Online tools and resources available to help states use health IT to improve health care quality and lower cost

Readers continue to have questions about how the health insurance marketplaces work and coverage requirements there. This week I answered some recent queries.

I purchased health insurance in Ohio through the marketplace in April. I then moved to Missouri and applied for marketplace coverage there that began in October. I had assumed that the Ohio marketplace would cancel my coverage there, but that didn’t happen. What should I do?

When people relocate, it’s up to them to inform the marketplace and their insurer, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

If you don’t inform the marketplace that you’re cancelling your subsidized plan, a 90-day grace period will begin the first month that you don’t pay your premium. The grace period is intended to protect consumers from losing coverage immediately because of a late payment. During the first 30 days, insurers are required to continue coverage and pay claims. For the next 60 days, if consumers still haven’t paid up, insurers may delay paying claims. During this period, consumers can still pay their back premiums and continue their coverage if they wish. After 90 days, the insurer can cancel coverage.

You could be on the hook for the entire premium for the first month of the 90-day period, according to officials at the Centers for Medicare & Medicaid Services. Although consumers would not generally be responsible for repaying any premium tax credit for that first month, in some circumstances they might have to pay that back when they file their taxes, CMS says.

Solomon’s advice: “Call the Ohio marketplace and ask them to retroactively cancel her coverage.”

I help people apply for marketplace policies and I’ve noticed that some of the plans sold on the state marketplaces don’t cover tobacco cessation medication and other products for free as a preventive service. Isn’t that required? 

Under the health law, most health plans have to cover without cost sharing by patients the preventive services that are recommended by the U.S. Preventive Services Task Force, a nonpartisan group of medical experts. The only exception is for plans that are grandfathered under the law.

The task force recommends that doctors ask patients whether they smoke and provide smokers with cessation interventions. In an FAQ last May, the administration spelled out what would be covered:  at least two stop-smoking attempts annually that include at least four counseling sessions and all FDA-approved tobacco cessation medications, both prescription and over the counter options.

Only 17 percent of insurers on the state marketplaces cover tobacco cessation medications without cost sharing, according to a report released Tuesday by the American Lung Association.

Stingy smoking cessation coverage is short-sighted, says Brian Hickey, director of federal government relations at The Campaign For Tobacco-Free Kids, an advocacy group.

“It’s not overutilized and it’s not particularly costly, especially when you consider its ability to reduce future medical costs,” he says.

If a plan doesn’t offer comprehensive coverage, Hickey recommends bringing it to the attention of the state insurance commissioner.

As a small employer, I believe that my employees may be better off if I dropped our group health plan and let them get coverage from the public exchanges. Is there any way for me to provide my employees pre-tax reimbursement for the premiums they pay on the exchanges?

No, that’s not possible. As a small employer, you won’t be fined if you don’t offer health insurance on the job to your employees. In contrast, employers with 100 or more workers face penalties of up to $3,000 per worker for not offering good coverage and those with more than 50 employees will have the same penalties next year. But no matter how many people you employ, you’re not allowed to give workers cash for the purpose of buying their own policy on the exchange, according to published guidance from the Obama administration. That arrangement would count as a group health plan, and under the law those arrangements can’t be integrated with individual exchange coverage.

However, as a small business owner, “you can always pay more in cash to the worker and the worker can take the cash and use it as he wants, whether to buy health insurance or for something else,” says J.D. Piro, a senior vice president at Aon Hewitt, who leads the benefits consultant’s health law group. As an employer, you just can’t earmark that cash for health insurance.

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The National Institute of Mental Health unveiled a five-year strategic plan emphasizing research it hopes will ultimately give clinicians a better understanding of what mental illness looks like inside the brain — before a patient shows outward symptoms.

NIMH is part of the National Institutes of Health.

The plan signals investment to figure out the genes associated with mental illness, develop new treatments based on those findings, make sure research findings are eventually implemented into practice and find brain patterns for a range of disorders.

