Tuesday’s re-election of Republican governors in closely contested races in Florida, Georgia, Wisconsin, Maine and Kansas dims the chances of Medicaid expansion in those states.
Advocates hoping for Democratic victories in those states were disappointed by the outcomes, but Alaska, which also has a Republican incumbent, remains in play as an independent challenger holds a narrow lead going into a count of absentee ballots.

“No one would say it was a good night for the prospects of Medicaid expansion,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University.

Still, Alker said the playing field for Medicaid expansion didn’t shift dramatically. “The debate continues to be within the Republican party — with more pragmatic Republicans saying yes and ideologues driving the opposition. So what happens next is a good test case to see how Republicans will resolve these internal tensions.”

Even if Democrats had been victorious in governor races, they still faced a long shot getting Medicaid expansion through Republican-controlled legislatures. The one exception was Maine, where Gov. Paul LePage, who was re-elected, has five times vetoed efforts by his state’s Democratic-controlled legislature to expand the program.

In Florida, Republican Gov. Rick Scott has supported Medicaid expansion, but has done little to persuade state lawmakers to extend the program to 850,000 residents.

If Democratic challenger Charlie Crist had won, he would have faced strong opposition in the Republican-dominated state House, said Sean Foreman, associate professor of political science at Barry University in Miami Shores. “Scott’s victory means Medicaid expansion is dead the next four years,” he said.

Meanwhile, the future of Arkansas’ “private option” Medicaid expansion could be in trouble with the election of Republican Asa Hutchinson as governor and GOP gains in the state House and Senate. Hutchinson replaces Democratic Gov. Mike Beebe, who had championed the state’s expansion plan and who was barred by term limits from running.

Hutchinson has not taken a position on the program, saying he will assess its costs and benefits to “determine whether the program should be terminated or continued.” Arkansas’ expansion is vulnerable because by law, the legislature must reauthorize it every year with a 75 percent majority.

In Alaska, Bill Walker, an independent candidate who favors expansion, holds a small lead over incumbent Gov. Sean Parnell, who opposes it. Should Walker prevail after absentee ballots are counted, he still must get the support of his Republican-controlled legislature. About 26,000 Alaskans would gain coverage through expansion.

Since the Supreme Court made Medicaid expansion an optional part of the Affordable Care Act, 27 states and Washington, D.C. have extended the program to individuals with incomes under $16,100. While most of those states expanded eligibility at the beginning of 2014, Michigan and New Hampshire came on later this year and Pennsylvania’s expansion will start in January.

Nationally, Medicaid enrollment has increased by more than 8 million people since last October and has been seen as the biggest factor in reducing the number of uninsured Americans by about 25 percent this year.

State lawmakers have sometimes blocked Medicaid expansion even with a supportive executive. In 2013, Democrat Terry McAuliffe had campaigned on expanding Medicaid, but after he was elected Virginia governor he was unable to persuade state lawmakers who demanded the program be reformed first.

Carolyn Pearson, vice president of consulting firm Avalere Health, said expansion advocates will turn their attention to Utah, whose Republican governor hopes to take a plan to the GOP-controlled legislature, and Wyoming, where Gov. Matt Mead, also a Republican, has expressed interest in widening eligibility for Medicaid. Indiana is also negotiating with the Obama administration to expand Medicaid.

Pearson argued that Arkansas lawmakers are unlikely to unravel that state’s Medicaid expansion, which has helped more than 60,000 gain coverage. “It is incredibly difficult to take benefits away from state residents once they have been granted,” she said.

She said more Republican-led states could move ahead as the issue cools politically.

Sara Rosenbaum, professor of health policy at George Washington University, said it’s hard to tell how big an impact the election will have.

“One possibility is that now that a bitterly contested election is over, the governors may be open to discussion,” she 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.

The American health care system is poorly equipped to care sensitively for patients at the end of life, a recent report from the Institute of Medicine found. But it is possible, through careful planning, for individuals to choose the kind of death they want. Consumer Reports has released a guide to end-of-life planning for families. The report offers tips for caregivers and individuals and profiles one man’s “beautiful death” at home.

KHN staff reporter Jenny Gold interviewed author Nancy Metcalf about the report. What follows is an edited transcript of their conversation.

Q: You called your report “A Beautiful Death.” What does a beautiful death look like?

