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With Millions of Sign-ups So Far, Obamacare Enrollment Is Brisk


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Enrollment in the Affordable Care Act’s insurance exchanges is on track for meeting Obama administration projections.

Kaiser Health News

A month into this year’s enrollment period, health care experts say sign-ups are on course to hit or exceed the Obama administration’s projection of about 9 million enrollees in 2015.

Several weeks into the second year of the Affordable Care Act’s insurance exchanges, at least 2.5 million people have enrolled in coverage, according to data from state and federal exchanges.

Healthcare.gov 2015 portal

Healthcare.gov 2015 portal

As of Dec. 12, almost 2.5 million had enrolled through the federal insurance exchange, which serves 37 states, the Centers for Medicare & Medicaid Services reported this week. Hundreds of thousands of others chose plans through state exchanges, according to a Kaiser Health News analysis of state exchange data.

Many more are expected to have signed up ahead of a Dec. 15 deadline to get coverage that begins Jan. 1, 2015. Those enrollment figures will be available later this month.

“Exchange enrollment is far ahead of 2014’s pace due to improved technology performance,” said Caroline Pearson, vice president of Avalere Health, a consulting firm.

She said sign-ups are on track to “far exceed” the Obama administration’s 9 million projection, made just before open enrollment began in November. If enrollment continues at this pace, she said, the federal and state exchanges should enroll between 4 and 5 million new participants, she said. That’s in addition to 6.7 million who got coverage for 2014, many of whom are expected to re-enroll for 2015.

Enrollment in 2014 plans reached nearly 7 million despite the disastrous rollout of the federal and several state exchanges, which made it difficult if not impossible to sign up in the early months.

Sign-ups for 2015 began Nov. 15 and continue through Feb. 15. However, those who wanted coverage in January needed to enroll by this past Monday.

Some Republicans have argued that enrollment would suffer in the law’s second year because people would be unhappy with their coverage and prices would skyrocket. So far, that does not appear to be happening.

Several state insurance exchanges reporting data appear to be ahead of where they were several weeks into open enrollment last year, including Massachusetts, Maryland and Vermont.

It is not known how many of the enrollees in some state exchanges are new to the market. But on the federal exchange, about 48 percent of the people selecting plans are new, while 52 percent had coverage in the marketplace this year, according to the CMS.

California officials said it was too early to tell how many of the 1.1 million current enrollees have returned for 2015. In most states, consumers will be automatically re-enrolled in the same plan or one like it if they had not selected a plan by Dec. 15. They can switch before Feb. 15.

“The pace of enrollment is very strong,” Peter Lee, executive director of Covered California, told reporters Wednesday. The state is already on its way to meeting its goal of 750,000 new enrollees this year, Lee said.

He said he expected the momentum to continue, with more than 40 enrollment events planned through Dec. 15.

On the federal exchange, tens of thousands of people have started accounts but not yet selected a plan.

Charles Gaba, a blogger based in Bloomfield Hills, Mich. who accurately forecast 2014 enrollment, predicts that about 12 million Americans will enroll in exchange coverage in 2015.

The Congressional Budget Office had predicted about 13 million sign-ups for 2015, but in November, administration officials estimated about 9 million, in part because fewer employers than expected were dropping coverage and sending their workers to the exchanges. That includes those who re-enroll in coverage as well as new sign-ups.

Similar to last year, the biggest surges in enrollment were expected immediately before the Dec. 15 deadline to have coverage by Jan. 1 and then again right before Feb. 15, which is the final deadline to have coverage in 2015, Gaba said.

Dan Schuyler, senior director of exchange technology at consulting firm Leavitt Partners, said state exchanges are performing much better than they did last year, though there have been minor glitches.

Two state exchanges, Nevada and Oregon, switched to the federal healthcare.gov portal after abandoning their own failed software. Maryland, meanwhile, took software from the Connecticut exchange.

“It seems like state exchanges have turned the corner this year,” Schuyler said.

Jon Kingsdale, who oversaw the Massachusetts health insurance exchange from 2006 to 2010 and is a managing director of the Wakely Consulting Group, said customer call centers are also working better with better-trained staff.

