Posts Tagged 'Medicaid'

Healthcare Crisis: Not Enough Specialists For The Poor, but Calif to Cut Medi-Cal Spending

Healthcare Crisis: Not Enough Specialists For The Poor

LA Times, December 15, 2012

With months-long waits for Medi-Cal patients to see specialists, some turn to emergency rooms — exactly what healthcare reform is banking on avoiding.

By Anna Gorman, Los Angeles Times

The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.

He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.

Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much he is considered legally blind.

PHOTOS: Waiting in vain to be seen

“I want to see again,” he said. “I’ve been waiting a long time.”

Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation’s healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence’s problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.

But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals — a linchpin in reducing medical spending — will be virtually impossible without the ability to make timely patient appointments with specialists.

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”

The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.

“Where needs are absolutely critical, we are able to work out special arrangements,” said Rise Phillips, chief executive of T.H.E. Clinic. “That is not the norm. That is, rather, the exception.”

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

The challenge can be seen in Belinda De Leon’s cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center’s clients — and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she’s juggling more than 1,000 pending referrals.

One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.

On a recent visit, she told De Leon she is scared to wait any longer. But she can’t afford to pay for the test out of pocket. “I’m hoping it’s not anything like cancer,” she said.

De Leon promised to update Barrera’s referral paperwork to indicate she is experiencing pain. “Hopefully that will help,” she said.

Waits for specialist appointments vary dramatically, depending on the type of specialist needed. Patients willing and able to travel across L.A. County to specialty clinics may be able to see a doctor within a month or two. Others who lack transportation and must go to a nearby facility can wait up to a year for a dermatologist or neurologist and up to 18 months for a cardiologist or ophthalmologist.

The county is trying to make the system more efficient, reduce wait times and ensure that those who don’t need more advanced care don’t overburden the system, said Mitch Katz, head of the L.A. County Department of Health Services. County officials risk losing newly insured patients, along with government funding, if they can’t find ways to reduce the bottleneck.

One focus is using technology to improve communication and better screen patients. A pilot program, for example, is allowing primary care doctors at community and public clinics to quickly transmit patients’ medical information via computer to a public health specialist for a consultation.

The electronic consults are streamlining referrals and helping clinic doctors make better treatment choices, said Louise McCarthy, executive director of the Community Clinic Assn. of Los Angeles County.

During an August visit to T.H.E. Clinic, Lawrence saw nurse practitioner Sandeep Lehil for the first time. He told her he was controlling his diabetes with medication and a modified diet. But his vision wasn’t getting any better.

“My eyes are really bad,” he told Lehil. “I can barely see.”

Lawrence’s medical record showed that he wouldn’t be seeing an ophthalmologist for many months.

“That’s a long time to live with blurry vision,” Lehil said.

“By that time, I’ll be blind maybe,” Lawrence responded.

Lawrence, who has a soft voice, an accent and a lanky frame, arrived in the U.S. nearly 20 years ago to pick apples, and overstayed his visa. He can’t work or drive, and he relies on others to cook meals to avoid burning himself. His immigration status prevents him from getting health insurance or unemployment benefits. He lives with a friend, spending most days listening to a television he can barely see. When the phone rings, he lifts it almost to his nose to see who is calling.

In mid-October, Lawrence was back at the clinic and saw a different, fill-in doctor who knew nothing about his situation, nor when his surgery would be scheduled. “You haven’t received any notice?” asked physician David Hwang. “No, not yet,” Lawrence answered, adding that he checks his mailbox every day.

De Leon, the referral clerk, later gave Lawrence unwelcome news: The wait to see an ophthalmologist at the county’s Harbor-UCLA Medical Center was still about a year. She said she was trying to get him an appointment elsewhere sooner.

Weeks later, Lawrence took matters into his own hands. With the help of a friend, he took three buses to reach the emergency room at Los Angeles County/USC Medical Center northeast of downtown. He waited several hours but finally saw an emergency room physician, who managed to get him an appointment the next day with an eye doctor.

“You have to do what you have to do,” Lawrence said.

At the medical center’s specialty clinic, ophthalmologist Simon Bababeygy told Lawrence his cataracts probably were caused by his diabetes, high blood pressure and high cholesterol.

He described the surgery he would perform, on one eye at a time. And he spoke the words Lawrence had been waiting for: He should be seeing much more clearly by the end of the year.

Preparing for the surgery, doctors got an abnormal result on a heart test. Now, Lawrence has to wait to see a county cardiologist before going back to Bababeygy to schedule the eye operation. He has no idea how long that could take.

“Every time, it’s something else,” he said. “My eyes are getting worse. And now it’s my heart.”

anna.gorman@latimes.com

Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism.

Copyright © 2012, Los Angeles Times

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LA Times, December 13, 2012

Court Ruling Could Cut California Spending On Medi-Cal

A 9th Circuit appeals panel decides California can reduce its Medi-Cal reimbursements to doctors, pharmacies and others. Providers say the doctor shortage will worsen.

