Tag: Patient’s Rights
The calls may come in the middle of the night and from hospitals more than an hour away. Someone is having a stroke and is en route an emergency room in the Florida Keys, but there aren’t any neurologists on call.
Within 15 minutes, a University of Miami neurologist pops onto a computer screen and can order an IV drug that should be given within three hours. It’s that sort of potentially life-saving technology that some lawmakers say will drive down health care costs, while also addressing serious doctor shortages around the state.
A Senate bill would increase the use of telemedicine in Florida and establish requirements for health providers who treat patients remotely. A companion bill is also making its way through the House, but that bill doesn’t require doctors to have a Florida license — only that they be licensed in their home state and registered in Florida.
“If we didn’t have an access problem we wouldn’t be here today … everyone would rather see the doctor face to face, but when your mother is having a stroke in rural Florida and the choice is having a doctor via telehealth versus having no doctor,” said Rep. Cary Pigman, an emergency room physician who supports the bill.
The Senate bill requires doctors providing telemedicine services to patients within the state to be licensed in Florida or meet an alternative requirement. For example, an insurer using a doctor that’s in-network in another state would also be allowed to treat a Florida patient. The bill recently passed a Senate committee, but has two more stops before it’s heard on the floor. Dozens of other states have passed legislation supporting telemedicine.
The Senate bill also would require Medicaid to reimburse for telemedicine services and allow doctors to negotiate payment rates with insurers. The House bill doesn’t address payments.
“If you’re a patient in Florida and you have a specific heart defect and the guru is a doctor in Philadelphia, you should be able to consult with her,” said Republican Sen. Aaron Bean, who is championing the bill.
But critics worry that requirements for doctors in other states could compromise patient care. Some say that doctors practicing telemedicine in Florida should be licensed here.
“It may be the wave of the future, but I still think we need to concentrate on the patients and the bottom line is these (out of state) doctors are not licensed in Florida so they don’t have the same accountability,” said Sen.Dorothy Hukill, who voted against the bill.
Bean said they will be held accountable through the insurance company or the doctor’s network they practice within.
Rep. Gayle Harrell, voted for the bill, but noted it still has problems.
“I also need to know what my recourse action should be should some malpractice incident take place,” she said.
She also wants to see a website created where people can find information about the out-of-state doctors who may be treating them. After all, she noted, patients can’t walk into the office of an out-of-state doctor and see medical degrees on the wall.
The Florida Chamber and several other groups, including ones representing nurse practitioners, physician assistants, nurses and pharmacists all support the bill.
But the powerful Florida Medical Association is strongly opposed, worrying it doesn’t require treatment by a licensed Florida physician or mandate a review of the patient’s medical history. The organization said such technology holds great promise, but does not support the bill in its current form.
“This will revert Florida back to the days of the Wild West where anyone with a bottle of whiskey, a pocket knife and Skype can practice medicine. That’s what happens to the bill in its current form, said David Custin, a lobbyist for the group.
Several hospitals around the state have had success with telemedicine in recent years, helping patients in rural areas connect to specialists or getting multiple consultations conducted simultaneously for acute emergency cases. University of Miami neurologist Dr. Gustavo Ortiz has done more than 600 consultations since their program’s inception in 2009.
Telemedicine saves money by reducing hospital and ER admissions and doesn’t require medical transportation, supporters say.
Dr. Kim Landry, an emergency room physician and EMS medical director for four counties in the Panhandle, began a pilot program where 911 responders connect patients remotely to an ER doctor for a quick evaluation.
“Eight out of 10 times, they don’t require transport to the hospital, so in a lot of cases, it’s made life easier for a lot of sick patients,” said Landry, who found those results after testing the program in nursing homes.
During a recent consultation, University of Miami dermatologist Dr. Anne Burdick asked an assistant at a Fort Pierce county health clinic to zoom the camera in on some scaly, white patches on a 10-year-old boy’s legs. The boy is often kept indoors and complains of constant itching at night. Burdick, who diagnosed him with eczema, modified his prescriptions and added a weekly bleach bath to reduce bacteria. The boy was one of five pediatric patients seen remotely from her Miami office that day.
Burdick, who estimates 40 percent of her practice includes telemedicine patients, also does medical consultations for two cruise lines, the Indian Health Service and a weekly program for school children.
