FAQ: Medicare Lays Out Plans For Changing Doctors’ Pay

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Federal officials have unveiled their roadmap to a revamped Medicare physician payment system designed to reward doctors and other clinicians for the quality of care delivered, rather than the quantity.

The proposed regulation would replace a patchwork of programs that now govern physician payments in Medicaid. It would allow doctors to choose from a new menu of measures and activities that officials said would be tailored to the type of care clinicians provide in Medicare’s traditional fee-for-service program.

“By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care and give them the opportunity to participate in a way that is best for them, their practice and their patients,” said Patrick Conway, acting principal deputy administrator and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), the federal agency that is implementing the new physician payment program.

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Currently doctors are paid for things like tests, treatments and other procedures, but not necessarily for spending time with patients to learn more about their health or develop a treatment plan. Officials say the new payment program will change that.

With wide bipartisan support, Congress last year voted to scrap the existing Medicare physician payment formula and transition to a new system focused on quality, value and accountability. Here are some questions and answers about the newest phase of this effort.

Q: What is the government offering?

A: The proposed regulation would create two new payment systems. One, called the “merit-based incentive payment system,” or MIPS for short, would evaluate the value and quality of care on four performance categories: cost, quality, how doctors use electronic health record technology in their daily practice and share that information with other providers, and activities that improve care, such as care coordination or how much beneficiaries are engaged in their care. That composite score is used to determine a positive, negative or no adjustment to a provider’s Medicare Part B payment for a medical service.

The second system for doctors sets payments through “advanced alternative payment models” or advanced APMs. Under these models, clinicians accept more risk — and could also make more money — for providing coordinated, high-quality care, according to CMS. Examples include efforts to create a centralized “medical home” in which a team of health professionals provide coordinated care to improve patients’ health, and newer models of accountable care organizations in which doctors, hospitals and other health care providers form networks that work together to help improve the quality and reduce the spending for patient care.

CMS officials expect that most Medicare clinicians will initially participate in the MIPS program but over time will move more toward the alternative payment models.

Q: Who will get paid this way?

A: Most doctors that treat patients in the traditional Medicare program, as well as other clinicians, such as physicians assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, that also provide care to Medicare beneficiaries, will be paid under either the MIPS or advanced APMs system. Clinicians can be exempted from MIPS if they are new to Medicare, have less than $10,000 in Medicare charges or see 100 or fewer Medicare patients or are “significantly participating” in an advanced APM.

Q: Why is this happening now?

A: As part of legislation Congress passed last year to overhaul the Medicare physician payment system, CMS had to publish a plan by May 1 that detailed how it would measure physician quality under the new system. Doctors and other interest groups can now comment on the proposal until June 26, and CMS is expected to issue a final rule this fall.

Q: What happens next?

A: Under the law setting up the changes in payment, physicians will receive a fee increase of 0.5 percent per year between 2016 and 2019 as the new system is developed and put into place. In 2017, Medicare will begin measuring performance for doctors and other clinicians for the MIPS program, with payments based on those measures beginning in 2019. Under that system, payments generally won’t increase or drop by more than 4 percent, rising gradually to 9 percent from 2022 and beyond. Doctors can earn additional bonuses for exceptional performance.

Practitioners who pursue APMs would qualify for a 5 percent Medicare Part B incentive payment for the years 2019 through 2024.

Q: Does this mean that Medicare beneficiaries will pay more to see their doctors?

A: No. Medicare Part B premiums, which cover visits to a physician and other outpatient services, are set by law and adjusted yearly. Once the Part B deductible is met, beneficiaries usually cover 20 percent of the amount Medicare pays, or purchase a supplemental policy that can pick up much of that cost.

Q. How did the doctor payment formula become an issue?

A: The prior physician payment system, which was called the sustainable growth rate or SGR, was created in a 1997 deficit reduction law, a broader legislative effort to control federal spending. For the first few years, Medicare expenditures did not exceed the target in that law and doctors received modest pay increases. But in 2002, doctors were furious when their payments were reduced by 4.8 percent. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size of the fix needed the next time. Last year, lawmakers finally agreed to cut a deal for repeal and move on.

Q: What’s been the reaction to the new physician payment proposal?

A: Doctor and physician groups appear to be on board so far and a few lawmakers in both parties also have expressed support. All pledge to continue to monitor the process.

In a statement, the president of the American Medical Association, Dr. Steven J. Stack, said the group’s “initial review suggests that CMS has been listening to physicians’ concerns” in particular by modifying federal rules concerning physicians and electronic health records and reducing burdens on quality reporting. The new system, Stack said, “needs to be relevant to the real-world practice of medicine and establish meaningful links between payments and the quality of patient care, while reducing red tape.”

Robert Berenson, a fellow at the Urban Institute, said a key question for the law is “have they set it up so small practices can actually stay in business and report so they don’t have to throw in the towel and get hired by somebody because the reporting burden is too great?” Berenson, who has been critical of the new Medicare physician payment law, is a member of a technical advisory committee created in the law to evaluate its implementation.

Paul B. Ginsburg, who serves as director of the Center for Health Policy at the Brookings Institution and is also director of public policy at the Schaeffer Center at the University of Southern California, said the proposed rule gives physicians a lot of flexibility in choosing how they are rated under the MIPS program but is more restrictive on what qualifies as an APM.

Payment increases under either system may not be generous enough to keep up with other costs, such as increases in practice expenses. “This is better than a 20 percent cut (under the old system) but in a sense it means that the very severe constraint on physician payment is going to continue for some time,” he said.

Q: Where can I read more about this new plan?

A: CMS has published a web page, a fact sheet and a video to explain the proposal.

HHS Acts To Help More Ex-Inmates Get Medicaid

Administration officials moved Thursday to improve low Medicaid enrollment for emerging prisoners, urging states to start signups before release and expand eligibility to thousands of former inmates in halfway houses near the end of their sentences.

Health coverage for ex-inmates “is critical to our goal of reducing recidivism and promoting the public health,” said Richard Frank, assistant secretary for planning for the Department of Health and Human Services.

