2017 Individual and Family Medical Plans Require a Primary Care Physician

Beginning January 1, 2017 all individual and family health plans in California will require that members select a Primary Care Physician (PCP) or have one recommended by their health plan.

The terminology used in this case is confusing. A PCP has historically been a physician who is associated with an HMO which limits your choice. This is not the case in this instance.

You must choose a general physician who is in the network of your insurance company. If you do not choose a physician the insurance company will assign one to you. I know that at least one company will review your claims history in order to assign a physician that you have seen in the past.



The thought behind this is that if one is attached to a name of a physician, it is less likely that one will go to Urgent Care or the Emergency Room. An office visit or a phone call supposedly will lower health care spending.

In Summary, choose a physician or have one chosen for you.

Rate Increases for 2017 Medical Insurance Plans

There will be a significant rate increase for 2017 plans. The reasons given are the end of funding that was available in the first three years to offset rates, the rise in specialty medication and claims from those who enroll during Special Enrollment Periods.

In regard to the specialty medication, sometimes pharmaceutical companies are raising prices of medications when the need for a medication increases. Newer specialty medications can approach $100,000 per course of treatment and/or per year.

Below is the press release from Covered California on July 19, 2016

SACRAMENTO, Calif. — Covered California unveiled its rates for 2017 on Tuesday and announced that some health insurance plans will be expanding into new areas throughout the state to compete for consumers in California.

The statewide weighted average change will be 13.2 percent, up from approximately four percent in each of the last two years. However, most consumers will see a much smaller increase — or pay less next year — if they switch to another plan.

“Shopping is going to be more important this year than ever before,” Covered California Executive Director Peter V. Lee said. “Almost 80 percent of our consumers will either be able to pay less than they are paying now, or see their rates go up by no more than 5 percent, if they shop and buy the lowest-cost plan at their same benefit level. That’s the power of shopping.”

Lee said the opportunities to shop and save show that California has succeeded in building a competitive marketplace for health insurance, with rate increases that are still below trends in the individual market before the Affordable Care Act was passed.

“This is a new era of health care, where the consumer is in the driver’s seat with the power to look easily for a better deal, and where subsidies help absorb the impact of rate changes,” Lee said. “These options did not exist before the Affordable Care Act.”

Some consumers who choose to keep their plan will see a significant increase in their premium for 2017, while others will see a more modest increase, depending on where they live and what insurance plan they have. Consumers will begin receiving notices in October, when they will have an opportunity to review their new rates and change plans for their 2017 health coverage.

For many of those insured, the bulk of the premium increase will be absorbed by the subsidy paid by the government to help enrollees buy health insurance. Approximately 90 percent of Covered California enrollees get help to pay for their premiums. The average subsidy covers roughly 77 percent of the consumer’s monthly premium, and while premiums will rise, the subsidies will rise as well.

“Even though the average rate increase is larger this year than the last two years, the three-year average increase is 7 percent — substantially better than rate trends before the Affordable Care Act was enacted,” Lee said.

Lee said the average rate increase reflects the cost of medical care for consumers, not excessive profit.

“Under the new rules of the Affordable Care Act, insurers face strict limits on the amount of profit they can make selling health insurance,” Lee said. “So, while all plans are experiencing different cost pressures, we can be confident their rate increases are directly linked to health care costs, not administration or profit, which averaged 1.5 percent across our contracted plans.”

For consumers who get a tax credit to lower their costs — which is about 90 percent of those who sign up through Covered California — the amount they pay is impacted not only by the premium choice, but by changes in their tax credit. While the average rate increase is higher than past years, Covered California’s risk mix — the ratio of consumers who are healthy vs. sick — remains one of the best in the nation according to the Centers for Medicare and Medicaid Services (https://www.cms.gov/CCIIO/Programs-and-Initiatives/Premium-Stabilization-Programs/index.html).

Other reasons for rate increases include:
A one-year adjustment due to the end of a funding mechanism in the Affordable Care Act known as reinsurance, which was designed to moderate rate increases during the first three years when exchanges were being established. The American Academy of Actuaries estimates this will add between 4 percent and 7 percent to premiums for 2017.
Special enrollment by some consumers who may be enrolling in health insurance only after they become sick or need care, which seems to have had a significant impact on rates for two insurance plans.
The rising cost of health care, especially specialty drugs.
Pent-up demand for health care now being accessed by those who were locked out of the health care system before the Affordable Care Act was enacted.
Lee said Covered California is working to address some of these issues on multiple fronts. The exchange is aggressively marketing to attract healthy consumers year-round, and it is working to ensure special enrollment is available only to those who meet qualifying circumstances. It is also sampling the special enrollment population to better understand how to make any further improvements needed.

“We work hard to build a robust exchange that drives competition by attracting as many consumers as possible,” Lee said. “Now, consistent with the vision of the Affordable Care Act, we will redouble our efforts to make sure our consumers and potential consumers understand the importance of signing up during open enrollment and remaining covered throughout the year.”

Lee said Covered California’s 11 health insurers are competing across the state for its 1.4 million members.

“The sheer number of enrollees and their overall health means consumers in the individual market are benefiting from competition,” Lee said.

Below is the complete list of the companies selected for the 2017 exchange:
Anthem Blue Cross of California
Blue Shield of California
Chinese Community Health Plan
Health Net
Kaiser Permanente
L.A. Care Health Plan
Molina Healthcare
Oscar Health Plan of California
Sharp Health Plan
Valley Health Plan
Western Health Advantage
Rate details by pricing regions can be found in “Covered California’s Health Insurance Companies and Plan Rates for 2017,” posted online at:http://coveredca.com/news/pdfs/CoveredCA-2017-rate-booklet.pdf

The preliminary rates are subject to a 60-day public comment period and regulatory review by the California Department of Managed Health Care. In addition, the California Department of Insurance will review Health Net’s EPO.

Some insurance carriers will be increasing their coverage areas in 2017:
Oscar will be entering the market in San Francisco, Santa Clara and San Mateo counties.
Molina will expand into Orange County.
Kaiser will be available in Santa Cruz County.
With the expansion of its current carriers, almost all consumers (92.6 percent) will be able to choose from three or more carriers, and all will have at least two to select from.

In addition, more than 93 percent of hospitals in California will be available through at least one Covered California health insurance company in 2017, and 74 percent will be available in three or more plans.

Covered California also is improving its patient-centered benefit designs by increasing a consumer’s access to care by reducing the number of services that are subject to a consumer’s deductible.

Starting in 2017, consumers in Silver 70 plans will save as much as $55 on an urgent care visit and $10 on a primary care visit. In addition, consumers in Silver, Gold and Platinum plans will pay a flat copay for emergency room visits without having to satisfy a deductible, which could save them thousands of dollars.

These improvements build on features already in place that ensure most outpatient services in Silver, Gold and Platinum plans are not subject to a deductible, including primary care visits, specialist visits, lab tests, X-rays and imaging. In addition, some Enhanced Silver plans have little or no deductible and very low copays, such as $3 for an office visit. Even consumers in Covered California’s most affordable Bronze plans are allowed to see their doctor or a specialist three times before the visits are subject to the deductible.

In addition, the contract with health insurers for 2017 ensures consumers select or are provisionally assigned a primary care physician within 60 days of effectuation so they have an established source of care.

“Health care reform isn’t just about making insurance affordable, it’s about doing things to make it easier for consumers to get the right care at the right time,” Lee said.

