Friday, February 24, 2006

HEALTH ACCESS UPDATE
Friday, February 24th, 2006


LANGUAGE ACCESS RULES AT STAKE IN DMHC PROCEEDING

• Comments Due at March 3rd on New Cultural and Linguistic Access Standards
• Hearings Highlight Need for New Rules at Department of Managed Health Care
• Emotional Testimony About Errors, Lack of Care Because of Language Barriers
• Health Access VMI Projects Show Solutions Possible, If Policies in Place

Patients who speak little English, gave eloquent and emotional testimony at Department of Managed Health Care hearings in Los Angeles and Oakland last week in an effort to influence proposed regulations that would require health plans to provide sufficient interpreters for patients.


COMMENTS DUE MARCH 3RD: Advocates for health care and communities of color will have until March 3 to submit written comments to follow up on the Cultural and Linguistic competency regulations. Written comments can actually be submitted online, at the DMHC website, at:
http://wpso.dmhc.ca.gov/regulations/regs/submit.aspx?key=12

HEARINGS ON LANGUAGE ACCESS PROCEEDINGS: These hearings were held to assist DMHC who is charged with developing regulations to implement SB 853, the 2004 legislation by Sen. Martha Escutia. This law essentially says all patients – regardless of their primary language -- have the right to competent medical interpreters. The responsibility of providing interpreters falls on health plans and the providers that they contract with. A full copy of the regulations (entitled “2004-0115: Language Assistance Programs”) are available at the DMHC website, at:
http://wpso.dmhc.ca.gov/regulations/regs/?key=12

Language access to health services is a central issue, especially in California , where 40 percent speak a language other than English at home. According to the California HealthCare Foundation, “the most recent California Experience Survey (PEP-C) found 49% of patients reported not being able to receive interpretive services when needed.”

Advocates are also calling on plans to compile a demographic profile of enrollees, including race, ethnicity and primary language—a requirement that is not yet reflected in the regulations.

LOS ANGELES HEARING: In the Los Angeles hearing, over 70 beneficiaries, interpreters, advocates, providers, association representatives, and academics gave testimony in the all-day hearing, including California Pan-Ethnic Health Network (CPEHN), a sponsor of the SB853, as well as Health Access California, National Health Law Program (NHeLP), Asian Pacific American Legal Center (APALC), Pacific Asian Language Services (PALS for Health), and many others.
The theme of the testimony emphasized that insufficient attention to language, race, ethnicity, and culture lead to limits to access to providers and poor quality of care. This, in turn, results in health care disparities and poor, even tragic health outcomes. The testimony was dominated by beneficiaries, many of whom spoke through interpreters.

• One Korean speaker told of taking his wife to the hospital emergency room because she was bleeding. They waited from 8:00 a.m. to after 11:00 pm because no one spoke Korean. She ultimately had to undergo risky treatment due to the significant loss of blood.
• One woman spoke tearfully of the aftermath of her diagnosis of breast cancer. Her doctor sent her for a biopsy of the lump, but the technicians did the biopsy on the wrong breast. She tried to tell them of their mistake, but she couldn’t communicate with them and they did not speak Spanish. She tried to enlist the help of her young daughter and her brother to translate for her, but her daughter’s vocabulary was insufficient and her brother was embarrassed to talk about her condition. Due to her fear about her health and the frustration of making herself understood, she abandoned getting any further treatment. Ultimately, she had to suffer through more radical and painful surgery and treatments because of the delay in diagnosis and treatment.
• One woman spoke of her trip to the hospital emergency room after the collapse of her infant daughter. She took her 13-year-old along to interpret. When she returned to the hospital she was not able to bring her teenage son, so the hospital brought in an aide from another department. The aide did translate for part of the visit but literally stopped in mid-sentence when the doctor began to explain that her infant daughter had a terminal disease.
• A frail Asian woman told of her involvement in a clinical trial where she was called upon to sign several complicated release forms without understanding a single word.
• Another man described going for emergency treatment, but because his English was so poor, he could not be understood. The hospital went out into the parking lot and pulled a construction worker off a hospital renovation project to interpret for him. Although the construction worker could speak Spanish, he had no knowledge of the patient’s medical condition, treatments, and no particular skill in interpreting in a sensitive situation.
  