“For some areas in the state, it’s going to be impossible to get specialists to that area and so telemedicine is really the best option, ” said Burdick. “The bill will be a really good step forward for Florida.”
Federal officials are considering new Medicare Advantage rules to help protect seniors when insurers make significant reductions to their networks of doctors and other health-care providers.
The proposals follow UnitedHealthcare’s decision to drop thousands of doctors from its Medicare Advantage plans in at least 10 states last fall.
The government’s response is part of the148-page announcement of proposed rules and payment rates for next year’s Medicare Advantage plans, which were released last month by the U.S. Centers for Medicare and Medicaid Services. Officials said the terminations a few weeks before Medicare’s Dec. 7 enrollment deadline may not have given seniors enough time to find new doctors, choose a different plan or rejoin traditional Medicare, which does not restrict beneficiaries to a limited network of providers.
The proposals would give beneficiaries more than 30 days’ notice of network changes and providers at least 60 days’ notice of a contract termination. Even Medicare officials need more notice — “no less than 90 days” — so they can ensure that the remaining providers “will continue to meet required network standards.” Officials are soliciting suggestions on how plans should prove that their reconfigured networks are adequate.
The doctor terminations sparked protests to Medicare and UnitedHealthcare from patients, as well as doctor groups across the country, state officials and members of Congress.
Nearly 16 million people, about a third of Medicare beneficiaries, are enrolled in the private Medicare Advantage plans, which are an alternative to traditional Medicare. The government reimburses insurers to care for these seniors.
Although the announcement does not name any insurance companies, officials prefaced the proposals by writing, “Recent significant mid-year changes to MAOs’ [Medicare Advantage organizations’] provider networks have prompted CMS to reexamine its current guidance on these requirements and to consider augmenting such guidance in response to such changes.”
Medicare Advantage rules allow beneficiaries to change plans if they move out of the coverage area or for other special reasons, but not if they lose their doctors or hospitals. Otherwise, they can switch plans once a year, during the fall seven-week enrollment period. Since most beneficiaries are locked into their plans, CMS is considering whether to restrict insurers’ ability to drop doctors during the plan year.
If insurers expect to drop providers in the coming year, they should say so in the letter highlighting changes that they are required to send to plan members every year before the open enrollment season. CMS would also add “required language” to the letter explaining patients’ rights in the event that network providers leave the plan during the plan year.
Final rules are expected as early as April 7.
“These are exactly the things we talked about with CMS back in the fall,” said Mark Thompson, executive director of the Fairfield County (Conn.) Medical Association, which, along with the Hartford County Medical Association, sued UnitedHealthcare to block the terminations. The American Medical Association and 35 state medical associations and doctor advocacy groups filed legal papers in support of the doctors.
“Someone was paying attention and listening to us,” Thompson said.
A federal judge in December issued an injunction halting the cancellations in those counties, and a panel of three federal appeals court judges in February upheld that decision until the doctors had time to challenge their terminations before independent arbitrators.
Representatives for UnitedHealthcare and Humana, the two leading Medicare Advantage insurers, declined to answer questions or provide copies of their comments to CMS related to the proposals. UnitedHealthcare said earlier that the cancellations were partly the result of cuts in federal reimbursements required by the Affordable Care Act and also part of an effort to improve quality and reduce costs.
However, America’s Health Insurance Plans, which represents more than 1,300 health insurers, warned CMS that the proposed rules could hinder insurers’ contract negotiations with providers, which “occur throughout the year” and could also weaken enforcement of contract terms that allow for provider terminations. In addition, notifying beneficiaries of potential terminations before contracts may be successfully completed “would be unnecessarily disruptive,” the group said.
Doctors worry they won’t get paid by some patients because of an unusual 90-day grace period for government-subsidized health plans.
So several professional groups for doctors are urging their members to check patients’ insurance status before every visit. Consumer advocates say these checks could lead to treatment delays or denials for some patients.
If a person with subsidized insurance falls behind in paying the premiums, the Affordable Care Act requires insurers to cover his medical bills for 30 days.
But for the next 60 days, insurers can hold off paying those claims — and ultimately, deny them if the patient doesn’t pay the premiums in full. An insurer’s denial means doctors don’t get paid for their services. If the insurer ends up canceling the policy after 90 days, doctors can bill patients directly but may face difficulty collecting.