Advocates praised the changes but cautioned that HHS and states are still far from ensuring that most people leaving prisons and jails are put on Medicaid and get access to treatment.

“It’s highly variable. Some states and jurisdictions are having a lot of success” enrolling ex-prisoners, said Kamala Mallik-Kane, a researcher at the Urban Institute who has studied the process. “Others of them have initiatives in place that aren’t reaching the kinds of numbers that are making a dent.”

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The 2010 health law made nearly all ex-prisoners eligible for Medicaid in states that chose to expand the state and federal insurance program for the poor. Many welcomed the chance to cover a group with high rates of chronic disease, mental illness and substance abuse problems.

But prisons and jails, burdened with ineffective computers, understaffing and complicated Medicaid enrollment procedures, have been slow to sign up released inmates.

Federal and state prisons let out more than 600,000 people a year. Millions more cycle through jails. But a study published in Health Affairs found prisons and jails nationwide enrolled only 112,520 emerging inmates between late 2013 up to January 2015.

In Maryland, often cited for progressive social policy, the prison system is enrolling fewer than one in 10 released inmates, Kaiser Health News reported this week.

Much of HHS’ guidance repeats existing policy, reminding states that those on probation or parole are eligible for Medicaid and urging states to keep prisoners’ names in the Medicaid computers while they’re locked up. (That eases re-enrollment.)

Inmates are generally ineligible for Medicaid while incarcerated. Prison and jail medical systems care for them.

HHS is “providing encouragement and a nudge” to states to improve sign-ups as well as money to upgrade enrollment computers, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied ex-inmate enrollment. “They understand that this is a technology issue.”

Making up to 96,000 halfway-house inmates eligible for Medicaid is new policy, designed to connect people with care before they’re fully released. Prisoners often move to halfway houses or home detention near the end of their terms, closely supervised but frequently allowed to shop, apply for jobs and see a doctor.

Under the new policy, “if you have a fair amount of freedom of movement” in a halfway house, “you’re not considered an inmate” for Medicaid purposes, said Sarah Somers, an attorney for the National Health Law Program, an advocacy group. “That will be very helpful for a lot of people who are trying to transition out of incarceration.”

Nathan Sharpe recently spent two months in a home detention program in West Baltimore between leaving prison and being fully released. He wanted to get a checkup to make sure there was no lasting damage from a stabbing he received last summer in Maryland’s Jessup Correctional Institution.

But he had to wait until home detention ended last week to be covered by Medicaid, he said.

“That helps a lot” if people like him could get on Medicaid after they first leave prison, he said. “People can get the health care they need sooner. I’ve been out a week now and I still haven’t been able to see a doctor because I don’t have my card.”

Ex-inmates have extremely high rates of HIV and hepatitis C infection, diabetes, mental illness and substance abuse problems. They are especially vulnerable after they leave the prison medical system and before they connect with community doctors.

One study in Washington state showed that ex-inmates were a dozen times more likely to die than the general population in the first two weeks after their release.

Immediate Medicaid coverage “can mean the difference between life in the community and recidivism and even life and death,” Michael Botticelli, the White House’s director of national drug control policy, told reporters.

HHS has been urging states to enroll ex-inmates in Medicaid for years. But the Affordable Care Act’s Medicaid expansion made many more of them eligible for coverage, giving policymakers a new reason to promote sign-ups, advocates said.

So far 31 states and the District of Columbia have expanded Medicaid under the law.

Even As Birth Rates Fall, Teens Say They Are Getting Less Sex Education

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Teenage girls are catching up to teenage boys in one way that does no one any good: lack of sex education, according to a recent report.

The proportion of teenage girls between the ages of 15 and 19 who were taught about birth control methods declined from 70 to 60 percent over two time periods, from 2006-2010 and 2011-2013, the analysis of federal data found. Meanwhile, the percentage of teenage boys in the same age group who were taught about birth control also declined, from 61 to 55 percent.

“Historically there’s been a disparity between men and women in the receipt of sex education,” said Isaac Maddow-Zimet, a coauthor of the study and a research associate at the Guttmacher Institute, a reproductive health research and advocacy group. “It’s now narrowing, but in the worst way.”

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The study, which was published online in the Journal of Adolescent Health in March, analyzed responses during the two time periods from the Centers for Disease Control and Prevention’s National Survey for Family Growth, a continuous national household survey of women and men between the ages of 15 and 44.

In addition to questions about birth control methods, the study asked teens whether they had received formal instruction at their schools, churches, community centers or elsewhere about sexually transmitted diseases (STDs), how to say no to sex or how to prevent HIV/AIDS.

A rear view image of a high school classroom with teenagers learning science and chemistry.

Overall, 43 percent of teenage girls and 57 percent of teenage boys said in the most recent time frame that they hadn’t received any information about birth control before they had sex for the first time.

The proportion of young women who said they had been taught about how to say no to sex declined from 89 to 82 percent over the two study periods. For young men, the proportion remained essentially unchanged, inching up to 84 from 82 percent.

There were slight declines in the proportions of young women and men who said they had been taught about STDs and HIV/AIDS, but the responses were above 85 percent during both study periods for both sexes.

Teens talked with their parents to varying degrees about birth control and STDs. However, 22 percent of young women and 30 percent of young men said they didn’t talk with their parents about any of the topics.

The study also notes that the decline in formal education about birth control occurred even though the federal government spending has increased for teen pregnancy prevention programs.

Despite the lack of formal teaching, teenage pregnancy rates have declined for more than two decades and are now at historic lows. Racial disparities remain, however, and few teens use highly effective long-acting contraceptives such as intrauterine devices or hormonal implants.

“Even though the teen pregnancy rate is declining, it might decline faster if teens were getting sex education,” Maddow-Zimet said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Pregnant Women In Houston And Their Doctors Weigh Risks Of Zika

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As summer approaches, anxiety about Zika is growing in states like Florida and Texas. The virus hasn’t spread to mosquitoes along the Gulf Coast, and it may not, but experts are preparing nonetheless.

And because Zika can cause birth defects in newborns, many women — and their doctors — are nervous. In the waiting room at Houston IVF, patients are handed a map of Zika-affected countries and asked to fill out a questionnaire.