In May, the Centers for Disease Control and Prevention announced that California’s uninsured rate had fallen to 8.1 percent at the end of 2015, down from 17 percent at the end of 2013, right before the Affordable Care Act began offering coverage.

“We can all be very proud of the extraordinary gains we have made in reducing California’s uninsured rate to a historic low,” Lee said.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the Governor and the Legislature. For more information about Covered California, please visit www.CoveredCA.com.

This article is from the Los Angeles Times date July 20, 2016

California Obamacare rates to jump

Premiums are set to go up an average of 13.2% next year. Rising medical costs are one reason, officials say.


Premiums for Californians’ Obamacare health coverage will rise an average of 13.2% next year — more than three times the increase of the last two years and a jump that is bound to stir debate in an election year.

The big increases come after two years in which California officials had boasted that the program helped insure hundreds of thousands people in the state while keeping costs moderately in check.

Premiums in the insurance program called Covered California rose just 4% in 2016 after rising 4.2% in 2015 — the first year that exchange officials negotiated with insurers. The program insures 1.4 million Californians.

On Tuesday, officials blamed next year’s premium hikes in the program on rising costs of medical care, including expensive specialty drugs and the end of a mechanism that held down rates for the first three years of Obamacare.

Two of the state’s biggest insurers — Blue Shield of California and Anthem Inc. — asked for the biggest hikes. Blue Shield’s premiums will jump an average of more than 19%, according to officials, and Anthem’s rates will rise more than 16%.

For consumers, the effect will depend on whether they get taxpayer-supported subsidies for their premiums and whether they are willing to switch to less-expensive plans that may come with higher co-pays and deductibles. Changing plans could also mean a new network of physicians, which could be disruptive to care for those with chronic conditions.

The rates vary significantly by region and insurer. Los Angeles and the rest of southwest Los Angeles County will see an average increase of almost 14%.

Blue Shield’s preferred provider organization rate in Los Angeles, chosen by 21% of those using the exchange, is increasing by an average of 19.5%. For a 40-year-old single person making $17,820 to $23,760, choosing a silver level plan, the monthly rate currently is $122, while the government pays Blue Shield $196. Next year that same person would pay $170, while the government would chip in $211 a month.

“We’re paying more for less,” said Jamie Court, president of Consumer Watchdog in Santa Monica. “Insurers are limiting access to doctors and hospitals while also demanding a higher price.”

Horacio Chavez, 34, of Boyle Heights said he made less than $25,000 last year as an education coordinator at a youth center. He currently pays a $100 premium for a Covered California plan that he uses for an annual checkup and a safety net in case of emergencies.

“I do want healthcare — I want the peace of mind that if anything happens to me that there’s some kind of coverage,” Chavez said. But “a 13% hike … that’s going to affect people.”

He said he’s already barely making ends meet trying to pay his rent, student loans from the University of Chicago, car payments and his health insurance premium.

“I’m already living check to check,” Chavez said.

Covered California officials defended the system Tuesday, saying that the competition among insurers offering coverage on the exchange was working to keep rates lower than they otherwise would be.

“California has a very competitive marketplace,” said Peter Lee, executive director of Covered California.

Obamacare has significantly reduced the number of uninsured Californians. Since the state’s health insurance exchange began offering coverage in 2014, the share of Californians without health insurance has fallen from 17% at the end of 2013 to 8.1% at the end of last year, according to officials.

Rates are expected to jump in other states too, although complete details won’t be available until later this year.

An analysis of 14 metro areas that have already announced their 2017 premiums found an average jump of 11%. The changes ranged from a decrease of 14% in Providence, R.I., to an increase of 26% in Portland, Ore., according to the analysis by the nonpartisan Kaiser Family Foundation.

The federal healthcare-  .gov   exchange provides insurance under the Affordable Care Act in 38 states. California and a few other states operate their own exchanges.

Around the country, several insurers, including giant UnitedHealth, have stopped selling health plans on the exchanges, and a number of new nonprofit health insurance co-ops have gone out of business.

Those decisions have fueled charges from the law’s critics that Obamacare isn’t working.

Former Secretary of State Hillary Clinton, the presumptive Democratic presidential nominee, is pushing a number of specific steps to ease price pressure on consumers, including allowing Americans ages 55 to 64 to buy into Medicare.

Republican presidential nominee Donald Trump has argued the health law should be repealed.

The health law’s next enrollment period begins a week before election day.

The state and federal health insurance exchanges provide coverage to about 12 million people nationally, representing just a fraction of the nation’s total insurance market. The vast majority of Americans — more than 250 million people — are in health plans purchased through an employer or provided by a government plan such as Medicare or Medicaid.

But the exchanges are a pillar of the Affordable Care Act’s program for guaranteeing Americans’ insurance coverage. And monthly premiums have become a closely watched barometer of how the law is performing.

Covered California’s Lee told the House Ways and Means Committee on July 12 that 2017 would be “a transitional year” for Obamacare, with rates seeing “significant adjustments” across the nation.

He said one reason for the increase was the end of a program designed to keep rates down during the insurance exchange’s first three years. The program had assessed a fee on all health insurers and then redistributed those funds among carriers whose members had the highest medical expenses, Lee said.

Lee added that some insurers had also not charged enough in the first two years because they didn’t have full data on the medical costs or health status of those signing up. Now they’re adjusting to account for those higher costs.

Mia Campitelli, a Blue Shield spokeswoman, said Tuesday that the insurer’s average 19.9% premium increase was “driven by our members using more healthcare services than we expected,” as well as the phaseout of the federal mechanism that had kept rates down in the law’s early years.

Anthem spokesman Darrel Ng said: “Factors such as increased use of medical services and added costs of drugs and medical therapies put upward pressure on rates and underscore the additional work that needs to be done to moderate the growth in healthcare costs.”

The financial pain for most Californians getting insurance through the exchange will be muted because 90% get taxpayer assistance to cover the premiums.

Americans making less than four times the federal poverty level — about $47,000 for a single adult or $97,000 for a family of four — qualify for the assistance.

Nonetheless, Americans who make too much to qualify for subsidies are likely to feel the brunt of the higher premiums. That will probably increase pressure on the new president — Democrat or Republican — to review the exchanges in 2017 for ways to make health plans more affordable.

A year ago, Lee wrote an op-ed in The Times saying that Covered California’s power in negotiating with insurers was allowing Obamacare to work in the state.

“We now have the full picture in California, where we are proving that health insurance exchanges can keep prices in check,” he wrote.

Though the Affordable Care Act has improved care for millions of Americans — for example, insurance companies can no longer set lifetime limits on care or exclude anyone because of a preexisting condition — the 6-year-old law contains few controls on overall costs.

Spending on the country’s medical system averages more than $10,000 for every American, according to statistics released by the Obama administration this month, far higher than any other nation. melody.petersen

@ latimes.com   noam.levey@latimes.com   Times staff writer Soumya Karlamangla contributed to this report.


“CALIFORNIA has a very competitive marketplace,” said Peter Lee, executive director of Covered California. Above, Lee discusses the program last year.

Medicare and Social Security Trustees Warn of Shortfalls

Below is an article discussing the financial state of Medicare and Social Security. There is a pending rate increase in Medicare premiums.

Medicare and Social Security Trustees Warn of Shortfalls

By ROBERT PEARJUNE 22, 2016 New York Times

Carolyn W. Colvin, the acting commissioner of Social Security, during a news conference in Washington on Wednesday. Credit Andrew Harnik/Associated Press

WASHINGTON — The Obama administration said Wednesday that the financial outlook for Medicare’s hospital insurance trust fund had deteriorated slightly in the last year and that Social Security still faced serious long-term financial problems.

