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The finish line or a false start?
There’s a lot of concerns about the VA’s race to rollout The MISSION Act. Harris Meyer reports at Modern Healthcare:
With just a few weeks to go before its June 6 launch, lawmakers, providers, and advocates are wary about the Veterans Affairs Department’s ability to roll out an expanded private-care program for veterans on schedule without experiencing major glitches like the last time.
They fear the 9.2 million veterans eligible for VA-paid healthcare will continue having trouble accessing timely, high-quality care outside of Veterans Affairs hospitals and clinics.
Non-VA providers hope the new Veterans Community Care program, mandated by the VA Mission Act enacted last year, will improve their ability to share patient data with VA facilities and receive timely payment for serving veterans. Those have been major problems for the Veterans Choice program, which ends when the new program begins.
The VA selected Optum Public Sector Solutions as the third-party administrator for three regions, though that selection is being contested, while contractors for three other regions haven’t yet been selected. TriWest will continue as interim administrator for the Choice program while the new contractors ramp up their networks and processes over the coming year.
There also are concerns about whether the private providers in the new third-party administrators’ networks will be held to the same standards of quality and levels of familiarity with veterans’ health issues that VA providers must meet. Read the full article at Modern Healthcare.
“Nuanced care” needs to drive opioid prescription reform
Stefan G. Kertesz, M.D., a physician at the Birmingham Veterans Affairs Medical Center and professor at the University of Alabama at Birmingham School of Medicine, and Kate M. Nicholson, J.D., co-chair of the Chronic Pain/Opioids Task Force for the National Centers on Independent Living, write about the pitfalls of shortcuts when combatting the opioid epidemic at STAT News:
Declarations from two federal agencies offer hope — and possible action — for people in pain who have lost access to prescribed opioids. These declarations come not a moment too soon for those who have been abandoned by their health care providers or denied appropriate treatment and are suffering in real time.
In 2016, the Centers for Disease Control and Prevention released guidelines for prescribing opioids for chronic pain. Although these guidelines have been useful for many clinicians, they have been misapplied by individual prescribers, institutions, and agencies, too often causing the kind of pain they were meant to address. Writing in this week’s New England Journal of Medicine, the authors of the guidelines admitted that they have been misapplied by those seeking “shortcuts” to safer prescribing.
The authors, Dr. Deborah Dowell and Tamara Haegerich from the CDC and Dr. Roger Chou from Oregon Health and Science University, noted that ranges given in the guidelines related to opioid dosages and the number of days for which an opioid should be prescribed were often translated to “inflexible” limits that have been pushed, mandated and incentivized by countless insurers, state agencies, and regulators in ways that exceed or even contravene the guidelines.
This misapplication of a few select provisions in otherwise useful guidelines, which wisely urge caution in starting and escalating opioids, has occurred at a breakneck pace since they were published, with real human consequences. Patients in serious pain face delays and denials when they attempt to fill their prescriptions, sometimes with tragic results. Some doctors have felt compelled by the guidelines to put patients who have relied on opioids to safely and effectively manage pain — often for decades — on lower doses or to take them off opioids altogether, even when they believe patients are benefiting from the medication, because they fear oversight and liability. Read the full article at STATNews.com.
Coming up on Capitol Hill
House Committee on Veterans’ Affairs
- Monday, 4/29 at 7 p.m.: Full Committee Oversight Hearing: Tragic Trends: Suicide Prevention Among Veterans
- Tuesday, 4/30 at 10 a.m.: Health Subcommittee Legislative Hearing: Draft Legislation including H.R. 100, H.R. 712, H.R.1647, H.R. 2191
- Tuesday, 4/30 at 2 p.m.: Economic Opportunity Subcommittee Hearing: Fiscal Year 2020
- Wednesday, 05/1 at 10 a.m.: President’s Budget: Requests Related to Veterans’ Readjustment Benefits
- Wednesday, 5/1 at 2 p.m.: Economic Opportunity Subcommittee Markup: Pending Legislation
- Disability Assistance and Memorial Affairs Subcommittee Hearing: H.R. 1199, H.R. 1200, H.R. 1126, H.R. 1628, H.R. 1826, and other draft legislation
- Thursday, 5/2 at 10 a.m.: Health Subcommittee Oversight Hearing: Cultural Barriers Impacting Women Veterans’ Access to Healthcare.
Veteran Suicides on VA Campuses
Leo Shane III details the steps being taken to address on-campus suicides at MilitaryTimes:
Despite three suicides in six days on Veterans Affairs campuses earlier this month, department officials are confident they have made progress in preventing such deaths.
At least 24 suicides have occurred on VA campuses in the last 18 months, the most recent two weeks ago when a veteran shot himself in front of a crowd in the lobby of a Texas VA outpatient clinic. That came less than a week after two other veterans died by suicide at separate VA locations in Georgia.
