January 31, 2005

A "Little Side Step" Means You Get Stomped On! The Bed Tax and New Mexico.

Ooo I love to dance a little sidestep,
Now they see me, now they don't,
I've come and gone,
AND Oooo I love to sweep around the wide step,
Cut a little swathe and lead the people on."

- "The Sidestep," sung by the Governor in The Best Little Whorehouse in Texas

Remember that little song and dance routine in the movie, The Best Little Whorehouse in Texas? The Governor is exulting over his ability to pull the wool over people's eyes.

When will we ever learn about the promises of politicians when it comes to taxes? You may know that New Mexico passed a $8.82-a-day bed tax on nursing homes back in 2004. In order to get it passed, the governor:

...agreed to increase the state's Medicaid reimbursements to New Mexico's 80 nursing homes to cover the cost of the tax, so it would, in effect, be a wash for the homes. The tax was to be paid to the state by the nursing homes, which would then have the option of passing it on to their patients.

The administration also agreed to a bill that would allow the state's 1,200 to 1,500 private pay nursing home residents to deduct the $3,219-a-year tax from their state income taxes by applying for a tax credit.

MSNBC is reporting that the governor wants to take it back. No--not the bed tax. He wants to go back on his word about the tax credit that the private pay nursing home residents are presently allowed.

The idea was that passing such a bed tax would allow the state to get a three-to-one match in federal Medicaid dollars. The Feds were on to that when:

...the Centers For Medicare & Medicaid Services, the federal agency that administers the Medicaid program, ruled that portions of it were illegal under federal law and that the agency would not provide the three-to-one funding match.

It is illegal under federal law to reimburse taxpayers for such taxes, and federal Medicaid officials cited the tax credit as a flaw in the program.

The governor is fighting to preserve the tax and do away with the credit. The legislators who tried to warn that CMS would never accept the plan as written are fighting to do away with the entire tax.

Here's government at work--pass a tax with promises you've been warned you can't, by law, keep--and then do away with the promises--but keep the tax. That's a new twist on the old "read my lips" approach.

What do you bet that the Medicaid reimbursement increase either doesn't happen or that there is an attempt to take it back?

January 25, 2005

Medicaid and Provider Taxes--A Primer on Economics

I know that some in Texas support the idea of a provider tax on nursing homes to make up for shortfalls in Medicaid funding. For those who do--and those who don't know one way or another--I invite you to go read Dr. Bob at The Doctor is In about a similar tax his state of Washington contemplates putting on physicians for the same reason--a shortfall of Medicaid funding. I excerpt portions:

The large majority of Washington physicians would prefer to see Medicaid patients, but are quite simply financially unable to do so. For years, both Medicare and Medicaid have operated under an unspoken and hidden tax, paying for less than the cost to provide services while relying on providers to make up the difference from their insured patients.(Me: insert private-pay residents here) As insurance carriers have progressively ratcheted their reimbursements down in response to spiraling health care costs and insurance premiums, subsidizing patients insured under Federal programs such as Medicare and Medicaid is no longer feasible.


The State government in Olympia has come up with an ingenious new plan to solve this crisis: it plans to tax physicians to generate additional revenue to pay for higher Medicaid reimbursements. (Me: Insert nursing homes for physicians)In his final budget, our previous Democratic governor, Gary Locke, proposed a 67% increase in the state business and occupation tax on physicians. Unlike most states, Washington does not have an state income tax, but instead levies a business and occupation tax on gross receipts, as well as a substantial sales tax. The specific tax rate varies by industry and business type. Our new governor, Christine Yanukovich Gregoire, formerly Governor Locke's Attorney General, also supports this idea:

Gregoire said she supports the goal behind Locke's proposal. "I can't imagine that it wouldn't get us more providers," she said. "I hope that means that those who are in need actually have access.

Now, as a physician, it should come as no surprise that I am somewhat resistant to the idea that I have been specially singled out for this honored responsibility. But it really does go beyond my personal reluctance to pay higher taxes -- even narrowly targeted ones such as this proposal. The simple fact is, this legislation, if passed, will not result in "those who are in need actually have[ing] access", but will severely exacerbate the crisis of access to health care for low income individuals in Washington State.