The report, from the trustees of the two programs, could inject a note of fiscal reality into a presidential campaign that has given scant attention to the government’s fiscal challenges as the population ages. Hillary Clinton, the presumptive Democratic presidential nominee, has proposed increasing Social Security benefits and allowing people age 55 to 64 to “buy into” Medicare, while Donald J. Trump, the presumptive Republican nominee, has repeatedly said he would not cut either program.

Under existing law, the trustees said Wednesday, Medicare’s hospital trust fund would be depleted in 2028, two years earlier than projected in last year’s report.

In addition, they said, the Social Security trust funds for old-age benefits and disability insurance, taken together, could be depleted in 2034, the same year projected in last year’s report. Tax collections would then be sufficient to pay about three-fourths of promised benefits through 2090, they said.

Social Security and Medicare account for about 40 percent of all federal spending.

Obama administration officials often say the Affordable Care Act has slowed the growth of health spending, compared with estimates made just before the law was adopted in 2010.

But the trustees said Wednesday that the short-term financial outlook for Medicare had worsened in the last year because of changes in their assumptions and expectations. Medicare actuaries now expect higher use of inpatient hospital services, as well as lower projected improvements in workers’ productivity and lower payroll tax revenue, as a result of slower growth in wages in the next few years.

In their report, the trustees — four administration officials — said that the costs of Medicare and Social Security would grow faster than the economy through the mid-2030s because of the aging of the baby boom generation. As for Medicare, they said, “growth in expenditures per beneficiary exceeds growth in per capita gross domestic product over this time period.”

The projected growth in Medicare spending will not immediately set off automatic cuts in the program under a controversial provision of the Affordable Care Act that generally requires such cuts when spending is expected to exceed certain benchmarks. However, such cuts could be required in a few years under the trustees’ forecast.

President Obama told an audience in Elkhart, Ind., this month that Social Security should paid for “by asking the wealthiest Americans to contribute a little bit more.” Credit Zach Gibson/The New York Times

Under current projections, they said, the automatic cuts could take effect for the first time in 2019.

Medicare now spends an average of nearly $13,000 per beneficiary, and this figure is expected to exceed $16,000 in five years, the report said.

“High-cost drugs are a major driver of Medicare spending growth,” said Andrew M. Slavitt, the acting administrator of the federal Centers for Medicare and Medicaid Services.

Such projections in years past have prompted leaders in both parties to at least broach the idea of benefit cuts or tax increases for entitlement programs.

By contrast, President Obama said in Elkhart, Ind., this month that Social Security should be made “more generous,” and that “we could start paying for it by asking the wealthiest Americans to contribute a little bit more.”

Treasury Secretary Jacob J. Lew said Wednesday that he saw no contradiction there. The two objectives — ensuring the solvency of Social Security and increasing benefits — are “not at all inconsistent” if they are discussed in the context of “a broader conversation” about taxes and benefits, he said.

The report predicts that Social Security will provide a modest cost-of-living adjustment, increasing benefits by two-tenths of 1 percent next year. But, it warned of a “substantial increase” in Medicare premiums in 2017 for about 30 percent of beneficiaries. Under assumptions in the report, the standard premium, now $121.80 a month, would rise to $149, and the change could be announced just weeks before Election Day on Nov. 8.

Congress took action last year to shore up Social Security’s disability insurance trust fund, but the report says the legislation was a short-term fix. The law postponed the projected depletion of the disability trust fund by seven years, to 2023, Mr. Lew said.

Like other Democrats, Mr. Lew said the report showed the “positive impact” of the Affordable Care Act. Since the health law was signed, he said, “increases in health care costs have slowed substantially.”

Carolyn W. Colvin, the acting commissioner of Social Security, said Americans should begin a serious discussion of how to close the “future financing gap” in Social Security. Sixty million people now receive Social Security benefits totaling more than $74 billion each month. The number of Social Security beneficiaries is expected to reach 76 million by 2025.

Firm Accused of Bilking Medicare

From the Los Angeles Times Business Section, dated May 26, 2016

Firm bilked Medicare, U.S. says
Justice Department joins whistle-blower case accusing Prime Healthcare of overbilling.
The U.S. Justice Department has joined a whistle-blower case against Prime Healthcare Services, adding significant weight to allegations of widespread Medicare overbilling at 14 of the company’s hospitals in California.

A Los Angeles magistrate judge granted the agency’s request to intervene in the case Tuesday, one day after the government declared in a court filing that its investigation of the Ontario- hospital operator has “yielded sufficient evidence” that the facilities “submitted or caused the submission of claims to Medicare for unnecessary inpatient stays.”

Prime finds itself under federal scrutiny because of a whistle-blower complaint submitted in 2011 by Karin Berntsen, a registered nurse and director of quality and risk management at Alvarado Hospital in San Diego. Berntsen’s lawsuit accuses Prime of routinely making Medicare patients’ illnesses seem more severe than they really were in order to justify billing for additional services and increasing hospital admissions.

Berntsen alleged that this practice occurred not only at Alvarado but also at 13 other Prime properties. Most of these hospitals are in Southern California, including Centinela Hospital Medical Center in Inglewood, Encino Hospital Medical Center, Sherman Oaks Hospital and Huntington Beach Hospital.

Berntsen’s litigation estimates the total amount of overbilling at $50 million, an amount that now could result in a significant financial payoff for her — and potentially large damages against the company.

Anti-fraud statutes allow fines of $5,500 to $11,000 — plus triple damages under certain circumstances — for each false or inaccurate bill submitted by hospitals and other healthcare companies . Whistle-blowers are entitled to 15% to 25% of the money recovered in cases involving the Justice Department.

In 2012, for example, pharmaceutical giant GlaxoSmithKline agreed to pay $2 billion to the federal government to resolve accusations that it overbilled for the prescription drugs Paxil, Wellbutrin and Avandia. In 2006, Tenet Healthcare was crippled after paying $900 million in a case involving alleged Medicare bill-padding, kickbacks and changing of billing codes to obtain higher reimbursements.    Prime has denied Berntsen’s allegations, calling them “speculative nonsense” after her complaint was unsealed in 2013.

In a new statement issued after the federal government’s intervention, the company was a bit more subdued. It said Medicare billing is complex and that there is a “lack of clarity between what federal regulators and physicians believe is necessary to adequately document medical necessity for hospital admissions.”

Prime also said its hospitals have successfully undergone Medicare billing audits conducted by an array of organizations, including the Joint Commission, the Healthcare Facilities Accreditation Program, the California Department of Public Health and government “recovery audit” contractors who are rewarded for spotting billing irregularities. The company currently owns 43 hospitals across14 states.

“Over 600 medical records that were appealed to the Administrative Law Judges and Medicare Appeals Council, all had rulings in Prime Healthcare’s favor, with no exception,” Prime’s statement said. “Given this precedence of successful appeals on thousands of claims, Prime Healthcare is confident it will prevail and ultimately be exonerated.”

But the Justice Department in a wide-ranging investigation referenced in its court filing this week cited “multiple witnesses who have worked at different Prime hospitals” who told the government that Dr. Prem Reddy, Prime’s chairman, president and chief executive, criticized emergency department physicians and demanded “their termination if he decided they were passing up opportunities to cause the admission of Medicare beneficiaries.”