“This puts the physician and their patients in a very difficult situation,” said Dr. Ardis Dee Hoven, president of the American Medical Association, which advised physicians Wednesday about how to minimize their risk.
“If a patient is being treated for a serious illness that requires ongoing care, the physician is having to assume the financial risk for this,” she said. “That’s the bottom line.”
The way things work now, insurers generally cancel a policy if a subscriber falls behind more than 30 days. The insurer is usually on the hook for bills incurred before that cancellation.
The AMA and dozens of other physician groups have urged the administration to spell out how and when insurers must notify physicians when their patients fall behind on premiums.
Doctors’ groups got a prompt-notification law passed earlier this month by the Washington state Legislature.
But some consumer advocates fear that doctors who know they may not get paid have a strong incentive to withhold treatment. “The reason they want that notification is so they can start denying services,” said Brian Haile, senior vice president for health care policy at Jackson Hewitt Tax Service.
If the insurer notifies the physician that a patient is behind on premiums and the insurer is holding up claims payments, “Nine times out of 10 the doctor is not going to provide the services — no matter what their network contract says.”
“The doctors aren’t bad guys — they’re business people,” Haile added. “Any economically rational actor would do it.”
For some medical specialties, treating patients who have fallen behind on their payments could end up being quite costly.
Oncology practices that administer chemotherapy drugs costing thousands of dollars have to purchase them in advance. If a patient’s claims aren’t paid, the cost to the practice is high.
Obstetricians who provide prenatal care throughout pregnancy could also take a hit if women fall behind on payments when they’re about to deliver their babies.
Hoven, the AMA president, said physicians are contractually and ethically bound to continue caring for their patients. “Most physicians are not going to turn away these patients, particularly if someone comes in with a life-threatening condition,” she said.
The AMA’s guide to the grace period specifically warns physicians that postponing or rescheduling patients could be a breach of contract because of anti-discrimination clauses in many managed care contracts.
“This is the kind of thing we’re going to watch really closely, and it’s one of the reasons we want to make sure people are careful on the front end selecting plans that are affordable,” said Kirsten Sloan, senior policy director for the American Cancer Society Cancer Action Network.
Dr. Dan McCoy, vice president and chief medical officer for Blue Cross Blue Shield of Texas, said his plan will cover claims throughout the entire 90-day period as a result of a state prompt-payment law but can recoup payments from physicians if patients’ policies are terminated.
He stressed that participating physicians are expected to care for patients throughout that period even if payments have lapsed. “We strongly feel that people who carry a Blue Cross Blue Shield card in their pocket should be treated as members,” he said.
The AMA, meanwhile, is encouraging doctors to broach financial concerns with their patients and explain why it’s important to maintain insurance coverage.
The group released materials Wednesday including a sample letter to patients explaining that while the doctor will continue to see them during the grace period, “you may be obligated to pay the full cost of services that we provide to you” if insurance is terminated. The letter also encourages patients to discuss changes in their financial circumstances with doctors.
Healthcare providers and policy analysts are increasingly anxious that Congress will fail to eliminate Medicare’s flawed physician payment formula and once again default to a temporary fix.
All eyes turned to the Senate after the House of Representatives passed a bill on Friday that repeals the sustainable growth-rate formula and also includes a five-year delay of the financial penalties for people who don’t purchase health insurance—which the Senate is sure to reject.
Congress will return from a weeklong recess on March 24, which gives lawmakers one week until the temporary SGR patch expires on March 31.
Under an amendment added by House Ways and Means Committee Chairman Dave Camp (R-Mich.), the House bill would keep the Patient Protection and Affordable Care Act’s individual mandate in place but would not penalize anyone for violating it until 2019. The nonpartisan Congressional Budget Office estimated this week that this move would increase the number of uninsured Americans by about 13 million in 2018.
The SGR Repeal and Medicare Provider Payment Modernization Act passed 238-181 and picked up support from 12 Democrats. Though cheered by House Republicans, the legislation is viewed by Democrats, policy analysts and healthcare providers as purely a political move that is not likely to go anywhere beyond the House floor.
“We’re dismayed that Congress sabotaged their own work by linking legislation to unrelated, ideological issues—particularly in light of the nearly universal opposition to such action from patients, insurers and the medical community,” Dr. Reid Blackwelder, president of the American Academy of Family Physicians, said in a statement reacting to the vote.
