in his own account in Newsweek: “When I got bullied at my old school, the bullies would always compare me to them and make me feel like I am less of a person because of my right hand.”  His high school engineering teacher noticed his limitations, got permission from his mother to create a prosthetic for him, and assigned three students to the project.

Within a week, they’d used a 3D printer to create a prototype, and over the next couple weeks they’d iterated it to a version Sergio was happy with. “As he was adjusting it, I felt very happy,” Sergio writes.  “It looked cool and robotic, and it was grey and blue. We then tested weather [sic] I was able to grip objects with it…My teacher was so happy that the hand worked. It was exciting for him to see me catch a ball for first time in 15 years.” 

3D printing has been one of the big breakthroughs for prosthetics. The Afghan and Iraq wars unfortunately created a huge demand for them, and the military health services stepped up. Dr. Peter Liacouras, the Director of Services for the 3D Medical Applications Center at Walter Reed, says: “Over the past ten years, we have concentrated on filling the gaps in prosthetics through 3D printing. 3D printing has been highly flexible and applicable for specialty solutions of limited production needs.”  Ukrainian soldiers are now benefiting from this expertise.

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