“The first thing I’m discussing now is Zika,” said Dr. Jamie Nodler.

Public health officials said there have been 15 travel-related incidences of Zika in the Houston area. Nodler said at least a few couples have had to delay starting fertility treatment because the woman or her partner already may have been exposed to the virus while traveling south.

This map shows the predicted distribution of Aedis aegypti, the mosquito that can carry the Zika virus. The redder the area, likelier you are to find A. aegypti there. (Courtesy Kraemer et al., eLife)

“Especially in Houston a lot of our patients and families are in the oil and gas industry,” Nodler said. “These aren’t people who are traveling to Mexico and Puerto Rico for fun or vacation. These are people who have to work in some of these offshore drilling areas.”

Even for patients who haven’t traveled, Nodler is advising they slather on repellant, just in case the virus is already here, but we don’t know it yet.

“No one wants to see an affected child,” he said.

Nodler says couples will need to manage Zika risk together. If his partner is already pregnant, a man should use condoms to avoid sexually transmitting the virus.

All over the city, parents and would-be parents have been absorbing the news about Zika.

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“They’ve been saying Zika is coming to Houston, they don’t know when,” said Annie Tursi. She’s 35, owns four hair salons and her husband is a consultant. She said they were going to try for a third baby in 2016, but now they’re going to watch and wait.

“I think we’re really blessed to have two healthy boys, and if it does come this summer and it is a risk, then I probably just won’t even try for another one.”

Between their jobs and the toddler and the baby, there’s no way she can simply hunker inside all summer avoiding mosquitoes.

“Right now there’s just so many unknowns and I think by the time they have a vaccine and know more that we’ll be done” with having children, she said, chuckling. “We’ll be out of diapers and we’ll be done.”

Because of concerns about Zika, Annie Tursi and her husband Brian are rethinking plans to try for a third child in 2016. Here with Oliver (2) and Arthur (6 months). (Courtesy Annie Tursi)

Because of concerns about Zika, Annie Tursi and her husband Brian are rethinking plans to try for a third child in 2016. Here with Oliver (2) and Arthur (6 months). (Courtesy Annie Tursi)

Another Houston mom, Tracy Smith, couldn’t make that choice. She was already pregnant with twins when she heard about Zika. At a recent check-up, she learned she still had to be cautious even though her first trimester was over.

“She said it’s something to be concerned about your whole pregnancy you need to be in long sleeves, and long pants, wearing DEET,” said Smith, who was shocked to get that advice.

“My first thought was ‘I’m pregnant, I’m not going to put DEET all over myself!’ But I guess that’s what we do this summer,” she said.

She’s now wondering if she and her two other kids should move to her parent’s house for the summer, in a less buggy part of Houston.

“The probability is low,” that she’ll contract Zika, she said, “But the potential impact is so great and those are the kinds of threats that can be scary and disproportionately sort of taking up space in my brain.”

Health officials say because U.S. cities have a lot of closed spaces with air conditioning or screens, people are generally better shielded from mosquitoes than in some other countries.

Nonetheless, doctors in Houston have already opened a special clinic where women who have traveled to affected countries can get blood tests and counseling. A second clinic will open this summer.

Dr. Kjersti Aagaard, a professor at Baylor College of Medicine, said doctors are offering those clinic patients an ultrasound 15 weeks into pregnancy.

“We’ve actually developed a protocol around looking for very special views of the fetal brain and the eyes to look at for any evidence of fetal malformation with the Zika.”

Dr. Kjersti Aagaard, an associate professor of obstetrics and gynecology at Baylor College of Medicine, is helping screen pregnant women in Houston who may have been exposed to Zika through travel or a partner who has traveled to affected areas. (Courtesy Baylor College of Medicine)

Dr. Kjersti Aagaard, an associate professor of obstetrics and gynecology at Baylor College of Medicine, is helping screen pregnant women in Houston who may have been exposed to Zika through travel or a partner who has traveled to affected areas. (Courtesy Baylor College of Medicine)

Aagaard reminds her patients that Zika is just one of many possible risks during pregnancy — and risks can be managed, whether that’s through prenatal vitamins, genetic screening, or bug spray.

Zika is tough to talk about, though, because the studies are just not there yet.

“As much as we wish we could give them a very set of clear facts around: this is your risk, this is the time in pregnancy you’re at highest risk, or this is the time prior to planning a pregnancy you’re at highest risk. We simply don’t have that information,” she said. “We don’t know.”

Despite the unknowns, doctors in Houston aren’t telling people not to get pregnant.

What they are telling them is that they need to add mosquito bites to the list of cares and calculations that surround any pregnancy.

This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.

Democrats Increasingly Want Expansion Of Health Law, Poll Finds

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When Democrats fault the Affordable Care Act, it’s increasingly because it does not go far enough, a poll released Thursday shows.

The results come as Democratic presidential candidate Bernie Sanders has repeatedly derided the law for including too many concessions to the private health care industry and costing consumers too much.

The Kaiser Family Foundation poll found that 51 percent of Democrats want to expand the law, a 15 point increase since December. (KHN is an editorially independent program of the foundation.)

“This increase may be due to the rhetoric surrounding universal health care in the Democratic presidential campaign, with both candidates advocating universal coverage as a goal,” the pollsters wrote.

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This month overall disapproval for the law continued to climb, growing to 49 percent of the public while support for the law decreased to 38 percent. Views about the law have seesawed since it was passed in 2010, but opponents have outnumbered supporters consistently since last fall.

Democratic support for the law slightly slipped this month, and now a quarter of party members hold an unfavorable view. Among those, four in 10 want to expand what the law does and almost three in 10 want to scale it back or repeal it entirely. The pollsters did not ask specifically how people would like the law to be expanded.

The law remains unpopular with three-quarters of Republicans, while independents are split.

The poll found that voters of all persuasions view the economy and jobs as the most important issue in the presidential election, with 30 percent saying they would like the presidential candidates to discuss those topics. National security was the next subject the public identified as important, followed by immigration and border control and then health care, which 15 percent of voters wanted candidates to talk about.

