Can We #RepealAndReplace #ObamaCare?

The Patient Protection and Affordable Care Act (PPACA, aka ACA, or more often as “ObamaCare”) might be analogized to an onion, insofar as:
1.) It has many layers, and;
2.) Peeling back the layers may cause tears.

Enacted in 2010, it has been decried primarily by Republicans, none of whom voted for the bill’s passage, either in the House, which approved it 219-212 with 34 Democrats voting “NO” – or in the Senate, which approved it 60-39 along party lines, with 1 Republican (Jim Bunning, KY) “Not Voting.”

The Patient Protection and Affordable Care Act contains nine titles, each addressing an essential component of reform:
1.) Quality, Affordable Health Care For All Americans
2.) The Role Of Public Programs
3.) Improving The Quality And Efficiency Of Health Care

4.) Prevention Of Chronic Disease And Improving Public Health
5.) Health Care Workforce
6.) Transparency And Program Integrity

7.) Improving Access To Innovative Medical Therapies
8.) Community Living Assistance Services And Supports
9.) Revenue Provisions

Immediate improvements through reform included:
• Eliminate lifetime and unreasonable annual limits on benefits
• Prohibit rescissions of health insurance policies
• Provide assistance for those who are uninsured because of a pre-existing condition

• Require coverage of preventive services and immunizations
• Extend dependent coverage up to age 26
• Develop uniform coverage documents so consumers can make apples to apples comparisons when shopping for health insurance

• Cap insurance company non-medical, administrative expenditures
• Ensure consumers have access to an effective appeals process and provide consumers a place to turn for assistance navigating the appeals process and accessing their coverage
• Create a temporary re-insurance program to support coverage for early retirees

• Establish an Internet portal to assist Americans in identifying coverage options
• Facilitate administrative simplification to lower health system costs

While no law is perfect – and the ACA is not perfect – there are provisions within it which many think worthy of keeping, notable among them, provisions for guaranteed coverage, prohibiting cancellation, extending dependent’s coverage, removing annual & lifetime limits,

UPDATED: If #ALpolitics Would #ExpandMedicaidNow, They Could CUT Medicaid Co$t$ More Than 50%

UPDATE: Tuesday, 11 August 2015
CORRECTION ADDENDUM

In my first & earlier calculations, I inadvertently overlooked multiplying the Annual Medicaid Spending in Alabama figure (which is a TOTAL of $5,241,269,869) by 70%, which would represent the portion paid for by the Federal government. Alabama’s 30% share of that figure (the share paid for by the state) would be $1,572,380,960.70. It would also be reasonable to expect that Expanding Medicaid in Alabama to 138% of the Federal Poverty Level would increase total economic activity (through Medicaid spending) in the state at least 38%. So to Expand Medicaid, the baseline figure for TOTAL Medicaid spending (combined Federal and State funds) would approximate $7,232,952,419. According to the provisions of the law, Alabama’s sharing portion (if Governor Bentley chose to Expand Medicaid) would still be 2016-100%; 2017-5%; 2018-6%; 2019-7%; 2020 and beyond-10%. The corrections to the figures herein are dollar amounts only (based on the $7,232,952,419 total expanded figure), not the %ages. Data & figures are now also shown in table format.

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Folks, it may (or may not) surprise you to know a sampling of the collective thoughts of our wrong-wing friends, and relatives on matters political in Alabama, especially as they pertain to Medicaid.

Here’s a verbatim excerpted sampling of what I came across today.

• No one want increased entitlements. Too much waste and abuse. get a job folks. no to medicaid
• Medicaid is a lifestyle
• scare tactic. nursing homes overcharge. working people of Alabama are tired of taking care of lazy people
• ask any hospital administrator or physician in private practice. Medicaid devalues services. Reject medicaid

I dare say, MOST are clueless about the genuinely tangible economic and public health benefits Medicaid provides to this state, and the revenue and jobs it creates. All they hear are the wails and moans of representatives and/or senators – mostly of whom, if not exclusively, are Republican.

Where does Alabama’s Medicaid money come from?
Where does it go?
Source: Alabama Medicaid Agency Annual Report – FY 2012

Medicaid is a Federal/State matching/sharing program which provides (pays for) healthcare services for the impoverished wherein states pay a minority matching portion, while the Federal Government through CMS (Centers for Medicare and Medicaid Services) pays the majority portion. Within reasonable guidelines, the states have broad discretion and liberty to operate Medicaid according to the way they see fit, and the needs of the residents they serve. There are, however, certain minimums standards to which every state must adhere.

Under the provisions of the OLD law, the states that do NOT Expand Medicaid pay a higher %age rate for their services than they would if they were to Expand Medicaid to provide services to those whom are at 138% of the Federal Poverty guidelines – which is what the PPACA provides. The PPACA is the Patient Protection and Affordable Care Act- though it’s more often called the ACA “Affordable Care Act,” and colloquially referred to as “ObamaCare.”

Under the provisions of the PPACA, states that choose to Expand Medicaid will have 100% of those costs paid-for by the CMS beginning 2014, until 2016. The incentive for expansion is based upon

Alabama Medicaid Incompetency: State must repay Federal Childrens Health Insurance Program $88,197,498

Did you know? (No, you probably didn’t.)