According to Governor Locke's own statistics, Medicaid currently reimburses at 62 percent of Medicare rates. Hence, even without considering the issue of profit, physicians seeing Medicaid patients are already picking up over a third of the tab for provider services in Washington State. The proposed legislation would increase reimbursements to 75 percent of the Medicare rate. So, a substantial new tax will be added for providers, while still paying them less than the cost to provide this care. The income from services to Medicaid patients is not exempt from the tax on gross receipts, and therefore the higher reimbursements will also be taxed at the new rate.

Now Dr. Bob explains the bad economics behind this plan in understandable terms:

Imagine you are selling computers. You build a computer with a supply cost of $1000 (not including your time and expertise to make it), and must sell it retail for $620. Needless to say, this business model will not win you any Nobel prizes in economics. Now the State comes in, and wants to buy a large number of your computers, and offers to pay you $750 a computer -- but is going to nearly double your tax on that $750. Such a deal! It is not hard to see what you will do: you are going to stop selling computers, or sell them only to someone who will pay you more than $1000 -- or go out of business. The end results of this brain-dead legislation is simple: physicians in large numbers will simply stop seeing Medicaid patients, as they will be increasingly unable to afford to do so, no matter how strong their desire to care for the poor.

Perhaps a counter argument to this is that nursing homes--unlike physicians--will have no choice but to admit Medicaid residents in order to survive at all. Dr. Bob--or an economist-- might respond: Perhaps in the short run--but--given the inexorable realities of economics-- how long will it be before Atlas Finally Shrugs?

Reflections On Being A Nurse

Shrinkette, a psychiatrist, provides a roundup of the reflections of a number of Nurses on what it takes to survive in the profession. She begins with a list of what it takes to be a nurse compiled by a nursing instructor at Top of My Head:

What is takes to be a nurse:
1. To see people at their worst and know it was part of their job to help them in anyway they could.
2. To be exposed to things that many people could never imagine and continue to do their job and not think twice about their career choice.
3. To hold a crying son/daughter after their mother/father had died and cry with them during their pain.
4. To hold a crying mother/father after their son/daughter had died and cry with them during their pain.
5. To get hit and/or punched by a confused patient while working in the emergency room.
6. To be criticized by patients/family members because they thought they did not do enough for their family member.
7. To always be an advocate for their patients and do what it took to give them the best care and do things in their best interest no matter what others thought.
8. To hold the hand of a dying patient who had no family.
9. To have a vision of what nursing was and where it should be.
10.To evaluate their patients’ needs and try their best to see what resources are available to help them.
11. To help the homeless by volunteering

Then there is this from Tales of An Aspiring Nightengale:

I oftentimes wonder what I was thinking, leaving my cushy desk job and going into a high stress job where I'm on my feet for twelve hours at a time, dealing with sickness, life and death situations, and people who want me to do hundreds of things at once. Then I remember why I became a nurse:To save the life of someone who's potentially having a heart attack.To restore blood in an anemic patient so he can go home to his wife and son.To release the nursing home patient back into her community in better health.To ease the mind of a woman who is worried about her ill father.As a nurse you sacrifice a little of yourself: your time, your energy, your dignity, your lunch, your need to pee. But the end result, your impact on your patients and their lives, makes the job worth while.The end result helps me get up the next morning, report to the unit at seven o' clock, and do it all over again.

Kind of gives us non-nurses a whole new perspective, doesn't it?

January 24, 2005

Medicare & Wheelchairs

The Washington Post reported that CMS has reconsidered its criteria for covering motorized wheelchairs. According to the writer, Cindy Skrzycki:

The Medicare program recently introduced three major regulatory initiatives to tighten up eligibility, reduce payments and assure the legitimacy of the providers.

Then you have to read through almost the entire long article about the history of this to find out what the initiatives are. I've excerpted them for you here:

Reacting to the pressure, CMS said it was reverting to its original qualifications criteria and was talking with industry and contractors' medical directors about their concerns. It convened a wheelchair working group last summer, and its recommendations have become part of a major reform effort underway within the agency.

It anticipates changing to a "functional" definition to determine who gets a chair -- in other words, can a person do daily activities without one? It also proposes requiring physicians to have face-to-face contact with patients before a prescription for a chair is written. The agency wants to change coding for the chairs to more accurately represent how much the government should be billed. And it plans to install more checks to make sure suppliers are legitimate.