Metcalf: A beautiful death is probably different for each person. The gentleman whom we focused on – Paul Sheier, a retired dentist from a suburb of Buffalo — was very clear about what he wanted. He wanted to die at home. He had terminal lung cancer. He preferred to be kept comfortable, to forgo what he believed would be futile chemo, so he could spend his last months of life with his family and friends playing golf rather than at the hospital hooked up to an IV drip.

We also did a national survey along with this article, and we found that 86 percent of adults said they would like to spend their final days at home. Fifty percent preferred pain management and comfort care over other medical treatments. Yet even among adults age 65-plus, only 47 percent had completed an advanced directive or living will, and overall only about 20 percent of adults had done that. So they haven’t really taken steps to assure what they want to happen will happen.

Q: How can we give ourselves the best chance for a beautiful death?

Metcalf: The Institute of Medicine report that came out a few months ago made very clear that we have a very medicalized way of death in the United States. And I think anyone who has gone through the loss of an older family member has probably experienced that.

Everybody over the age of 18 should have a living will or advanced directive, including young people, and very few of them have it. Bad stuff can happen anytime. You want to have those documents, and you want to think about what you want to put in them. You don’t have to go to a lawyer or do anything expensive. You can download these documents online. There’s a site called Caringinfo.org that has state-specific living will forms.

You need to make your documents accessible. The one thing you should not do is put it in a safe deposit box. That’s really hard for people to get to. You should make many copies of it and make sure your family members know where it is. You should probably give one to your regular doctor as well.

You also should designate a health care proxy –somebody you want to make medical decisions for you if you can’t make them yourself. And you need to have a conversation with that person about your preferences and values, even if it’s general. It’s something you can revisit as your health status changes and you get older.

And you need to have the conversation with everybody in your family. Because a big source of problems at the end of life is when family members have disagreements about how someone’s care should proceed, if someone isn’t able to express their own wishes. It freaks doctors out and makes them very reluctant. Those are often the situations where people can end up in court and get guardianship. You don’t want that to happen. It’s so much better if everyone is on the same page.

One of the interesting results in our survey was that 42 percent of people had provided end-of-life care for a friend or relative. That’s a big, big number — so many of us have experienced the chaos that can come with end-of-life care.

Q: How can families make sure that their loved ones have the death they want?

Metcalf: It’s very typical at the end of life for people to be demented, in and out of nursing homes, assisted living and hospitals. It’s often not even clear when the end of life is near. That can be extremely difficult.

One resource that’s hugely important is palliative care. It can work with hospice, but it can also be offered to people who have not entered hospice. These are doctors who specialize in managing [care of the] whole person, talking to them about what their values are and finding out what’s important to them in their day-to-day lives. Do they want to be treated in such a way that they can survive to see a grandchild’s college graduation, or a wedding, or one last Christmas? Or do they want to maximize feeling good and [being] unmedicated as they spend time with their family members?

There’s no wrong answer here. But the palliative care specialist is trained to listen for that and work out ways that it can happen, either in conjunction with ongoing treatment or in conjunction with end-of-life care.

It was a little upsetting, frankly, that our survey found that 61 percent of adults had never even heard of palliative care, and only 10 percent had a really good understanding of what it does. And that’s really too bad because it’s a tremendous resource for people.

If you do feel chaos surrounding you, and you don’t feel you’re getting the right stuff from your health care providers, you need to make some noise and say, “I’m having a hard time here.” And ask for a palliative care consult. Almost every decently sized hospital has that option now. You don’t have to wait for a doctor to refer you to someone — you can pick up the phone and ask for one.

Q: How do you know when it’s time for hospice?

Metcalf: It’s hard to tell. There’s a formal definition that Medicare has created which is that you can be put in hospice if, in the opinion of your provider, you have less than 6 months to live. But people usually go in much too late. It’s a fine line—you don’t want to put people in there too soon because one you go into hospice, you’ve said you’re not going to get any more treatment to cure your illness. But hospice workers are very, very oriented towards a good end-of-life care experience for the patient and they also offer enormous resources for families.

You have to ask the doctors – how much longer? And if they guess wrong, and the person lasts longer but is still on a terminal track, they can be recertified. And the amount of care hospice gives isn’t always the same. It might be very little at the beginning of a person’s terminal course and very intense at the end. Hospice care can be delivered in all kinds of settings. A great many people get it at home. You can also get it in assisted living, nursing homes or in a hospital. And many hospices have their own inpatient units.

You don’t have to wait for a doctor to refer you to hospice. If you feel like you’re pretty sure that medical treatment isn’t going to help anymore from your conversations with medical providers, you can refer yourself. You can pick up the phone and call.