These four objectives form a broad roadmap – part of what NIMH director Thomas R. Insel, M.D., describes as a “path to discover” – beginning with the fundamental science of the brain and behavior, and ending with public health impact. An estimated 9.6 million Americans have a serious mental illness that impairs daily functioning.

One of the hopes is that the research will enable health professionals to identify people who are at risk and begin treatment early in the disease process.

“Just as brain tumors are detected through CAT scans and diabetes is diagnosed through blood sugar testing, NIMH is focused on employing brain imaging to detect common mental disorders and severe mental illnesses before full-blown clinical presentation,” said Al Guida, the president of Guide Consulting Services, a Washington-based government relations firm that specializes in behavioral health.

Early diagnosis would make a big difference on a variety of levels, allowing people to finish school, find jobs and lead more productive lives.

Shelli Avenevoli, chief of NIH’s Developmental Trajectories of Mental Disorders Branch, says NIH already has research going on that seeks to get help for people right after their first psychotic break. The trial results have been so promising that Congress required each state, starting last year, to implement a program based on the findings.

“For those of us in this area, it’s an aspirational goal: to identify those at risk as early as possible and hopefully before onset of full syndrome so that we can then not just treat something, but prevent it,” Avenevoli said.

But even with private and public research investment, it could be decades before the scientific advances are applied so that a child could be screened for mental illness with a CT scan or some other such tool, said Paul Gionfriddo, president and CEO of patient advocacy group Mental Health America. He added, though, that science already shows that early signs of mental health problems — sleep problems, unusual risk taking, disorganization and difficulty forming friendships — need to be taken into account when diagnosing mental illness.

“Long before the first psychotic break, these symptoms worsen over time and affect school success, relationships with siblings and parents, and inclination to self-medicate,” Gionfriddo said. “We didn’t wait until we had a cure for cancer before doing early identification and starting to fight it, and we can’t afford to wait until we have a cure for psychosis before fighting that either.”

Shifting resources from treating people when they have a full-blown illness to when they are just presenting symptoms or have an irregular brain scan will mean a change in how the mental health system works, said Ken Duckworth, medical director for patient advocacy and lobbying group the National Alliance for Mental Illness. “NIMH is helping to drive a culture change,” he added.

But despite the promise, some experts also offer reminders that even with such advances there will still be room for error.

“They’re looking for a perfect indicator before intervention, but is anyone noticing what’s going on with mammograms and other imperfect early indicators that work well enough, but have flaws? Elevated cholesterol levels don’t necessarily mean you’ll have a heart attack,” and the same will be true for mental illness, said William McFarlane, director at the Center for Psychiatric Research at the Maine Medical Center in Portland, Maine.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Whether a patient is in the hospital for an organ transplant, an appendectomy or to have a baby, one complaint is common: the gown.

You know the one. It might as well have been stitched together with paper towels and duct tape, and it usually leaves the wearer’s behind hanging out.

“You’re at the hospital because something’s wrong with you –  you’re vulnerable – then you get to wear the most vulnerable garment ever invented to make the whole experience that much worse,” said Ted Streuli, who lives in Edmond, Okla., and has had to wear hospital gowns on multiple occasions.

Put another way: “They are horrible. They are demeaning. They are belittling. They are disempowering,” said Camilla McRory of Olney, Md.

The gowns are among the most vexing parts of being in the hospital. But if efforts by some health systems are an indicator, the design may be on its way out of style.

The Cleveland Clinic was an early trendsetter. In 2010, it introduced new gowns after being prompted by the CEO, who often heard patient complaints when he was a practicing heart surgeon. That feedback led to a search for something new, said Adrienne Boissy, chief experience officer at the hospital system.

The prominent academic medical center ultimately sought the help of fashion icon Diane von Furstenberg, settling on a reversible gown with a front and back V-neck, complete derriere coverage, and features such as pockets, softer fabric and a new bolder print pattern.