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Last fall, the Joint Commission — an independent non-profit that tracks more than 21,000 health care organizations nationwide — noted the rate of suicide in VA medical centers sits below that of the private sector, and dropped more than 80 percent (to 0.74 per 100,000 admissions) following department focus on the problem.
The figures “suggest that well-designed quality improvement initiatives can lead to a reduction in the occurrence of these tragic events,” researchers wrote.
The contradiction of progress with suicide prevention at VA versus a rise in publicly visible deaths will get renewed focus next Monday, when members of the House Veterans’ Affairs Committee hold a hearing on VA suicide prevention efforts. Read the article at MilitaryTimes.
Quick Clicks
- FierceHealthcare: Cerner Corp. sees its profits increase as problems persist with its work on the VA’s Electronic Health Record
- Arkansas Democrat-Gazette: State-run veterans’ nursing home receives low rating; state officials struggle to sustain funding, staffing levels
- APIC.org: Study examines antibiotic overprescription in one VA outpatient setting
- VAntage Point Blog: Persistent hiring challenges at the VA (lack of private sector pay parity, a complex hiring process, lack of performance bonuses, and an unhealthy skepticism from lawmakers and the media) are keeping the nation’s best from serving veterans – including in high-level leadership positions.
- Newsweek: President Trump, conservatives, and Rep. Ocasio-Cortez spar on VA privatization
Privatization Plays Out
Iowa’s Medicaid system was turned over to private companies to administer. Here are the results, from Tarbell.org:
Hurst says the private companies will even challenge his professional opinions—something he says the previous, state-run Medicaid program rarely did. “I was not asked to jump through hoops to justify a medical decision,” he says. “It was just about what Medicaid covered and what it didn’t.” Hurst’s experience is not unique; reports of MCOs questioning medical decisions—even for the amount of help a paralyzed man needs—have drawn scorn.
Shortly after the 2016 privatization, reports of unexplained reductions in benefits began to pour in across Iowa. Disabled patients who require intensive care reported less access to care and less medical help. Soon, over 200 of these disabled patients sued one of the private insurers. (The suit was dropped after that company closed up shop and left the state.)
Critics say the MCOs have tried to cut costs by cutting services. “People need to know what they’re doing to Medicaid patients,” says Medicaid recipient Denise Boots, who suffers from hereditary spastic paraplegia, a neurological degenerative disease that impacts her ability to use her legs. Boots told Tarbell she was kicked off Medicaid for one month after her MCO demanded she produce documentation for what turned out to be a $116.25 cash value life insurance policy. Once she was able to track down the document, she got her Medicaid back, but she had to pay out of pocket for the month she missed. She’s since been in a protracted appeal process to get reimbursed for the lost month.
The MCO practice of delaying and denying Medicaid payments means hospitals and nursing homes are getting paid less. This hurts their finances and puts them at heightened risk of having to cut services, reduce staff, consolidate, or even close. When publicly owned, facilities become susceptible to privatization and outsourcing. Some nursing homes and mental health facilities are having to borrow money to fill the reimbursement gap, and some hospitals are outsourcing services like mental health and home care. All of this contributes to increased consolidation of the health-care industry. By the end of 2017, at least three Iowa nursing homes had gone out of business.
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In 2018, Black Hawk County in Northeast Iowa announced that MCOs owed its county-owned nursing home over $500,000 in Medicaid reimbursements. Soon, the county decided it could not sustain the losses and, in October 2018, the county board of supervisors voted 4-1 to sell the facility—owned by the county government for over 100 years—to Pritok Capital, a national private nursing home company.
The impacts of such privatizations are multifold. There is a loss of democratic control, a profit motive is created, and the previous public employees lose their government jobs. The contract between Pritok and Black Hawk reportedly does not require the private company to keep the existing county staff or “meet minimum wage or benefit levels for workers.”
Other impacts of privatization are personal. Boots said she has noticed some changes in the home care she receives since her local, county-run hospital decided to outsource its home care service to a private company in early 2018. She says there’s been more turnover in the nurses, and their scheduling is less consistent, making it difficult for her to plan her day’s activities. She speculates this may be in part because the company’s nearest office serves eight counties—compared to the previous Adair County Home Care, which only serviced Adair. (The public Adair County Home Health service sold its building shortly after its services were outsourced in 2018.)
Peter Damiano, director of Iowa University’s Public Policy Center, says this type of industry consolidation—where larger companies take over smaller providers—is a national trend. Nationally, 2017 had the highest rate of health-care mergers and consolidations in “recent history,” according to Xtelligent Healthcare Media.
However, Damiano says it’s hard to attribute the trend to one cause, like delayed and reduced Medicaid reimbursements. Read the full article at Tarbell.org.
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