OAKLAND HEARING: The hearing in Oakland featured more testimony from providers and advocates, such as Latino Issues Forum, California Immigrant Welfare Collaborative, Asian Pacific Islander American Health Forum, Asian Health Services, Health Rights Hotline, Latino Coalition for a Healthy Coalition, and Bay Area Legal Aid.

For example, Dr. John Pescetti, of La Clinica de La Raza in Oakland , emphasized the moral and financial costs of miscommunication with a limited-English proficient patient. He said that knowing a patient’s medical history is 70 percent of a doctor’s diagnosis, but when a doctor can’t understand the patient, bad advice will be dispensed. This, in turn, could result in increased malpractice lawsuits and costs.

While Director Cindy Ehnes sympathized with testimony from all sides, she questioned how interpretation could be implemented in a cost-efficient way. Providers also spoke up, emphasizing how they felt the regulations were burdensome and potentially costly. Keith Pugliesse, representing the physician groups, suggested patients should “be allowed to use their families and friends – anyone they feel comfortable with.’’ Leanne Gassaway from the California Association of Health Plans said patients can already look in “provider directories’’ to find physicians that speak their language.

Advocates responded that friends and family don’t have the training to do medical interpretation, and that patients who do rely on children or family do so largely because they have no choice. While Ehnes did empathize with providers, she did seem open to looking at evidence of health care discrimination and looking for concrete ways that interpreter programs can work.

VIDEO MEDICAL INTERPRETATION: At these hearings, Health Access Foundation provided information about its Video Medical Interpretation (VMI) projects, which work to implement videoconferencing technology to cost-effectively provide trained language interpretation services in Bay Area public hospitals. Health Access is incubating these pilot projects to show that the language access problem is solvable, with the appropriate policies in place.

Janice Chin of Alameda County Medical Center spoke about their hospital’s commitment to interpretation services, and their use of VMI, in partnership with San Francisco General Hospital , to serve their diverse patient population, to reduce wait times and provide a greater range of languages. More information about this project which is coordinated by Health Access, is available at:
http://www.health-access.org/providing/docs/VMIProject.DOC

Another Health Access project is laying the groundwork of a Health Care Interpreter Network (HCIN), where using either mobile video conferencing units or ordinary telephone equipment, participating healthcare providers will be able to access the Video/Voice Over IP Call Center interpreter services throughout the multi-hospital system. More information about this project, which has started at San Joaquin General Hospital , is available at:
http://www.health-access.org/providing/docs/RVVMIProject.DOC

--

NOTE: If you had problems getting the text from the last Health Access Update about the hospital financing waiver, it is archived, along with all Health Access Updates, at the Health Access website, at:
http://www.health-access.org/blogger.html

FYI, the Stakeholders Meetings for the hospital waiver "coverage initiative" will be held on Monday, February 27th in Sacramento, and on Friday, March 10th in Los Angeles.

Labels: Updates

posted by Anthony Wright | Permalink | 5:32 PM


 

Monday, February 20, 2006

HEALTH ACCESS UPDATE
Monday, February 20, 2006


MEDI-CAL PROVIDER CUT RESCINDED; HOSPITAL FINANCING WAIVER ACTIONS

• Governor Signs SB912 (Ducheny), to Rescind 5% Medi-Cal Cut
• Hearing Last Week on Hospital Financing Waiver
• Action on Lack of Payment of Federal Funding to Public Hospitals
• Stakeholder Meetings on "Coverage Initiative" on February 27th
  

PROVIDER RATE CUT RESCINDED

Last Friday, Governor Arnold Schwarzenegger signed SB912 (Ducheny), to rescind the 5% rate reduction for Medi-Cal providers that took effect on January 1, 2006. The bill passed the Legislature on a bipartisan, unanimous vote, reversing an action made a few years ago during the height of the budget crisis. The enactment of the rate reduction was delayed until this year by litigation challenging the cut's impact on access to health care.

Even with the signing of SB912, California is ranked 50th of all 50 states in the amount that Medicaid (Medi-Cal in California) reimburses doctors and other providers. This effort against the rate cut, led by the California Medical Association, was supported by health and consumer advocates that are concerned that fewer providers and specialists are offering care to those with Medi-Cal coverage. Already, an estimate half of California providers do not take Medi-Cal patients, creating barriers to get the care they need.