The poll was conducted among 1,201 people from April 12 through 19. The margin of error is +/- 3 percentage points. The poll respondents included 379 Democrats; answers from them had a margin of error of +/- 6 percentage points.

Counterfeit Opioid Poisonings Spread To Bay Area

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An outbreak of poisonings linked to a counterfeit prescription painkiller — previously seen in the Sacramento region — has reached the Bay Area, according to the U.S. Centers for Disease Control.

The CDC reported Tuesday that seven patients were treated for overdoses in Bay Area hospitals in late March and early April after taking what they thought were tablets of Norco, a brand-name painkiller that combines acetaminophen and hydrocodone.

Photo of four counterfeit Norco “M367” tablets obtained from patient 6 during the investigation of a counterfeit Norco poisoning outbreak — San Francisco and Bay Area, California, 2016 (California Poison Control System, San Francisco Division)

But the counterfeit Norco, which the patients bought off the street, mostly contained the opiate fentanyl, which is 100 times more powerful than morphine, according to the CDC.

In addition to the fentanyl, the pills contained promethazine, an allergy drug that’s believed to intensify the effects of fentanyl.

None of the patients died, but they suffered nausea, vomiting, breathing problems, lethargy and unconsciousness. Some needed treatment with naloxone, an antidote medication that can reverse the effects of an opioid overdose.

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Sacramento County health officials in late March reported at least 36 overdoses related to similar counterfeit Norco tablets laced with fentanyl. Nine of those 36 patients died.

Since then, another 16 overdoses, three fatal, have been reported in the county.

The California Poison Control System has been on alert for new cases but has not received any reports of counterfeit Norco overdoses elsewhere in the state, said Stuart Heard, the system’s executive director and a clinical professor at the University of California-San Francisco School of Pharmacy. Some of the pills analyzed by experts contained as much as 3.5 milligrams of fentanyl, a potentially lethal dose, he said.

“The only safe prescription to take is prescribed to you by your doctor and received from a legitimate pharmacy – not from a coworker, a friend or off the street,” said Casey Rettig, a spokeswoman for the Drug Enforcement Administration’s San Francisco division, which is investigating the counterfeit Norco.

Drug enforcement and health officials are increasingly concerned about fentanyl making its way into counterfeit versions of common prescription drugs.

Last year in California, seven people took fentanyl-contaminated counterfeit Xanax, an anti-anxiety drug; two of them died, according to the CDC. The addition of the booster promethazine — seen in the Bay Area but not Sacramento overdose cases — additionally worries public health officials, because it strengthens the effects of already powerful fentanyl.

The recent Bay Area cases may strengthen the arguments of some California lawmakers trying to pass a bill, SB 1323, which would increase prison sentences and fines for major traffickers of fentanyl. The bill remains in committee.

To aid its investigation, the DEA’s San Francisco division recently set up an anonymous tip line at 530-722-7577.

“Fentanyl is available, it’s relatively cheap, a little goes a long way and it’s very profitable,” the DEA’s Rettig said. She said could not comment on the progress of the DEA’s investigation. But typically, she said, fentanyl is purchased from China, shipped to Mexico and transported into the United States across its southwest border.

At some point in Mexico or in the U.S., the fentanyl is processed into counterfeit tablets that carry the markings of legitimate prescription medications, including hydrocodone drugs like Norco, Rettig said.

“Why these manufacturers are making it so potent and doing in their own customers is very puzzling,” Heard said. “To me, it speaks to amateurs doing this, or people who just don’t care.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

Medi-Cal AIDS Program Is Underfunded, Advocates Say

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VAN NUYS, Calif. — Andy Martin’s body had rejected another HIV medication, and now his viral load was spiking.

Sitting in his living room, Martin told a nurse and a social worker that he’d recently spent three days in the hospital with a high fever. The social worker, Scott Blackburn, told him that if his viral load didn’t drop, he could end up there again.

“The most important thing, regardless of what treatment regimen you are on, is that you are under a doctor’s care,” Blackburn said. “I just want to make sure there are eyes on you.”

The visits to Martin, 61, are part of a Medi-Cal program designed to help HIV and AIDS patients avoid costly hospitalizations and nursing home stays. Medi-Cal is California’s version of Medicaid, the federal-state program that provides health coverage for people with low incomes.

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In Medi-Cal’s HIV-AIDS program, the state pays for a range of services, including case management, nursing, caregiving, therapy, transportation and home-delivered meals.

But the agencies that provide services under the $12 million program say it’s getting harder to do so, because funding has remained largely stagnant for 15 years. That has led some providers to stop or reduce their participation.

The program, known as the AIDS Medi-Cal Waiver, started in 1989. Through a temporary but renewable waiver, the federal government allows the state to pay for services that would not otherwise be covered by Medicaid dollars.

To qualify, AIDS or HIV patients must have incomes low enough to receive Medi-Cal and be at risk of being placed in a nursing home. The participants do not pay for the services.

The number of participants statewide is just under 1,400 — a 40 percent drop since 2008, according to state data. Also since then, the number of agencies providing services has declined from 44 to about two dozen.

About 137,000 people are living with HIV, the virus that causes AIDS, in California. More than 5,000 Californians were diagnosed in 2014, according to the Centers for Disease Control and Prevention.

Andy Martin, 61, is part of a Medi-Cal program designed to help HIV and AIDS patients avoid costly hospitalizations and nursing home stays. (Heidi de Marco/KHN)

HIV providers in California simply can’t meet the demand with the payments they receive from the Medi-Cal program, and many fragile patients aren’t getting the services they need, said Scott Singer, director of behavioral health for AIDS Project Los Angeles.

“If more money doesn’t come through, more programs are going to end up closing their doors,” he said. “Hospitalizations are going to go up and that is going to cost the state more money.”

Assembly member Mike Gipson (D-Carson) introduced a bill last year that would have increased funding, but his proposal didn’t make it out of the special session on healthcare, said legislative director Jay Jefferson.