How will this affect you?

January 23, 2005

Medicare Prescription Drug Rules Now Issued

Fifteen hundred pages of rules governing the Medicare Prescription Drug program have now been published in final form. Are you feeling a little overwhelmed at this point?

The Washington Post published a piece on this describing the changes made to the rules as proposed last summer:

The agency also outlined several changes made in the regulations since a preliminary version was announced in July. They now assure that beneficiaries have access to convenient pharmacies, and charity payments have been added that can count toward true out-of-pocket spending needed before catastrophic coverage kicks in.

Rules also are being put in place to ensure that beneficiaries will be able to get drugs that might not be on the plan's list and to ensure that decisions whether medications would be covered under the plan are made within 72 hours or faster for expedited requests, McClellan said.
The plan guarantees that beneficiaries living in nursing homes will be able to enroll in a drug plan and provides automatic enrollment for people eligible for both full Medicaid and Medicare benefits to avoid gaps in coverage.

The article gives an overview of the plan:

The rules create a new regional Medicare Advantage program for preferred provider organizations, with 26 regions. All regional PPO plans are required to offer benefits identical to those of traditional fee-for-service Medicare.

Under the new program, participants will pay $35 monthly premiums and the first $250 in drug costs. Medicare will pick up 75 percent of the next $2,000 in prescription expenses. After that, a gap is built into coverage during which participants are responsible for the entire drug bills until costs top $5,100, after which the government pays 95 percent.

In a separate article, the Washington Post writes that the Administration is going to automatically sign up millions of low-income seniors:

After a lackluster response to its Medicare drug discount card, the Bush administration announced yesterday that it will automatically enroll millions of low-income seniors in the full drug benefit program when registration begins next fall.

Yet another article in the same paper says that Medicare will extend coverage for surgically implanted heart- shocking devices for people with weakened hearts:

The government has decided to expand its coverage for surgically implanted heart-shocking devices for people with weakened hearts, in what could be the most expensive single decision in Medicare's history, federal officials said yesterday.

More than half a million Americans with the progressive heart-weakening condition known as congestive heart failure could be eligible for the battery-powered implants and accompanying surgery under the plan, which Medicare officials said they will roll out in the next week or so.

Do Your Residents Use Plavix?

The New York Times published a piece about a study raising questions about its safety:

Patients taking Plavix, a popular and expensive antistroke drug, experience more than 12 times as many ulcers as patients who take aspirin plus a heartburn pill, a study to be published today in The New England Journal of Medicine found.

Up to half of those now taking Plavix do so because their doctors assume that Plavix is safer on the stomach than aspirin, said Dr. Francis K. L. Chan, the study's lead author. Both the American College of Cardiology and the American Heart Association recommend that heart and stroke patients at risk of developing ulcers be given Plavix instead of aspirin.

Here is a description of how Dr. Chan conducted his study:

Dr. Chan said he was surprised to find that almost no studies had been done to confirm whether this assumption was true. He found 320 patients whose ulcers had healed and gave half of them Plavix and half of them aspirin plus Nexium, a heartburn pill. He followed them for a year.

However, the physician blogger over at DB's Medical Rants puts this study in perspective:

Reports like this make the news, especially the financial news. The challenge that clinicians and clinician scientists must understand involves putting each new data piece into perspective. Several questions come to mind immediately, prior to reading the remainder of the article:

  • Would PPIs (proton pump inhibitors) also decrease ulcer rates in Plavix treated patients?
  • Which patients really benefit from Plavix?
  • What duration of therapy should we use?
  • How important were the ulcers (did they bleed, cause pain, or were they “incidental” findings)?
  • Thirteen of the patients taking Plavix, or 8.6 percent, experienced renewed ulcer bleeding during the year while just one, or 0.7 percent, of those taking aspirin and Nexium had an ulcer bleed.


This is the wrong study. The results make Plavix look bad, but it does not answer the key questions:

  • Given a patient with NO ulcer history - does Plavix induce ulcers?
  • How would a combination of Plavix + a PPI compare with ASA + a PPI in patients with previous ulcer?

