Nurses from Seattle Children’s Hospital got down and groovy for an online video challenge to their very own remake of Abba’s Dancing Queen.  The nurses went all out with disco moves and sparkly bell bottoms. Watch the fun video below.

Nurses from Seattle Children’s Hospital got down and groovy for an online video challenge to their very own remake of Abba’s Dancing Queen.  The nurses went all out with disco moves and sparkly bell bottoms. Watch the fun video below.

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WARSAW, Ind. – Tom Till eyes the morning’s email to see who’s angling to hire his students: A local employer, which had already hired 23 people in less than a year, says it needs three more to help make the artificial hips, knees and other devices manufactured here in the self-proclaimed “Orthopedic Capital of the World.”

“Everyone is going gangbusters,” said Till, who oversees an advanced manufacturing program at Ivy Tech Community College in this lake-dotted region two hours north of Indianapolis.

Till’s bullish view of the medical device industry – he says he can’t crank out graduates fast enough — contrasts sharply with what industry lobbyists are telling lawmakers in the nation’s capital. They say a 2.3 percent tax on the sale of medical devices put in place two years ago by the Affordable Care Act has already cost more than 30,000 jobs and is stifling innovation.

The tax, projected to bring in $29 billion over 10 years, is the industry’s share of the cost of expanding health coverage to millions of Americans. Other industries expected to gain business from the health law, including hospitals, insurers and drug makers, are also paying a share of its costs, but none has been as vocal in opposition as the device makers, which have poured $30 million a year into lobbying Congress since 2010.

This month, with Republican leaders citing repeal of the tax as a top priority, the industry may finally achieve its aim. The effort also has the support of at least a handful of Democrats from districts with large concentrations of device makers, including Sens. Elizabeth Warren of Massachusetts and Al Franken and Amy Klobuchar of Minnesota.

(Whether GOP leaders would have enough Democratic support to muster a two-thirds override should President Barack Obama veto a repeal bill is unclear.)

“No one likes a tax, especially this tax, which goes onto a lot of innovative companies,” said Dan Mendelson, CEO of Avalere Health, a health care consulting firm. It “was not a tax that even the people who voted for the bill liked. It was put in to establish parity with other health industry payments.”

Challenging Times

To hear the industry tell it, the last few years have been particularly tough ones marked by flat revenues and declining investment, especially in early-stage innovations.

The biggest challenge is “price pressure, mostly from hospitals” seeking to curb their own costs, said analyst Jeff Jonas, portfolio manager for Gabelli Funds in Rye, N.Y. “The effect of the tax has been a negative, but the device industry has been able to offset it,” primarily through layoffs and restructuring.

While a few large firms account for the lion’s share of annual sales – estimated between $106 billion and $116 billion a year — the companies range from startups to global giants like Johnson & Johnson and Medtronic.

Publicly traded firms reported flat revenues in 2013, the first year the device tax was in effect, according to EY, an advisory service that is part of Ernst & Young Global Limited.

Slow or flat revenue growth continued in 2014, said Jason McGorman, medical device analyst for Bloomberg Intelligence.

As in other health care sectors, a slew of mergers has swept the industry – in Warsaw, Zimmer Holdings has made a $13.4 billion bid to buy cross-town rival Biomet – raising concerns about consolidations and layoffs. A few firms are also reportedly considering moves overseas both to capture fast-growing markets and take advantage of less demanding regulations and taxes.

Yet a visit to Warsaw, a town often viewed as a barometer of the device industry because one of every four jobs here is tied to it, suggests a stable, if not thriving, sector. Besides Zimmer Holdings and Biomet, Warsaw is also home to DePuy Synthes, part of Johnson & Johnson, along with about 14 other device companies and suppliers.

Students in Till’s program sometimes get job offers even before they finish their coursework.  And unemployment in surrounding Kosciusko County in November was 4.8 percent, lower than the national average of 5.8 percent.

To be sure, the area may be more insulated from job losses because its firms specialize in orthopedic devices, which have been more profitable in recent years than cardiac devices or spinal implants, say analysts.

Amy Pritchett, who went back to school to learn to operate specialized machinery after a back injury forced an end to her 15 years as a nursing home aide, revels in her new career as a machinist.

“The money is better. Life is better. And I’m nowhere near as stressed,” said the 34-year-old about her job at the vast Paragon Medical plant just outside Warsaw.