Now, Gipson is working with a coalition of HIV providers throughout the state to seek a nearly $5 million increase for the program in the governor’s budget, Jefferson said.

The AIDS Medi-Cal Waiver has lower payment rates than similar Medi-Cal programs serving other vulnerable populations, Jefferson said. “This is a crucial program and it’s clear it is underfunded,” he said. “We just want some parity with other programs so it is sustainable.”

State officials acknowledge that the number of agencies and participants has decreased but they aren’t convinced it’s because of reimbursement rates, said Rebecca Schupp, chief of the long-term care division of the Department of Health Care Services.

The agency is researching the issue but said HIV and AIDS patients may be receiving services through other Medi-Cal programs.

Schupp said any changes to the program before 2017, when the current waiver expires, are unlikely. The state plans to submit an application this summer to renew the program in 2017. Schupp said she hopes to see more people enrolled and more services available for HIV patients who are homeless or have substance abuse disorders.

Singer, of AIDS Project Los Angeles, said that while fewer HIV and AIDS patients are dying than in the past, the program is still critical. Many of the participants are dealing with the complications of living with the disease for decades. Some also have other chronic illnesses such as heart disease, high blood pressure and diabetes.


    Caregiver Darrell Mitchell and Andy Martin get ready to go to the laundromat on April 12, 2016. Mitchell visits Martin twice a week to help with him daily chores as part of the AIDS Medi-Cal Waiver program. (Heidi de Marco/KHN)


    Caregiver Darrell Mitchell helps Andy Martin with his laundry at a local laundromat in Van Nuys, California, on April 12, 2016. “I help with anything he needs done that day,” Mitchell said. (Heidi de Marco/KHN)


    Darrell Mitchell and Andy Martin walk across the street to have breakfast while they wait for Martin’s laundry. (Heidi de Marco/KHN)


    Andy Martin, 61, and his caregiver, Darrell Mitchell, wait for their breakfast. Mitchell has been Martin’s caregiver for eight years. “He helped me learn to walk again,” said Martin. (Heidi de Marco/KHN)

    Martin was diagnosed with HIV in the late 1980s. He was first enrolled in the AIDS Medi-Cal Waiver program after being hospitalized with kidney failure. He was bedridden for years.

    Through the program, Martin got an in-home caregiver, Darrell Mitchell, who helped him learn how to walk again. “We would walk down the street just a little ways, then I would rest,” he said. “Darrell was right by my side.”

    Mitchell continues to help Martin with cleaning, laundry and getting to appointments — “all the things I can’t do,” he said.

    Miller said he credits the program with helping him recover physically and emotionally. “I’m so glad they came into my life,” he said. “At that point, I had lost so much. … I really didn’t know why I was being allowed to live again.”

    The program also helped Martin get subsidized housing and appointments with a therapist.

    And Blackburn, the social worker, and Jeannie Acdan, a nurse, regularly visit to make sure he is taking his medications and that he has the social and medical support he needs to stay well.

    Acdan said she has been visiting Martin for about 10 years now.

    “We have gone through a rollercoaster together, but we are still here,” she said.

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    Three Hospitals Hope To Spark A Reduction In Surgeries By Inexperienced Doctors

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    After James Happli of Mosinee, Wisconsin, was diagnosed with pancreatic cancer, he was referred to a surgeon at a local hospital where he had been treated for lymphoma 28 years earlier. The surgeon told Happli and his wife that although she had never successfully performed a Whipple procedure — the pancreatic cancer operation widely regarded as among the most difficult in surgery — she believed she could do it with the help of a second surgeon.

    But Happli’s operation had to be aborted after it proved too difficult. Several months later, the pipe fitter, now 58, traveled to Froedtert Hospital in Milwaukee, 175 miles from his home. His operation, one of 127 Whipples done at Froedtert last year, was performed successfully by chief surgeon Douglas B. Evans.

    The procedure involves removing part of the pancreas and small intestine as well as the gallbladder, and reconnecting the digestive organs. It proved to be particularly complicated in Happli’s case, Evans said, because of tissue damage caused by radiation treatment for his lymphoma.

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    “If this patient is not getting referred [to a specialist], then who is?” asked Evans, who said he has seen a recent uptick in patients treated unsuccessfully by inexperienced surgeons at smaller hospitals.

    The largely unfettered ability of surgeons with minimal expertise to perform high-risk procedures — particularly at hospitals that lack experience caring for significant numbers of patients — has been the subject of a contentious, long-running battle known as the volume-outcome debate.

    A groundbreaking 1979 Stanford study found that patients who underwent operations at hospitals that did more of those surgeries had significantly lower death rates than those treated at hospitals where they were done infrequently. That finding has since been replicated repeatedly across many specialties and found to apply to surgeons as well as hospitals. Last month, a large study found that the risk of complications was far higher among surgeons who performed only one thyroid removal annually than among those who did 25 or more of the tricky procedures per year.

    Recently the volume battle was reignited when a trio of prominent health systems — Johns Hopkins, Dartmouth-Hitchcock and the University of Michigan — pledged that they will require their surgeons and 20 affiliated hospitals to meet minimum annual thresholds for 10 high-risk procedures. The three systems have asked other hospital networks around the country to join them.

    Under the terms of the volume pledge, believed to be the first of its kind, surgeons must perform at least five pancreatic cancer surgeries annually in hospitals where 20 such operations are done each year. For knee or hip replacements, the requirement is 25 per surgeon and 50 per hospital. There are provisions for emergency surgery and for surgeons who sometimes do not meet the threshold because they were on leave; such surgeons might be required to perform a certain number of procedures under supervision.

    “There is this intractableness of patients undergoing surgical care in places that have no business doing it” or performed by “hobbyists” — surgeons who infrequently perform risky surgeries, said John Birkmeyer, chief academic officer at Dartmouth. Birkmeyer devised the pledge with Peter Pronovost, an internationally known expert who directs the Armstrong Institute for Patient Safety and Quality at Johns Hopkins.

    At large teaching hospitals, Birkmeyer noted, “there are usually one or two or three surgeons who are recognized as go-to doctors” for certain procedures and do them frequently. “But there’s this tail of other surgeons who do only a few a year,” such as a shoulder surgeon who performs a handful of hip replacements or a breast cancer surgeon who occasionally attempts a Whipple.