The agency said those witnesses also accused Reddy of requesting “increased work schedules for [emergency department] doctors whose patients had a relatively high rate of admission,” of decreasing or discontinuing such shifts for physicians with low rates and of telling emergency department doctors “to find a way to admit all patients over 65 because they all have insurance.”

In contrast, the government said, Reddy allegedly worked to minimize hospital stays for uninsured patients — instructing that they should stay in the emergency department for only six to eight hours to get test results and then be discharged.

The Justice Department also cited the results of a Medicare contractor’s review of the company’s hospital admissions that “put Prime on notice of the same pattern of seemingly unnecessary inpatient admissions.”

Kathleen Clark, a Washington attorney who is an expert on the False Claims Act that governs whistle-blower cases, said the government’s involvement raises the stakes, given that federal regulators participate in only about one-quarter of such cases.

“It is actually quite significant when the government decides to intervene in one of these cases. The government brings to bear significant investigatory resources and leverage,” Clark said. “Intervention is seen not as a guarantee of a win, but it’s a very good sign for the whistle-blower and [his or her] lawyers.”

Marlan Wilbanks, an Atlanta attorney who is one of several lawyers representing Berntsen, said the government’s involvement could turn up additional evidence in the case disproving Prime’s assertion that previous audits proved the company’s billing practices are sound.

“Those entities were not designated to look for fraud,” he said. “Prime was given the benefit of the doubt. However, those entities did not have the evidence and the documents that the government and [Berntsen’s party] now possess.”

It’s unclear how long the legal discovery phase might take, especially because the Justice Department’s intervention will likely spur a series of procedural adjustments in the case. paul.sisson

@ sduniontribune.com

Medicare for More

The following article from the Atlantic states that lowering of the Medicare age from 65 to a younger age might infuse needed money into the Medicare system. Additionally, rates for those who are younger and not Medicare eligible might benefit if older sicker people enroll in Medicare. All will depend on the healthcare needs of those who are shifted around.

Hillary Clinton’s new proposal to expand coverage for middle-aged adults provides a glimpse at how she would make Obamacare her own.


MAY 23, 2016

What’s the next step for Obamacare? Much of the 2016 presidential race functions as a referendum on just what to do with the the six-year-old Affordable Care Act. Despite some mixed returns on costs and the stability of insurance markets, the health-reform law has brought the uninsured rate to its lowest point in American history. Reflecting that mixed legacy, most Americans now favor modifications to the ACA over continuing to implement it as it is or repealing it.

That puts most Americans on the opposite side of whatever Donald Trump’s health care plan might be. But both Hillary Clinton and Bernie Sanders have plans to modify and expand Obamacare. Sanders’s plan of “Medicare for All,” a radical overhaul of the current system based on a single-payer system, has received most of the attention. Clinton’s more modest proposals to expand tax credits and allow undocumented immigrants access to health-insurance marketplaces have garnered less press. But recently, Clinton has made waves with a new idea to allow people over 50 or 55—the specifics have not yet been announced—to purchase Medicare plans.  At present, only those over 65 and a select few of their dependents are eligible for Medicare. This “Medicare for More” concept is a significant addition to the Clinton health plan, but what does it mean for the future of Obamacare?

A new report from Avalere extrapolates what it might mean for the future of 50-somethings. There are about 13 million people between the ages of 50 and 65 who are either uninsured or have purchased private insurance on the Obamacare marketplaces. This population represents most people in the age range without affordable employer- or group-insurance coverage and who don’t qualify for Medicaid. Assuming that this is the population that would be eligible for Clinton’s Medicare for More, Avalere reports that it is “unclear” if Medicare would automatically be a good deal for them.

With no knowledge of premiums or subsidies yet, a Medicare buy-in might just be too costly for those uninsured adults above 50 who have low incomes but are ineligible for Medicaid because of state rules. For those in private plans, Medicare has a distinct number of cost disadvantages, including a 20 percent cost-sharing requirement, no lifetime cap on out-of-pocket expenditures, and drug benefits that are generally less generous. Also, it is unclear if people under 65 could qualify for the Medicare Advantage plans that help fill in gaps in coverage. Sicker elderly adults regularly run up against the limits of Medicare, and it is hard to envision cases in which Medicare would make more financial sense for near-elderly adults with serious chronic illnesses than medium-cost marketplace plans.

Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy.

But Medicare has always been a good deal for those who don’t use many health-care services, and it might beat out low-cost marketplace plans for healthy adults between 50 and 65 with few health problems. Medicare provides access to one of the broadest networks of physicians, providers, and benefits possible, and consumers value continuity. A buy-in at 50 could allow people to remain on the same insurance coverage with the same providers for the rest of their lives. Also, while Medicare has not been shown to have a serious effect on health trajectories for uninsured adults who become enrollees at age 65, at age 50 it might provide services early enough to change outcomes. Medicare also provides protection against medical debts, and if premiums could be made affordable to uninsured adults over 50, it could have serious value as health issues mount with age.

Medicare for More might have more value to the Medicare program than to any individual beneficiary. People between 50 and 65 are healthier than those over 65, and many of the costs that penalize high utilization can be seen as offsets for having to cover the most expensive population in the country. Even for Medicare, which has broad power to affect prices and policy, covering services, visits, drugs, surgery, and hospital stays costs money, and as patients near costly end-of-life holding patterns, the cost curve skyrockets. Adding healthier, younger people to the risk pool might bring down the per-person costs of the program. If the subsidies are equivalent to marketplace subsidies, premiums and savings from the over-50 crowd could actually cut back net costs for the Medicare albatross. Removing more middle-aged adults from marketplace risk pools might actually make insurance cheaper for young adults as well.

The results of a Medicare buy-in for potential beneficiaries and the program will likely depend on specifics as detailed by the Clinton campaign, but its rhetorical value is much more readily assessed. Allowing private purchase of one of America’s two big public-insurance programs is an addition to Obamacare’s willingness to blur the lines between public and private insurance, risk, and public-health responsibility. The proposal gives Clinton ammunition both against Sanders in the primary and, should she win, Trump in the general.

But above all, Medicare for More is a step away from Clinton’s position as a defender of President Obama’s legacy and towards her central policy identity as an architect of American health policy. Obamacare could very well be a platform for Clinton to achieve some of the goals that remain unfulfilled from the 1993 health plan that she spearheaded. Combined with some recent support from Clinton for the idea of a public option, a Medicare buy-in can be seen as a very Clinton-esque way of using the market to provide universal care. The free market solution to coverage, along with the major expansion of Medicare as a coverage pathway for non-elderly adults, is reminiscent of the ‘93 plan, and the population that it impacts is massive. Medicare for More would also cement Obamacare as the foundational law of all of American health policy, and establish a regime of incrementalism not unlike the coverage shifts seen in the decades between Medicare and Obamacare. The proposal might open the door for other shifts, such as allowing even younger people or government employees Medicare buy-ins.

For those further to Clinton’s left, however, Medicare for More might close the door for hopes of more radical overhauls while the figurative iron is still hot and while the ACA is still a hotly debated law. Sanders’s plan rests on frustrations about the compromising nature of the Affordable Care Act, which whittled down some of the more ambitious coverage plans in favor of  a market-based solution that still leaves millions uninsured. The current Obama-Clinton doctrine of health-care views zero uninsurance as a lofty and likely unreachable goal more than a first-order cause. Much of Sanders’s momentum with Medicare for All comes from the fact that the liberal benchmark––a universal public option supported by high, progressive taxes––has still not been reached. Clinton’s incrementalism would in all likelihood reset the clock on that dream.

