Not Enough Doctors In Medicaid, State Director Says

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Why The Response To A Philadelphia Abortion Doctor’s Ongoing Murder Trial Gets It All Wrong

A Philadelphia-area abortion doctor is currently on trial for murder, based on gruesome reports about the illegal techniques that he and his staff used to perform late-term abortions for desperate, low-income women. Dr. Kermit Gosnell’s high-profile case is sparking understandable outrage, as evidence has emerged that he may have taken advantage of vulnerable women, violated multiple medical codes, and performed inhumane surgeries.

According to prosecutors, Gosnell’s clinic went 17 years without an inspection — and abortion opponents are leveraging that to go after other abortion clinics that have no affiliation with Gosnell or his crimes. “Unfortunately and tragically in Pennsylvania, facilities were going uninspected for years,” Maria Gallagher, a lobbyist with the Pennsylvania Pro-Life Federation, said in reference to the ongoing trial. That’s a big reason why abortion opponents like Gallagher were able to push Pennsylvania legislators to tighten restrictions on abortion clinics in 2011, updating state law to require abortion clinics to adhere to the same standards as outpatient surgery centers. According to NPR, Gosnell’s case was “mentioned frequently” as Pennsylvania lawmakers considered, and ultimately approved, the unnecessary new restrictions.

If proven guilty, there’s no doubt that Gosnell and his staff committed horrific crimes. But the knee-jerk reaction to his murder trial — the assumption that most abortion doctors aren’t adhering to medical standards, and that the women who visit health clinics are in grave danger of receiving unsafe care — is off-base. In fact, as the right-wing pushes for tighter abortion clinic standards to make sure nothing like this ever happens again, that crusade could end up having exactly the opposite effect.

Pennsylvania’s abortion clinic restrictions fit into a larger anti-choice effort across the country that is solely intended to force abortion clinics to close their doors. In states like North Dakota, Virginia, Indiana, Mississippi, and Texas, abortion opponents are pushing legislation to force abortion clinics to adhere to unneccesary new regulations in the name of “ensuring women’s safety.” That sounds like a noble goal. But these measures — known as the Targeted Regulation of Abortion Providers, or TRAP — aren’t really about ensuring women’s safety at all. As Mississippi’s Republican governor once admitted behind closed doors at an anti-choice event, TRAP laws are about indirectly restricting women’s access to abortion by shutting down health clinics.

In Pennsylvania specifically, one Planned Parenthood affiliate was forced to spend nearly a half a million dollars to get two of its clinics into compliance with the new regulations. That involved unnecessary updates like installing hands-free sinks, replacing the floors, and updating the air-conditioning system. The affiliate’s CEO, Dayle Steinberg, explained to NPR that the state’s stricter requirements didn’t actually do anything to improve the care provided to the women at her clinics, where the complication rate is already less than one-tenth of 1 percent. “They were thinly disguised as improving patient safety, when really it was about increasing the cost for abortion providers — hoping that some of them wouldn’t be able to afford it,” Steinberg said.

In fact, it’s quite the opposite. Women’s health advocates consider TRAP measures to be some of the most dangerous threats to women’s access to safe abortion services across the country. In North Dakota, where anti-choice Republicans are advancing the most stringently anti-abortion legislation in the nation, one doctor warned lawmakers that the new TRAP law will force women into dangerous, “backroom” abortion procedures. Retired pediatrician Ted Kleiman worked at a hospital before Roe v. Wade legalized abortion in 1973, and he watched women die from botched abortions. “The thought of returning to those days is really beyond imagination,” Kleiman told his state lawmakers, urging them not to shut down the only abortion clinic left in North Dakota.

Women’s health advocates, particularly those who work at health clinics, are extremely concerned about ensuring that women receive the highest standards of reproductive care. But clinics that allow women to terminate a pregnancy in the first trimester of pregnancy — which involves taking a pill, and is not actually a surgical procedure — aren’t analogous to Gosnell’s clinic, which performed incredibly late-term, illegal abortion services. Over-regulating the clinics like Planned Parenthood’s, where the vast majority of patients are already receiving incredibly safe care, will actually limit women’s options instead of keeping them safe. That could lead more desperate women who feel like they don’t have any other options left to seek out doctors like Gosnell.