One big challenge facing the exchanges, he said, is how well they “hand off” enrollments to health plans, which was a problem in some states last year.

The exchanges also have to make sure automatic re-enrollment works later this month, Schuyler said. Many consumers who are automatically re-enrolled may be shocked to learn their plans have raised rates or changed their benefits, he said.

State and federal officials also have to keep reaching out to consumers. California’s insurance exchange has partnered with hospitals and medical groups to get the word out about the availability of coverage. The agency also stepped up advertisements, including a bilingual campaign featuring people who enrolled last year.

Anna Gorman and Lisa Gillespie contributed to this story.

This story originally appeared in Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Fracking Regulators Deny Legal Request for Air Pollution Rules


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Commissioners at the N.C. Mining and Energy Commission said they don’t have the legal power to institute new air rules, but agreed to study the issues surrounding drilling’s air pollution.

By Gabe Rivin

State drilling regulators on Friday rejected a legal petition from environmentalists who sought new rules to minimize the air pollution released by natural gas wells, which may soon dot North Carolina’s map.

Members of the N.C. Mining and Energy Commission concluded that they don’t have legal authority to develop air pollution rules. The Blue Ridge Environmental Defense League filed a legal petition in August requesting that the commission develop these rules.

Amy Pickle, the vice chairwoman of the MEC, found that the commission doesn't have the legal authority to develop air rules. Photo courtesy Duke University

Amy Pickle, vice chairwoman of the MEC, found that the commission doesn’t have the legal authority to develop air rules. Photo courtesy Duke University

“We have to have statutory authority to promulgate any rule that we write, including rules that we are petitioned to write,” said Amy Pickle, vice chairwoman of the MEC and the director of the state policy program at Duke University’s Nicholas Institute for Environmental Policy Solutions. “[The air rules] are not rules that we have the authority to change.”

Pickle had previously chaired a committee that reviewed BREDL’s request. At a hearing on the petition in October, the committee discussed the potential shortcomings of the state’s current rules.

But despite the concerns raised by Pickle and others, the committee ultimately recommended that the MEC reject the petition. Their reasoning was steeped in a close reading of state law. SB 820, a 2012 law, established the MEC and set the state on course to issue drilling permits. Before issuing permits though the MEC must finish writing a large bundle of rules, a task it is required by a newer law to complete by January.

Despite the breadth of their work, the MEC is not tasked by SB 820 to develop air rules. Instead, the N.C. Environmental Management Commission bears both the authority and responsibility to develop those rules.

This means the MEC does not have the power to carry out BREDL’s request, Pickle’s committee found.

The MEC voted unanimously at Friday’s meeting to agree with this legal interpretation.

New regulations

BREDL’s petition requested that the MEC amend the state’s rules to list gas drilling as a source of air pollution.

This, they said, would require future drillers to secure air permits. And these permits would limit drillers’ abilities to pollute the air.

Their cause for concern is significant, if recent academic studies are any indication. Researchers have found that drilling can release harmful pollutants into air near drilling sites. Those pollutants include benzene, a volatile organic compound that’s known to cause leukemia. Gas drilling elsewhere has caused spikes in ground-level ozone, which can cause respiratory problems even at low levels, according to the U.S. Environmental Protection Agency.

But the Environmental Management Commission chose to not develop any new rules for drilling’s air pollution.

A natural gas well. Drilling can release numerous harmful pollutants, including benzene, a known carcinogen. Photo courtesy U.S. Bureau of Labor Statistics

A natural gas well. Drilling can release numerous harmful pollutants, including benzene, a known carcinogen. Photo courtesy U.S. Bureau of Labor Statistics

The EMC opted instead to rely solely on federal rules. But environmentalists say those rules are limited at best, and could offer large loopholes for future drillers.

According to Lou Zeller, BREDL’s executive director, BREDL initially tried to spur the EMC to action. In a letter last September, the group laid out its request for new air rules.

Zeller said the EMC failed to respond, which is why the group petitioned the Mining and Energy Commission instead.

