All posts in Non Clinical

Health Care Reform Goes Live: Day Three

The Familiar Path of Health Care Reform

This article first appeared August 5, 2013, in the Daily Journal.

Friedrich Nietzsche wrote: “When we are tired, we are attacked by ideas we conquered long ago.”

More than three years deep into the Affordable Care Act, 13 months since the U.S. Supreme Court confirmed its constitutionality, and almost 10 months after the American public approved reform through the Electoral College, modern American health care is now poised to shine or make its claim as a historical disaster. As the nation prepares for the health insurance exchange, the next few months shall prove critical in determining the trajectory — and thus the fate — of our health care system, and we would be remiss not to notice the storm clouds forming overhead. Continue reading →

The Spectacular Aspect of Contemporary Health Care

This article first appeared in the Daily Journal on September 11, 2012.

Spectacular – adj.: of or like a public show; striking, lavish (spek ‘tækjulə(r))[1]

As images of NASA’s 2012 “Curiosity” expedition continue to capture public interest, the word “spectacular” has been getting a lot of play in recent national media. By replacing images of our nation’s beloved hero Neil Armstrong bouncing on the lunar surface[2] with “a one-ton, automobile-size piece of American ingenuity” that is destined to spend the next two years “examining rocks within the 96-mile crater” into which it landed[3], NASA has proven how far we as a unified nation can come in under fifty years with a well-designed, properly funded and tightly executed plan.

Unlike with space travel, gauging the progress of the evolution of a health care system is not nearly so cut and dry. While advances in modern medicine since the introduction of Medicare[4] have in many ways been equally riveting from a technological, political and sociological standpoint, each new period of change has brought with it a divisiveness that has forced individuals to decide whether the system’s latest step is spectacular in its success or failure. When it comes to health care, Americans tend to see things in black and white.

Much of what we now take for granted the field of modern medicine was unthinkable fifty years ago. Technologically, the jumps have been astounding. From its humble origins in the 1970s, X-ray computed tomography has evolved from being able to give a reading that included 160 images, each taking 2.5 hours to process, into today’s 256-slice CT scanner which can in seconds measure subtle changes in blood flow or blockages in blood vessels the width of a toothpick within the heart and brain.[5] Continue reading →

Understanding the Minimum Medical Loss Ratio

Under the Affordable Care Act (ACA), in 2012 consumers anticipate the return of an estimated $1 billion in rebates from health insurance issuers (issuers).

Commonly referred to as the “80/20 provision” of the ACA, the regulations governing Medical Loss Ratio (MLR) rebates appear in Title 45 of the Code of Federal Regulations, Part 158. The minimum MLR (45 C.F.R. § 158.210) applies as follows:

  • Large group market:  For all policies issued in this market during the MLR reporting year, an issuer must provide a rebate to enrollees if the issuer has an MLR of less than 85% (subject to adjustments as discussed below).
  • Small group market and individual market:  For all policies issued in these markets during the MLR reporting year, an issuer must provide a rebate to enrollees if the issuer has an MLR of less than 80% (also subject to certain adjustments).

States, however, retain the option to set a higher MLR, provided the State ensures adequate participation by health insurance issuers, competition in that State’s health insurance market, and value for consumers to ensure that premiums are used for clinical services and quality improvements.  (45 C.F.R. § 158.211.)

While there are specific requirements relating to the aggregation of data in calculating an issuer’s MLR (45 C.F.R. § 158.220), generally an issuer’s MLR is: The ratio of the issuer’s incurred claims plus the issuer’s expenditures for activities that improve health care quality (the numerator) to the issuer’s premium revenue, less any Federal and State taxes as well as licensing and regulatory fees (the denominator). Continue reading →

An Overview of the Hospital Value-Based Purchasing Program

Section 3001(a) of the Affordable Care Act (ACA) includes a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing (VBP) Program.

Under the VBP Program, beginning October 2012 hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS), as these funds will be used to pay for the performance bonuses under VBP Program. By 2015, hospitals that continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement. Continue reading →

CMS Updates Hospital Compare Website

The Centers for Medicare & Medicaid Services (CMS) recently announced updates and expanded tools to its Hospital Compare and Nursing Home Compare Websites.

CMS stated that both Websites have been enhanced to facilitate navigation by users with new comparison tools. According to Acting CMS Administrator Marilyn Tavenner: “These enhanced tools give patients, their families, and caregivers the ability to make an informed decision on where to seek care by looking at how well hospitals and nursing homes are performing on important quality measures. . . Anyone looking to compare hospitals or nursing homes – not just those on Medicare – can take advantage of these websites.”