    “We decided to use volume as a pilot case, an initial foray into setting quality and safety standards,” he said. “And we wanted to do it in a way” that was not subject to the discretion of hospital officials.

    Critical Information

    As smaller community hospitals affiliate with larger ones, the questions of which surgeons should do which procedures and where are increasingly confronting health systems. Hospitals of all sizes — both large academic centers and smaller community institutions — face a variety of sometimes competing incentives: to retain lucrative surgical cases and to avoid angering surgeons, who fiercely prize autonomy and wield considerable clout because they generate substantial revenue. And while hospitals formerly reaped a financial reward if patients suffered complications and had to be readmitted, they now face penalties under the Affordable Care Act.

    The Leapfrog Group, a nonprofit organization that represents large employers and purchasers of health care and seeks to advance patient safety, has focused on volume in its hospital rating system. “Volume is a really critical piece of information,” said the group’s chief executive officer, Leah Binder.

    “I think every medical staff should be grappling with these volume benchmarks,” she said, endorsing the pledge. “It’s fundamental.”

    Ashish K. Jha, a practicing internist and professor of health policy at Harvard’s T. H. Chan School of Public Health who has written about efforts to improve medical quality, calls the pledge “very reasonable.”

    Low-volume hospitals, he said, typically lack specialized teams to care for patients as well as state-of-the-art equipment and systems designed to prevent or quickly spot complications — critical factors in improving outcomes. “None of us care about volume; we care about outcomes, and volume is a surrogate” measure of outcomes, Jha noted. “Even though we’ve been talking about this for 35 years, a ton of high-risk surgery still happens among low-volume providers.”

    But surgeons’ groups and the president of the Joint Commission, the Chicago group that accredits the nation’s hospitals, have criticized the pledge as simplistic and overly prescriptive. Some officials say they fear it could unfairly penalize low-volume surgeons and smaller hospitals that have good outcomes.

    “There’s room to improve in low-volume and high-volume hospitals,” said Kevin Bozic, chairman of the department of surgery at the Dell Medical School at the University of Texas at Austin, who heads the committee on research and quality for the American Academy of Orthopaedic Surgeons. “There are high-volume, low-quality hospitals” as well as the converse.

    “I know Harvard may be better than McPherson, Kansas,” said Tyler Hughes, a surgeon at the 25-bed hospital in McPherson and a director of the American Board of Surgery. “But for many patients, the best possible surgery is closest to home.”

    Irate Surgeons

    Although patient-safety experts and some insurance companies have long encouraged patients, especially those with serious illnesses or complex diagnoses, to seek care from experienced specialists at high-volume hospitals, there is little to prevent doctors and hospitals from doing whichever surgeries (other than organ transplants) they see fit, no matter how rarely they do them.

    Many patients don’t know to ask a doctor about volume or outcomes or are unable to ferret out relevant information when choosing a surgeon or hospital. One reason, Leapfrog’s Binder said, is that much important information such as complication rates remains hidden. Hospitals report detailed data about surgical outcomes to registries for internal use, but the information is not publicly available.

    Kerry O’Connell, 59, a Denver construction executive, said that only after a botched elbow operation that required seven corrective surgeries did he learn that his was the second such procedure his orthopedist had performed. “I went to the one clinic where the ER sent me, and the surgeon seemed like a nice guy,” he said.

    “We don’t have enough transparency in health care,” Binder said. “It’s the first thing everyone wants to know: Who’s the best surgeon? And anyone in health care picks up the phone and asks their friends.”

    Recently, Binder notes, there have been new efforts to inform patients. In the past year, the journalism organization ProPublica and Consumer’s Checkbook have launched databases that rate surgeons. Since 1995 New York state has published some data on heart surgeons. And Consumer Reports and the federal government’s Hospital Compare website provide hospital-specific information.

    A report by Leapfrog found that in 2013, one-third of hospitals that performed procedures to remove all or part of the esophagus, a demanding surgery to treat cancer, did only one or two annually, far below the level needed to achieve proficiency. A CNN investigation of an extremely low-volume Florida heart surgery program launched in 2011 found that six babies died in a two-year period, far more than expected; the program has since closed. And a U.S. News analysis last year found that Medicare patients who had knee replacements at the lowest-volume hospitals in the country were 70 percent more likely to die than those whose surgery was performed at the highest-volume centers; for hip replacement, the figure was 50 percent.

    Disparities can be seen among hospitals in the same system, Birkmeyer noted.

    “One of our highest priorities is insuring consistent quality and safety” regardless of where a patient seeks treatment, he said. In the past decade, Dartmouth has grown from a single hospital in Hanover, New Hampshire, to eight in northern New England. Baltimore-based Hopkins has affiliated with smaller hospitals in Washington, D.C. and suburban Maryland.

    Among the most irate reactions Birkmeyer said he encountered came from about 10 surgeons affiliated with Dartmouth’s main hospital who were told they would no longer be allowed to do procedures for which they didn’t meet annual minimums. “They said things like, ‘I’ve been credentialed to do this for 20 years and I’ve never had a complication, and now you’re telling me I can’t do it?’ ”

    That anger and the months required to get the boards of hospitals and their executive committees to agree to the new rules may be among the reasons only three systems have signed on so far, Birkmeyer said. More than a dozen others have expressed interest.

    Some surgeons say that the focus on volume is misguided.

    The problem “is actually much more complicated than volume” said David Hoyt, executive director of the American College of Surgeons. Hoyt said that the group is drafting its own guidelines that will address volume.

    Beyond Numbers

    To Mark Chassin, president of the Joint Commission, the pledge misses the mark. “The surgeon’s contribution to the outcomes patients experience is only one component,” he said.

    “Volume should never be used by an accrediting organization as a measure of quality” because it is too imperfect a measure, Chassin added.

    Patients can help protect themselves, he added, by taking “as much responsibility and interest” as possible in their care.