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A Doctor's Big Ideas For America

 Highlight transcript below to create clipTranscript:  Print  |  Email Go  Click text to jump within videoMon 25 Mar 13 | 07:00 PM ET Dr. Ben Carson, director of Johns Hopkins Pediatric Neurosurgery, discusses his future plans after retiring, and expands on the idea that the rich shouldn't be punished. Keith Boykin, CNBC Contributor and Jim Pethokoukis, American Enterprise Institute, weigh in.

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Insurers Limit Doctors, Hospitals In State-Run Exchange Plans

California's health insurance rates for a new state-run marketplace came in lower than expected this week, but one downside for many consumers will be far fewer doctors and hospitals to choose from.

People who want UCLA Medical Center and its doctors in their health plan network next year, for instance, may have only one choice in California's exchange: Anthem Blue Cross. Another major insurer in the state-run market, Blue Shield of California, said its exchange customers will be restricted to 36% of its regular physician network statewide.

And Cedars-Sinai Medical Center, one of Southern California's most prestigious and expensive hospitals, said it's not included in any exchange plans at the moment.

Those types of exclusive arrangements, increasingly tight networks and outright exclusions are becoming more common as insurers and government officials search for ways to hold down rising medical costs.

The vast majority of Californians get their health coverage through their employers and won't be immediately affected by these limitations in the state-run market. But private companies are pursuing similar changes to shave costs. More employers have been adopting these narrower networks and the government's overhaul of the individual insurance market is accelerating the trend.

Some consumer advocates express concern that insurers will go too far and deprive patients of meaningful choices. State officials sought to blunt that criticism this week, pointing out that the 13 health insurers selected will offer access to about 80% of California's practicing physicians and hospitals.

"If we want to keep costs down, something has to give," said Betsy Imholz, special projects director for Consumers Union. "At first blush, it seems like Covered California has negotiated some good deals, but in any given community we will see how this network issue plays out."

Covered California, the state agency implementing the federal healthcare law, said these trade-offs are necessary in many cases to keep premiums reasonable for California's families. Officials said they took steps to ensure that health plans offer an adequate number of quality medical providers and have measures in place for expanding their networks in the event that more people than expected sign up.

More than 5 million Californians are expected to be eligible for coverage in the exchange, and about half of them could qualify for federal premium subsidies.

Details on these insurance networks aren't known yet as insurers and providers wrap up their contracts and await regulators' review in the coming weeks. It's possible some medical groups and hospitals could be added.

Health Net Inc., another exchange option in Southern California, said it expects to seek state approval to use its existing network, which includes both UCLA and Cedars-Sinai, for one of its exchange plans.

Once all those decisions are finalized by early July, Covered California said it will help consumers find out online whether particular doctors and hospitals are in a health plan's network. Enrollment in the exchange opens Oct. 1 for policies that take effect in January, when most Americans must have health insurance or pay a penalty.

"When people come to choose their plan, we will have a directory so they can make sure Dr. Ramirez is in these three plans, for instance," said Peter Lee, executive director of Covered California. "Consumers care about that information."

Meanwhile, some insurance agents said it's hard to judge these proposed prices in the state exchange without knowing what's on the menu in terms of available providers.

"Trying to determine whether these rates are low or high without knowing the provider networks is like trying to tell the value of a car when you can only see the tires — you don't know if you are looking at a Ferrari or a Yugo," said Bruce Jugan, an insurance agent in Montebello and president of Benefitscafe.com, which sells health insurance to individuals and businesses.

Paul Markovich, chief executive of Blue Shield, said renegotiating with hospitals and physician groups for lower reimbursements was a key factor for insurers in holding down rates. Medical providers are sometimes willing to accept lower payments in return for higher patient volume from these narrow networks.