Patients “loved the gowns,” Boissy said. “People felt much more comfortable in the new design, not just physically but emotionally.” In recent years, she added, “hospitals are looking at everything they do and trying to evaluate whether or not it contributes to enhancing the patient experience.”

It’s all part of a trend among hospitals to improve the patient reviews and their own bottom lines – fueled in part by the health law’s focus on quality of care and other federal initiatives. The Centers for Medicare & Medicaid Services increasingly factors patients’ satisfaction into its quality measures, which are linked to the size of Medicare payments hospitals get.

Sometimes the efforts involve large capital improvement projects. But they can also mean making waiting rooms more comfortable, improving the quality of food served to patients or, as in this case, updating hospital gowns.

Ultimately, this focus leads to “a better patient experience,” said John Combes, senior vice president of the American Hospital Association.

The Detroit-based Henry Ford Health System is in the process of updating its gowns, an initiative that began when the system’s innovation institute challenged students at the city’s College for Creative Studies to identify and offer a solution to one hospital problem.

The students responded with the suggestion to redo the garment that has often been described by patients as flimsy, humiliating, indecent and itchy. The process took three years, but last fall, the institute unveiled a new and improved version. It’s made of warmer fabric – a cotton blend – that wraps around a patient’s body like a robe and comes in navy and light blue, the hospital’s signature colors.

Patient expectations are part of the calculus. They “are demanding more privacy and more dignity,” said Michael Forbes, a product designer at the Henry Ford Innovation Institute.

When the institute tested his gown design, Forbes said, patient-satisfaction scores noticeably increased in a few days.

The new gown “was emblematic … of an attitude that was conveyed to me at the hospital – that they cared about me as a whole human being, not just the part they were operating on,” said Dale Milford, who received a liver transplant during the time the redesign was being tested. “That was the subtext of that whole thing, was that they were caring about me as a person and what it meant for me to be comfortable.”

But replacing the traditional design is no easy task. What patients wear needs to be comfortable yet allow health professionals proper access during exams, meaning it must open and close easily. The gowns also need to be easily mass-manufactured, as well as efficiently laundered and reused.

New designs, though, can be expensive. After Valley Hospital of Ridgewood, N.J., switched to pajamas and gowns that provide extra coverage, costs went up $70,000 per year, said Leonard Guglielmo, the facility’s chief supply chain officer, because the new garments cost more to buy and maintain.

Beyond cost, more ingrained cultural expectations might also play a role in what hospitals think patients should wear, said Todd Lee, an assistant professor of medicine at McGill University, who co-authored a 2014 study in the journal JAMA Internal Medicine, examining whether gowns were important and whether patients might be fine wearing their own or hospital-provided pants, instead of or along with gowns.

Often, doctors reported that pants or undergarments beneath gowns would have been okay, but patients said they were never given those options. Traditional gowns make it easier to examine patients quickly, and several doctors Lee spoke to seemed shocked at the idea that patients might wear garments other than the open-backed gown during their stay.

But the most common challenge isn’t necessarily doctor expectations or costs. It’s navigating hospital bureaucracies, said Dusty Eber, president of the California-based company PatientStyle, which designs and sells alternative gowns. In his company’s experience, hospital decisions are often made by committees, not individuals.

“There’s a lot of bureaucratic runaround,” Eber said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

HHS gave around $12 million to BioCryst Pharmaceuticals of Durham, North Carolina, for the advanced development of a promising experimental drug for Ebola, including preparing for large-scale manufacturing of the drug and conducting related studies.

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SAN FRANCISCO — Dan Swangard knows what death looks like.

As a physician, he has seen patients die in hospitals, hooked to morphine drips and overcome with anxiety. He has watched death drag on for weeks or months as terrified relatives stand by helplessly.

Recently, however, his thoughts about how seriously ill people die have become personal. Swangard was diagnosed in 2013 with a rare form of metastatic cancer.

To remove the cancer, surgeons took out parts of his pancreas and liver, as well as his entire spleen and gallbladder. The operation was successful but Swangard, 48, knows there’s a strong chance the disease will return. And if he gets to a point where there’s nothing more medicine can do, he wants to be able to control when and how his life ends.