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

Moving to close what many see as a major loophole in Affordable Care Act rules, the Obama administration will ban large-employer medical plans from qualifying under the law if they don’t offer hospitalization coverage.

The administration intends to disallow plans that “fail to provide substantial coverage for in-patient hospitalization services or for physician services,” the Treasury Department said in a notice Tuesday morning. It will issue final regulations banning such insurance next year, it said.

Hundreds of lower-wage employers such as retailers and temporary-staffing companies have been preparing to offer such plans for 2015, the first year large companies are liable for fines if they don’t provide minimum coverage. Some have enrolled workers for insurance beginning Oct. 1.

For employers that have committed as of Nov.4 to such coverage, the administration will temporarily allow it under the health law, the notice said.

As reported by Kaiser Health News in September, an online calculator published by the Department of Health and Human Services allows large-employer coverage to pass the law’s “minimum-value” standard even if it doesn’t include inpatient benefits. Many see the calculator as flawed.

For employees enrolled in such plans, the disadvantage is double, say consumer advocates. Not only do they lack hospital coverage; but if employees are offered insurance passing the minimum-value standard at work, they are barred from receiving federal subsidies to buy better coverage through online marketplaces.

The administration said in Tuesday’s bulletin that it intends to fix that problem, too. Final regulations will say that “in no event” will workers offered such coverage be disqualified from subsidies, the notice said.

The administration had signaled last month it would move to disallow plans without hospital benefits from passing the minimum-value test. Large employers that fail to offer minimum-value coverage next year could be fined up to $3,120 per worker.

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

Two years ago, Inova Health System recruited a top executive who was not a physician, had never worked in hospital administration and barely knew the difference between Medicare and Medicaid.

What Paul Westbrook specialized in was customer service. His background is in the hotel business – Marriott and The Ritz-Carlton, to be precise.

He is one of dozens of hospital executives around the country with a new charge. Called chief patient experience officers, their focus is on the service side of hospital care: improving communication with patients and making sure staff are attentive to their needs, whether that’s more face time with nurses or quieter hallways so they can sleep.

It’s a dimension of hospital care that has long been neglected, patient advocates say, and it was put high on hospitals’ agendas only when Medicare started tracking patient satisfaction and, in late 2012, shaving payments to hospitals that fell short.

“There is a new recognition that the patient is important,” said Leah Binder, president and chief executive of the Leapfrog Group, an employer-based coalition that advocates for greater health-care quality and safety.

Hospital routines have traditionally been designed to suit employees, not customers, she said. “The patient used to be maybe 10th on the list of a hospital’s priorities.”

The financial penalties introduced by the Affordable Care Act are part of a broader effort to transform health-care delivery and improve quality while reining in costs, increasing transparency and holding hospitals and providers accountable for their work.

The penalties — which for now make up only a fraction of Medicare reimbursements — are based on a hospital’s ranking relative
to other hospitals. One component is how they do on surveys of recently discharged patients. The hospitals are judged on answers to such questions as how well their doctors and nurses communicated with them, how clean and quiet the hospital was, whether they received help when they needed it and how well providers explained the drugs they were given.

Many hospitals commission additional surveys to use for their own purposes, such as marketing and branding.

Chief patient experience officers treat these survey results like sacred texts.

“The one thing I’m not trying to do is to put a mint on the pillow,” said Westbrook, who reports directly to Inova’s president and chief operating officer. “This is a different customer, with very different needs.”

But as patients’ out-of-pocket costs have risen, he said, they have become savvier, more demanding consumers.

“They are going to look on the Internet and on Medicare’s site comparing hospitals, and they are going to read comments,” he said, and increasingly, they will select hospitals based on the reviews. “It’s no different from TripAdvisor.”

Lofty Goals, Practical Implementation

Unlike Westbrook, most chief patient experience officers rise through the ranks of a health system. Like him, though, they speak in lofty terms about teamwork, leadership and developing a philosophy and culture of compassion, service and respect at their institutions.

Westbrook, for instance, talks constantly about the “Inova promise” to “meet the unique needs of each person we are privileged to serve – every time, every touch.”
That phrase had “always hung on a wall,” Westbook said. “Now, we don’t begin a meeting without an Inova promise story.”

On the ground, the focus is doggedly practical. One common innovation is hourly rounds, a system where nurses are expected to check in on each patient regularly, not wait for the person to use the call button. And the interaction is supposed to be meaningful and thorough.