Markovich said premiums for Blue Shield's existing individual policyholders will rise 13% next year on average for coverage under exchange plans.

That marked an improvement from earlier predictions of even bigger rate hikes. The state issued a report in March that estimated premiums for many consumers could go up 30%, on average.

Premiums are generally rising to reflect the federal law's requirements for richer benefits and guaranteed coverage regardless of people's medical history.

"The physicians and hospitals that signed up for our network have agreed to accept lower reimbursement specifically to make the exchange more affordable," Markovich said.

Blue Shield's exchange network in the Los Angeles area doesn't include UCLA or Cedars-Sinai. Instead, it features hospitals such as Keck Hospital of USC, Long Beach Memorial and St. John's Health Center. Blue Shield said its statewide network for exchange policies will include about 24,000 physicians, compared with 66,000 doctors in its full preferred provider organization roster.

In Los Angeles County, state officials expect 1.6 million people to be eligible for coverage in the exchange. Premiums will vary based on a person's age, location and level of coverage.

For instance, in the north Los Angeles County region, the rates for a 40-year-old purchasing a Silver plan range from $222 a month for Health Net to $294 a month for Kaiser Permanente. There will still be other individual policies for sale outside those offered through Covered California, but federal subsidies can be used only inside the exchange.

Health Net sees growing acceptance of these narrower networks. The Woodland Hills insurer said enrollment among employers in California, Arizona and Oregon in those smaller networks has grown 37% in the last year.

chad.terhune@latimes.com

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Kansas Bill Would Protect Doctors Who Mislead Women About Their Pregnancies

The Kansas Senate Judiciary Committee recommended a bill yesterday that would effectively allow doctors to lie or withhold information about debilitating genetic conditions or birth defects in order to influence women’s decisions about their pregnancies.

Kansas SB 142 provides blanket protection from “wrongful birth” lawsuits to doctors, with section 1(a) reading:

“No civil action may be commenced in any court for a claim of wrongful life or wrongful birth, and no damages may be recovered in any civil action for any physical condition of a minor that existed at the time of such minor’s birth if the damages sought arise out of a claim that a person’s action or omission contributed to such minor’s mother not obtaining an abortion.”

The Arizona State Senate passed a similar law in 2012, but that proposal contained a provision absent from the Kansas bill allowing wrongful birth suits in the event of “an intentional or grossly negligent act or omission.”

The proposal was included as a provision in an omnibus anti-abortion bill last year, but was so controversial that it ending up being submitted as a standalone bill in this cycle, according to Kansas NOW lobbyist Elise Higgins. Despite Kansas’s dismal reproductive rights record, Kansas legislators have already introduced over 90 pages of anti-choice legislation in 2013.

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State Lacks Doctors To Meet Demand Of National Healthcare Law

Or is it? One major obstacle is that there won't be enough doctors to see all the newly insured patients under Obamacare. Some California lawmakers want to fill the gap by redefining who can provide healthcare. (Saul Loeb, AFP/Getty Images / June 28, 2012)

SACRAMENTO — As the state moves to expand healthcare coverage to millions of Californians under President Obama's healthcare law, it faces a major obstacle: There aren't enough doctors to treat a crush of newly insured patients.

Some lawmakers want to fill the gap by redefining who can provide healthcare.

They are working on proposals that would allow physician assistants to treat more patients and nurse practitioners to set up independent practices. Pharmacists and optometrists could act as primary care providers, diagnosing and managing some chronic illnesses, such as diabetes and high-blood pressure.

"We're going to be mandating that every single person in this state have insurance," said state Sen. Ed Hernandez (D-West Covina), chairman of the Senate Health Committee and leader of the effort to expand professional boundaries. "What good is it if they are going to have a health insurance card but no access to doctors?"

Hernandez's proposed changes, which would dramatically shake up the medical establishment in California, have set off a turf war with physicians that could contribute to the success or failure of the federal Affordable Care Act in California.