Environmentalists aren’t the only constituency that expressed frustration over the state’s inaction. Residents in Lee County, a potential hotspot for drilling, have grown frustrated too, according to Matt Matthews, a commissioner with the MEC.

“What we see is the feds seem to be dragging their feet; the state seems to be dragging its feet,” Matthews said.

A study committee

Pickle on Friday reiterated her concerns about potential loopholes in state and federal rules. She also acknowledged that the MEC has not yet issued recommendations to the EMC about air rules, a requirement under SB 820.

Pickle recommended that the MEC establish a permanent committee to study air rules. The committee would look at potential loopholes in federal rules and technologies used to capture air pollution, in addition to related issues.

The MEC adopted this recommendation as well, and agreed to begin this work quickly.

Federal Officials Urge Marketplace Consumers To Look For Better Deals In 2015


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By Mary Agnes Carey

Kaiser Health News

More than 70 percent of people who currently have insurance through the health law’s federal online marketplace could pay less for comparable coverage if they are willing to switch plans, officials said Thursday.

With a Dec. 15 deadline looming for coverage that would begin Jan. 1, current policyholders should come back to healthcare.gov to see if they can get a better deal, the officials said. They’ll find more plans available and nearly eight in 10 current enrollees can find coverage for $100 or less a month, with subsidies covering the rest of the cost.

Healthcare.gov 2015 portal

Healthcare.gov 2015 portal

A Department of Health and Human Services analysis of 2015 individual market premium data for 35 of the states participating in the federal marketplace, or exchange, found that premiums for the lowest-cost silver plans will increase on average by 5 percent, while prices will increase on average by 2 percent for the second-lowest-cost silver plans, which is called the benchmark plan because subsidy levels are pegged to its cost.

“The plans offering the lowest prices have sometimes changed from 2014 to 2015, so consumers should shop around to find the plan that best meets their needs and budget,” the report advises.

If they stay in their current plan, consumers may discover that their subsidy may not go as far if the price of the benchmark plan declined for 2015.

“We strongly, strongly encourage people to come back to the website and shop,” marketplace CEO Kevin Counihan told reporters during a press call. Federal marketplace enrollees who do not switch plans by Dec. 15 will be automatically re-enrolled in their current coverage.

The number of companies offering policies for next year has increased by 25 percent. Consumers can choose from an average of 40 plans for 2015, up from 30 in 2014, based on the HHS analysis, which examined plan rates at the county level.

Consumers have until Feb. 15 to enroll for coverage in 2015, the marketplace’s second year.

The HHS analysis, mirroring other reviews of 2015 premiums, shows that what consumers pay for coverage depends on where they live. In Juneau, Alaska, for example, a 27-year-old enrolled in the second-lowest-cost silver plan would pay $449 per month for coverage in 2015 before tax credits, a 34 percent increase from 2014. In Jackson, Miss., that same level of coverage would cost $253, or 24 percent less than $332 charged in 2014.

Kaiser Health News (KHN) is a nonprofit national health policy news service. 

Hospitals Take Cues From the Hospitality Industry


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.

butlerIt’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 2010, 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 is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Family Doctors Push For A Bigger Piece Of The Health Care Pie


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By Lisa Gillespie

Kaiser Health News

Family medicine doctors are joining forces to win a bigger role in health care – and be paid for it.

Eight family-physician-related groups, including the American Academy of Family Physicians, have formed Family Medicine for America’s Health, a coalition to sweeten the public perception of what they do and advance their interests through state and federal policies.

Getting patients in to see primary care practitioners is key to the Affordable Care Act. Image courtesy DIBP Images, flickr creative commons.

Primary care practitioners are looking to get more focus on the role they play in the health care system. Image courtesy DIBP Images, flickr creative commons.

The launch of their five-year, $20 million campaign Thursday comes at a critical time for primary-care doctors. Thanks to the health law, millions more people can seek care with newly gained insurance.  But there’s growing debate about whether nurse practitioners and physician assistants should provide a lot more basic care, either on their own or as part of clinics sponsored by pharmacies or other businesses. Some major doctor groups have challenged the ability of lesser-trained medical professionals to independently treat patients.