By Maura Dolan and Chris Megerian, Los Angeles Times

SAN FRANCISCO — In a potential windfall for the state, a federal appeals court decided unanimously Thursday that California may cut reimbursements to doctors, pharmacies and others who serve the poor under Medi-Cal.

A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned injunctions blocking the state from implementing a 2011 law that slashed Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves low-income Californians.

The ruling could make it harder to find doctors for as many as 2 million new patients who could become eligible for Medi-Cal under President Obama’s healthcare law — a possible 25% expansion of the program. California already provides one of the lowest rates of reimbursement in the nation for medical services to the poor, and there is a shortage of doctors to serve those patients.

Lynn S. Carman, an attorney for a group of pharmacies, said the decision would be costly for providers, worsen the doctor shortage and would be appealed.

“If this decision stands it will not only destroy the Medicaid program in California, but it will destroy the Obamacare program for millions of Americans who are now being shoved into the Medicaid program under the Affordable Care Act,” Carman said.

“They will not be able to obtain quality healthcare or access to services because providers cannot provide services at less than what it costs to furnish them,” Carman said.

The ruling could make it considerably easier for the state to close its budget gap.

The state is facing a $1.9-billion deficit next year, although Proposition 30’s temporary tax hike and an improving economy are projected to shift the state back into surpluses in the near future.

Medical providers said Thursday that the cutback should be lifted now that the state’s fiscal outlook has improved. The ruling can be applied retroactively to June 1, 2011.

“Now that the state has money, it would be like Scrooge for Gov. Brown not to pass a bill to eliminate at least the retroactivity part of it,” Carman said.

For the governor, Medi-Cal cuts could serve one policy aim at the expense of another.

Balancing the budget has been Brown’s first priority since taking office, and cutting healthcare — the state’s second-biggest cost after education — has been key to his fiscal goal.

But at the same time, he has wanted California to be out front in healthcare reform, and lead the country in efforts to put the federal law into place.

A spokesman for Gov. Brown released a statement Thursday that implied that Brown was inclined to put his budget priorities first, and was not likely to rescind the cuts.

“Today’s decision allows California to continue providing quality care for people on Medi-Cal while saving the state millions of dollars in unnecessary costs,” the spokesman wrote.

In a ruling written by Judge Stephen S. Trott, appointed by President Reagan, the panel said the lower court injunctions were unwarranted because the federal government had approved the cuts.

“Neither the State nor the federal government ‘promised, explicitly or implicitly,’ that provider reimbursement rates would never change,” Trott wrote.

California has estimated that the 10% cut to medical providers and pharmacies would save the state $50 million a month.

Medi-Cal typically covers families and disabled Californians. The federal law will extend its coverage to single, childless adults beginning in 2014.

The California Medical Assn., which joined dentists, pharmacists, medical suppliers and medical response companies in trying to block the cutbacks, urged Brown to repeal them.

Dr. Paul R. Phinney, president of the doctors’ association, said the cuts shrink the number of providers who could afford to serve both existing Medi-Cal patients and the new ones who could become eligible for coverage in 2014.

“We need to ensure that health insurance isn’t just an empty promise for these patients,” Phinney said.

According to the California HealthCare Foundation, Medi-Cal patients already have difficulty finding doctors.

A foundation study published in July 2010 said 25% of physicians provided care to 80% of Medi-Cal patients.

Although 90% of physicians told the foundation they were accepting new patients, only 57% said they were taking on new Medi-Cal patients.

Dr. Ted Mazer, a San Diego ear, nose and throat surgeon, said he had to stop taking fee-for-service Medi-Cal patients several years ago because the reimbursements didn’t cover his costs and Medi-Cal patients were inundating his practice.

“So few doctors will see Medi-Cal patients that I was seeing them from the Mexican border to Riverside County to Orange County,” said Mazer, an officer of the California Medical Assn. “The reimbursement costs are so poor they don’t even cover costs, let alone pay for the administrative hassle. I can only see so many until I go under.”

Chris Perrone, deputy director of the foundation, said Thursday’s ruling will make it harder to block rate cuts in the future.

“The hurdles for people who want to block these rate cuts are little higher,” said Perrone.

maura.dolan@latimes.com

chris.megerian@latimes.com

Dolan reported from San Francisco and Megerian from Sacramento.

Times staff writer Anna Gorman contributed to this report.

Shortlink to this posting:  http://wp.me/p3xLR-to

CARA Flash Mob: Hands Off Social Security, Medicare, Medicaid! Tax the Top 2%!

The nation’s richest banks and corporations have rung up billions in deficits with wars, tax cuts for the richest, bank bailouts, and reckless speculation, and now they want us to pay by sacrificing Social Security, Medicare, Medicaid, and every other part of the Safety Net!

Democrats and Republicans alike are burning the midnight oil in search of a bi-partisan Grand Bargain to screw seniors, people with disabilities, kids, and low-income workers.

No Way! Join our Flash Mob for social justice: We demand:

* No cuts to Social Security, Medicare, Medicaid, or services to low-income people.

* End the tax cuts for the rich

* Create millions of jobs

Our goal is to video our flash mob and have it go VIRAL – so the whole country puts pressure on Congress to demand that we do not cut our essential programs in order to make the Grand Bargain on the deficit and avoid sequestration before the end of the year.