Pritchett got four job offers last January, right after she finished a 22-week training program at Ivy Tech.  “They literally all came in on the same day,” she said.

Who Will Really Pay The Tax?

Proponents of the device tax say the industry will simply pass the cost along to customers, or will make up for it through increased use of their products as more people gain health insurance.

Wells Fargo Securities analyst Larry Biegelsen projects that demand for medical devices will grow, along with the number of insured Americans.  “We believe this will be sufficient to offset the 2.3 percent med-tech tax,” Biegelsen wrote during the first year of the tax.

Wall Street has also been optimistic about the industry’s prospects, with companies’ share prices growing faster than the S&P 500 in the first half of 2014. Orthopedic companies saw a 39 percent increase in share prices, according to a report from Mercer Capital, a valuation firm based in Memphis.

While there have been some jobs lost as a result of the device tax, industry figures of tens of thousands are greeted skeptically by Wall Street, as well as by government analysts.

In November, the Congressional Research Service reported the device tax had “fairly minor effects,” with output and employment dropping by “no more than two-tenths of 1 percent.”

The industry’s lobbying arm, AdvaMed, fired back, saying the report is flawed because it assumes the cost of the tax would be passed along to customers. But that’s been difficult to do because hospitals are seeing their own reimbursements drop, and are pushing back against price increases.  Analyst McGorman said prices across the industry have fallen 1 to 3 percent annually.

AdvaMed said it surveyed members after the first full year of the tax and they cited a loss of “approximately 33,000 industry jobs,” with about 14,000 of those direct cuts and the rest a more speculative accounting of jobs that would likely have been created without the tax.

Chilling Effect On Startups

Still, a jobs’ tally isn’t the only way to measure the impact of a tax which comes right off the top of revenues and can be harder on smaller, newer companies.

“We have not as a result of this tax had to lay people off … but it has definitely had a chilling effect on our ability to grow head count,” said Mark Throdahl, president and CEO of OrthoPediatrics, an 82-employee company in Warsaw that specializes in child-sized devices used in orthopedic surgery.

The tax put on hold plans to proceed with developing a ligament repair tool for a specific type of knee surgery. The tax will cost the not-yet-profitable seven-year-old firm $500,000 this year, he said.

“If we were a big company, we would have a profit stream to tap into to pay a tax like this,” he said, “but we’re not there yet. The only way we can pay it is by reducing expenses.”

Repealing the tax may have political appeal, but it could prove challenging as other industries that pitched in to cover the cost of ACA demand similar relief.

“We feel there is a delicate balance: Is this where Congress ought to spend their first $28 billion, restoring the device tax?” asks Mary Ella Payne, a senior vice president for Ascension Health, one of the nation’s largest nonprofit hospital chains.

Scott Caldwell, CEO of The Resource Group, which helps Ascension buy devices and other products, said that even if the device makers can’t raise prices because groups like his push back, many of the larger firms can handle the tax.

“I looked at the net income for the top five firms that sell devices to Ascension – and it’s 17 times more than Ascension’s,” he said.

But for smaller firms, repeal could restore some research funding and help win back investors, who have been reluctant to put money into firms, knowing a portion would be used to pay the tax, rather than build the product.

“If this tax went away,” said Throdahl at OrthoPediatrics, “it would be transformational to our ability to develop products for kids.”

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

This week I answered questions from readers who are running into difficulties with premiums and tax credits on their marketplace plans.

My 63-year-old husband has Alzheimer’s disease. Our annual income is $41,000, from a combination of his Social Security disability insurance (SSDI) and a disability policy he had from a previous job. Last year I bought a single policy on the health insurance exchange. My husband gets coverage through the Veterans Administration. The monthly premium was reduced by a $278 tax credit based on our estimated annual income. Now I’m reviewing IRS form 8962 that’s used to reconcile what we received in premium tax credits against what we should have received based on our actual income. It looks like we’ll have to repay $2,500! We can’t afford that. If the marketplace made a mistake in figuring our tax credit, do we still have to pay the money back?

If you received too much in premium tax credits, you’ll generally have to pay some or all of it back. Health policy experts say they know of no provision in the health law or rules that would excuse someone from repayment if  an error that resulted in a tax credit overpayment was made by the online marketplace. An administration official didn’t respond to a request to clarify whether those situations would be handled differently than if someone underestimates their own income and receives too much.