Medicare for More isn’t Sanders’s Medicare for All, and it certainly isn’t what many Sanders supporters are looking for, but it is a step for Clinton and would be a significant addition to the massive impact of Obamacare. If Clinton does wind up in the White House, it could be the beginning of a piecemeal process to bring the ACA closer and closer to its originally intended ideal of universal coverage, as Obamacare is a perfect platform for incremental increases in coverage. Now, it is another sign that the work of providing coverage and making the health care system more affordable and better is not yet done.

Medicare Physician Reimbursement Proposal Could Reduce Number Of Practices.

Many doctors are leaving the Medicare system due to low reimbursements. Will additional costs drive more away?

Below is an article from Modern Health Care

Docs face stark choices under new Medicare pay proposal

By Beth Kutscher  | April 30, 2016

The new draft regulations designed to change how Medicare pays clinicians represent the most sweeping overhaul the CMS has made in a long time to the business of running a physician practice.

The goal is to have the vast majority of CMS funding flow through payment models that reward doctors for the quality of care they deliver, not just how many patients they see.

The changes have the potential to upend the way medicine is practiced today, accelerating the move toward hospital employment and making the small group practice a thing of the past. At the very least, the rule, once finalized, will inspire closer collaboration between doctors and hospitals, since physicians will have more incentives than ever to steer patients away from high-cost medical centers.
The CMS’ 962-page proposed rule is the first major step in hashing out the details of physician payment that Congress outlined in the Medicare Access and CHIP Reauthorization Act, the 2015 legislation that replaced the controversial sustainable growth-rate formula.

RELATED STORIESSidebar: Medicare’s new quality program targets measurement fatigue

Sidebar: How Medicare’s new payment overhaul tries to change how docs use tech

In its attempt to move more physician payments through value-based arrangements, the CMS is combining three existing programs into a new Quality Payment Program.

Clinicians will have to choose one of two paths: submit to the Merit-based Incentive Payment System (MIPS), or put a significant portion of their business into a qualifying Alternative Payment Model (APM).

Both carry financial risk for failing to meet program goals. The potential impact on physicians’ Medicare revenue under MIPS—which will apply to the vast majority of clinicians—would be as high as 4% in the first year, rising to 9% in subsequent years. The program goes into effect in 2019, but the first performance period begins on Jan. 1, 2017.

“This really is a defining piece of legislation for how we pay for healthcare in America,” said David Muhlestein, senior director of research and development at consulting firm Leavitt Partners. “It changes the expectation of what practicing medicine is. It’s increasing the scope of responsibility for physicians.”

Even though Medicare spending on inpatient services was nearly double the amount spent on physicians, according to 2014 data, the rule makes it clear that physicians will increasingly be the ones held accountable for keeping hospital expenditures in check.

That contrasts with the old way of paying for medical services, in which the person or entity performing a service also controlled the revenue.

“What’s important is not just what the costs are, but who is responsible for those costs,” Muhlestein said. Clinicians “now have all sorts of incentives to steer people away from the hospital.”

Physicians are likely to respond by fleeing to hospital employment, large independent group practices or joint ventures with hospitals. “This will hasten the demise of the very small physician practice,” Muhlestein said.

Another element of the rule that puts pressure on physicians is the transition from the current incentive program for meeting meaningful use of electronic health records to the CMS’ broader Advancing Care Information program. The new requirements emphasize interoperability, information exchange and data security, creating some concern that doctors will need to invest in sophisticated information technology and analytics systems.

“It’s really an infrastructure question,” explained Eric Zimmerman, a principal at McDermott+Consulting. “What you might find with some of these small groups is sort of a downward spiral.”

The rule also came under criticism from the American Hospital Association for its narrow definition of an alternative payment model. The CMS exempted many of its current value-based payment models from qualifying as advanced APMs for the purposes of their exemption from MIPS. For instance, the rule excludes the Bundled Payments for Care Improvement initiative, as well as Track 1 of the Medicare Shared Savings Program, which delivers bonuses for meeting cost and quality targets but carries no downside risk.
MH TAKEAWAYS Physicians have traded the perennial threat of Medicare pay cuts for a framework that gives them little choice but to adapt their practices to value-based care.

Ninety-five percent of the 433 accountable care organizations in the Shared Savings Program this year are in that track.

APMs, the CMS said, must bear “more than nominal financial risk” in order to qualify.

The incentive payment system, meanwhile, is designed to be budget-neutral, which means there will be winners and losers when it comes time to dole out payments. The CMS is forecasting that there could be $833 million in negative payment adjustments and $1.3 billion in positive payment adjustments, which includes $500 million in “exceptional performance” payments for the highest-scoring physicians.

Under the framework the CMS laid out, it will be harder for physicians to tread the neutral middle ground.

“MIPS is essentially a linear performance score,” said Tom Lee, CEO of SA Ignite, a technology firm helping providers prepare for MIPS. “Every point counts. That’s going to increase the need for people to get educated that the game has changed.”

MIPS consolidates the Physician Quality Reporting System (PQRS), the Physician Value-based Payment Modifier and the EHR meaningful-use program—none of which was particularly popular.

Under those programs, huge numbers of physicians swallowed Medicare pay cuts rather than submit the quality data necessary to avoid the cuts and possibly earn a bonus. For example, about 5,400 out of 13,800 physician groups eligible for the value-based payment modifier in 2016 took a 2% pay reduction because they failed to meet the reporting requirements.

“No one liked PQRS and no one is going to really want to participate in MIPS,” said Sheila Madhani, a director at McDermott+Consulting. “So there’s going to be this push to get into APMs.”

APMs also provide more flexibility for physicians who want to make investments that otherwise would not be covered, such as hiring care coordinators.

But the CMS’ strict eligibility standards for APMs mean that the only way for many practices to avoid MIPS would be through an accountable care organization. “An ACO is basically the approach that most providers are going to end up with,” Muhlestein said.

Yet many of the APM deadlines are fast approaching. Applications for the Shared Savings Program, for instance, are due as soon as May 31. That doesn’t give providers much lead time to prepare, Lee said.

At the same time, a game of musical chairs will play out as physicians rush to find partners, either as a “virtual group”—a mechanism in the statute that allows small, independent groups to spread performance evaluation across a larger number of physicians—or through a more formal relationship.

“If I’m a practice manager, I’m probably getting pitched a lot,” Lee said. “The big underlying question is ‘What is the minimum amount of resources and support you need in order to play the value-based game?’ ”

Kaiser Medical School to be in Pasadena

Kaiser’s medical school will add focus to more practical areas of medical care.