Sponsored by the California Alliance for Retired Americans (CARA) and Jobs With Justice (JwJ).

See the Resolution on Social Security, Medicare, and Medicaid written by SF Gray Panthers and passed by the SF Central Labor Council.

Shortlink to this posting:  http://wp.me/p3xLR-tg

Severe, Long-Term Medicare and Medicaid Cuts Planned Will Impact Jobs Picture

The New York Times says cutbacks in healthcare planned in future years are so severe that the resulting layoffs and hiring freezes will  worsen the nation’s unemployment.   We need to take this very seriously. Half the Obama’s health plan is funded by scaling back $575 billion in planned increases in Medicare spending over the next decade, money intended to care for baby-boomers as they age into Medicare. Democrats and Republicans alike are calling for hundreds of billions in additional Medicare cuts.  All of these Medicare cuts are aimed at the doctors, hospitals, nursing homes, rehab facilities serving Medicare patients.  The cuts will result in many of these providers either dropping out of Medicare or giving dangerous care because of short-staffing.  Read more at http://wp.me/p3xLR-pJ . Proposed cuts to Medicaid providers, and cuts in Medicaid enrollment and services are even worse.

Capping and even cutting Medicaid and Medicare spending while allowing costs to rise to accommodate insurance, drug, and hospital profits means that government and its corporate partners are tossing away the notion of equal care for seniors, children, people with disabilities, and low-income workers.

New York Times, Thursday, August 18, 2011

Cuts in Health Care May Undermine Role in Labor Market

By REED ABELSON and KATIE THOMAS

Even during months of stubborn unemployment, the health care industry has provided a solid underpinning, reliably adding jobs in an otherwise dismal environment.

For example, hospitals, nursing homes and the like added about 430,000 jobs during the recession, as the country shed 7.5 million jobs. With the latest government reports showing a meager overall gain of 117,000 jobs in July, health care remained a significant contributor with an additional 31,000 jobs for the month, a tad higher than an average monthly addition of 25,000 health jobs in the last year. Hospitals, which had a slight decline in June, added 14,000 jobs in July.

While few experts can predict how the stock market’s gyrations and government cutbacks this month will affect the health industry, several health industry analysts warn that the sector is showing signs of economic sluggishness that has long kept other business sectors beleaguered.

The situation has led many in the health industry to caution that it cannot be relied upon to keep hiring workers. “It’s not realistic to believe that we’re going to continue to generate job growth when you’re speaking about Medicare and Medicaid reductions in the hundreds of billions of dollars over the next few years,” said Daniel Sisto, president of the Healthcare Association of New York, which represents the state’s hospitals and health systems.

Companies that rely on government spending have been bracing for deeper reductions, and President Obama recently alluded to another round of belt-tightening from one of the industry’s bedrock payers — Medicare.

Signs of a gloomier outlook have been surfacing in various spots, from a slowing in new construction plans to falling share prices of nursing home companies to announced layoffs among hospital support staff.“Nobody is sure what will happen,” said Alan M. Garber, a physician and health policy expert at Stanford. The cuts in government programs like Medicare and Medicaid, and pressure to reduce costs, are thwarting health care employers in trying to meet the rising demand for their services.

“The health care industry is facing greater uncertainty than in any time in memory,” Dr. Garber said.

Yet even though economists and other experts still predict increasing demand for health care as the population ages, with an accompanying demand for job growth, health care officials and executives cite a daunting cascade of recent events as reasons to reassess any expansions.

They point to Congress’ intent to reduce spending, economically depressed states struggling to deal with a rash of cuts in Medicaid programs and the continued uncertainty of financial costs that will be imposed by the federal health care law, including contradictory lower court decisions about the constitutionality of various provisions.

A survey by the Conference Board, a business research group, found that help-wanted ads for health care providers and technicians fell by 61,200 listings in July.

In Florida, for example, health care led the state in job gains during the recession — it was the only industry that did not lose jobs during that time. But since September of last year, the leisure and hospitality industry has been adding more jobs, according to a state economist.

The Palo Alto Medical Foundation, a large physician group in Northern California that employs 5,500 people, including 1,000 doctors, says it has no plans to add many more people in the near future. “Really our focus these days is to do more with the assets we have,” said Cecilia Montalvo, the vice president for strategic development for the medical group.

Hospitals also appear to be slowing the pace of building, as projects begun before the recession started are now being completed. The volume of tax-exempt debt for hospitals in the first half of the year has fallen by nearly half from a year ago, said David Johnson, a managing director at BMO Capital Markets. “We’re overinvested in hospitals and hospital beds,” he said.

The University of Michigan Health System, for example, is adding some 560 jobs as a result of new children’s and women’s hospitals it plans to open soon and an expansion of its emergency department. But Doug Strong, who heads the system’s hospitals, said his overall goal is to shrink his work force in future years as he tries to make the system more efficient.

While he expects the demand for health care services to rise, he believes he needs to deliver that care with fewer people at less cost. “I think that is what the nation is asking of all of us,” he said.