“It’s very real for me,” said Swangard, who lives in Bolinas, Calif. “This could be my own issue a year from now.”

That’s one of the reasons Swangard joined a California lawsuit last month [February] seeking to let doctors prescribe lethal medications to certain patients who want to hasten death. If he were given only months to live, Swangard said, he can’t say for certain whether he would take them.

“But I want to be able to make that choice,” he said.

The right-to-die movement has gained renewed momentum in California and around the nation following the highly publicized death of an East Bay woman with brain cancer. Brittany Maynard, 29, moved to Oregon to take advantage of its “Death with Dignity” law and died in November after taking a fatal dose of barbiturates prescribed by her doctor.

The California lawsuit asks the court to protect physicians from liability if they prescribe lethal medications to patients who are both terminally ill and mentally competent to decide their fate.

The lawsuit argues that while it is against the law in California for anyone to assist in another’s suicide, these cases are not suicides. Rather, the suit argues, they are choices by a dying person on how his or her life should end and decisions about one’s own body protected under the state constitution.

Separately, two California state senators have proposed a bill that would allow doctors to prescribe lethal medication to certain terminally ill adults.

Three states – Oregon, Washington and Vermont – already have laws allowing physician-assisted deaths. Courts in New Mexico and Montana also have ruled that aid in dying is legal, and a suit was also recently filed in New York.

Legislation is pending in several other states. Kathryn Tucker, an attorney on several of the court cases, is also spearheading the California lawsuit. This time, she and her legal team decided to include among the plaintiffs two doctors with life-threatening illnesses, Swangard and a retired San Francisco obstetrician.

Physicians “have a very deep and broad understanding about what the journey to death can be like,” said Tucker, executive director of the Disability Rights Legal Center. “The curtain is pulled back. For lay people, death is much more mysterious.”

Historically, doctors have been some of the most vocal critics of assisted suicide, also called aid-in-dying. The American Medical Association still says that “physician-assisted suicide is fundamentally incompatible with the physician’s role as healer.” Similarly, the California

Medical Association takes the view that helping patients die conflicts with doctors’ commitment to do no harm. “It is the physicians’ job to take care of the patient and that is amplified when that patient is most sick,” said spokeswoman Molly Weedn.

But a recent survey of 21,000 doctors in the U.S. and Europe shows views may be shifting. According to Medscape, the organization that did the survey, 54 percent of American doctors support assisted suicide, up from 46 percent four years earlier.

Swangard is among those who believe that taking care of patients means letting them choose how their lives should end. That’s not the same as killing patients or facilitating suicide, he said.

Swangard completed his medical residency in San Francisco in the in the middle of the AIDS crisis; young men were dying all around him. Throughout his career as an internal medicine doctor, a hospice volunteer and now an anesthesiologist, he has become frustrated with how the medical system handles death. Doctors spend so much time trying to extend life that few focus on what patients wanted in their last days, he said.

“I don’t think we know how to die,” he said. “We fight tooth and nail to keep that from happening.”

Swangard’s own illness was discovered in early 2013 during a long overdue check-up. He hadn’t been worried about his health – he was obsessed with fitness, swimming regularly and seeing a trainer twice a week. But when the doctor pressed on Swangard’s stomach, he felt a mango-sized mass.

He had a visceral feeling, he said, “something bad was happening.”

Within a week, a surgeon found a neuroendocrine tumor in the pancreas and metastasis in the liver. It was the same cancer that took Steve Jobs’ life – one that doesn’t generally respond to chemotherapy or radiation. “My fears became real,” he said.

The doctors told him they believed they got all the cancerous cells. But Swangard was tormented by questions: Am I going to be alive in a year? Is my cancer going to come back?

“I wasn’t sleeping, I wasn’t exercising, I was marinating in my own sadness and fear of what this all meant,” he said. “I thought, ‘This is going to kill me.’”

