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Puerto Rico’s Wounded Medicaid Program Faces Even Deeper Cuts

By admin | August 2, 2018

by Sarah Varney–KHN

Blue tarps still dot rooftops, homes lack electricity needed to refrigerate medicines, and clinics chip away at debts incurred from running generators. Yet despite these residual effects from last year’s devastating hurricanes, Puerto Rico is moving ahead with major cuts to its health care safety net that will affect more than a million of its poorest residents.

The government here needs to squeeze $840.2 million in annual savings from Medicaid by 2023, a reduction required by the U.S. territory’s agreement with the federal government, as the island claws its way back from fiscal oblivion.

Overall, Puerto Rico faces a crushing debt of more than $70 billion — much of it due to the territory’s large Medicaid expenses. That’s on an island where the average household earns $20,000 annually and diabetes and hypertension are widespread.

But physicians, health insurers and former government officials say the drastic cuts demanded provide far too little money to care for a population still traumatized by Hurricane Maria.

The cutbacks do nothing to address the underlying fiscal imbalance at the root of Puerto Rico’s health care woes, which stem from the fact that the federal government already contributes a much smaller fraction of the U.S. territory’s Medicaid budget, compared to what it contributes to the 50 U.S. states.

“We are rearranging the chairs on the Titanic,” says Dr. Jaime Torres, whose jurisdiction included Puerto Rico when he served as a regional director of the Department of Health and Human Services.

Already health plans have been forced to lay off social workers and nurses like Eileen Calderón, who once visited dozens of chronically ill Puerto Ricans each month, finding them specialists, supervising medicine compliance and arranging rides to doctor appointments.

“These people who have been under our service for the last four or five years — all of a sudden I have to abandon them,” says Dr. José Joaquín Vargaspresident and chief medical adviser for VarMed, the Bayamon-based company that operated the program that employed Calderón.

Health care crippled by debt

If Puerto Rico were a state, the federal government would pay 83 percent of its Medicaid costs. (It pays upward of 70 percent of Medicaid expenses in 10 states, according to a formula that takes a state’s economy into account.) But because of a 1968 law capping the amount of Medicaid money Washington sends to U.S. territories, the federal government pays only about 19 percent of Puerto Rico’s Medicaid costs, and as a fixed annual payment, or block grant.

In February, Congress approved $4.8 billion in additional funds to help pay the island’s Medicaid bills. But the additional payments are widely viewed as a stopgap measure; health economists say that extra money is likely to run out in September 2019, a grim estimate shared by the territory’s fiscal oversight board. That’s a federal control board established by Congress in 2016 to oversee Puerto Rico’s budget, negotiate with its creditors and help restructure at least some of the island’s debt.

Gov. Ricardo Rosselló’s administration aims to reduce Puerto Rico’s Medicaid spending and improve access to care by putting an end to years of regional monopolies by private health insurance companies. The insurers have locked patients into narrow networks of health care providers. Later this year, under Rosselló’s plan, the companies will be forced to offer island-wide insurance plans and compete for customers.

“We do not have the luxury” of continuing to spend inefficiently, says Ángela Ávila Marrero, executive director of Puerto Rico’s Health Insurance Administration.

If Rosselló’s overhaul fails to achieve adequate savings — as most observers predict — drastic cuts are in the offing. Among those cuts: Some 1.1 million of the 1.6 million Puerto Rico residents on Medicaid are at risk of losing coverage next fall, their health held hostage to the island’s need to pay back its crippling debt.

Puerto Rico’s government effectively defaulted on more than $70 billion in debt. Economists blame a decades-long recession, a corporate tax break that ended in 2006,and reckless spending by a bloated government.

But also to blame, they say, and largely unnoticed in discussions of the debt, is Puerto Rico’s staggering Medicaid burden.

Poverty is so pervasive here that nearly 50 percent of residents qualify for public health insurance; Medicaid expenses in 2016 totaled $2.4 billion.

Residents suffer from higher rates of chronic conditions like diabetes and asthma, and the percentage of people who are elderly is quickly rising.

Footing medical bills without the kind of federal assistance dispensed to states has effectively doomed the island’s fiscal health, health economists say.

Researchers of health care say that, putting aside interest on Puerto Rico’s debt, the territory’s primary fiscal deficit would have been erased had Congress paid the same share of Medicaid bills that it pays the 50 states and Washington, D.C.