The impact of state cuts in Medicaid are already being felt in doctor’s offices, hospitals, nursing homes and home health agencies around the country. Hospitals experienced reductions in Medicaid reimbursement in 37 states for next year’s budgets, according to Lisa Goldstein, an analyst at Moody’s, who predicts further cuts.

At the Elliot Health System in Manchester, N.H., the seemingly abrupt decision by state lawmakers to sharply reduce hospital reimbursements led the hospital to recently lay off 182 people.

“For the last 10 years, we’ve been pretty stable and we’ve been able to grow,” said Elliot’s chief executive, Doug Dean. But faced with the loss of millions of dollars in Medicaid revenue that would wreak havoc on the coming hospital budget, Mr. Dean said he had no choice but to cut jobs. “It was simply because of the economics of Medicaid,” he said. Elliot is among a group of hospitals filing a lawsuit to stop the cuts.

Health care employers are also confronting cuts to the federal Medicare program. In July, nursing home operators learned their reimbursements would be cut by 11 percent in October, and hospitals expect further reductions in what they are paid under the new health care law as well as in future efforts to reduce the federal deficit.

Still, these continue to be boom times in many corners of the industry. Partners in Care, a New York nonprofit provider of home health care services, is hiring so many home health aides that it recently opened a second training center to handle the flood of new employees.

Its staff of aides has grown from close to 5,800 in 2006 to about 9,200 today. In June, the group, which is part of the Visiting Nurse Service of New York, hired 374 new people, the second-biggest month in its history.

Jay Conolly, vice president of human resources at Partners in Care, said his group is benefiting, not just from the growing elderly population, but also from the consolidation of nursing homes and hospitals in the New York area and a heightened interest in low-cost alternatives to inpatient care. The Bureau of Labor Statistics has predicted that jobs will grow faster in the home health care area than in any other section of the health care industry.

“There’s never been enough home health aides, and there never will be,” Mr. Conolly said.

And many expect that when the economy finally does rebound, hiring will, again, take off, especially when more people are expected to be insured under the federal health care law. Geraldine Bednash, chief executive of the American Association of Colleges of Nursing, expects there is pent-up demand for their services, especially for nurse practitioners and nurse midwives, who would work in primary care. “We are going to see this huge onslaught of need for nurses,” she said. “So we’re in a blip, that’s all.”

There are some who wonder whether the country should continue to rely on health care as a stalwart supplier of new jobs. If spending on health care continues at its current pace, it will choke out other vital sectors and end up hurting the rest of the economy, said Joshua Shapiro, chief United States economist at MFR Inc. “I think the path that we’re on now is clearly unsustainable,” he said.

Tom Torok contributed reporting.

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Obama! HANDS OFF SOCIAL SECURITY, MEDICARE, AND MEDICAID

On July 24, President Obama was twisting arms to get Congress to agree to huge debt reductions that would cripple Social Security, Medicare, and Medicaid.

Angry defenders of these programs responded by staging a noisy demonstration outside the Obama Campaign’s Oakland California headquarters, where a training session was under way to organize volunteers into the 2012 campaign machine.

We tried to get inside to speak to the volunteers and explain that 80% of the people say they don’t want our programs cut, and that corporations and the rich should be taxed to solve the debt.  During the standoff, we got many leaflets inside. You can read the leaflet here. After we went outside and began our demonstration, one volunteer came out and said we were right, that she’d tried to talk with the people inside, and she was disgusted that the Campaign was determined to go ahead with their agenda and wasn’t willing to listen to why our programs need to be saved.

Fighting to save Social Security has been much harder this year than in 2005 when Bush tried to privatize it. A big reason is that now the proposed cuts, which are much worse, are being pushed by a Democratic president, causing many to be reluctant to fight back. We need to get over this hesitation, not only in word, but also in deed. Today’s small demonstration was a start.

short link to this post:  http://wp.me/p3xLR-sc

Obama shields states cutting Medicaid doctor payments

Bipartisan attack on Medicaid, healthcare for low-income children, seniors and workers.
  • The GOP’s justly-hated Ryan Plan puts states’ Medicaid programs on an ice floe, because it caps federal payments to states regardless of states’ needs (“block-granting”), and also gives states the rights to cut their Medicaid programs in defiance of federal standards of of who must be eligible and what services must be covered. 
  • But Democrats have also attacked Medicaid, beginning with the Clinton administration, which granted states huge numbers of waivers to the federal requirements.  Now the Obama administration is shielding states that are cutting their Medicaid programs by saying Medicaid patients and doctors cannot sue states for reducing doctor payments, even if such cuts cause a reduction in the number of doctors serving Medicaid patients to the point where patients cannot access care.
  • California has among the lowest Medicaid payments to doctors and pharmacies in the nation, and among lowest Medicaid doctor-to-patient ratios in the country.  Doctors, pharmacies, and patient advocates, including San Francisco and Sacramento Gray Panthers, sued California in response to Schwarzenegger’s 10% cuts to Medi-Cal.  Brown’s budget includes and additional 10% cut.  The suit has worked its way up to the Supreme Court, and it is this context that the Obama administration has submitted a brief saying states cannot be sued for cutting their Medicaid programs.
  • Democrats and Republicans are unified in their determination to cut our programs.  Medicare and Medicaid were won in the in the streets in the 1960s, and that is where they must be defended now.