Glen Stream, chairman of the new coalition, said that it plans to focus on:

– Paying primary-care doctors for more than just office visits, including the time they spend making referrals to specialists, checking in with patients about treatment regimens, being available 24/7 and calling and emailing patients. Specialty doctors generally are paid more for their time and for procedures they do.

– Creating additional incentives for medical school students to go into primary care and tying medical schools’ federal funding to the primary care training they provide.

– Making electronic health records less burdensome, freeing more time for conversation with patients.

– Getting doctors to switch to a team-based, patient-centered “medical home” format, with a payment structure that reflects the work that goes into coordinating care for a patient.

– Persuading private and public employers with health plans to lean on insurers to increase compensation for primary care services.

“If we don’t spend enough on primary care, outcomes in the future will suffer because much of the chronic diseases that drive spending are preventable,” said Stream, a family physician and former president of the American Academy of Family Physicians. He added that larger employers could negotiate higher payment rates for primary care when picking an insurance company.

While the campaign is touted as helping patients, it’s also about asserting that family doctors are important.

“It’s always a question of what motivates groups to do these kind of campaigns — is it looking out for patients or your own interests, and generally it’s a combination of both,” said Atul Grover, chief public policy officer at the Association of American Medical Colleges.

In September, the American Academy of Family Physicians announced recommendations on medical school funding, saying teaching hospitals should provide more primary care training as a condition of continuing federal funding at the same level. But Grover said the kind of training medical students receive doesn’t drive what type of doctor they become. The reimbursement system – which typically pays specialists at higher rates – is more important.

Grover also said that while primary care is important, taking funding away from specialty training isn’t necessarily a solution because an aging population will need more specialty care.

Other groups in the coalition are the American Academy of Family Physicians Foundation, American Board of Family Medicine, American College of Osteopathic Family Physicians, Association of Departments of Family Medicine, Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

By the Numbers in North Carolina: Domestic Violence


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By Hyun Namkoong

1. What is a domestic violence-related homicide under state law?

Under  state law, a homicide is considered domestic violence-related if the perpetrator and victim have one or any of the following six relationships.

Relationships include: (1) current or former spouses, (2) people of opposite sex who have cohabited or are cohabiting, (3) parent or children relationships, (4) people who have a child in common, (5) current or former household members and (6) people of the opposite sex who are in a dating relationship or have been romantically involved before.

Image courtesy Run Jane Fox, flickr creative commons

Image courtesy Run Jane Fox, flickr creative commons

2.  How many domestic violence-related homicides happened in North Carolina in 2013?

There were 108 domestic violence-related homicides in 2013, according to a report from the North Carolina Department of Justice.  Around two people died per week from domestic violence in 2013.

Since the 2007 passage of a state law requiring the reporting of domestic violence-related homicides in North Carolina, 2009 had the lowest number of homicides with 99.

In 2008, there were 137 homicides, the highest number of homicides since required reporting.

3. Who are the victims and perpetrators of  domestic violence-related homicides?

In 2013, nearly 43 percent of the victims were male, according to a report from the North Carolina Department of Justice.  Females accounted for the majority of victims of domestic violence-related homicide in the state.

In 2013, more than 75 percent of the perpetrators of domestic violence-related homicides were male. This is consistent with national data that show males are often the perpetrators of serious cases of domestic violence.

According to the U.S. Department of Justice, the most effective way of reducing the number of female homicide victims is to protect female victims of domestic violence. National statistics show that nearly one-third of female victims of homicide are killed by an intimate partner.

4.  Which counties had the most domestic-violence related homicides in 2013?

In 2013, Guilford County had the most domestic violence-related homicides in the state with 11 cases. Buncombe, Wake, Mecklenburg and Durham counties had the most homicides after Guilford, according to the North Carolina Department of Justice. 

Of these counties, Buncombe County had the highest homicide rate with 3.22 homicides per 100,000 people.