here is an article from the Los Angeles Times date, March 11, 2016
Site is near freeways, public transportation, affordable housing, medical provider says.
Kaiser Permanente is moving forward with its ambitious plan to open a medical school that’s more in tune with new technologies and local communities.
The Oakland-based healthcare provider said Thursday its institution will be located in Pasadena. And it talked about how it will try to attract a more diverse student body.
Kaiser said it chose central Pasadena because the site is close to major freeways, public transportation options and affordable housing. Kaiser is also well-established in the surrounding area, with 14 hospitals in Southern California and medical office complexes in Pasadena and Glendale. The school will also be within several miles of facilities where students will be trained.
“We have major medical facilities and resources in that particular marketplace, so we feel really great about the extension of Kaiser Permanente beyond the four walls of that medical school,” said Kaiser Chairman and Chief Executive Bernard Tyson.
Pasadena’s diverse community was another driving factor, as Tyson said it was “essential” to the model of medical education Kaiser wants to establish. Kaiser officials have said it wants to recruit more minority students and teach doctors how to care for an increasingly diverse patient population.
There are no set plans yet for recruitment, but Kaiser is considering offering scholarships or tuition forgiveness to students who can help them “reach the communities that we wish to reach,” said Dr. Edward Ellison, executive medical director of the Southern California Permanente Medical Group.
“When you look at what’s happening in the country today, healthcare has never gone through as much change as it has today,” he said. “We believe that the way in which we deliver care has a lot of applicability for solving challenges of the future.”
Kaiser first announced plans in December to open a medical school.
The campus size in Pasadena, as well as the tuition, has yet to be determined.
The school will be built on land that Kaiser already owns. The property, located at 94 S. Los Robles Ave., currently houses an unoccupied building, which will be torn down and replaced with a larger building, Kaiser spokesman Marc Brown said. A Kaiser office building and the Kaiser Permanente Department of Research and Evaluation are on the same lot and will remain there, he said.
That part of Pasadena is already being revitalized, said Mayor Terry Tornek. A new residential building and hotel are set for construction nearby and other parts of the city are also seeing new developments.
“It’s a big deal,” he said of the medical school. “You bring in these students, you bring in their instructors, you bring in their support staff…. It has a multiplier effect.”
Kevin Trieu, owner of Beany’s Cafe, located a block away from the Kaiser school site, said he thought the institution could increase the foot traffic around his restaurant.
“Any time you get more people within walking distance to us, then that’s going to generate business for us, especially since we don’t have our own parking lot,” he said. “The fact they’re so close, I think it’s going to be wonderful.”
Groundbreaking for Kaiser’s medical school is planned for next year, and the first class of about 40 to 50 students is expected in 2019. In time, Tyson said he hoped the class size would increase to 200 to 300.
He said the plan for the medical school was an evolution of what Kaiser was already doing. The organization has more than 600 physicians in residency programs at its facilities and thousands of others do some training at Kaiser.
Kaiser has said that its approach to medical education will differ from that of many established medical schools. The curriculum and teaching methods will more closely align to the company’s commitment to quickly adopting new technology and adhering to the latest medical evidence in patient care. Kaiser has been a leader nationally at adopting electronic medical records and offering doctor visits online.
It also plans to integrate hands-on learning early on so that “what you’re learning, you’re going to immediately apply,” Ellison said.
For example, Kaiser plans to train students as emergency medical technicians when they arrive at the school to give them a practical grounding in healthcare. Students will also go into the community, visiting patients’ homes and learning how to better implement health behavioral changes, Ellison said.
“Not all innovation is about shiny new technology,” he said.
Analysts have said that a medical school teaching Kaiser’s method of healthcare might not appeal to all students. Critics have also worried that a Kaiser medical school would focus on cutting costs that could negatively affect patient care, since some patients have said Kaiser’s system limited their care.
Kaiser operates 38 hospitals nationwide, owns hundreds of clinics and has almost 18,000 salaried doctors at its affiliated medical groups. Nearly 80% of its 10.2 million members are in California, though the healthcare provider operates in eight states and the District of Columbia.
With the location settled, Ellison said Kaiser is now working to create a curriculum, forming a search committee for the school’s first dean and going through the accreditation process. samantha.masunaga
@ latimes.com
Twitter: @smasunaga

Eliminating Confusing Health Plans

It has been my experience as an insurance broker that some insurance companies have far too many plan designs which are very confusing for the consumer. Hopefully changes will be adopted to make the process of choosing a plan more consumer friendly.
Below is a partial excerpt from Covered California’s Daily News, dated March 9, 2016 which discusses the issue.
New Analysis Urges Shift to Patient-Centered Benefit Designs to Cut Costs and Help Consumers Get Care
Posted: 09 Mar 2016 02:52 PM PST
Lessons Learned in California Can Help Avert a Collision Between Conflicting Reform Initiatives

SACRAMENTO, Calif. — A new analysis urges state-based marketplaces, the employer-sponsored insurance market and health insurance plans to take action and move toward plan benefit designs that put consumers first, and remove existing barriers to getting needed health care.
In an article written in the New England Journal of Medicine by Dr. Elliott Fisher, Director of The Dartmouth Institute for Health Policy and Clinical Practice, and Covered California Executive Director Peter V. Lee, both stress the importance of patient-centered benefit designs to reach the next level of health care reform.

“Health plans, states and employers should take to heart the lesson that offering a lot of different designs does not serve consumers well,” Fisher said. “Too many health plans, in exchanges and the employer sector, offer confusing benefit designs with out-of-pocket costs that prevent people from seeing their doctor.”

Lee said Covered California has a model that has worked for its consumers since the agency opened its doors in 2014.

“Covered California has led the way in the fight for consumers by shaping benefit designs that help consumers make apples-to-apples comparisons and to get the health care they need,” Lee said. “A good patient-centered benefit design is critical to making sure consumers get the right care at the right time.”

Fisher and Lee noted that the current health care system seeks to improve care and cut costs through provider-focused and consumer-focused reform initiatives that directly conflict with one another.
For example, provider-focused initiatives encourage physicians, hospitals and other providers to coordinate and improve care to lower costs. However, the consumer-focused approach discourages people from seeing their provider because of increased cost-sharing.

Studies show the proportion of Americans with employer-sponsored coverage involving deductibles of more than $1,000 has increased from 10 percent to 46 percent since 2006, with many plans requiring people to fully meet their deductible before receiving any coverage for primary care. A 2015 National Bureau of Economic Research study showed the adoption of a high-deductible health plan in a relatively high-income population led to a 10 percent reduction in the use of preventative services and an 18 percent drop in physician visits, with the greatest reductions occurring in the sickest patients.

“We want consumers to be able to see their doctor when necessary, so their health care needs can be met in the most effective and efficient way possible,” Fisher said.

The authors cite California’s approach as an example of how it might be possible to avoid this collision between provider- and consumer-focused efforts. Covered California, the state’s insurance exchange, requires plans to adopt patient-centered benefit designs that allow consumers at every metal tier (cost-sharing split between insurer and enrollee) to visit their primary care physician without the cost being subject to a deductible. “When a consumer is able to get the right care at the right time, it cuts down health care costs for everyone,” Lee said.

The Centers for Medicare and Medicaid Services recently announced it would allow health insurance companies to offer patient-centered benefit designs on the federal exchange.
“This is a good step for consumers,” Lee said. “However, more needs to be done if we are going to reach the next level in health care reform.”

The article, “Toward Lower Costs and Better Care – Averting a Collision between Consumer- and Provider-Focused Reforms,” is available atwww.nejm.org/doi/full/10.1056/NEJMp1514921.

About The Dartmouth Institute
Since 1988, The Dartmouth Institute for Health Policy and Clinical Practice has been working to find solutions to some of the most challenging problems in health care delivery. Our goal is to help create an affordable, high-performing health system for everyone.

About Covered California
Covered California is the state’s marketplace for the federal Patient Protection and Affordable Care Act. Covered California, in partnership with the California Department of Health Care Services, was charged with creating a new health insurance marketplace in which individuals and small businesses can get access to affordable health insurance plans. Covered California helps individuals determine whether they are eligible for premium assistance that is available on a sliding-scale basis to reduce insurance costs or whether they are eligible for low-cost or no-cost Medi-Cal. Consumers can then compare health insurance plans and choose the plan that works best for their health needs and budget. Small businesses can purchase competitively priced health insurance plans and offer their employees the ability to choose from an array of plans and may qualify for federal tax credits.