By Robert Pear

WASHINGTON — Medicaid recipients and health care providers cannot sue state officials to challenge cuts in Medicaid payments, even if such cuts compromise access to health care for poor people, the Obama administration has told the Supreme Court.

States around the country, faced with severe budget problems, have been reducing Medicaid rates for doctors, dentists, hospitals, pharmacies, nursing homes and other providers.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid recipients have access to care to the same extent as the general population in an area.

In a friend-of-the court brief filed Thursday in the Supreme Court, the Justice Department said that no federal law allowed private individuals to sue states to enforce this standard.

Such lawsuits “would not be compatible” with the means of enforcement envisioned by Congress, which relies on the secretary of health and human services to make sure states comply, the administration said in the brief, by the acting solicitor general, Neal K. Katyal.

In many parts of the country, payment rates are so low that Medicaid recipients have difficulty finding doctors to take them.

But, the Justice Department said, the Medicaid law’s promise of equal access to care is “broad and nonspecific,” and federal health officials are better equipped than judges to balance that goal with other policy objectives, like holding down costs.

The administration expressed its views in a set of cases consolidated under the name Douglas v. Independent Living Center of Southern California, No. 09-958.

In 2008 and 2009, the California Legislature passed several laws reducing Medicaid payment rates. Recipients and providers challenged the cuts in court, arguing that the California plan violated — and was pre-empted by — the federal Medicaid statute.

The law does not explicitly allow such lawsuits. But the United States Court of Appeals for the Ninth Circuit, in San Francisco, said beneficiaries and providers could sue under the supremacy clause of the Constitution, which makes federal law “the supreme law of the land.” In reducing payment rates, the appeals court said, California violated the requirements of federal Medicaid law and threatened access to “much-needed medical care.”

California appealed to the Supreme Court, which is likely to hear oral arguments in the fall, with a decision by next spring.

Consumer advocates were dismayed by the administration’s position, which they said undermined Medicaid recipients’ rights and access to the courts.

“I find it appalling that the solicitor general in a Democratic administration would assert in a Supreme Court brief that businesses can challenge state regulation under the supremacy clause, but that poor recipients of Medicaid cannot challenge state violations of federal law,” said Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, who is usually sympathetic to the administration.

Representative Henry A. Waxman of California, the senior Democrat on the Energy and Commerce Committee and an architect of Medicaid, said the administration’s brief was “wrong on the law and bad policy.”

“I am bitterly disappointed that President Obama would accept the position of the acting solicitor general to file a brief that is contrary to the decades-long practice of giving Medicaid beneficiaries and providers the ability to turn to the courts to enforce their rights under federal law,” Mr. Waxman said. He said that he and other Democratic lawmakers planned to file a brief opposing the administration’s view.

By contrast, many state officials agree with California and the Obama administration.

The National Governors Association and the National Conference of State Legislatures filed a friend-of-the-court brief endorsing California’s position that Medicaid recipients and providers could not sue.

In a separate friend-of-the-court brief, Michigan and 30 other states went further. “Allowing ‘supremacy clause lawsuits’ to enforce federal Medicaid laws will be a financial catastrophe for states,” they said.

Medicaid is financed jointly by the federal government and the states. The number of recipients and the costs increased sharply in the recent recession and will increase further with the expected addition of 16 million people to the rolls under the new federal health care law.

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Shortages of key drugs endanger patients. Free market to blame.

“Doctors, hospitals and federal regulators are struggling to cope with an unprecedented surge in drug shortages in the United States that is endangering cancer patients, heart attack victims, accident survivors and a host of other ill people.”  … The causes vary from drug to drug, but experts cite a confluence of factors: Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.”

This is a perfect illustration of why the research, development, ownership and production of medicines must not be left in the hands of private businesses.  Drugs must be researched and produced according to our needs, not profit opportunities. Private companies must not be allowed to own patents on drugs. Despite spectacular advances in research techniques, companies’ profit-driven research has produced few significant advances.  It is virtually impossible to oversee private manufacture of medicines, and companies regard fines in response to tragic “accidents” as a cost of doing business.

Washington Post, Sunday, May 1, 2011

Shortages of key drugs endanger patients

By Rob Stein

Doctors, hospitals and federal regulators are struggling to cope with an unprecedented surge in drug shortages in the United States that is endangering cancer patients, heart attack victims, accident survivors and a host of other ill people.

A record 211 medications became scarce in 2010 — triple the number in 2006 — and at least 89 new shortages have been recorded through the end of March, putting the nation on track for far more scarcities.

The paucities are forcing some medical centers to ration drugs — including one urgently needed by leukemia patients — postpone surgeries and other care, and scramble for substitutes, often resorting to alternatives that may be less effective, have more side effects and boost the risk for overdoses and other sometimes-fatal errors.