5. What kind of support services are available for victims of domestic violence?

A wide array of support services are available for victims of domestic violence in North Carolina. Services range from emergency shelters, crisis hotlines, court advocacy and support groups for adults and children.

State funding supports the NC Coalition Against Domestic Violence, an organization that provides support services for victims of domestic violence.

Support services for victims of domestic violence are available throughout the state.

6. What kind of legal action can victims of domestic violence take before it’s too late?

Under state law, victims of domestic violence have the right to file for a protective order.

The court determines the type of protections victims need. Depending on the case, a protective order can do a number of things to protect the victim from the perpetrator, such as evict the perpetrator from the residence or order payment to support the victim or children.

The court also has the power to order the surrender and disposal of firearms if the perpetrator has made threats to commit suicide or seriously harm or kill the victim and/or children.

7. Does domestic violence only include physical harm?

No. Under state law, domestic violence includes stalking, rape or other forms of sexual violence.

Many advocacy groups have expanded their definition of domestic violence to also include emotional abuse, economic abuse, isolation and coercion, according to a 2009 report from the North Carolina Domestic Violence Commission. 

8. Does alcohol or substance use play a role in domestic violence-related homicides?

It often does. According to a study of more than 400 women in North Carolina, offender intoxication was the most reliable predictor for calling the police. Almost two-thirds of abusers were found drinking at the scene of the incident and more than half of the abusers were described as binge drinkers by their victims.

DHHS Officials Update on Ebola Prep – Oct 22 – Storify

Health care worker dressed to treat Ebola patients.

CDC’s Safety Training Course for U.S. health care workers going to West Africa is the first step in preparing clinicians to work in Ebola Treatment Units (ETUs). Photo credit: Nahid Bhadelia/ CDC

Many Medicare Outpatients Pay More at Rural Hospitals, Federal Report Says


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By Jordan Rau

Kaiser Health News

Many Medicare beneficiaries treated at primarily rural “critical access” hospitals end up paying between two and six times more for outpatient services than do patients at other hospitals, according to a report released Wednesday by the inspector general at the federal Department of Health and Human Services.

There are more than 1,200 critical access hospitals, which are generally the sole hospital in rural areas and can have no more than 25 beds. Medicare pays them more generously so they won’t go out of business. In Illinois, 50 hospitals, more than a quarter, hold this designation.

rural barns

Image courtesy Donald Lee Pardue, flickr creative commons

Medicare requires patients to pay 20 percent of the amount a critical access hospital charges. At other hospitals, patients also pay 20 percent coinsurance, but it is based on the amount Medicare decides to reimburse the hospital, which is almost always significantly below what the hospital charges.

As a result, Medicare patients in 2012 receiving an electrocardiogram at a critical access hospital owed an average of $33, while patients at other hospitals had to pay $5, according to the report. Patients getting an initial infusion into a vein had to pay $56 on average at a critical access hospital, while patients at other hospitals paid $25.

Many supplemental insurance policies for the elderly pick up the tab, but one in seven Medicare recipients lacks such a policy. In addition, these higher medical costs are ultimately factored into the premiums insurers set.

The inspector general’s office recommended Congress change the law so that a Medicare beneficiary’s financial responsibility better reflects the cost of the service.

Brock Slabach, a senior vice president at the National Rural Health Association, said this issue has been raised before by the Medicare Payment Advisory Commission, or MedPAC, which counsels Congress. He said that because the law requires that critical access hospitals be paid their “reasonable” costs plus 1 percent, Congress would either have to change the law or Medicare would need to pay more to make up for the lower patient portions.

Map courtesy NC Hospital Association

Map courtesy NC Hospital Association

“The reason this hasn’t been solved is it would require the Medicare program to subsidize more,” Slabach said.

Since the MedPAC report in 2011, which offered a number of ways to fix the system, the share of medical costs picked up by patients has risen further, the inspector general found. The patients’ portions of critical access hospital bills in 2012 were 47 percent of Medicare’s estimate of the cost of the treatment, with Medicare paying the remainder, the report said. Medicare beneficiaries paid about $1.5 billion of the $3.2 billion in outpatient services at critical access hospitals.