Since his diagnosis, Swangard said he has had a greater understanding of his patients’ struggles. Occasionally, he holds their hands and tells them he has been where they are.

Earlier this year, a physician friend asked him if he’d be willing to join the California case. Swangard didn’t hesitate. He didn’t go into medicine to help dying people linger and wants to help change that approach — for his patients and for himself.

When he dies, Swangard said, he wants to be surrounded by people he loves. He doesn’t want to be in a drug-induced haze, nor consumed by worry about what’s next. He wants to be able to say good bye.

“It is a little bit of a blessing to know how I might die,” he said. “I don’t think a lot of patients have insight into what to expect.”

These days, he wears a Buddhist prayer bracelet, a reminder to focus on the present. He cut his work hours, swims as often as he can and meditates regularly. At home, he stares out at the ocean, often watching dolphins pass by. He makes every effort to stay calm and healthy.

He is in remission but he knows that what happens with the cancer is largely outside his control An MRI last year showed a small lesion in his liver, which doctors are watching closely.

“It’s this big unknown,” he said.

Dr. Robert Liner, a fellow plaintiff who only recently met Swangard, lives with the same uncertainty.

On his 69th birthday in May 2013, the retired obstetrician had a bad cough. He felt tired and short of breath. His wife took him to the hospital, where doctors discovered malignant masses on his kidneys –advanced- stage lymphoma.

After radiation and chemotherapy, the tumors shrank. He also is in remission. But if the cancer comes back, he said, “the prospects are not going to be good.”

He often thinks of a former patient, a 25-year-old woman with metastatic ovarian cancer. She wanted to die while she still was able to communicate. Liner wasn’t able to help ease her death because the law wouldn’t let him. “I felt like I’d failed her,” he said.

Years before his diagnosis, Liner, now 70, became involved with Compassion & Choices, an organization that promotes aid-in-dying. He has a shelf of books in his San Francisco home devoted to the subject: Being Mortal, Dying Right, Knocking on Heaven’s Door.

He keeps a stack of notecards with quotes about the end of life, which he often recites in speeches to church groups or senior centers. One reads, “The best preparation for death is a life well-lived.”

He believes having medication to hasten death helps terminally ill people live fully in their last weeks or months without being immobilized by fear. “If you are riddled with anxiety, you are not free to concentrate on what’s most meaningful to you,” he said.

Like Swangard, Liner doesn’t know if he would take the medication. He recently married the woman he calls his “beloved” and said he has lots of plans for his retirement years, including writing a screenplay and improving his piano playing.

“My wife says I’d be hanging on to life by my fingernails,” he said.

But that decision should be his to make, with his family and his doctor, he said. “I want the comfort of knowing it’s up to me when enough is enough,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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MARY AGNES CAREY:  Welcome to Health on the Hill, I’m Mary Agnes Carey. The troubled Medicare Physician payment formula is one step closer to repeal. After 17 short-term fixes over the last decade, the House of Representatives voted overwhelming to scrap Medicare’s Sustainable Growth Rate, or SGR, and replace it with a system that pays doctors based on the quality of care rather than the quantity.

The Senate is expected to act on the measure next month. Jennifer Haberkorn of Politico Pro joins us now with the latest. Thanks, Jen.

JENNIFER HABERKORN, POLITICO PRO:  Thanks, MAC.

MARY AGNES CAREY:  The House voted 392-37 to pass an SGR overhaul. President Obama supported this plan and there was a lot of pressure on the Senate to act, but it didn’t. Why didn’t the chamber vote on the SGR bill before it left town for a two-week recess?

JENNIFER HABERKORN, POLITICO PRO:  The Senate was wrapping up its “vote-o-rama,” which is a purely Washington term for 15 hours of straight voting on amendments to the budget. Some hoped, and some thought that they would then move to this and pass this Sustainable Growth Rate repeal immediately. But the Senate feels like they have some time – the Obama administration can delay Medicare payments, essentially delaying the cuts to doctors, for two weeks. So they have time to return to this and pass it before physicians would actually see a cut in their rates.