The Goverrnor did mention that the rate reduction was possible given a recent federal recalculation of the Medicare Part D "clawback" provision, which was expected to be a cost to the state. The signing statement is available under the "Press Room" and "Press Releases" section of Governor Schwarzenegger's website, as the "Legislative Update 2/17/06" at:
http://www.governor.ca.gov

Health advocates will continue to advocate for other priorities in the budget discussions this year, most notably for the expansion of children's coverage, and to ensure comprehensive prescription drug coveragefor the seniors and people with disabilities on Medi-Cal, to make up for the costs and gaps in the new Medicare Part D coverage.


THE HOSPITAL FINANCING WAIVER: THE NEXT CHAPTER

Last year, the Schwarzenegger Administration negotiated a new "hospital financing" Medi-Cal waiver with the federal government, changing the formulas and ways that public and safety-net hospitals have gotten crucial federal funding for many years.

According to a legislative hearing on the waiver last Tuesday, the transition to this waiver has not been smooth. Public hospitals have yet to see any money flow, even though it is reported that they are now owed over $600 million, creating a cash flow crunch at county hospital systems around the state. On Friday, a deal was reach between county, state, and federal agencies to address this issue in the near term.

THE "COVERAGE INITIATIVE"

Last year, Health Access and other advocates joined together to stop part of the hospital waiver that the Administration proposed to use to force seniors and people with disabilities on Medi-Cal into managed care plans, ready or not. This year, we face a different proposal—and a different attitude from the Administration.

By this September, California will need to tell the federal government how it plans to use its three-year, $180 million per year allotment to expand coverage. This money originates from the LA County 1115 waiver which funded the LA County hospital system.

This money, which starts flowing to the state in 2007-08, is part of the state’s Medi-Cal Hospital Financing Waiver. It is three one-time allocations of federal money, of $180 million each, that must be spent in the year for which the allocation is provided.

The new coverage initiative would cost a total of $440 million – of which $260 million could come from any state or local source. According to Stan Rosenstein, the state’s Medi-Cal director, the Administration proposes that it would come from counties and the University of California, rather than the State General Fund.

In broad strokes: the program would attempt to catch indigent adults who have no Medi-Cal coverage.
DHS also proposes several other key elements:

• Indigent adults
• Unified medical/health record, whether paper or electronic
• “Medical home” for the covered persons
• Defined benefit package: this means limits on benefits in some fashion.
• Supplement, not supplant Medi-Cal/Healthy Families.
• Operational on Sept. 1, 2007.

A push-pull is already happening. Private hospitals and health care plans are jockeying for their share. Public hospitals, which face flat funding in the last three years of the five year waiver and which are already suffering cash-flow problems from financing waiver hold-ups want to ensure that money stays with them.

The key is to have the program up and running by September 1, 2007. If the state does not use its full $180 million allotment for the year, it loses the money. The best way to use the money quickly, state administrators admit, is to expand existing programs.
The department has not yet decided how best to achieve that. That’s where you come in.
Stakeholders will be invited to meetings in both Los Angeles and Sacramento within the next few weeks to discuss the coverage initiative.

Stakeholder Meeting February 27th in Sacramento
DHS is convening a stakeholder meeting on Monday, February 27, 2006 at 1pm to 5pm, at the DHS Auditorium, 744 P St., First Floor, in Sacramento.
Another DHS meeting will be held in Los Angeles although the date, time and location have not yet been set.

The Sacramento stakeholder meeting is part of the ongoing process of stakeholder involvement that included the legislative hearing on February 14 as well as legislative budget hearings over the next six to eight weeks.

DHS’s concept paper on how to use the $180 million in years 3, 4 and 5 can be found here:
http://www.dhs.ca.gov/medi-cal%20reform/PDFs/Jan06/Final%20CMS%20MCal%20Coverage%20Initiative%20Proposal%201-31-06.pdf
(If that link doesn’t work, go to www.dhs.ca.gov. )

Health Access Key Principles: The Coverage Expansion Element of the Hospital Waiver

Health Access California has developed key principles for evaluating proposals for the coverage expansion element of the hospital waiver.