Medicare offered a short response to a draft version of the report in August, saying it “thanks the OIG [inspector general’s office] for its efforts and looks forward to working with OIG on this and other issues in the future.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

Turning 65? Nine Tips for Signing Up for Medicare


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By Caroline Mayer

Kaiser Health News

“Welcome to America’s hottest talk line. Ladies, to talk to interesting and exciting guys free, press 1 now. Guys, hot ladies are waiting to talk to you …”

Wait! I thought I was calling Social Security to ask a question about enrolling in Medicare.

It’s the first hour of my mission to sign up for Medicare and already I’m making mistakes. In this case, it’s minor (and amusing), misdialing the toll-free number by one digit. But it serves as a warning: There are many missteps I can make, some of them serious, if I’m not careful.

Even for me, a consumer reporter who has written about health-insurance issues, enrolling in Medicare is a daunting task. The terminology is confusing and the options are seemingly infinite, based on the amount of promotional material that’s begun arriving in my mailbox. The letters from various insurance carriers began appearing exactly six months before my 65th birthday, and after three months they weighed 1.5 pounds. More packets arrive daily. Medicare experts tell me I can thank the data brokers for the onslaught: Names and birth dates are for sale to anyone.

Enrolling is a task I’d like to put off, but I can’t. I no longer have job-based insurance, and my current health insurer has notified me that my policy will soon expire, on the first of the month in which I turn 65.

I know that the decisions I make may differ from those made by friends, relatives and even my husband. Yet we share many of the same frustrations in the sign-up process. For anyone in a similar situation, here are some of the lessons I’ve learned since I embarked on my Medicare sign-up mission.

Just do it!

Yes, Medicare is complicated, but turning 65 is the time to deal with this. The government will not automatically enroll you unless you are already drawing Social Security benefits.

logo for Seniors' Health Insurance Information ProgramYou may be like many people who have chosen to delay receiving Social Security payments until at least age 66 to ensure the full monthly payout. But you’ll be sorry if you do the same for Medicare, because there’s a very strict enrollment period that runs from three months before your birthday to three months after you turn 65. If you miss that, you will be penalized unless you have health insurance through your job or your spouse’s job.

First stop: Medicare, with its helpful Medicare.gov website and its “Medicare and You” booklet, available through the mail or online. Medicare is also easy to reach by phone (as long as you dial correctly) at 800-MEDICARE. If there’s a long wait to talk to a representative, you can leave your number and someone will call you back. Really. It worked for me.

More information – and even one-on-one guidance – is available from your State Health Insurance Assistance Program (SHIP), a federally funded, free counseling service.

Some North Carolina Medicare resources:

NC State Health Insurance Information Program:

Call: 855 408 1212

The NC Department of Insurance has a good website with lots of Medicare information: http://www.ncdoi.com/shiip/

Every county has certified SHIIP counselors; find yours here: http://www.ncdoi.com/shiip/shiip_county_sites.aspx

You should also ask at your local senior center; a listing of DHHS funded senior centers is here: http://www.ncdhhs.gov/aging/scenters/srcenter.pdf

Get to know the lingo

Unless you understand how Medicare is structured, you may not be able to make good decisions about what you’re buying. These are some of the terms you might see:

Part A of traditional Medicare covers inpatient hospital services, skilled nursing home care and hospice, among other things.

Part B of traditional Medicare helps cover preventive care and physician and outpatient services, among other things.

Part D plans are private insurance plans covering prescription drug costs.

Medicare Advantage is an alternative to traditional Medicare. In this program, private insurance plans are paid by the federal government to provide coverage that is equivalent to original Medicare.

– Private Medigap plans supplement traditional Medicare and help pay some out-of-pocket costs, such as co-payments and deductibles and sometimes emergency medical expenses overseas. These policies are optional, but if you want one, you’re best buying it when you sign up for traditional Medicare. Otherwise, you won’t be guaranteed coverage and may be subject to medical underwriting, through which you could be denied coverage or charged a higher rate for preexisting conditions.