    In the view of general surgeon Linda Halderman, doctors are the best judges of their abilities. “Every surgeon has to exercise judgment of their own capabilities” and know when to refer to a more experienced colleague, said Halderman, who is based in Selma, California.

    But Harvard’s Jha disagrees. Many surgeons, he said, tell him they “have excellent results and I’ll say, ‘How do you know? Do you actually track your outcomes?’ ” Most, he said, do not.

    Two months ago, Linus Linaweaver, 76, chose to undergo elective abdominal surgery in his home town of McPherson, Kansas, after robotic prostate surgery at a larger hospital in Wichita nearly killed him and left him with a colostomy.

    “I wanted to be back in our town,” he said, adding that he had confidence in Tyler Hughes, his surgeon, and McPherson Hospital. His seven-hour operation went well, and Linaweaver recently said he is “almost back to normal.”

    James Happli is back at work after a year’s medical leave. Following his failed Whipple surgery, the local surgeon proposed trying again. That offer was withdrawn after a second specialist refused to participate. At that point, Happli was referred to Evans in Milwaukee.

    If he had it to do over again, Happli said, “I would have gone to a bigger place” and a more experienced surgeon the first time.

    Will Covered California Sell Health Coverage To The Undocumented?

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    California legislators are attempting to clear the way for undocumented immigrants to buy health insurance through the state’s insurance exchange — potentially setting a national precedent.

    The fusion of illegal immigration and the Affordable Care Act, two of the most highly charged elements on the periodic table of U.S. politics, could engender a combustible reaction, especially in an election year.

    Immigrants living in the country illegally are excluded from the insurance-expanding provisions of Obamacare. They are not eligible for Medicaid (called Medi-Cal in California), and they are not allowed to purchase a health plan from the federal marketplace or any of the state exchanges.

    Without that provision, Congress would not have approved the health reform law to begin with.

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    This story can be republished for free (details).

    Now, however, some California families and advocates are pinning their hopes on a bill by state Sen. Ricardo Lara (D-Bell Gardens) that would open the door for undocumented immigrants to buy health plans from the Covered California exchange. Unlike most exchange customers, however, they would get no federal dollars to help them do so.

    That, many observers say, makes the proposal a largely symbolic gesture, since most undocumented immigrants would not be able to afford the premiums without financial assistance.

    Lara’s bill was approved by the Senate last year, and it will be taken up Tuesday by the Assembly’s Committee on Health.

    The bill faces a number of hurdles.

    It would not actually allow immigrants without papers to buy insurance through the state exchange. It would only request that the federal government exempt California from the rule that forbids such purchases. It’s the feds who make the call.

    If the feds were to greenlight the plan, Covered California would be the first exchange in the country to sell insurance to undocumented immigrants — a prospect that is not welcomed by critics of illegal immigration.

    There’s no apparent legal reason why the feds wouldn’t sign off on such a request, said Tim Jost, a professor emeritus of law at the Washington and Lee University in Virginia. But it could generate some significant political fireworks, especially in a presidential election year, he said.

    “I can almost guarantee in the right wing media, this would play a pretty big role,” he said. “This would become a case of ‘we told you so’ that Obamacare would help undocumented workers.”

    But Katherine Hempstead, a senior advisor at the Robert Wood Johnson Foundation, said the fact that no federal dollars would be involved makes it less of a hot button issue. “It’s just another distribution channel,” she said.

    Before Lara’s proposal even makes it to the federal level, it must first get through the legislature and past the desk of Gov. Jerry Brown.

    Some health policy experts believe the bill has a decent shot of getting through California’s political hierarchy.

    Shannon McConville, a research associate at the Public Policy Institute of California noted that while Gov. Brown has been fiscally conservative for the most part, he did sign a law — scheduled to take effect next month — that allows undocumented children to get full Medi-Cal benefits.

    “The [Lara] bill, at least in its current state, doesn’t have a large price tag, so it seems possible he’d approve it,” McConville said. “But you can never know for sure.”

    At the federal level, the Affordable Care Act provides for an “innovation waiver,” which allows states – with federal approval – to modify certain sections of the health reform law in order to expand coverage. Such changes must have no net impact on the U.S. budget, which is why federal subsidies are excluded from Lara’s bill.

    An analysis of the waiver proposal, presented by Covered California staff members to the exchange’s board earlier this month, estimated that enrollment would increase by about 50,000 if immigrants without papers could buy coverage through the exchange.

    Covered California’s executive director, Peter V. Lee, did not stake out a position on the plan, but he said exchange officials stood ready to assist the legislature in pursuing this option.

    “The ball is in their court,” Lee said.

    Although undocumented immigrants would not qualify for financial help under the proposal, they would still benefit from the considerable investment Covered California has made in infrastructure to inform and enroll consumers, McConville said.

    Some opponents of the plan think selling to immigrants without papers should not be a high priority for Covered California. “The state has failed on its commitment to health care providers and their patients, and my budget priority is to take care of them first before expanding the pool,” said state Sen. Joel Anderson (R-Alpine), who voted against the bill in the Senate last year.

    Others simply believe that neither the state nor the federal government should confer any benefits on people who are in the country illegally.

    Ira Mehlman, a spokesman with the Federation for American Immigration Reform, said that providing coverage to undocumented immigrants under the Affordable Care Act is tantamount to accepting their unlawful presence in the country.

    He predicted that if California is allowed to do it, states like Illinois and New York might follow.

    And, he argued, this is just the first step in eventually getting subsidized coverage.

    Without subsidies, it is uncertain whether many undocumented immigrants would actually buy Covered California plans.

    After all, they can already buy private plans through brokers or directly from insurers, but they are not rushing to do it, said Alex Hernandez, an insurance agent in Merced. “Cost is always what drives them away,” he said.

    The plans sold by Covered California carry very similar price tags.

    Hernandez calculated that a person in her mid-20s, making around $45,000 a year, would pay $304 per month for a standard Anthem-Blue Cross plan through Covered California. That same plan purchased directly from Anthem by the same person would cost $303.30, he said.

    Advocates for expanding health coverage concede that allowing people without papers to purchase it on the exchange won’t necessarily make it more affordable for them, but they say it would open the door to broader access and a sense of inclusion.