Even the conservative Heritage Foundation did not support Friday’s House vote. “If you are going to have a permanent repeal, which incurs permanent costs, you need permanent savings to offset those costs,” Robert Moffit, a senior fellow at Heritage, said in a statement.
Senate Finance Committee Chairman Ron Wyden, who introduced a version of the SGR repeal this week, said he is committed to sound, sensible policy over politics.
The Oregon Democrat also cautioned that hospitals, home health providers, drug companies and skilled-nursing facilities will once again be at risk if Congress doesn’t find approve a permanent SGR repeal. “Make no mistake about it: Those providers are going to be the ones who pay for yet another patch,” Wyden said on the Senate floor.
The bill that Wyden introduced this week—the Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014—includes the compromise agreement from the Senate Finance, House Ways and Means and House Energy and Commerce committees to repeal and replace the SGR, as well as the extension of certain Medicare programs that are expiring.
It does not, however, include a way to pay for these provisions. Meanwhile, the House bill that passed on Friday includes the compromise agreement on SGR, no language on the Medicare extenders and the dead-on-arrival delay in the ACA’s individual mandate to pay for it.
“For me, the positive side is the House has done something,” said Julius Hobson, a senior policy adviser at law firm Polsinelli and a former lobbyist for the American Medical Association. “And when they get back from recess, the Senate will attempt to do something. It may heighten talks between the House and Senate, and that’s my hope.”
But others expressed more frustration than hope, given that lawmakers still are not talking seriously about how to pay for repealing the SGR, which the CBO estimates will cost $138.4 billion over 10 years. This week, the bipartisan Committee for a Responsible Federal Budget released a statement that criticized House Republicans for trying to pay for a permanent repeal of the SGR with a temporary delay of the individual mandate’s penalties, which the nonpartisan fiscal watchdog group said will only add to long-term deficits.
The organization also criticized House Democrats for proposing “phantom war savings” as a way to pay for the overhaul and the Senate for proposing none. The “phantom war savings” refers to funding for the Global War on Terrorism/Overseas Contingency Operations, most commonly referred to in Washington as “OCO funds.” Congress provided about $92 billion in OCO funding for 2014 and none for subsequent years, according to the CBO.
“There are ways to look at a package of things, from expanded means-testing to rationalizing co-payments to reforming Medigap plans,” said Maya MacGuineas, president of the Committee for a Responsible Federal Budget.
Thursday’s Florida Supreme Court decision that threw out medical malpractice limits on “pain and suffering” drew quick rebukes from doctors and applause from trial attorneys.
The 5-2 landmark decision, issued two years after oral arguments, called into question the very reason the Legislature imposed the limits in the first place: the “alleged medical malpractice crisis.”
Second-guessing the legislative intent in such a case is extraordinary, says Jay Wolfson, University of South Florida professor of public health and medicine.
“This ruling can have a significant domino effect that may dramatically affect the status and future of tort reform in Florida and elsewhere in the nation,” he said.
The Florida Medical Association predicted an increase in lawsuits, an exodus of physicians from the state and an “intensified access-to-care crisis.”
The opinion is a product of “activist judges,” said FMA General Counsel Jeff Scott.
Dr. Alan Pillersdorf, a Palm Springs plastic surgeon and president-elect of the FMA, said the patients are the “real losers” from this court opinion.
“Every time there’s a very complicated case, the doctor is going to have this hanging over this head,” Pillersdorf said. “He’s going to shy away from very difficult cases. He’s going to shy away from poor people. You’ve unleashed the Florida trial bar on the population.”
But trial attorneys who specialize in negligence suits said the decision removes a law that unfairly targeted the victims of just one kind of negligence.
“Medical malpractice is the only type of claim that had these caps, so if you were run over by a Greyhound Bus, or killed by a defective product, there were no caps,” said longtime St. Petersburg attorney Tom Masterson.
The decision in McCall v USA applied only to cases in which the patient died, and only those filed from now on. But the principle is the same for other cases of alleged negligence by a physician, for which the “non-economic damages” were limited to $500,000 or $1 million, depending on the situation, Tampa trial attorney Anthony Martino said.
“It’s clear that the court was very concerned these caps are just unfair, and create different classes of people without any rational basis,” Martino said. “We believe the court will eventually overturn all claims involving caps on non-economic damages.”