Doctors say giving non-physicians more authority and autonomy could jeopardize patient safety. It could also drive up costs, because those workers, who have less medical education and training, tend to order more tests and prescribe more antibiotics, they said.

"Patient safety should always trump access concerns," said Dr. Paul Phinney, president of the California Medical Assn.

Such "scope-of-practice" fights are flaring across the country as states brace for an influx of patients into already strained healthcare systems. About 350 laws altering what health professionals may do have been enacted nationwide in the last two years, according to the National Conference of State Legislatures. Since Jan. 1, more than 50 additional proposals have been launched in 24 states.

As the nation's earliest and most aggressive adopter of the healthcare overhaul, California faces more pressure than many states. Diana Dooley, secretary of the state Health and Human Services Agency, said in an interview that expanding some professionals' roles was among the options policymakers should explore to help meet the expected demand.

At a meeting of healthcare advocates in December, she had offered a more blunt assessment.

"We're going to have to provide care at lower levels," she told the group. "I think a lot of people are trained to do work that our licenses don't allow them to."

Currently, just 16 of California's 58 counties have the federal government's recommended supply of primary care physicians, with the Inland Empire and the San Joaquin Valley facing the worst shortages. In addition, nearly 30% of the state's doctors are nearing retirement age, the highest percentage in the nation, according to the Assn. of American Medical Colleges.

Physician assistants, nurse practitioners, pharmacists and optometrists agree that they have more training than they are allowed to use.

"We don't have enough providers," said Beth Haney, president of the California Assn. for Nurse Practitioners, "...so we should increase access to the ones that we have."

Hernandez, who said he would introduce his legislation and hold a hearing on the issue next month, said his own experience as an optometrist shows the need to empower more practitioners. He said he often sees Medicaid patients who come to his La Puente practice because they have failed their vision test at the DMV. Many complain of constant thirst and frequent urination.

"I know it's diabetes," he said. But he is not allowed to diagnose or treat it and must refer those patients elsewhere. Many of them may face a months-long wait to see a doctor.

The California Medical Assn. says healthcare professionals should not exceed their training. Phinney, a pediatrician, said physician assistants and other mid-level professionals are best deployed in doctor-led teams. They can perform routine exams and prescribe medications in consultation with physicians on the premises or by teleconference.

Allowing certain health workers to set up independent practices would create voids in the clinics, hospitals and offices where they now work, he said. "It's more like moving the deck chairs around rather than solving the problem," Phinney said.

His group proposes a different solution: It wants more funding to expand participation in a loan repayment program for recent medical school graduates. Doctors can now receive up to $105,000 in return for practicing in underserved communities for three years.

Still, it typically takes a decade to train a physician. Health experts say the pool of graduates cannot keep pace.

"We're not going to produce thousands of additional doctors in any kind of short-term time frame," said Assemblyman Roger Dickinson (D-Sacramento). "It makes sense to look at changes that could relieve the pressure that we're going to undoubtedly encounter for access to care."

Administrators of community clinics and public hospitals say nurse practitioners and other non-physician providers already play key roles in caring for patients, a trend they predict will grow as more Californians become insured and enter the healthcare system.

At Kern Medical Center in Kern County, two clinical pharmacists have run the hospital's diabetes clinic, treating about 500 patients a year, since the specialist physician in charge retired. They are licensed to perform physicals, order lab tests, prescribe medicines and counsel patients on lifestyle changes.

"We're going to have to get a whole lot more creative about how care is provided," said Paul Hensler, Kern Medical Center's chief executive.

michael.mishak@latimes.com

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Doctors, Insurers Trade Blame on Out-of-Network Fees

Just over a year ago, Angel Gonzalez, 36, awoke with searing chest pain at 2 a.m. A friend drove him to the closest emergency room.

Though he was living on $18,000 a year as a graduate student, Mr. Gonzalez had good insurance and the hospital, St. Charles in Port Jefferson, N.Y., was in his network. But the surgeon who came in to remove Mr. Gonzalez's gallbladder that Sunday night was not.

