Quality Tickler File

The AP reported:

U.S. Department of Health and Human Services' inspector general reported that between 40 and 65 percent of clinical studies of federally regulated medical products were done in other countries in 2008, and that proportion probably has grown. The report also noted that U.S. regulators inspected fewer than 1 percent of foreign clinical trial sites.

Trust, but don't verify.  How might this express in the next decade?

Texas Senate Bill 7's Surprises

"I mean, people have access to health care in America. After all, you just go to an emergency room."--President George W. Bush, July 2007

That's fixin' to change.  Texas Senate Bill 7 states on page 20:

...the executive commissioner of the Health and Human Services Commission shall adopt cost-sharing provisions that encourage personal accountability and appropriate utilization of health care services, including a cost-sharing provision applicable to [require] a recipient who chooses to receive a nonemergency [a high-cost] medical service [provided] through a hospital emergency room.

The ER will have to conduct a medical screening exam to determine the situation is not an emergency.  Clerical staff will intervene to collect the cost sharing.  How will the patient respond?   It could depend on why they presented to the ER in the first place.  Many Medicaid repeat hospital users have mental health diagnoses.

SB 7 plans to reward hospitals for good performance:

...the commission shall to the extent feasible adjust child health plan and Medicaid reimbursements to hospitals, including payments made under the disproportionate share hospitals and upper payment limit supplemental payment programs, in a manner that rewards or penalizes a hospital based on the hospital ’s performance in reducing potentially preventable readmissions and potentially preventable complications.

The Commission released its Potentially Preventable Readmissions Report for 2009 in 2011.  Hospitals will be rewarded or punished based on data well over a year old. 

The commission must provide the report required under Section 536.151(b) to a hospital at least one year before the commission adjusts child health plan and Medicaid reimbursements to the hospital under this section.

It appears there will be a two year gap, one to produce the report, followed by the required year wait.  How would B.F. Skinner's rat respond if the food pellet or shock came long after it pushed the bar?

There is a common caveat to the planned reward schemes.

The commission may implement financial incentives under this section only if implementing the incentives would not require additional state funding because the cost associated with th eimplementation would be offset by expected savings or additional federal funding.

They must save money or be funded from Washington, D.C.  

The commission may develop a quality-based payment system for health homes under this subchapter only if implementing the system would not require additional state funding because the costs associated with the implementation would be offset by expected savings or additional federal funding.

The bill is chock full of extrinsic motivators for providers:

the executive commissioner may approve efficiency performance standards that may include the sharing of realized cost savings with health care providers and facilities that provide health care services that exceed the efficiency performance standards. The efficiency performance standards may not create any financial incentive for or involve making a payment to a health care provider or facility that directly or indirectly induces the limitation of medically necessary services.

It's a shame health care providers need to be bribed.  I thought they had good work to do.

Nearly 200 Lose Health Insurance through City

One hundred and ninety two people no longer have health insurance through the City of San Angelo as of January 1, 2011.  The breakdown for those dropping coverage is:

130 employee dependents
37 employees
21 early retirees/dependents
4 "over 65" retirees

An additional ninety one employees chose to decrease coverage.  Most switched to the low plan, which carries high deductibles.

Health reform's pre-existing conditions coverage added 393 people to the coverage rolls.  COSA wiped out half of PPACA's statewide progress.  The irony is the City is an Early Retiree Reimbursement Program participant, qualifying on August 31, 2010.  The program is intended to keep health insurance affordable for early retirees.  Dependent premiums soared 34 to 58% in December.

It seems few local, state and national leaders are paying attention to the shifts.  When will it be too late?

San Angelo Going Backwards on the Uninsured

Texas added 393 people through PPACA's preexisting conditions coverage. The City of San Angelo dropped at least 122 previously insured people with premium increases. That wipes out 31% of the statewide gain.  Irony grows with San Angelo's approval for PPACA's Early Retiree Reinsurance Program (ERRP). 

When the city applied for federal health reform funds it stated on the application:

"Reimbursement through ERRP will allow the City 'to continue to provide the same quality of care without passing on additional costs to its participants.'"

Hardly...

A Tale of Two Countries

"It was the best of times.  It was the worst of times."  How might this apply to corporate profits?  Starting with the worst, note the AP's take on why tax proceeds are down (as a percent of GDP):

Corporate taxes will be lower by a third, according to projections by the nonpartisan Congressional Budget Office. The poor economy is largely to blame, with corporate profits down and unemployment up. But so is a tax code that grows each year with new deductions, credits and exemptions.

Contrast this with recent record corporate profits from 3rd quarter 2010. The fourth quarter looks even better.  The WSJ reported:

With about 50% of companies already reporting, fourth-quarter profits for the biggest U.S. corporations have been exceptionally strong and 2010 is poised to deliver the third-best full-year gain since 1998.

Marketplace gave this report:

Mergers and profits galore took markets higher today.

Why won't record profits galore turn into dollars for the U.S. Treasury?  Senator Kent Conrad gave his expert opinion:

"The current state of the tax code is simply indefensible. It is hemorrhaging revenue."