“This doesn’t mean just pausing at the door, saying, ‘Are you okay? Can I get you anything?’ and off you go,” said Susan Eckert, chief nursing executive at MedStar Washington Hospital Center. “We’re telling our nursing staff that you should actually sit down, look at the patient, talk a little bit, and give them several
minutes of time during which they are the only thing that exists in the world . . . It’s a very powerful experience.”

Hospitals that have put hourly rounding in place say the practice does not require extra staffing because it is more efficient to prevent problems before they occur. Taking time to reposition a patient prevents bedsores, for example, and helping patients to the bathroom prevents falls.

Another priority is having nurses call patients at home within 48 hours of their discharge, to keep their recoveries on track. (One Medicare question specifically asks patients whether they got good instructions about what to do when they get home. Hospitals can also be penalized if too many patients bounce back to them.)

Hospitals are increasingly taking their cues from patients, both by listening to the advice from new patient and family advisory councils and by using the surveys to identify weak spots.

At Yale-New Haven Hospital, where an executive director of patient relations and a medical director work together to improve the patient experience, officials have made a concerted effort to lower noise so patients can get optimal rest. Hospital staff are told to use “library voices 24/seven” and not to “vent” where patients might hear them. Overhead page calls have been eliminated, beepers are kept on vibrate, doors are closed when staff discuss cases and efforts are made to reduce alarms, pings and beeps at the bedside.

The Cleveland Clinic requires all 3,000 staff physicians to take a day-long relationship and communication class. In 2010, the hospital showed each doctor what patients had said about him or her in surveys. About half the comments were negative — and most of those had to do with how physicians talk to patients.

Doctors were stunned when they saw the results, said James Merlino, a surgeon who is Cleveland Clinic’s chief experience officer.

“Physicians were shocked, dismissive, disbelieving. They said, ‘This isn’t true, the methodology is bad, the sample size is too small,’ ” he said.

Now, he said, “we put physicians through communication training so they learn how to listen better, let the patient set the agenda and organize the encounter better.”

The result is a big increase in physician communication scores since 2008.

At UCLA Health System, parents of pediatric patients created an educational video about central-line catheters that is shown to physicians and nursing staff “to remind them how scary that catheter is for patients and their family members,” said Tony
Padilla, UCLA’s chief patient experience officer, adding that catheter-related infections can be
dangerous and even fatal.

“It drives home the message that during your very busy day as a nurse or physician, please remember: You’re accessing the child’s lifeline.”

Moving The Needle

Moving the needle on Medicare surveys can be a hard slog. Inova Mount Vernon’s composite score went up from 66.6 percent to 68.4 percent from 2010-11 to 2012-13. That means that on average, 68.4 percent of patients gave top marks to the hospital on survey questions in 2012-13. Scores at Inova Fairfax dropped and scores at Inova’s other three hospitals remained about the same.

Hospitals face a balancing act.

“We want to be attentive to a patient’s needs and wants, yet not do things just to please the patient, like overprescribing pain medication,” said Atul Grover, chief public policy officer for the Association of American Medical Colleges, which represents nearly 400 major teaching hospitals and health systems, in addition to U.S. medical schools. “You want to make sure patient satisfaction isn’t driving patient care.”

Some question whether the hospitals that score best on patient surveys are also the ones that provide the best care. Grover, for example, worries that hospitals that don’t offer amenities, such as single rooms, will be dinged in the surveys.

But some research suggests a strong correlation between patient satisfaction and outcomes, said Richard Staelin of Duke University’s Fuqua School of Business.

One of his studies, published in the journal Circulation in 2013, found that the death rate among heart attack patients was lower at hospitals where patient satisfaction scores were high, even when researchers controlled for the quality of care, meaning the care was equivalent.

Another study found higher overall patient satisfaction was associated with lower readmission rates a month after patients were discharged.

Studies have also found that hourly nurse rounds result in more-satisfied patients, with fewer falls and pressure sores.

“Patients co-produce the service,” Staelin said. “What I mean by that is that when someone is sick, the doctors can’t solve the problem without their help. … As a patient, I have to communicate with the doctor or nurse, I have to listen to the
doctor, I have to follow the instructions.”

“There are still lots of doctors who don’t believe it, but gradually the medical profession is coming around,” he added.

Indeed, several patient experience officers said some physicians at their hospitals resisted doing things differently until it was no longer an option.

The financial penalties “are brilliant,” Westbrook said. “That’s what’s driving change.”

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