He billed Mr. Gonzalez $30,000, and an assistant billed an additional $30,000. Mr. Gonzalez's policy covered out-of-network providers, but at a rate it considered appropriate: $2,000. "I was on the hook for more than I made in a year," Mr. Gonzalez said.

A health-insurance industry report to be released on Friday highlights the exorbitant fees charged by some doctors to out-of-network patients like Mr. Gonzalez. The report, by America's Health Insurance Plans, or AHIP, contrasts some of the highest bills charged by non-network providers in 30 states with Medicare rates for the same services. Some of the charges, the insurers assert, are 30, 40 or nearly 100 times greater than Medicare rates.

Insurers hope to spotlight a vexing problem that they say the Affordable Care Act does little to address. "When you're out of network, it's a blank check," said Karen Ignagni, president and chief executive of AHIP. "The consumer is vulnerable to 'anything goes.' "

"Unless we deal with cost, we won't have affordability," she added. "And unless we have affordability, we won't have people participating" under the Affordable Care Act.

Among the fees on the report's list are a $6,205 outpatient office visit to a doctor in Massachusetts for which Medicare would have paid $152; a $12,000 bill for examining a tissue specimen in New York for which Medicare would have paid $128; and a $48,983 surgeon's fee for a total hip replacement in New Jersey that Medicare would have reimbursed at $1,543. Many of the highest billers were in New York, Texas, Florida and New Jersey.

Elisabeth R. Benjamin, co-founder of the Health Care for All New York coalition, who is often at odds with the insurance industry, said that "is one area we totally agree on." She continued, "Out-of-network billing is just out of control."

Even when out-of-network fees are compared with average commercial insurance reimbursements, which are usually greater than Medicare, she said, "It's pretty outrageous."

Doctors say the report is skewed because it focuses on a few dozen cases of overcharging that are not representative of their billing. In response to the insurers' report, the American Medical Association noted on Thursday that a recent analysis found that doctors' services account for just 16 percent of health care costs.

"There are outliers in every profession, in every business," said Dr. Andrew Y. Kleinman, a plastic surgeon who is vice president of the Medical Society of the State of New York.

Dr. Kleinman also noted that insurers had effectively shifted the costs of out-of-network care onto patients by changing reimbursement formulas. Instead of the rates commercial insurers usually pay doctors, insurers increasingly are basing their out-of-network payments on Medicare rates, usually far lower.

A growing number of high-end, flexible health plans offer policies that cover outside providers at, for example, 140 percent of Medicare. "They're selling you an insurance product you can't use," Dr. Kleinman said. "You're buying an insurance policy where the out-of-network benefit is worthless."

The industry's own report suggests that using Medicare rates as a benchmark will lead to patients' picking up much more of the cost for out-of-network care, whether they carefully select a specialist or, as in the case of Mr. Gonzalez and many others, have no choice in the matter.

Had Mr. Gonzalez been 65 or older, Medicare would have paid only $958 for the surgery. The average commercial price is $12,292, according to FAIR Health, an independent nonprofit group that tracks information on health care costs.

But Mr. Gonzalez's health plan, United Healthcare, determined the fee should be $1,273, of which the company paid $838. Mr. Gonzalez filed appeals, which were rejected. He then contacted Community Health Advocates at the Community Service Society of New York for help, and the group's caseworkers negotiated with the surgeon on his behalf.

After months of wrangling, the surgeon agreed to accept a significantly reduced payment: $340.

Consumer advocates and health insurance executives are calling for greater transparency in health care pricing, including upfront disclosure of prices of medical procedures and services.

"The health care industry can give you an estimate, just like any other industry," said Carrie H. Colla, an assistant professor at the Dartmouth Institute for Health Policy and Clinical Practice, noting that the Dartmouth-Hitchcock Medical Center has a patient price estimator online.

"It's just not current practice right now," Dr. Colla said. "Sometimes a doctor won't even know. The patient really has to push for it."

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Doctors Praise Bill To Repeal Medicare Cost-Cutting Board

The American Medical Association praised the reintroduction Wednesday of a bill to repeal the controversial Medicare payments board in President Obama's healthcare law.