    People in mixed-status families — ones with some members who are in the country illegally and others who are legal residents or U.S. citizens — would benefit most, consumer advocates say. Data discussed at a Covered California meeting in February showed that 74 percent of households headed by undocumented immigrants have family members who are citizens.

    Proponents of the plan believe that if some family members already interact with Covered California or Medi-Cal, it could encourage others in their household to seek coverage.

    Opening the exchange to the undocumented, they say, would simplify enrollment for the entire family by creating a “one-stop shop” for all household members.

    “It’s a modest step forward, but important for the goal of health care for all,” said Anthony Wright, executive director of Health Access, a consumer advocacy group. He said supporters of the bill are fully aware that people will continue to face affordability issues, but there also thousands who may be able to afford it.

    Maria Galvan, an undocumented resident in San Fernando, California is not one of them. She does not think she would purchase coverage without subsidies. She knows how expensive it can be, even for small business owners like herself and her husband.

    Galvan, said she does not seek much preventive care. When she gets sick, she usually weathers it out with home remedies. If it gets serious, she goes straight to the emergency room at Olive View- UCLA Medical Center in Sylmar, her nearest hospital.

    “Maybe one day the system will improve for us,” Galvan said. “Maybe one day we will receive financial assistance.”

    This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

    High Court Ruling May Hinder Plans’ Efforts To Recoup Consumers’ Legal Awards

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    Accidents happen, and if they’re someone else’s fault, you can go to court to try to get compensation for your medical expenses, lost wages, and pain and suffering. If you win, though, the pot of gold you receive may be considerably smaller than you expect: Your health plan may claim some or all of it as reimbursement for money it spent on your medical care.

    It’s completely legal and it happens all the time. But a recent Supreme Court decision gives consumers ammunition to push back.

    The basic facts of the case are common. In December 2008, a drunk driver ran a stop sign and hit Robert Montanile, seriously injuring him. Montanile had lumbar spinal fusion surgery and other medical treatment that cost $121,044, which was paid for by his employer plan, the National Elevator Industry Health Benefit Plan. Montanile sued the drunk driver and won a settlement of $500,000. He paid his attorneys $263,788 in fees and expenses, leaving him $236,212.

    Montanile’s health plan claimed it was entitled to be reimbursed for his medical care.

    More from this series

    Contract provisions allowing most health plans to reimburse themselves if a member receives a personal injury settlement or jury award are routine and often assert that the plan should be first in line for settlement or award money. The notion is that if the person is permitted to keep the money paid on his behalf for medical expenses, he’s essentially getting his medical bills paid twice, once by the insurer and then again under the settlement.

    Montanile hired another lawyer to negotiate with the health plan, but when they reached an impasse, the lawyer informed the plan’s trustees that if he didn’t hear from them in two weeks, he would release the remaining settlement money to Montanile. When the plan didn’t respond, that’s what he did.

    The health plan later sued Montanile for the money, but he said he had spent nearly all of it to pay his second lawyer and care for himself and his daughter. Lower courts ruled that even though he spent the settlement funds, the plan was entitled to reimburse itself from Montanile’s general assets. The Supreme Court disagreed, ruling 8-1 in January that the health plan was entitled to take only the specific pot of money he received in the settlement or goods that could be traced to it.

    The case was remanded back to a lower court, and the plan may be able to recover some money from Montanile if it can trace assets to the settlement he received, said Radha Pathak, one of Montanile’s lawyers at Stris & Maher, the Los Angeles-based law firm that represented him in the appellate and Supreme Court cases.

    In the simplest sense, the case turned on a lapse in timing. If the health plan had responded to the letter sent by Montanile’s attorney within 14 days, it might have received the funds it was entitled to.

    “The clearest message is that if plans want to assert their rights, they need to do it promptly,” said Leslie Anderson, a partner in the Washington Resource Group at benefits consultant Mercer.

    But the case also has a significant impact on consumers, who are often fighting an uphill battle in these “subrogation and reimbursement” cases. The Supreme Court’s decision makes it clear that plans can’t seize an individual’s general assets to pay themselves back for medical expenses. It may also improve consumers’ odds of receiving a larger portion of their settlement or jury award by prompting the health plan to negotiate early.

    In these cases, problems sometimes arise when there’s not enough money to go around. The total — especially after paying legal bills — may not be large enough to cover the injured person’s medical bills as well as the amounts awarded for lost wages and pain and suffering. In those cases, health plans may claim all or a significant portion of the settlement, leaving the injured person who brought the lawsuit with nothing or much less than the amount awarded.

    Jason Lacey, a partner at Foulston Siefkin in Wichita, Kansas, who represents employers in subrogation cases, said he understands how the process may seem unfair to individuals who have taken on the task of going to court. “I took the time to go out and file this lawsuit, and you’re swooping in at last minute and feeding off my efforts,” is how they might feel, Lacey said.

    About half of the states have laws that limit or prohibit health plans from reimbursing themselves in subrogation cases until the consumer has received all that she was awarded, such as lost wages and pain and suffering. But those laws don’t apply to self-insured plans that pay health care claims directly rather than buying insurance — a process generally used by large businesses.

    Although the Supreme Court’s decision doesn’t alter the general landscape of these cases, it may encourage plans to sit down and negotiate with an injured worker sooner to agree on how to divvy up a settlement or jury award in a way that’s fair to both sides, said Matt Wessler, a principal at Gupta Wessler in Washington, D.C., who has represented workers in these types of cases.

    It can be hard for workers and their lawyers to learn whether a health plan intends to assert a lien and if so, for how much, Wessler said. Now, after the Montanile decision, it’s clearer that plans may lose the ability to recover any funds if they wait to share their intentions with the plan member. Armed with that information, workers and their lawyers can use the leverage that they may not pursue the money at all, if the health plan doesn’t come to the table to negotiate early in the process.

    If health plans don’t notify the worker or his lawyer early in the process that they have an interest in any potential award, “they risk the possibility that by the time they actually get something sorted out the money will be gone,” he said.

    Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.