“It’s a crisis,” said Erin R. Fox, manager of the drug information service at the University of Utah, who monitors drug shortages for the American Society of Health-System Pharmacists. “Patients are at risk.”

The causes vary from drug to drug, but experts cite a confluence of factors: Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.

“It seems like there were a lot of things happening with consolidations and quality issues and more things coming from overseas,” said Allen J. Vaida, executive director of the Institute for Safe Medicine Practices, a nonprofit group that helped organize a conference last fall to examine the issue. “It just reached a point where the number of shortages was slowly going up and up, and now we have a national crisis with this huge shortage of critical medications.”

While the dearth that has garnered the most public attention is — ironically — for a barbiturate that is hindering prisons trying to execute inmates, the scarcities are having a much broader impact on keeping people alive, especially in emergency rooms, oncology wards and intensive care units.

No one is systematically tracking the toll of the shortages, but reports are emerging of delayed treatments, anxious searches for desperately needed drugs, devastating injuries from mistakes and less-adequate drugs, and even possible deaths.

Federal regulators have been rushing to alleviate the shortages, sometimes helping firms resume production more quickly or approving emergency imports of supplies from overseas.

The Food and Drug Administration eased a shortage of the anesthetic propofol last year by allowing foreign importation, for example, and this year approved bringing in several other medications, including two cancer drugs.

“The types of products we’re seeing shortages of are really concerning,” said Valerie Jensen, who heads the FDA’s Drug Shortages Program. “This is affecting oncology drugs, critical-care drugs, emergency medicine drugs. We’re doing everything we can under our current authority to try to deal with this situation.”

In Congress, legislation has been introduced to address the problem. For example, a bill would require companies to notify the FDA in advance about anything that might cause a shortage and give the agency new powers to try to assuage them.

“We can’t put patients’ lives at risk simply because there’s some snafus in a process or a manufacturer decides it’s less profitable to make a certain drug,” said Sen. Amy Klobuchar (D-Minn.). “Patients deserve better than that.”

‘Very global supply chain’

Many of the shortages involve older, cheaper generic medications that are less profitable, causing many firms to stop producing them and leaving fewer sources. Most involve “sterile injectable” medications that are more complicated to produce and therefore are more prone to manufacturing problems.

In addition, drug companies increasingly rely on raw materials from other countries.

“We’ve certainly reached a very global supply chain for drug products, with the active ingredients typically made outside of the United States,” said Gordon Johnston, vice president for regulatory sciences at the Generic Pharmaceutical Association. “It could be Europe, India — some cases China. If there’s a problem at a facility in Italy or India, it leads to disruption of the drug supply in the United States.”

Some industry representatives blame part of the problem on increased oversight by the FDA, which has made drug safety a higher priority after coming under intense criticism for being too lax.

“As you know right now, FDA has taken a heightened approach towards drug safety,” said Maya Bermingham, senior assistant general counsel at the Pharmaceutical Research and Manufacturers of America. “FDA has stepped up inspections. The more you look, the more you may discover problems.”

While acknowledging that the industry needs to do a better job of coordination, some company officials said the agency should coordinate enforcement actions and drug shortage issues more closely to avoid administrative requirements that cause interruptions.

“We’re not sure how much of that is going on recently because we’ve seen more and more shortages in the industry. We think that maybe some of those coordination issues can be worked on,” said Joshua Gordon, vice president and general manager of specialty pharmaceuticals at Hospira, the largest producer of specialty generic sterile injectables.

Shortages of pre-loaded epinephrine syringes and propofol, for example, occurred when suppliers dropped out just as the FDA was demanding additional documentation, he said.

“They are very focused on taking quick and and aggressive action,” Gordon said. “We applaud the agency’s role in assuring quality, but it can slow things down significantly.”

FDA officials dispute that greater government oversight is a major factor, saying manufacturing problems were the cause of most shortages.

“There has not been a significant increase in domestic enforcement actions (seizure or injunction) for this class of products in recent years,” Jensen wrote in an e-mail.

‘Too many . . . will die’

Whatever the causes, many of the affected drugs are mainstays of medical care, such as the potent painkiller morphine, norepinephrine, which is commonly used in emergency rooms, and electrolytes, which are often given to patients in intensive care.

But shortages have been reported in many categories of drugs, including antibiotics, and drugs central to the treatment of many cancers, forcing oncologists to delay or alter carefully timed chemotherapy regimens.

“We have heard some horror stories where patients are really begging to get the drugs from other sources and where practices or institutions are forced to kind of triage patients and save the drugs for those — quote — most curable, where they have the best prognosis and using substitutes where there isn’t a cure possibility,” Michael Link, president-elect of the American Society of Clinical Oncology.

The drug cytarabine has caused the most concern and gotten the most attention because it is highly effective for treating several forms of leukemia and lymphoma but must be administered as quickly as possible, especially to patients with acute myeloid leukemia.

“With this drug they can be cured and without this drug too many of them will certainly die. That’s the simplest way to put it,” said Deborah Banker, vice president for research communication at the Leukemia & Lymphoma Society. “The disease progresses so rapidly that untreated patients can sadly die within days. There is no time for delay and no certainty of a good outcome if you can’t get a full dose.”