The amount you’ll have to repay is capped based on your income. A couple with an income between 200 and 300 percent of the federal poverty level ($31,460 to $47,190 for a family of two in 2014) would have to repay up to $1,500. (People with incomes above 400 percent of poverty –$62,920 for a couple — would have to repay the entire amount.)

It’s hard to know if or where an error occurred. It’s possible that you or the marketplace calculated your income incorrectly. SSDI counts as income when figuring your eligibility for premium tax credits, but disability insurance payments received from an employer policy may or may not count as income depending on who paid the premium, says Karen Pollitz, a senior fellow at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)

Perhaps you or the marketplace entered information incorrectly, transposed figures or made some other manual or computer entry error.

By early February you should receive Form 1095-A from the marketplace detailing how much you received in tax credits for reconciliation purposes. It will be important to use that to make sure your calculations on Form 8962 are correct.

If you discover there was an error in your premium tax credit last year, you’ll still have time to sit down with a navigator to go over your 2015 coverage choices before open enrollment ends Feb. 15.

“If she made a mistake, she doesn’t want to compound it by making it again,” says Pollitz.

I had coverage through a health insurance marketplace plan last year, and this year I’m told my costs will increase significantly. The actual premium the insurance company will charge won’t change and my income hasn’t changed. But the amount of premium tax credit I receive will go down. What can I do?

Before you renew your coverage with the same plan you had last year, go back to the marketplace and check out what else is available. It sounds as if the benchmark plan in your area may have changed, and that could mean a higher bill for you unless you switch plans.

Here’s how it works: Premium tax credits are based on the second-lowest-cost silver plan in your area, called the benchmark plan. If the cost of the benchmark plan this year is lower than it was last year, your tax credit may be lower as well. That’s not a problem if you switch to the new, cheaper benchmark plan. But if you renew your old plan, you’ll have to pay the difference in cost between its higher premium and that of the new benchmark plan.

“Even though your premium didn’t change and your income didn’t change, you could see a significant difference in what your contribution is because the premium for the second lowest cost silver plan is different,” says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

I am being told that I must furnish automatic debit card information before an insurance company will provide me with coverage through the exchange. Can they do that?

Health insurers that sell coverage on the marketplaces are required to accept various forms of payment, says Sandy Ahn, a research fellow at Georgetown University’s Center on Health Insurance Reforms. That includes paper and cashier’s checks, money orders, electronic funds transfers and pre-paid debit cards.

An insurance industry representative said this sounded like a misunderstanding. “Plans accept various forms of payment and wouldn’t limit a consumer only to a debit card,” says a spokeswoman for America’s Health Insurance Plans, an insurance industry trade group. “Health plans regularly work with their members to establish the payment plan that works best for them.”

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.

As a consultant who counsels families on end-of-life care management, Johanna Turner often shares the story of her mother’s final days 21 years ago. Thanks to the skilled and loving care provided by a local hospice, Turner was able to keep her promise to let her mother die in their Oakton, Va., home.

“She had the best of care for five months,” says Turner, a District resident. “A hospice licensed practical nurse came first thing in the morning to help change complex dressings, a primary nurse visited several times a week, there was an on-call nurse to help address pain-control questions in the middle of the night, plus a social worker and a chaplain. It took all of us to get through those weeks.”

Still, Turner tells families, she had to bear much of the caregiving, even taking a leave of absence from her job. “I treasured that time, but it was physically and emotionally exhausting. Hospice made it doable, but the truth is, it was still a lot of hard work.”

Some families, she says, may not be able to bear that burden, certainly not without hiring extra help. But, she says, “the hospice gave me the skills and confidence to do what I wanted so badly to do for my mother. I will always be grateful.”

Introduced to the United States in the 1970s, hospice care is becoming an increasingly common treatment. Last year, 1.65 million people received hospice care, up from just more than 1 million in 2004, according to the National Hospice and Palliative Care Organization. In addition, there were more than 5,500 programs in the U.S. last year, compared to 3,100 in 2000.

Although the growth in hospice programs has given patients and their families more choices than ever, a recent Washington Post investigation into the industry found widespread concerns about the quality of care. The Post cited numerous complaints, noting that although hospices are supposed to provide continuous nursing care to patients whose pain or symptoms are out of control — commonly called “crisis care” — one in seven do not.