Also the Senate really wanted to amend this policy. It was passed by the House, they were kind of miffed that they weren’t involved. So they want to be able to vote on making some changes to policy. Those amendments are unlikely to be approved, but they want to be able to make a point. There was also some concern that they didn’t have enough time to read the legislation and then all of the budget votes, and they were skeptical of passing this at about 4 in the morning.

MARY AGNES CAREY:  The Senate doesn’t come back until April 13, and that leaves a lot of time for lobbying on this package – maybe people who like it, people who don’t. What are you expecting?

JENNIFER HABERKORN, POLITICO PRO:  Traditionally in Washington, the more time you have, the more opportunity there is for opposition to fester. That should be a concern in this case because it is two weeks before the Senate returns, but the House vote, as we said, was overwhelming: 392 votes. Advocacy groups are pretty overwhelmingly supportive of it. And I don’t see any real opposition brewing unless something new comes out – something unexpected like there’s a provision in the bill that no one realizes was there or something really significant like that. So I see the next two weeks – physician groups putting some lobbying time into ensuring the Senate vote is as strong as possible.

MARY AGNES CAREY:  You mentioned Senate amendments a moment ago. What sort of amendments are we likely to see when the Senate takes up this package?

JENNIFER HABERKORN, POLITICO PRO:  The Senate really wants four years of funding for the Children’s Health Insurance Program. The policy right now is only two years and they want to be able to vote on doubling that to four. I don’t think that is likely to pass, particularly because it is a pretty expensive policy change. We are also likely to see an amendment on a budget point of order, which is really just acknowledging that this policy is not fully paid for, so it would add to the deficit in the first ten years and particularly conservative budget hawks would like to be able to voice opposition to adding to the deficit.

MARY AGNES CAREY:  Let’s go back to that House vote for a minute. Just want to get your impressions, I mean I found it so interesting that House Speaker John Boehner could convince many conservative Republicans to vote for this, even though as you say it wasn’t fully paid for. Nancy Pelosi the Democratic leader also got her troops mostly to go along, even though they had concerns, same concerns as Senate Democrats about the Children’s Health Insurance Program funding, there were some concerns that beneficiaries are picking up too much of this package. How did that all come together?

JENNIFER HABERKORN, POLITICO PRO:  I think a couple really strategic decisions by leadership were key. Conservatives were able to get the early support of Americans for Tax Reform, which is really influential with conservatives who are concerned about the budget. That kind of quelled some of that opposition. Nancy Pelosi very early on made it clear that she wanted more money for the CHIP program, but just wasn’t going to be able to get it in this deal.  And so, that really tapped down opposition from the far ends of both sides, Republicans and Democrats.  Also, this policy was just so widely hated that there was a lot of support for getting rid of it even if you had to accept some things that you didn’t like.

MARY AGNES CAREY:  Do you think that House vote, coupled with the likely Senate action on the sustainable growth rate scrapping this formula once and for all, is this a sign that we are going to see more bipartisan cooperation on health care in the future?

JENNIFER HABERKORN, POLITICO PRO:  You know, it’s certainly a sign that it’s possible. Whether we are going to see more of this, it’s really hard to say at this time.  This deal seemed to come out of nowhere. You know, we’ve been doing “doc fixes” like you mentioned earlier for a decade. No one thought the policy would going to get repaired anytime soon. And it was perhaps less about health care and more about just this recurring, very Washington, problem of fixing this budget problem.  But I will say, this was the number one policy concern of just about every physician organization, a lot of the hospital organizations because they were always taxed to pay for these doc fixes. So it kind of clears the plate of health advocacy organizations and helps health policy people on Capitol Hill.

MARY AGNES CAREY:  We’ll see were it goes. Thanks so much Jennifer Haberkorn of Politico Pro.

JENNIFER HABERKORN, POLITICO PRO:  Great to talk to you.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.