That happens to be 180 degrees from his comments as a member of Obama's Deficit Commission, made up of global corporatists. 

A second news story revealed more about America.  A record 111 million people watched the Super Bowl.  It beat last year's number of 106.5 million, which eclipsed the 105.9 million for the final episode of M.A.S.H.  A radio DJ asked why the Super Bowl beat M.A.S.H?  One answer, there are more Americans watching iin 2011 than in 1983.

2011--310 million, meaning 36% of the population tuned in.

1983--233 million, signifying 45% of Americans watched M.A.S.H

M.A.S.H beat the Super Bowl 45-36.  There was no need for overtime...

San Angelo's Muddy Health Benefit

San Angelo's Employee Health Clinic is intended to provide less expensive primary care than purchasing services from area providers.  The City's cost for 2010 was $553,493 for 5,400 patient visits.  That's $102.50 per visit.  The city budget called for spending $537,869 in 2011.

SACMC's proposal is to take care of 3,600 visits (5,400 -1800 uninsured dependents) for $475,000 per year, roughly $132 per visit.  On a per visit basis, this is a 30% increase.

Adding a midlevel provider brings the cost to $560,000 to $595,000 per year, roughly $104 to $110 per visit. SACMC wanted to charge a $100 visit fee for uninsured dependents.  Council specified the new uninsured fee be between $10 and $100 and left it to management to negotiate the amount. 

The base SACMC proposal is the most expensive on a per visit basis. It remains to be seen where fees land for uninsured dependents.  Will they be closer to $10 or $100?  Also, it's not clear what happens to clinic revenue, budgeted at $132,400 for 2011.  Does the City keep it or are the revenues assigned to SACMC?

Oddly, the City's July 7, 2010 Early Retiree Reinsurance Program (ERRP) application stated:

Reimbursement through ERRP will allow the City "to continue to provide the same quality of care without passing on additional costs to its participants." 

This statement wasn't true for 2011 health insurance premiums, nor for the City Health Clinic.  ERRP money will be banked until 2012.  That's not the only money that could be brought to bear, given forty five employees or retirees dropped health insurance for 2011. With the forty five gone, the City won't have to pay $357.53 per person per month.  That totals $193,000.

Even more dependents fell from the rolls, but a precise number is not yet available from City staff.  During December open enrollment sessions, HR staff handed out CHIP applications to workers.

The City's commitment "to provide the same quality of care without passing on additional costs" looks hollow.  Shifting risk to the individual or a tapped out Uncle Sam is a greater priority.

City of San Angelo Adds to Texas Uninsureds

Forty five San Angelo City workers, dependents and retirees joined America's legions of uninsureds as of January 1.  They couldn't shoulder massive premium increases, ranging from 34% to 58% for dependent coverage. 

The forty five join 6.2 million Texans or  25.6% of the population who have no health insurance coverage.  HealthCare.gov claims 393 Texans received coverage through the Preexisting Condition Insurance Plan. That addresses .00065% of the problem.  The City of San Angelo's forty five person drop negated 11% of HealthCare.gov's statewide improvement.

Irony grows with the City's approval for federal Early Retiree Reinsurance Program (ERRP) funding.  The City plans to bank ERRP reimbursement until December 31, 2011, before using the money to reduce premiums or increase benefits.  Checks from Uncle Sam will likely be smaller for 2011 given 44 early retirees canceled coverage, dropped dependents or decreased their plan level.  That's roughly 17% of the total covered, likely meaning less federal ERRP dollars for 2011.  

There will be much pain between now and 2014.  Texas' legions of uninsureds will stress safety net hospitals, forcing many to close or sell out on the cheap to their for-profit brethren.  As politicians offer little more than hot air, more people will be on their own.  Many will go without coverage and care.  It's predictable but rarely noted, much less reported.

Ty Meighan, Public Information Officer, provided the following data:

Active Employees:

722 = No Change
37 = Canceled Coverage All Together
12 = Added Dependents or Increased Plan Level
128 = Decreased Dependents or Decreased Plan Level
1 = Dropped Dependents & Increased Plan Level
900 total

165 or 18.3% canceled, decreased dependents or decreased plan level

Under 65 Retirees:

206 = No Change
4 = Canceled Coverage All Together
5 = Increased Plan Level
38 = Dropped Dependents or Decreased Plan Level
1 = Dropped Dependent and Increased Plan Level
254 total

42 or 16.5% canceled, decreased dependents or decreased plan level

Over 65 Retirees:

216 = No Change
4 = Canceled Coverage All Together
220 total

Update 2-5-11:  Uninsured city workers and retirees may have to pay up to $100 to be seen at the City's Employee Health Clinic.  They've paid $10 per visit in the past.  Council authorized management to negotiate a new fee, specifying it be between $10 and $100.  Open enrollment occurred in December, when employees did not have information on this change.  Mayor Alvin New didn't want to incentivize employees to be uninsured.  Did he fail to see how increasing dependent premiums 34 to 58% would do that very thing?  The drip of health care pain continues for many.