We clearly should understand the risks of Plavix, but this article does not really help. Most patients who receive Plavix, do so for clear indications. We need to understand side effects in patients who resemble our patient populations.

January 21, 2005

What About Tort Reform?

Dr. Charles alerts us to an archived editorial on tort reform published in the New York Times. Common Good excerpts the article here. The title of the article is It's Time to Try Special Health Courts. Here's the excerpt:

We hold no brief for the current medical liability system, which does a poor job of compensating most victims of medical malpractice. An authoritative study of thousands of patients in New York State found that the vast majority who were harmed by medical errors or negligence never filed suit, whereas the vast majority of those who did file suit were not actually harmed by negligent doctors. Some studies suggest that, once a suit is filed, the courts do a reasonably good job of sorting out who deserves compensation, while other research has found that juries are swayed more by the severity of a plaintiff's injuries than by evidence of negligence. But in a medical system that is coming under increased fire for failing to deliver consistent quality in hospital care, it is clear that only a small number of people are being compensated for malpractice.

Common Good makes the following observation:

Not only does the current system fail to reliably compensate injured patients, it also fails to weed out bad doctors. The Times recognized the need for a system that effectively "weed[s] out the small number of negligent doctors responsible for generating most malpractice awards."
The Times also recognized the need for consistent damage awards: "Congress ought to consider requiring guidelines for judges and juries to help determine what compensation is reasonable in a given circumstance."

As proposed by Common Good, special health courts would award damages--in addition to a patient's medical costs and lost income--according to a pre-determined schedule established by experts.

Lou Dobbs weighed in on this issue earlier this month, making the observation that limits on damages for pain and suffering may not be enough. He goes on to discuss European systems where the loser pays all legal costs. We have a mechanism for that in Texas via HB4--but it has to be elected.

And, the Bush Administration is gearing up for some national form of tort reform saying that he rejects the idea of state by state tort reform " because he said trial lawyers simply go to the states with the weakest guidelines."

The continuing need for tort reform in the field of health care is exemplified by this article picked up by Dr. Kevin. Dr. Kevin summarizes the case:

Doctor prevails in malpractice case, but was it frivolous to begin with?It was a case of a bronchoscopy for hemoptysis. The patient apparently consented to the procedure, but not the subsequent biopsy that occurred (which is normally routine in these procedures). A damned if you do or don't situation. What if a suspicious lesion was found, but wasn't biopsed? Surely the doctor would have been sued anyways for missing a potential cancer.

What kind of lawyer took this case?

January 17, 2005

Ms. Manners For Surveyors

Representative Deshotel has filed a bill which mandates that surveyors treat nursing facility staff with courtesy during inspections. It reads specifically:

Sec. 242.0447. DUTIES OF REPRESENTATIVES. The department shall adopt written policies requiring representatives of the department to treat the residents of an institution and the institution's staff with courtesy, consideration, and respect during an inspection, survey, or investigation conducted under Section 242.043 or 242.044 or in accordance with Chapter 32, Human Resources Code.

To enforce this section, the statute calls for the creation of an Internal Affairs Office to investigate complaints:

Sec. 242.0448. INTERNAL AFFAIRS OFFICE. (a) The department shall establish an internal affairs office to investigate complaints by institutions related to an inspection, survey, or investigation conducted under Section 242.043 or 242.044 or in accordance with Chapter 32, Human Resources Code. (b) An institution inspected, surveyed, or investigated by the department or by a representative of the department may report a suspected violation of department policies adopted under Section 242.0447 to the internal affairs office. (c) The internal affairs office shall investigate complaints received from institutions regulated under this chapter.

The Department may not retaliate against a complainant and, if it is found that a violation occurred--the surveyor survey, inspect or investigate the facility after the date such a finding is made:

d) A representative of the department may not retaliate against an institution for filing a complaint with the department's internal affairs office under Subsection (b). A representative of the department who violates this subsection may not inspect, survey, or investigate the institution after the date the department determines the violation of this subsection occurred.

It seems to me that this statute should specify how the facility is to be notified of the results of its complaint. The statute should also have time frames within which the complaint is to be investigated and acted upon.

Also, shouldn't this concept be applied to all providers surveyed, investigated and inspected by DADS?