Covered California is an independent part of the state government whose job is to make the new market work for California’s consumers. It is overseen by a five-member board appointed by the governor and the Legislature.


The article below, from The Los Angeles Times, dated March 7, 2016 discusses the threat of superbugs in the environment and the task we face.
Instead, dangerous bacteria arriving from hospitals thrive at the facilities and could endanger beachgoers.
Every day Southern California hospitals unleash millions of gallons of raw sewage into municipal sewers.
The malodorous muck flows miles to one of the region’s sewage plants, where it is treated with the rest of the area’s waste and then released as clear water into a stream or directly to the Pacific.
Scientists at the Environmental Protection Agency recently announced they had discovered a lethal superbug — the same one that caused outbreaks at UCLA and two other Los Angeles-area hospitals — in sewage at one of those plants. They declined to name the facility.
EPA scientists did not test treated wastewater flowing out of the plant to determine whether it still contained CRE, or carbapenem-resistant enterobacteriaceae.
But a growing number of studies show sewage plants can’t kill the superbugs. Instead the facilities serve as “a luxury hotel” for drug-resistant bacteria, a place where they thrive and grow stronger, said Pedro Alvarez, a professor of environmental engineering at Rice University, one of the scientists studying the problem.
Alvarez and other researchers say the failure of sewage plants to eliminate the dangerous bacteria is one way they may be spreading from hospitals to the environment.
“Chlorine is just not doing it,” Alvarez said of the treatment used by most plants.
The fear is that healthy people otherwise not at risk from the bacteria — including swimmers at the beach — could be infected.
Already officials are worried about the surprising number of people sickened with CRE who have not recently visited a medical facility: 8%, according to an October study.
Hospitals are not breaking laws by releasing the sewage. Laws regulate the overall level of disease-causing bacteria in the nation’s surface waters, but there is no specific regulation of bacteria resistant to antibiotics.
Deemed the “nightmare bacteria” by federal officials, CRE survives nearly all antibiotics. It kills as many as half its victims.
Government officials, including those at the federal Centers for Disease Control and Prevention, say they are monitoring the wastewater studies but have so far made no recommendations to hospitals about the treatment of sewage that may harbor CRE.
“The prevention and control of CRE is an evolving process,” said Melissa Brow-er, an agency spokeswoman. “CDC will continue to assess the appropriateness of this as new information becomes available.”
Researchers have tried for years to raise the alarm about hospital sewage. The sludge includes not just waste from patients suffering from drug-resistant infections but also high levels of antibiotics prescribed to treat them.
As the sewage mixes, the antibiotics kill off weaker bacteria, leaving the more lethal ones to thrive. The bugs reproduce rapidly, and different species can swap genes, transferring their ability to withstand the drugs.
Last year, the nation’s treatment plants were alerted to the risks of untreated medical sewage when a few American hospitals began caring for patients who had been struck by Ebola in Africa.
The CDC directed hospitals to allow the Ebola patients to use the toilets in their rooms, but said sewer workers should wear protective clothing, including goggles and a face mask, to protect themselves from the highly contagious virus.
Concern about that case prompted a foundation supported by water utilities to study what contaminants, including bacteria, hospitals are releasing in sewage.
“The idea of CRE flowing down our sewer pipes gets me nervous,” said Dr. James McKinnell, an infectious disease expert at the Los Angeles Biomedical Research Institute , who has been working to stop superbugs from spreading. “We should be testing our runoff.”
Inside hospitals, staff go on high alert when a patient tests positive for CRE.
Infected patients are isolated. Nurses don protective gowns and gloves. Family and friends are warned about visiting.
So far at least 75 of the 100 hospitals in Los Angeles, Orange and Ventura counties have reported patients infected with CRE. Los Angeles has the state’s highest rate.
CRE thrives in water. Hospitals have found it living in sink drains. The bacteria are happy in patients’ intestines and it passes through in urine and waste.
Every day, 2 million gallons of raw sewage from Los Angeles hospitals flows to the city’s Hyperion treatment facility.
The Disneyland-sized complex of pipes, giant tanks and pools sits at the edge of the Pacific, near Los Angeles International Airport.
Like other plants, Hyperion intentionally creates an ideal environment for microorganisms to thrive. The plant mixes non-disease-causing bacteria into the sewage and pumps in oxygen, allowing the bugs to feed and break down the waste.
The solids are settled out, and the clear water is piped five miles offshore and released 190 feet below the waves. It is treated with chlorine only in rare cases when it is released a mile offshore.
Hyperion employees test the treated water for levels of bacteria, but do not hunt for those that resist antibiotics like CRE.
Timeyin Dafeta, Hyperion’s manager, said that if CRE was present it “would be in extremely low concentrations” because hospital sewage accounts for just 0.5% of the city’s wastewater.
“We have no indication the effluent is coming back to impact the shoreline,” Dafeta said.
Farther south, dozens of other sewage plants release treated wastewater into creeks and concrete channels that eventually flow into the Pacific.
Some surf spots — like the Santa Ana River jetties in Orange County — have become known as places with great waves that can make you sick.
“Just check yourself for cuts prior to entering,” the surfing magazine Stab recently warned about the site on the northern border of Newport Beach. “Oh, and keep your mouth shut.”
California officials don’t know what bacteria is in the seawater. They monitor the ocean water for what they call fecal indicator bacteria — a sign of raw sewage. But they rarely test for specific bacteria, including those that are drug-resistant.
A 2010 study estimated that 689,000 to 4 million people are struck by gastrointestinal illnesses caught from Southern California beaches each year. An additional 693,000 are sickened with respiratory problems.
In December 2014, Barry Ault died on Christmas morning a few days after surfing off Sunset Cliffs in San Diego.
A staph infection attacked the 71-year-old’s heart valve, which had been replaced 10 months before.
Ault’s friend also got seriously ill. The two went surfing just after a rainstorm when it’s not possible for sewage treatment plants to handle all the runoff.
Sally Ault, Barry’s wife, said that the two were surfing in an area known for not being polluted. She said her husband, who grew up in Arcadia, had fully recovered from the earlier heart operation and was in great shape.
“It was nothing other than the bacteria,” she said.
It’s difficult to find which regulatory agency is responsible for monitoring what hospitals release to the sewers.
The state public health department referred questions to State Water Resources Control Board officials.
That agency referred questions to county officials, who said they had made no recommendations to hospitals to pre-treat sewage from CRE patients.
Enrique Rivero, a spokesman for UCLA, where three patients died after being infected by CRE from a contaminated medical scope, said that no one was available to comment.
A spokesman at Cedars-Sinai, site of a similar scope-linked outbreak, said the hospital follows all regulations relating to the handling of patient waste.
Cathy Milbourn at the EPA said agency scientists believe there is “insufficient information available to reach a definite conclusion on the presence and fate” of drug-resistant bacteria in sewage plants.
Last fall, a team of EPA scientists reported that they had found CRE in sewage at treatment plants across the country — including one in Southern California and another in the northern part of the state.
“I tested seven different plants and I found it in all of them,” said Jill Hoelle, a scientist in the EPA’s office of research and development.
The scientists concluded that CRE is “widespread” in America’s sewage — a finding that Hoelle said she found surprising given that reported patient infections are still relatively rare.
Alvarez, the Rice professor, said that with the rise of ever more dangerous bacteria like CRE, there is a risk of returning to a time, before the invention of water treatment, when infectious diseases were a major cause of death.
“We can save more lives by treating water than doctors can,” he said. melody.petersen
@ latimes.com
Twitter: @melodypetersen


Will a drop in C-Sections decrease insurance rates?