In a report dated August 2013, the Department of Health and Human Services Office of Inspector General (HHS OIG) conducted a criminal and administrative investigation and found that Alabama claimed, and was paid millions in unallowable performance bonus payments under the Children’s Health Insurance Program Reauthorization Act (CHIRPA).

This FRAUD was because of INCOMPETENCY in Alabama governance.

The HHS OIG found that the Alabama state agency overstated its FYs 2009 and 2010 current enrollment in its requests for bonus payments. The State agency overstated its current enrollments because, rather than

Reaching the End of Life: What Do We & Loved Ones REALLY Need?

Recollecting, one of my patients was similarly diagnosed, suffering terminal lung cancer of the small cell carcinoma type, and had one lung removed. He had presented to the ED (Emergency Department) with extreme hypoxia (lack of oxygen), to such an extent that his lips had a distinctive blue cast to them. His oxygenation was so exceedingly poor, that he would turn in bed, and his sats (oxygen saturation level) would drop to 70% – neither a good, nor one that would sustain life.

In conversation with him, I asked him what he wanted to have happen to him, how he wanted things to turn out for him. He wasn’t under any misguided notion about his state of well-being or health and wanted to depart the ICU.

He said, “I want to go home to die.”

I responded by saying, “We want you to go home too. Let’s see what we can do to get you back there.” At that point, I began some very simple teaching about his breathing. He was a habitual mouth breather, and he knew it. I’d glance up at him, and his mouth would be gaping open as he watched teevee. Problem was, that every time his mouth opened, his sats dropped, even though he was receiving high flow O2 therapy via specialized nasal cannula.

So I instructed him that by keeping his mouth closed and breathing through his nose, his sats would increase. And barring any other unforeseen circumstance, were his sats to consistently maintain above 90%, that would be the greatest step toward his objective to go home.

At the end of my shift, he was consistently satting 98%.

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Doctors are practicing irrational medicine at the end of life

by Monica Williams-Murphy, MD on September 22nd, 2012, in Physician

I just took care of a precious little lady, Ms. King (not her real name), who reminded me that, too often, we doctors are practicing irrational medicine at the end of life. We are like cows walking mindlessly in the same paths; only because we have always done things the same way, never questioning ourselves. What I mean is that we are often too focused on using our routine pills and procedures used to address abnormal lab values or abnormal organ function, to rightly perceive what might be best for the whole person, or even what may no longer be needed. Our typical practice habits may in fact become inappropriate medical practiceat life’s end.Ms. King was a case in point: She was a 92-year-old nursing homepatient on hospice for metastatic breast cancer. Ms King had been transferred to the ER for a sudden drop in blood sugar, presumably due to her oral diabetes medication. Her appetite had apparently been trailing off, as is common at the end of life, and her medication appeared to have become “too strong.” Her glucose level had been corrected by EMS during her trip from the nursing home to the Hospital, so when I came into see Ms King she was at her ‘baseline.’I opened the door to bed 24 and a grinning little white-haired lady peered at me from over her sheet. “Hi,” she said greeting me first.“Hi, Ms King,” I smiled back at her and picked up her hand.

She reached over with her free hand to pat me on my forearm, “You sure are a cute little doctor,” she said smiling.

I couldn’t hold back a little laughter. “Well, you sure are a cute patient too,” I smiled and winked at her.

She winked back at me.

“Wow, this is the most pleasant 90-year-old I have cared for in a while,” I thought to myself.

As we chatted it became clear to me that she had some mild dementia but had no pain or complaints at the time. She just said, “I think I had a ‘spell’” ( a “Southernism” for some type of unusual and undefined episode of feeling ill or fainting); and “I’m not hungry” when I offered her food.

Leaving her room still smiling after our pleasant exchange, I went back to look at her medical record from the nursing home and two things immediately struck me:

What happens when physician pay is tied to efficiency & quality?

What would it be like if you were paid for your success?

What would it be like if you were rewarded for high efficiency?

Is it possible that successful patient outcomes could be correlated to compensation?

How would one measure non-compliant patients, or those with poor prognoses?

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Medicare moves to tie doctors’ pay to quality and cost of care

By Jordan Rau, jrau@kff.org Published: April 14

CMS plans to base the 2015 bonuses or penalties on what happens to a doctor's patients during 2013.

Twenty-thousand physicians in four Midwest states received a glimpse into their financial future last month. Landing in their e-mail inboxes were links to reports from Medicare showing the amount their patients cost on average as well as the quality of the care they provided. The reports also showed how Medicare spending on each doctor’s patients compared with their peers in Kansas, Iowa, Missouri and Nebraska.

The “resource use” reports, which Medicare plans to eventually provide to doctors nationwide, are one of the most visible phases of the government’s effort to figure out how to enact a complex, delicate and little-noticed provision of the 2010 health-care law: paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare’s costs without better results.

Making providers routinely pay attention to cost and quality is widely viewed as crucial if the country is going to rein in its health-care spending, which amounts to more than $2.5 trillion a year. It’s also key to keeping Medicare solvent. Efforts have begun to change the way Medicare pays hospitals, doctors and other providers who agree to work together in new alliances known as “accountable care organizations.” This fall, the federal health program for 47 million seniors and disabled people also is adjusting hospital payments based on quality of care, and it plans to take cost into account as early as next year.

But applying these same precepts to doctors is