The two Websites contain data about hospital and nursing home performance on quality measures, and now both are accessible through mobile devices.  CMS has also improved navigation, new search functionalities and enhanced glossaries and web resources. Continue reading →

The Right to Strike vs. the Right to Care

Modern day health care is a troubled industry. Enshrouded in a net of oft-conflicting regulations and entrusted with the safety of America’s sick and wounded, many of whom lack the necessary insurance to guarantee reimbursement to their providers, the financial stability of our nation’s medical facilities is called into question on a daily basis. Today’s hospital has the unenviable task of walking a fine line between caring for its patients and remaining solvent as a business, a laudable goal attainable at least in part by recognizing the inextricable connection between the institution itself and the nurses who form an infantry amongst its ranks. Even as these nurses form an ever-present “front line” on the hospital battlefield, the recent threat of strikes around the nation shines a harsh if necessary light on certain issues plaguing our current health care system as it stands so precariously with one foot on either side of a dangerous fence.

The nature of the nurse’s role begs the question: does participation in a labor union extend to the right to strike? Continue reading →

The War on Health Care

This article first appeared in the Daily Journal on June 15, 2012.

Throughout history, America’s methods of providing health care have always had an understated yet powerful impact on the way she chooses to wage war.  And yet, this may be the first time that health care is itself under siege. Indeed, the specter of war has provided countless opportunities to test society’s mettle in battle, while forcing those in power to prioritize in terms of their country’s health care. As sides are drawn and campaigns evolve, the strategies of combat take shape in ways previously unforeseen. This is certainly true in contemporary America, though in our modern age of reform it is health care itself that has come under attack.

Medically speaking, advances in science, technology and the provision of health care have commandeered the new millennium, both in practice and politics. And yet, medicine’s inestimable progress since the Civil War is often largely taken for granted by both the decision makers and the recipients of a country that has come to expect state-of-the-art facilities and easy access to providers. A century and a half ago, the delivery of medicine was grossly misunderstood, frequently useless and often barbaric. “Civil War surgeons cleaned their instruments by periodically rinsing them with water, usually at the end of the day. . . . Typically, the operator wiped the blood and other material from his knife with a quick swipe across the front of his large apron, which was usually stained with blood and pus from prior sessions.”[1]

Such an abysmal depiction of health care in the middle of the nineteenth century serves to underscore the catastrophic losses endured by both North and South in the deadliest conflict on American soil, while highlighting the need for a potent, reliable and inclusive health care structure on which to rely.. Dr. Jonathan Letterman, Civil War medical director of the Army of the Potomac, offered a wise analogy describing the relationship between the science of medicine and our ability to deliver it:  “Without proper means, the Medical Department can no more take care of the wounded than the army can fight a battle without ammunition.”[2] Continue reading →

Advice from Antiquity

“Life is like riding a bicycle. To keep your balance you must keep moving.”  – Albert Einstein

This article first appeared on the PBS affiliated Website This Emotional Life.

Every so often I stop to reflect upon the seemingly random series of events that have led my life to its current point. In times like these my mind rarely gravitates toward any single individuals who left lasting impressions, positive or negative, but instead remains fixed on the patterns that have emerged over time.  Make no mistake, I still search for a seemingly insignificant or banal event from my past that might offer some magical context to help define the person I have become, especially in light of my newfound fatherhood.  And yet, while I am not holding out for such an epiphany any time soon for myself, such a revelation could do wonders for my son as he crawls faster and faster toward the conclusion of his first year.

At the age of eleven, I read my first Greek myth, and I was hooked. Eleven years later, I graduated from college with a major in classical studies, a discipline I have described as familiarization with an abundance of Greek myths experienced in a written rather than spoken format, in a language that dates back seven to ten thousand years.  From this historical depository of dactylic hexameter and Socratic dialogue, a few key tenets have remained permanently etched in my brain, and it is not uncommon for me to draw upon these scraps of wisdom on any given day. While often overshadowed by the technological advances that largely define our fast-paced modern society, I continually find that those bits of knowledge I learned twenty years ago are more than enough to help me navigate through even the most baffling of days.

Victory comes to men in turns.”

This famous quote from a traditional English translation of Homer’s Iliad is a source of comfort and hope in troubled times as well as a gentle reminder for us all to strive for humility at any stage. Continue reading →

 

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