Failing to sign up can be costly

You may be in for a surprise if you’re among the many baby boomers I’ve encountered who believe Medicare is free. It’s not. Not only is there an annual deductible ($147 for Part B in 2014), but there are also monthly premiums, ranging from $104.90 to $335.70 for individuals. (The exact premium is pegged to your income, generally based on the tax return you filed two years earlier.)

If you don’t sign up in your initial enrollment period or when your job-based coverage ends, you will pay a penalty that will raise your premiums for Medicare Part B and Part D for the rest of your life. Every year you delay signing up for Part B, your monthly premium rises by 10 percent – and missing the deadline by just one month is considered a one-year delay. There is also a waiting period for the coverage to kick in, so you could be without any insurance for several months, perhaps even a year, if you miss the deadline. For Part D, the penalty is 1 percent for every month’s delay. So a year’s delay would add 12 percent to the monthly drug premium base, currently set at $32.42.

Don’t make assumptions

Perhaps the biggest mistake you can make is assuming that your health insurance will stay the same when you turn 65. Retiree plans can end, and even coverage from some workplace plans ends, especially if you or your spouse is employed by a firm with fewer than 20 employees. You also need to apply for Medicare at 65 if you are on COBRA, the program that allows you to purchase health coverage offered by your employer if you’ve been laid off. You also need to apply even if you are entitled to the military’s Tricare coverage for life.

Don’t rely solely on advice from your spouse or close friends. “You need to look at your own medical needs: doctors, hospitals, drugs,” advises Jennifer Whittaker, operations supervisor for Allsup Medicare Advisor of Belleville, Ill., a company that provides enrollment advice for a fee.

‘Open enrollment’ may be a misnomer

Once you’ve signed up for Medicare, you should be notified each fall about an open season that allows you to switch plans. But the open enrollment period allows easy switching only for certain plans, not all of them – and that may affect what you do when you turn 65.

Open enrollment does not give you a free pass to move from one Medigap plan to another, for instance. Although some plans (and some states, like New York) do guarantee the ability to make a change, Medicare allows plans to evaluate your health if you try to switch. So if you’ve developed an illness, you may be rejected or face a sharp rate increase. (If you stay with your existing plan, your rates can always rise – but only if they are rising for the plan or group as a whole.)

“If you didn’t pick a benefit you wanted initially, you may not be able to get it in the future,” said Diane Omdahl, co-founder of 65 Incorporated, another for-fee consulting firm based outside Milwaukee.

That’s also the situation you could face if you want to change from a Medicare Advantage plan to traditional Medicare with a Medigap plan. One of Omdahl’s clients who was on a Medicare Advantage plan recently developed diabetes, and he concluded that switching to traditional Medicare with Medigap would work better financially. But his diabetes kept him from finding an affordable Medigap plan. If he had signed up for traditional Medicare with a Medigap plan, he would not have been charged extra when he subsequently developed diabetes.

So what does open enrollment really mean? If you’re on a Medicare Advantage plan, you can switch to another plan. You can also switch Part D drug plans annually. And since both Medicare Advantage and the drug plans change premiums, benefits and providers regularly, it’s important to review your plans yearly.

Consider your health over the long term, not just how you feel now

Since it may not be easy to switch Medigap plans in the future, many Medicare advisers suggest that if you are choosing a Medigap policy, buy the best coverage you can afford when you sign up.

The cheapest price is not necessarily better

Consider more than the cost of the premium when you sign up for a Medicare Advantage or Medigap plan. Look at co-payments and deductibles too. The cheapest premium might not provide you with the cheapest overall plan. Also, review a company’s complaint records as well as its financial stability to hopefully ensure that it will be around as long as you plan to be.

For Medicare Advantage plans and drug plans, the Centers for Medicare & Medicare Services (the agency that runs Medicare) provides a helpful five-star rating system based, in part, on member satisfaction surveys.

Customer satisfaction ratings for Medigap plans are harder to find, but one valuable site for me was Missouri’s Complaint Index for Medigap issuers. (Many of the companies on this list operate nationwide.)