• First, do no harm. Don’t reduce access for some of the uninsured while expanding coverage for others.
• Second, it’s a hospital waiver, not a coverage waiver. This money originates from the waiver that saved the LA County hospital system. Health Access supports both safety net institutions and coverage expansions.
• Third, look at building on existing systems to maximize effective use of funding. If the each of the three $180 million allocations has to be spent in the year in which it’s allocated, building on existing systems is the only way to go from zero to $180 million.
• Fourth, be mindful that this expires in 2011.

For more background, see the linked statement of principles.

(If that link doesn’t work, go to www.dhs.ca.gov.
Click on “Projects and Initiatives’’ on the left column.
Click on “Medi-Cal Redesign’’ in the middle column.
Click on “Hospital Financing’’ on the right under “Topics of Interest.’’
“Healthcare Coverage Initiative Concept Document, January 31, 2006’’ is the link you want.)

Other issues concerning the Hospital Financing Waiver:

• Public hospitals which normally receive the majority of their federal funding in December/January have not been paid yet and may not be paid for months to come. For Alameda, Ventura, Monterey, Kern and other counties, this had become already a serious problem.
• $400 million for Safety Net hospitals will become available after CMS okays the definition of Certified Public Expenditures. The CMS okay occurred on Friday, February 19, 2006.
• $1 billion due to Disproportionate Share Hospitals probably won’t be released until the fiscal year is over. That’s because once “Certified Public Expenditure’’ issues are resolved with CMS, the state and public hospitals still must agree on a plan amendment.

Labels: Updates

posted by Anthony Wright | Permalink | 7:47 AM


 

Thursday, February 09, 2006

HEALTH ACCESS UPDATE
Thursday, February 9th, 2006

BUSH BUDGET CONTINUES TO CUT HEALTH CARE

• Cuts to Medicaid & Medicare Providers, Impact on Hospitals and Patient
• Major Expansion of Health Savings Accounts; High-Deductible Plans
• Also: President Bush Signs Budget Reconciliation Yesterday Cutting Medicaid

Earlier this week, President George W. Bush unveiled his 2007 fiscal year budget proposal, a $2.8 trillion budget that would start October 1, 2006. It features $182 billion in cuts for non-defense programs over five years (a second straight year of proposed reductions), as well as proposals for $285 billion in tax cuts over the same period. The actual budget document is available from the White House website at:
http://www.whitehouse.gov/omb/budget/fy2007/

Analyses of the federal budget are available from the California Institute for Federal Policy Research (CIFPR), and the Center on Budget and Policy Priorities (CBPP):
http://www.calinst.org/pubs/prbdg07.htm
http://www.cbpp.org/2-6-06bud.htm


HEALTH CARE: The proposal does make significant cuts to public health care programs, including Medicare (serving seniors and people with disabilities) and Medicaid (Medi-Cal in California , serving low-income children, parents, seniors and people with disabilities). It also seeks major changes in the private healthcare marketplace through tax and policy changes, encouraging high-deductible plans and Health Savings Accounts, and proposing the elimination of state consumer protections for insurance. The U.S. Health and Human Services Department has a summary of its budget on their website, at:
http://www.hhs.gov/budget/07budget/2007BudgetInBrief.pdf


MEDICAID: The Bush budget calls on Congress to “build on the momentum” of the budget reconciliation act that the President signed yesterday. That act provided almost $40 billion in cuts to Medicaid, child care, student loans and other vital services, and was passed the Senate by 51-50 (with Vice President Cheney breaking the tie), and the House just last week by 216-214 (on a strict party line vote for the California Congressional delegation).

• Allows the state to charge co-pays for Medi-Cal services.
• Require burdensome documentation (either a birth certificate or a passport, which many legal citizens do not have) for Medi-Cal applicants
• Make changes in the Medi-Cal assets test, making it harder to get Medi-Cal coverage, or far more expensive for many seniors and people with disabilities.