The legislature came up with the caps 11 years ago, at a time when there was a hue and cry about the cost of medical malpractice and resulting defensive medicine, which drove up costs. The idea of imposing caps was a compromise, and then-Gov. Jeb Bush signed it into law.
The number of cases then fell, which physicians interpreted as a sign that the caps were deterring frivolous lawsuits. Medical-malpractice attorneys say, however, that many legitimate cases were turned away because of the caps and other barriers the legislature set up to bringing medical-malpractice suits.
Caps made law firms cautious about fronting the cost for cases that are expensive to litigate, since the caps could leave the plaintiffs with little or nothing at the end.
“This is a monumental decision,” prominent trial attorney Ken Sobel of Fort Lauderdale told the Times/Herald Tallahassee Bureau. “It is being resoundingly applauded by our side of the bar, and quietly applauded by the defense bar.”
As the deadline approaches for most Americans to obtain health insurance, a flurry of changes by the Obama administration has led to a frenzied effort among employers, insurance companies, politicians and consumers to try and understand what they might mean.
The latest batch of adjustments came Wednesday, when the administration disclosed that it was delaying, once again, the deadline for people with old private health plans to buy beefed-up versions required under the health-care law. The cancellations of the old plans have been politically damaging for Democrats and the White House, because President Obama had vowed that the law would not prevent people from keeping insurance plans that they liked.
By allowing many people to keep their old plans for two years longer, the administration softened the blow for congressional Democrats up for reelection this fall. No longer do members have to fear a wave of cancellation letters right before the November midterm election.
But the changes have contributed to consumer confusion, as people try to sort through their options on the already hard-to-understand subject of health insurance, and race to meet a March 31 deadline to carry health coverage or face a fine. And the changes fuel suspicions that the law is deeply flawed, forcing the administration to try to patch it on the fly.
Republicans immediately leapt on the Wednesday announcement as a recognition that the law, as written, is unworkable.
“The administration has acted dozens of times over the last year to unilaterally delay or change the law because it was not ready for prime time,” House Energy and Commerce Committee Chairman Fred Upton (R-Mich.) said in a statement shortly after the change was announced.
Since April 2010, there have been about two dozen legislative or administrative actions changing the Affordable Care Act, according to media reports and the Congressional Research Service.
The changes range from small clarifications to major shifts, like last year’s delay of a major provision that requires employers with at least 50 workers to offer health coverage to full-time employees.
To add to the confusion, some modifications are changes to previous changes. For example, this is the second time that the administration has allowed some people to keep noncompliant plans longer than previously announced.
Many experts had predicted that the law would need to be tweaked. It is typical that large, complex pieces of legislation are adjusted and clarified during the implementation phase, as policies move from paper to the real world. Usually, Congress makes such technical corrections.
But, because the parties have been so polarized over the law, Congress has been unwilling to pass bills aimed at fixing the problems, with Republicans bent on repealing the law and Democrats fearful of reopening debate on such a divisive subject. As a result, the administration has made certain changes using the president’s executive authority.
“I broadly view the administrative delays as a pragmatic realization that it is actually harder to do some of these things in reality than we thought when we put it down on paper,” said Bob Kocher, a former Obama health-policy adviser.
Some of the adjustments came as a result of the rocky rollout of HealthCare.gov, the main federal portal for people in three dozen states to buy subsidized health insurance. For example, in December, the administration announced that there would be a “special enrollment period” to give people who ran into technical glitches on the Web site more time to sign up for coverage.
Meanwhile, people appear to be as confused as ever about the law. In a February poll taken by the nonpartisan Kaiser Family Foundation, about half of uninsured people said they do not have enough information to understand how the law will affect their families.
Some critics view the constant moving of the goal posts as a sign that the White House is not confident that consumers will ever warm to the health-care law.
“It sure looks like we’re on a ramp to more changes, and those changes are occurring because people aren’t buying it — literally and figuratively,” said Robert Laszewski, an insurance industry consultant who has been an outspoken critic of the administration’s handling of the rollout.
Many supporters acknowledge that the law is playing out differently than envisioned when it was enacted, but they contend that it remains on track to accomplish its goal of curbing the rise in health-care costs, improving the quality of care and making insurance affordable for virtually everyone.
“It’s just that it is accomplishing it much more slowly and painfully than anyone ever imagined,” said Sara Rosenbaum, a health law professor at George Washington University and a supporter of the law.