Rep. Phil Roe (R-Tenn.) reintroduced his bill to repeal the Independent Payment Advisory Board (IPAB) — a panel of 15 healthcare experts with the power to cut Medicare payments to doctors if spending grows faster than a prescribed rate.

The AMA and other healthcare providers strongly oppose the IPAB, which would essentially have the power to make Medicare cuts now reserved for Congress — and thus subject to intense lobbying by groups trying to avoid a cut to their payments.

"IPAB is a panel that would have too little accountability and the power to make indiscriminate cuts that adversely affect access to healthcare for patients," AMA President Jeremy Lazarus said in a statement.

Rep. Allyson Schwartz (D-Pa.) is again cosponsoring Roe's bill, as she did in the last Congress.

Republicans — including Majority Leader Eric Cantor (R-Va.) — have called for IPAB repeal to be on the table in debt and deficit negotiations, but because the IPAB reduces costs, repealing it would add to the deficit.

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RPT-UPDATE 1-Merck steers doctors away from HDL cholesterol drug

Jan 11 (Reuters) - U.S. drugmaker Merck & Co said it is taking steps to suspend availability of its drug Tredaptive after the medicine, used to raise "good" HDL cholesterol, failed to prevent heart problems in a large study.

The medicine is not approved in the United States but is sold in about 40 countries.

Merck said it is recommending that doctors stop prescribing Tredaptive, based on negative findings from the trial which were announced last month. The study followed more than 25,000 patients in Europe and China for almost four years.

The company said it will encourage doctors to consider alternative treatments to control their cholesterol, but advised patients not to discontinue Tredaptive without first speaking with their physicians.

Merck did not say, in its press release, when it plans to halt shipments of Tredaptive.

Tredaptive combines an extended-release form of niacin with another drug meant to reduce facial flushing, a side effect of niacin. The medicine has annual sales of less than $20 million. That makes it a tiny product for Merck, which has global annual revenue of about $50 billion.

Merck in December said Tredaptive did no better in the study at preventing heart attacks, deaths or strokes than traditional statin drugs that lower "bad" LDL cholesterol.

Moreover, Merck said the medicine significantly raised the incidence of some types of nonfatal but serious side effects in the study. They included blood, lymph and gastrointestinal problems, as well as respiratory and skin issues.

Tredaptive was approved in the European Union in 2008, but the U.S. Food and Drug Administration was unwilling to approve the pill until Merck conducted the costly long-term study to better assess its safety and effectiveness.

Some analysts had expected Tredaptive to capture annual global sales of more than $1 billion, if it were to win approval in the United States.

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Hillary Clinton admitted to hospital after doctors discover blood clot

Secretary of State Hillary Clinton was hospitalized on Sunday after doctors found a blood clot.

Clinton is receiving treatment at Presbyterian Hospital in New York where doctors will monitor her for the next 48 hours, her spokesman Philippe Reines said in a statement. 

The clot, resulting from a concussion she suffered earlier in December, was found during a follow-up exam on Sunday, according to the State Department.

"Her doctors will continue to assess her condition, including other issues associated with her concussion. They will determine if any further action is required," Reines said.

Clinton fainted and suffered a concussion earlier in the month when she was suffering from a stomach virus. At the time, the State Department said that she would continue her recovery at home and was being monitored by her physicians.

The illness forced the secretary to cancel a trip to the Middle East and an appearance before Congress.

Clinton was due to testify before Congress on Dec. 20 about the investigation into the September attack on the U.S. Consulate in Benghazi, Libya, which killed four Americans.

Two senior aides to Clinton testified on her behalf, but Republicans, who have been sharply critical of the administration’s handling of security for the Benghazi mission, have said they still expect Clinton testify in person.

Clinton has said she will step down from her post as the nation’s top diplomat, and President Obama has nominated Sen. John Kerry (D-Mass.) to succeed her.

— Amie Parnes contributed to this report.

— Updated at 10:03 p.m.

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