I have personally know someone whose C-Section was performed for the convenience of the doctor.

Below is an article from the Los Angeles Times dated March 8, 2016.

Low-risk surgeries in state hospitals fell from 27.3% in 2013 to 26.1% in 2014 amid pressure to cut costs.
At hospitals across California, administrators are pushing doctors to perform fewer caesarean deliveries, hiring birth coaches and asking pregnant women to stay in labor longer.
For years, medical experts have said that C-sections were being done too often, yet the rates kept climbing.
In 2014, however, delivery hospitals in California reduced the number of C-sections performed by more than 1,000 compared with 2013, according to a Times analysis of new data.
What’s changed recently, some experts say, is the nature of the healthcare system, which focuses increasingly on eliminating unnecessary expenses.
In the era of the Affordable Care Act and its emphasis on low-cost medical care, C-sections — which cost more than vaginal deliveries — have become a sticking point for hospitals and a target for the people paying the bills.
Childbirth is the most common reason for hospitalization in the U.S., said Katy Kozhimannil, a health policy professor at the University of Minnesota, so when insurers and self-insured employers “look at where their costs are going, you start to see caesarean delivery rises to the top.”
Hospitals not only face direct pressure from insurers to curb C-sections, but they’re also concerned that a high rate could affect business. As more data on medical facilities is available to patients, hospitals don’t want to fall to the bottom of the pack and lose patients who see higher C-section rates as unfavorable.
Dr. Allyson Brooks, an obstetrician and chief quality officer at Hoag Memorial Hospital Presbyterian in Newport Beach, remembers that a few years ago the hospital was under fire from its insurer because of a higher-than-average C-section rate.
In California, maternal care plus a vaginal delivery cost commercial insurers $15,259 on average, while maternal care plus a C-section cost $21,307, according to a report commissioned by the Center for Healthcare Quality and Payment Reform, a nonpartisan research center.
Over the last two decades, many U.S. doctors began opting for C-sections in part out of convenience, because the procedure is often much quicker than waiting for a woman to deliver vaginally, experts say.
Some patients chose to have C-sections — a trend made famous by celebrities in the 2000s and labeled “too posh to push.”
Though generally safe, C-sections are still invasive surgeries, with a longer recovery time than vaginal deliveries.
And once a woman has one C-section, she has a 90% chance of delivering her next babies by C-section.
The World Health Organization says the ideal C-section rate is around 15%, but in the U.S. it reached 32.9% in 2009.
The rates were influenced by factors such as the culture of a hospital and type of community it serves. Three years ago, Brooks recalled seeing posts on social media by Orange County residents such as, “If you want to have a vaginal delivery go to a different hospital, if you want to have a C-section go to Hoag.”
Brooks said that though most obstetricians agree C-section rates are too high, it can be difficult to get them to consider doing fewer.
They worry that trying to bring down rates will harm women. C-sections can be necessary if the umbilical cord is dangerously tied around a baby’s neck or a woman’s uterus is at risk of rupturing.
So she began calculating a low-risk, or NTSV, C-section rate for her hospital. It includes only women considered the least likely to need C-sections — first-time mothers, having a single baby around their due date, and carrying a baby positioned head down.
The U.S. surgeon general has called for reducing the low-risk C-section rate to 23.9% by 2020.
Hoag began requiring that doctors show clear medical reasons to induce labor in women, and also started calculating and sharing each doctor’s low-risk C-section rate.
At Hoag, the low-risk C-section rate dropped from 31% in 2013 to 26% in 2014, one of the biggest declines in the state.
And it wasn’t just Hoag. From 2013 to 2014, the rate of C-sections among low-risk moms in California dropped from 27.3% to 26.1%, a reduction of 1,219 procedures statewide, according to data released last month by the California Hospital Assessment and Reporting Task Force and analyzed by The Times.
The analysis also found that the percentage of California’s 244 delivery hospitals that met the surgeon general’s goal jumped from 32% to 42% between the two years.
Hoag negotiated with its insurer to be paid an equal rate for C-sections and vaginal deliveries so it wouldn’t lose money when rates dropped.
But other hospitals that have reduced their C-sections rates have faced financial consequences.
The six Providence Health & Services hospitals in Southern California took a revenue hit from doing fewer C-sections, said Regional Chief Medical Officer Michael Bernstein. They also spent money to hire obstetricians to staff the labor and delivery wards in shifts, so doctors wouldn’t feel rushed and opt for C-sections because they’re quicker procedures.
Bernstein said he thinks the change is better for patients and could be good for the hospital group in the long run.
Increasingly, under changes set into place by the Affordable Care Act, hospitals aren’t paid per treatment, but based on the quality of the care. Hospital leaders say C-section rates could become one of the metrics used in such calculations.
But Dr. Aaron Caughey, chair of the Department of Obstetrics and Gynecology at Oregon Health & Science University School of Medicine, said there’s no single low-risk C-section rate that all hospitals should aim for, and that rates will vary from hospital to hospital because of differences in the patient population.
“I would hate it if Medicaid said, ‘Every hospital whose rate is above the median, we’re not going to pay you a chunk of money.’ That is a bad approach because then people squeeze it down without attention to what’s best for patients,” Caughey said.
Even if hospitals aren’t being officially penalized for high C-section rates, administrators are worried about the financial effect of losing patients who want a vaginal birth.
Deliveries aren’t big moneymakers for hospitals, but once a hospital treats a mother, it’s likely to care for the rest of her family in the years to come.
Some mothers say that they felt as if their physicians rushed into C-sections, and they don’t want to repeat the experience.
When Anastasia Stone, 32, was pregnant with her first child, her doctor told her she needed to be medically induced to begin labor, which resulted in a C-section. “I was a typical first-time mom,” she said.
Stone, who lived in Santa Cruz at the time, said she later came to believe she could’ve had a vaginal delivery instead of a C-section if her physician had waited.
When she was pregnant with her second child, Stone went looking for a doctor who would try for a vaginal birth.
Dr. William Gilbert, regional medical director for women’s services at Sutter Health in the Sacramento region, said Sutter Davis Hospital has drawn such women from around the area because it had the lowest C-section rate in the state in 2014 — 12%.
The hospital uses nurse midwives, who deliver most of the babies, and reserves obstetricians for backup. Birth is treated as a natural process instead of a “health condition” that always requires medical intervention, said Carolyn Campos, nursing manager of the hospital’s birthing center.
Gilbert thinks that as more data on specific rates of procedures or treatments is available, patients will increasingly turn to that information when choosing where to seek care.
In 2014, low-risk C-section rates ranged from 12% to 70% at California hospitals.
Six years ago at Sutter Medical Center, Sacramento, Gilbert began encouraging physicians to allow longer labor in women, and began posting each physician’s low-risk C-section rate in the doctors’ lounge.
From 2010 to 2014, the hospital’s low-risk C-section rate dropped from 31% to 27%.
Gilbert thinks that most of the success came from publishing the doctor’s rates internally.
“Doctors don’t want to be the highest rate,” he said. soumya.karlamangla
@skarlamangla ryan.menezes

MARK BOSTER Los Angeles Times
LOW-RISK C-section rates at Hoag Memorial Hospital Presbyterian, where Dr. Allyson Brooks is chief quality officer, fell from 31% in 213 to 26% in 2014.


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