According to CBPP, the budget proposes legislative changes in Medicaid of $1.5 billion over five years, and regulatory changes that would reduce funding an additional $12.3 billion. Most of these changes are shifting costs to states, which in turn could pressure California to make programmatic changes and cuts. Other changes would:

• Limit funding to public and safety-net hospitals that now get money through DSH( Disproportionate Share Hospital ) payments to care for low-income and uninsured patients. Other changes would also have unclear and dangerous impacts on hospital financing in general.
• Reduce the taxes that states can charge providers from six percent to three percent. States use this tax to pull down federal matching funds.
• Restrict the kinds of services that can be claimed for rehabilitation services
• Relieves states of paying for prenatal care and preventative pediatric doctor’s visits when an absentee parent, spouse or domestic partner has health insurance that can be tapped.

MEDICARE: Ignoring the drama surrounding the implementation of the Medicare prescription drug benefit, the Bush budget’s largest single cut fell on Medicare. The program is expected to grow by $36 billion less than expected over the next five years. In 2007, that’s a $2.5 billion reduction in services.

The bulk of the Medicare cut won’t directly or immediately impact enrollees. Instead, 55 percent of the cut ($20 billion) would fall on hospitals, skilled nurses, ambulances and other health care providers. The proposal limits how much the federal government would reimburse these providers, meaning that providers would have to absorb higher costs as health inflation increases. The impact of these cuts, however, would eventually trickle down to patients, who would see either the quality of service, or service itself reduced.

Some beneficiaries would also feel a pinch. Currently, single enrollees in with incomes above $80,000 a year ($160,000 for couples) pay about 25 percent of their premiums for physician services. Bush is asking that those enrollees begin paying a higher premium – depending on their income – beginning in 2008. The income threshold does not increase over time with the cost of inflation. That means five years down the line – when more singles are earning $80,000 – enrollees will be asked to pay higher premiums.

These cuts are focused on Medicare Part A (Hospital Coverage) and B (Doctors Visits), the benefits directly provided by the Medicare program directly. They do not impact Medicare Part C or D, which have been contracted to private insurers.

HEALTH SAVINGS ACCOUNTS: Apart from public program cuts, President Bush proposes significant tax and policy changes to encourage people to buy high-deductible plans. To encourage people to store money in so-called Health Savings Accounts, Bush is proposing tax credits and deductions for those who open them. He is also increasing the amount that can be contributed to such plans annually. The amounts accrue annually – like a 401k retirement plan. These HSAs are tax shelters geared mostly for the wealthy, which also have a controversial impact on our health care system.

These HSAs, coupled with high-deductible, minimum-coverage plans, are being billed as an alternative to regular health insurance coverage.

Premiums with these plans are lower than typical health coverage and thus supposedly more appealing to younger and healthier people who might not see a doctor often. They’re also appealing for those who want to feel like they have health insurance, but can’t afford it.

The idea is this: the money that you save in premiums is funneled into the HSA account. Problems with this include

• Deductibles are high – in the thousands of dollars – so if a medical emergency arises, the consumer will be out a lot of money – possibly more than if they had actual coverage.
• As with 401ks, consumers will stock away as much money in these accounts as they see fit or can afford. If they’re choosing these plans (or have this type of benefit from an employer), it’s likely they can’t afford to put away much.
• If a medical need arises, the consumer is often unable shop around for the best and most economical care. These plans ask individual consumers to do what large purchasers like CalPERS have found a real challenge.

The President's budget also includes other proposals to change the private health care martketplace, including two proposals to eliminate state-based consumer protections. Association Health Plans would allow businesses to purchase insurance products outside of state regulation. Another proposal would simply replace California and other states consumer protection laws with one national set of standards, which would likely to be far less than what California currently has in place.

More information will be forthcoming about both Health Savings Accounts and President Bush’s budget proposals, especially their impact on California hospital, providers, and patients.

For comments and questions, contact Hanh Kim Quach at Health Access, hquach@health-access.org.

Labels: Updates

posted by Anthony Wright | Permalink | 1:50 PM


 

Reserving my right to critique coverage later...

 

From small changes to BIG changes...

 

The view from 10,000 feet.

 

A Zen Sen

 

Bush Whacking Kids

 

A San Francisco treat

 

Fireworks of a different kind...

 

Building a fence at the border for whom...

 

International House of Health Care

 

Dept. of Insurance