Unfortunately, there is no federal rating system — as there is for hospitals and nursing homes — that can help consumers make educated choices about the hospice they select.

For many families, hospice is an unfamiliar concept that prompts fear and questions, including where, why and even when someone should receive hospice care. To help patients and their caregivers, here are some hospice basics:

What Is Hospice Care?

Hospice is not a particular place, like a hospital, but a service that provides end-of-life care and support to the dying and their families, most often in a patient’s home. By signing up for hospice, patients generally agree to stop all disease-fighting treatments, such as chemotherapy and radiation, although some hospices allow such therapy if it is to help manage symptoms, such as pain or problems breathing.

One of the hospice’s primary goals is to alleviate pain. Through a team of caregivers — doctors, nurses, social workers, grief counselors, spiritual counselors, home health aides and volunteers — the hospice provides comprehensive care, including drugs, medical supplies and equipment. It instructs families on patient care and even provides special services such as physical therapy and psychological counseling.

“If we can manage and alleviate pain, we can help reinvigorate patients to help them accomplish whatever it is they want to do in their remaining days, whether it’s making peace with an estranged sibling, attending the wedding of their grandchild — or just going out to eat or fish,” says Malene Davis, president of Capital Caring, one of the first hospices in the Washington area. It now cares for about 1,200 patients a day.

How Much Care Does Hospice Provide?

Comprehensive care generally does not mean around-the-clock service, although many hospices provide 24/7 care when the patient is in crisis or near death.

“The hospice will teach families how to care for a patient, address their concerns and answer questions, but it does not take over the caregiving,” says Dale Lupu, an associate professor at George Washington University’s Center for Aging, Health & Humanities. “Someone on the hospice staff should be available by phone 24/7 in case there’s a crisis. But for hour-by-hour, day-to-day care, the family has to figure out a way to be involved,” even if it means hiring a private nurse or home health aide.

That’s one reason why hospice care may not be for everyone. “Families have to look within themselves and ask if they are comfortable being part of the dying process,” says Linda Kunkel, director of marketing and business development for Care Options, a Northern Virginia care-management firm. “It can be very gut-wrenching and, for some people, very hard.”

Who Pays For Hospice Care?

Medicare covers most hospices for its beneficiaries. Private insurance plans and HMOs also generally pay for hospice care, but they may have a preferred provider. Check with your insurer before you begin your hospice search.

In some cases, a small co-pay — such as $5 or 5 percent — may be required for medication, inpatient facility care and/or respite care.

Additionally, most hospices offer financial help for families in need. So make sure to discuss any financial concerns in your initial meetings.

If Hospice Is Not A Place, Where Do I Get Hospice Care?

Nearly two-thirds of hospice patients die at their homes, a nursing home or an assisted-living facility.

For patients who can’t be cared for at home — perhaps they live alone or have complications that can be treated only at a health-care facility — some hospices have inpatient facilities in freestanding centers or specially designated sections in hospitals or nursing homes.

Why Would I Want Hospice Care? Can’t My Doctors And Local Hospital Adequately Meet My Needs?

Surprisingly no, hospice experts say.

“The traditional medical approach is cure, cure, cure; but when a person is dying, he or she may need a different approach,” says Linda Adler, head of Pathfinders Medical, a California health-care advocacy firm that helps patients with complicated medical diagnoses. “The patient needs someone who’s willing to move the conversation from finding a cure to having best quality of life in the midst of an illness, someone who’s not afraid to talk about the end of life and provide compassion in the final days. Most physicians aren’t trained to do that.”

Hospice caregivers also have in-depth training and experience in palliative treatments for pain management. “Most doctors are not adequately trained in pain management, and the quality of pain control in hospitals and nursing homes is very uneven,” says Naomi Naierman, who was the president of the American Hospice Foundation before it closed last year.

When Should I Start To Think About Hospice?

Most hospices require an order from the patient’s physician as well as approval from the hospice medical director. Both must certify that the patient has six months or less to live if the illness runs its normal course. However, if a patient outlives that time, he or she can be “recertified” to continue receiving hospice care.

But experts in end-of-life care say most Americans need to start thinking about hospice long before the final six months is near. As the American Cancer Society notes on its website: “One of the problems with hospice is that it’s often not started soon enough. Sometimes, the doctor, patient, or family member will resist hospice because he or she thinks it means you’re ‘giving up,’ or that there’s no hope. This is not true. If you get better or the cancer goes into remission, you can leave hospice and go into active cancer treatment.”