Many hospitals are running low, and some have run out completely. That has required many facilities to ration the drug, giving priority to those who need it most urgently.

“It’s so unbelievable,” said Mary Collins, 57, of La Crosse, Wis., whose husband, Michael, 66, had problems obtaining cytarabine to fight lymphoma. “A cancer diagnosis is a long, very, very stressful circumstance. And then to learn that a particular drug is no longer available to you and that there seems to be no formalized mechanism in place to correct it just makes it worse.”

Cytarabine’s scarcity was caused by hitches that two out of the three manufacturers hit in obtaining raw materials, as well as the discovery of crystals in some shipments.

The third manufacturer was unable to make up for the shortfall. Some of the problems have been resolved, however, and the FDA is working on importing the drug.

The shortages are forcing hospital pharmacists to juggle supplies and hunt for new sources. Many hospitals, including several contacted in the Washington area, say they are usually able to patch together solutions.

But some resort to paying inflated prices or buying from unfamiliar suppliers, increasing the risk they may be getting counterfeits.

“When it becomes clear that some drug may be in short supply or going into a shortage, what happens is sometimes there are unsavory folks — small distributors — who buy up whatever is left and sell it back at exorbitant prices,” said Roslyne Shulman, director of policy development for the American Hospital Association.

‘Panic in the pharmacy’

When shortages occur, physicians turn to less optimal alternatives or find out too late that the drug they need is unavailable. Mark Warner, president of the American Society of Anesthesiologists, described two calamities that occurred in the past year because of shortages. In one, a 16-year-old boy suffered brain damage because doctors did not have one muscle relaxer needed to treat a complication from jaw surgery.

In another, a middle-aged woman was left in a permanent vegetative state because doctors did not have the drug epinephrine after she experienced complications from heart surgery.

“These are tragic cases,” Warner said. “It’s one of those things most anesthesiologists in the country think about when they are driving to work every day. We don’t know where the shortages are and they come on very quickly. ”

Nurses and doctors responding to emergencies, meanwhile, are losing precious minutes when they must work with unfamiliar substitutes or recalculate dosages, increasing the chances of overdosing or under-dosing patients. One of the biggest problems is a shortage of syringes pre-filled with precisely measured doses.

“Grabbing the right medication out of a crash cart that’s already in a syringe is a big advantage over having to get out the syringe, get out the needle, get the medication and get the measurement right,” said Angela Gardner, an emergency medicine physician at the University of Texas Southwestern Medical Center in Dallas and immediate past president of the American College of Emergency Physicians. “Those minutes are lives.”

Many hospitals are recalibrating electronic medication delivery systems or preparing the correct doses ahead of time, especially for the emergency room, to minimize mistakes.

“We’ve been extremely fortunate using strategies in cooperation with our medical staff,” said Jay Barbaccia, head pharmacist at the Washington Hospital Center. “We’ve had a lot of panic and inconvenience but minimal, if any, impact on our ability to provide care. It makes my life miserable — the panic is in the pharmacy when we’re scrambling around to find alternatives.”

Nevertheless, a long list of errors and near-misses have been reported, including incidents in which patients required emergency care to save them.

At least two patients reportedly died from overdoses of hydromorphone they received because of a morphine shortage.

At least 19 patients were sickened and nine died in Alabama this year after being infused with a solution through their feeding tubes that was apparently contaminated with bacteria by a pharmacy using an unfamiliar ingredient because of a shortage.

The shortage occurred because the manufacturer had trouble getting the product’s packaging.

“It’s horrible. It’s something that shouldn’t have happened,” said Donald J. Mottern of Alabaster, Ala., whose 71-year-old mother was one of the victims. “We lost the matriarch of our family. The loss to our family has left each of us very hollow.”

© 2011 The Washington Post Company

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Alternative Deficit-Reduction Plan: Death Spiral for Medicare and Its Patients

Bipartisan Policy Center (Domenici, Rivlin) Propose Their Deficit-Reduction Plan:
Privatize Medicare, Tax Employers’ Healthcare, Tax cuts for  Corporations and the Rich, and No Payments to Social Security Trust Fund for 2011.

Rivlin and Domenici propose a deficit-reduction plan that would privatize Medicare, cut its benefits, and further weaken Medicare’s financial basis.  Under their “premium support” plan, Medicare would no longer directly pay for seniors’ healthcare.  Instead, Medicare recipients will be issued voucher checks, and they will have to shop for their own health care, either traditional Medicare or a private health plan. The premiums of the private plans will go down because they can market themselves to healthy people at gyms, marathons etc. The premiums of traditional Medicare will go up because traditional Medicare must continue to accept sicker, more expensive patients.  Moreover, the voucher checks would not grow with the rate of medical inflation, but would be tied to the GDP plus 1%, so Medicare patients would pay increasingly out-of-pocket.  Over time, increasing numbers of seniors and people with disabilities would drop traditional Medicare because of its higher premiums, leaving traditional Medicare with the sickest, who could not survive the private plans’ managed care. As traditional Medicare’s patient base drops, its finances would become more precarious.  It is a death spiral for both Medicare and its patients.