Several companies rate the financial strength of insurance carriers, although you may have to pay to get information. Two of the most frequently cited rating firms are Weiss Ratings and A.M. Best, neither of which charges for basic information.

Make calls and ask questions; you’d be surprised by what you learn

Once you pick a plan, call and confirm its different points, such as the premium and out-of-pocket limits,” Omdahl advises. “It’s rare, but sometimes the information online isn’t accurate.”

You may also discover added discounts. After I narrowed my search to two Medigap companies, I learned that if I went with the plan that my husband used, we’d both get a 5 percent discount on premiums. None of my research mentioned a “household discount.”

Don’t be afraid to seek help

In addition to advice from Medicare and your state’s health-insurance assistance program, tools that helped me included the National Council on Aging’s MyMedicareMatters, AARP’s Medicare Question and Answer Tool and the Medicare Rights Center fact sheets. Consumer Reports “Managing Medicare” article also is a valuable primer.

You might also consider seeking advice from an independent insurance agent. But remember, these agents typically talk only about the plans they offer – and they usually receive a commission on the policies they sell.

There’s also a growing list of firms that will help you for a fee. These include:

65Incorporated.com, with a fee of $299 for an initial enrollment consultation, $499 for a couple.

Allsup Medicare Advisor, charging $500 to $850 for a complete initial assessment.

Goodcare.com, with a $585 initial consultation, $195 more for each additional hour.

Healthcare Navigation, with consultation fees ranging from $750 to $1,250.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

The Ebola Outbreak’s Cyber Connections to North Carolina


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UNC-Chapel Hill Associate Professor Steven King and Ken Harper, a professor from Syracuse University, launch a website to do real-time tracking of the Ebola virus in Liberia.

By Hyun Namkoong

The Ebola outbreak in West Africa has dominated headlines for several months, and North Carolina became the first state in the U.S. to have a direct connection to the outbreak when an employee of a missionary organization based in the state contracted Ebola in Liberia.

Now the Ebola outbreak has hit home, but in a starkly different way.

The Ebola in Liberia website developed at UNC-Chapel Hill to help the Liberian government track the spread of the epidemic currently raging in West Africa.

The Ebola in Liberia website developed at UNC-Chapel Hill to help the Liberian government track the spread of the epidemic currently raging in West Africa. Click photo to visit site.

UNC-Chapel Hill’s School of Journalism and Mass Communication Associate Professor Steven King, a team of students and Ken Harper, a professor from Syracuse University, have launched a website, Ebolainliberia.org, to track new cases and deaths of Ebola in Liberia.

The website was unveiled in a news conference by the Liberian Ministry of Health on Sept. 8.

Ebolainliberia.org uses the most current data on new cases and deaths, and tracks them geographically. Scroll on the map, and a user can easily see which regions of the country have been hit hardest by the virus.

King got involved when Harper asked him to work on the project. “[Ken] called me, and together we started assembling a team,” he said.

The team consists of current and former journalism, library science and computer science students from UNC.

King said the Liberia Ministry of Health and Ministry of Information work together to collect data on the ground to send to the team.

“We take that [data] and adjust that into a database and do lots of other things with it,” he said.

King said they run an analysis and generate the data views to the website. The site displays how many cases are probable or suspected, based on the data provided from the ground.

The website is the primary means of briefing decision-makers, including the president of Liberia, Ellen Johnson Sirleaf.

“Her daily Ebola briefing comes from our statistics, and they’re using it to keep people updated,” King said.

He said that the project is in the process of getting funding to scale-up the site to other countries that have been affected by Ebola.

But the trickiest part of launching the project, King said, is the data collection. Health care workers are most at risk for contracting the virus, but they are needed to collect and send the data to King and his team.

The site splices the data to show how many cases and deaths have been caused by Ebola in health care workers alone.

The Ebola virus has killed more than 3,000 people in West Africa, primarily Guinea, Liberia and Sierra Leone, according to the Centers for Disease and Control Prevention.

The first case of Ebola diagnosed in the United States was confirmed in Texas this week by the CDC.

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