Indeed, hospice experts say many people leave hospice, a situation that the late humorist Art Buchwald made famous when recounting his own discharge from a hospice. Patients can then be readmitted to hospice when their conditions deteriorate again.

J. Donald Schumacher, president of the National Hospice and Palliative Care Organization, says patients should discuss hospice options as early as they are diagnosed with a potentially fatal disease. “Don’t wait for the doctor to begin the conversation. Even if you agree to aggressive therapy, ask what are the plans if you don’t return to your optimum health.”

Are All Hospices The Same?

No; they vary greatly.

An increasing number of hospice organizations are for-profit, a distinct change from the early days of the hospice movement when they were mostly nonprofit. Today, 65 percent of hospice organizations are operated as for-profit companies, up from 34 percent in 2000.

Being a for-profit company is not inherently bad, but many of the complaints about substandard service have been leveled at for-profit hospice firms, The Post investigation found. The Post reported that the typical for-profit spent less on nursing and was less likely to have sent a nurse in a patient’s last days of life.

Still, Adler of Pathfinders Medical says consumers shouldn’t necessarily refuse to use a for-profit concern. “There are bad hospices, just like there are bad doctors” in both for-profit and nonprofit organizations, she says. “There are also great hospices in both kinds of groups. That’s why people need to do their homework.”

How Do I Find A Good Hospice?

First, seek recommendations from health-care providers and specialists such as geriatric-care managers. Ask which hospice they would use for themselves or a loved one.

Next, call the recommended hospices and ask questions about the issues that matter most to you, such as:

— How often do their caregivers come to visit? (A nurse’s aide should visit about three times a week and a nurse or doctor once a week, Naierman says.)

— Are their doctors and nurses certified in palliative care?

— Is there crisis care? How fast can a caregiver get to your home in case of a crisis? Will they come at any time, even 3 a.m. Saturday?

— Will the patient’s primary doctor still be involved in the medical care?

— Will a nurse or clinician be in the home when the patient is actively dying? (“The answer should be yes,” Naierman says. “If it is anything but yes, run, don’t walk, away.”)

— Is there an inpatient facility if the patient needs extra care? Is it conveniently located?

— Are there limits on radiation and chemotherapy, even if it’s to control pain? What about IVs, dialysis or blood transfusions?

— How does the hospice handle new health problems that are curable, such as urinary tract infections or pneumonia?

— What is expected from family members? What will they be required to do? Give medicine, including shots? Bathe the patient?

— Is respite care – providing relief and time off for caregivers – offered?

“Having a conversation with the hospice admission people helps you get a feel in advance on how receptive they will be to your needs,” says Naierman, who helped develop 16 key questions to ask a hospice.

Are There Any Other Criteria To Judge The Quality Of A Hospice?

Yes. Here are some details to look for:

— Accreditation status. Three organizations — the Joint Commission, the Accreditation Commission for Health Care and the Community Health Accreditation Program — inspect and approve hospice programs.

“I would always lean toward an accredited program when available because it speaks to a program’s willingness to open itself to review and, hopefully, improvement,” says Lupu, who notes that only 40 percent of hospices are accredited.

— Age and patient load. “Experience — gained over time and gained over a number of cases — usually helps build both individual clinician expertise and organizational/team expertise,” Lupu wrote in a recent post on Pallimed, a blog about hospice and palliative medicine. “Very new and very small hospices are unlikely to have the breadth of experience and the depth of resources to assist with challenging or unusual circumstances.” She suggested that patients should generally lean toward an organization with at least five to 10 years of experience that handles at least 80 patients a day.

— “Live discharge rates,” which is the proportion of people who leave hospice care before dying. A large number of departures may signal that patients were unhappy with care and services. “I’d select a hospice with a live discharge rates in the 10 to 20 percent range,” Lupu says.

Where Can I Go For Additional Help?

There is a lot of information on hospices on the Internet, including:

— The National Hospice and Palliative Care Organization’s Moments of Life website and its Caring Connections page.

— The American Hospice Foundation’s educational website.

— The American Cancer Society’s fact sheets on hospice care.

— The Washington Post’s online consumer guide.

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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