Kaiser Health News, November 17, 2010

New Deficit Report Recommends Seniors Pay More For Medicare
http://www.kaiserhealthnews.org/Stories/2010/November/16/bipartisan-policy-center-medicare.aspx

Offering the latest tough-love strategy to reduce the nation’s debt, a panel of high-profile Republicans and Democrats on Wednesday recommended that Medicare beneficiaries pick up far more of their health care costs and the government substantially curb the amount both Medicare and Medicaid programs can grow in future years.

The panel, led by former Republican Sen. Pete Domenici of New Mexico and Alice Rivlin, the budget director under President Bill Clinton, also calls for a national debt-reduction sales tax of 6.5 percent, as well as changes in Social Security and income tax rates.

The debt reduction task force was created by the Bipartisan Policy Center, established by former congressional leaders of both parties. Its recommendations come a week after the chairmen of President Barack Obama’s commission on controlling the national debt proposed increasing the age at which people qualify for Social Security to 68 by 2050.

Document: Restoring America’s Future

Backers of the latest plan said they hoped it would spur a reluctant public and elected leaders to grapple with painful choices needed to get the country’s spending under control. But others warned the political prospects of the plan seemed doubtful — particularly for some of the more far-reaching ideas, such as limiting the amount the government would spend on Medicare beneficiaries.

Right now, premiums account for 25 percent of the cost of Part B, or the physician component of the program, with the government paying the balance. The task force would increase beneficiaries’ share to 35 percent.

In addition, starting in 2018, traditional Medicare would be turned into a “premium support” program that would limit the rate of increase of federal spending per beneficiary to one percent above the growth rate of the economy. Under such a plan, beneficiaries likely would pay more to stay in traditional fee-for-service Medicare though they could save money by getting coverage though private health plans that would compete against each other for business.

“I think the premium support is a feasible way of controlling costs,” Rivlin said Wednesday at a press briefing.

But this approach has never drawn much political support over the years. “It’s hard to see either party embracing a full blown premium support plan,” said Henry Aaron, a Brookings Institution expert who helped develop the idea in the mid-1990s. “The Democrats would be largely against it because of cuts in benefits and not enough Republicans would have a stomach for it. It would mean big benefit cuts and a substantial increase in out of pockets costs.”

AARP Executive Vice President John Rother said his group would oppose premium support. Of the overall task force report, he said it “raises lots of questions because of how it shifts more costs to individuals.”

The task force also recommends slowing the growth rate of Medicaid, the joint state-federal program for the poor and disabled.  But the report did not provide any specifics other than saying the state and federal government should explore changing the way they split paying the cost of Medicaid.

In addition, the task force proposes phasing out by 2028 the tax exclusion on employer-provided health care benefits. The group also would eliminate the so-called Cadillac tax on high-cost plans, a provision of the new health law that takes effect in 2018. Taxing employee health benefits would generate about $10 trillion in savings by 2040, more than any other revenue generator, according to the report.

Labor unions have opposed eliminating the tax exemption on health benefits out of concern it would lead employers to provide stingier benefits, said Paul Ginsberg, president of the nonprofit Center for Studying Health System Change and a consultant to the task force.

Michael Cannon, a health policy expert at the libertarian Cato Institute, said the premium support change to Medicare would have greater ramifications than the ideas offered last week by the chairmen of Obama’s commission. Their report recommended increasing cost-sharing for Medicare beneficiaries, but didn’t specify an amount, and changing the way doctors and hospitals are paid to encourage more efficient care.

“You can fiddle with the price control formulas as much as you want, but the people whose incomes are determined by those formulas are probably going to carry the day,” Cannon said. He said the plan’s short-term political prospects were few.

Other recommendations:

* On Social Security, raise the amount of wages subject to payroll taxes – now $106,800 — so that 90 percent would be covered, and “slightly” reduce the growth in benefits for the top 25 percent of beneficiaries.

* Establish only two income tax rates, 15 percent and 27 percent; end deductions for mortgage interest and charitable contributions, replacing them with 15 percent refundable credits, and lower the top corporate tax rate from 35 percent to 27 percent.

But the task force also veered sharply in the direction of reviving the economy and creating jobs with a recommendation for a payroll “tax holiday” in 2011 that would excuse employers and workers from paying the 12.4 percent tax into the Social Security Trust Fund.

Taking these and other steps, by 2020 federal spending would be reduced from a projected 26 percent of GDP to 23 percent, and the federal debt would be brought down below 60 percent of GDP, the task force said.

Projected Health Care Savings By 2040

* $10 trillion: phasing out the tax exemption on employer-provided health benefits.

* $7 trillion: impact of premium support plan.

* $3 trillion: changing the way states and the federal government split the costs of Medicaid.

* $644 billion: new soda tax.

* $300 billion: medical malpractice reforms such as caps on damages.

* $123 billion: increasing Medicare premium costs for beneficiaries.

Source: Debt Reduction Task Force of the Bipartisan Policy Center

 

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