“The main issue is that we are not yet a state,” says Rep. Jenniffer González-Colón, the territory’s nonvoting member of Congress. The island must pay for Medicaid, she adds, “with local funds that we don’t have.”

Battered even before the storm

Puerto Rico’s health care system was already convulsing in September 2017 when Hurricane Maria struck. The federal government had issued warnings that the island would soon run out of additional Medicaid funds provided by the Affordable Care Act, and that 900,000 Puerto Rican residents would lose coverage.

Insurance companies, hospitals and physicians complained that the government was chronically late paying its bills. That frustration forced hospitals to defer maintenance and investments in new technology, and fueled the exodus of thousands of physiciansto the mainland in search of better incomes.

Today, Medicaid patients face long waits to see doctors on the island.

“If your kid needs a neurologist, for example, the waiting period is around six to 12 months,” says Dr. Jorge Rosado, a pediatrician in San Juan. “For a genetics specialty, it’s two to three years.”

The $4.8 billion in relief funding from Congress is propping up Medicaid while the Rosselló administration negotiates new contracts with health insurance companies and enacts other measures mandated by the fiscal oversight board. Those include a new Medicaid fraud detection system and enhanced data collection.

There is little time to waste

Barring the unlikely passage of bills that would eliminate the cap on federal Medicaid spending in Puerto Rico, the disaster relief fund is projected to run out in the fall. González-Colón also has authored a bill calling for statehood, which would eliminate the federal government’s unequal treatment toward the island’s Medicaid program.

The fiscal control board established by Congress openly acknowledges the impending disaster. In an April 19 report (p. 97 of “New Fiscal Plan For Puerto Rico: Restoring Growth and Prosperity”) the board projects monthly costs per Medicaid patient will rise nearly 40 percent over the next six years, barring any changes, and that Puerto Rico “will hit a ‘Medicaid cliff.’ ”

Beginning this fall, Medicaid patients in Puerto Rico will be able to pick from at least four insurers, instead of being assigned to the one that had covered their ZIP code.

Puerto Rico has long capped the monthly payments insurers receive for Medicaid patients regardless of how many medical services they use — a form of managed care.

But the government in San Juan believes that the insurers — without their regional monopolies — will be forced to compete, offering better care and more efficient delivery. They could save money by reducing unnecessary emergency room visits or hospital stays and by negotiating discounted payment rates to providers.

The island’s government has vowed to pay private insurers extra money to care for those patients that have expensive or chronic medical conditions. Insurers have cautiously welcomed the changes.

“I support the government on what they’re trying to do, but they didn’t price it properly,” says Dr. Richard Shinto, the president and chief executive of InnovaCare, an insurance company that sells plans in Puerto Rico.

“The oversight board is fixated on cuts,” he says, “but we’re never going to improve health care unless more money is put into the system.”

Government health officials argue that their changes mean Medicaid patients, especially those outside the San Juan metropolitan area, will gain access to more specialists, who are concentrated in the capital. But staff at the island’s clinics and hospitals fear they will be squeezed by insurers seeking to reduce costs, even as the clinics are still reeling from hurricane-related expenses.

For example, Hospital General de Castañer spent $5,000 every five days for gasoline to power the generators at its three sites for seven months; Health Pro Med, a community health center, spent at least $2,000 a day in added expenses, including private flights to ferry doctors to the storm-battered island of Vieques.

Many experts are skeptical that managed-care companies will hire the army of social workers and nurses needed to trudge up hillsides, knock on doors and do the tedious work that entails solving the daily problems of poverty.Viewed through a narrow lens, with an eye for cutting expenses, such problems can seem far outside the purview of medicine.

Many people displaced by the storm haven’t yet been able to return home, and that, too, can complicate health care delivery. Carmen Ramos, executive director of Redes del Sureste, a conglomerate of 22 medical groups in Puerto Rico, says 60 percent of the letters she recently sent to patients on her mailing list were returned.

“The managed-care companies need to produce revenue,” says Victoria Sale, a senior director at Camden Coalition, a pioneer of social and health programs for the chronically ill. “That’s a setup for concern.”

Bottom line? The economic overhaul doesn’t rectify Puerto Rico’s fundamental problem — it can’t sustain its Medicaid program so long as Congress treats the territory differently than it treats states.

“Next year, we will go back to Congress demanding the funding we deserve as U.S. citizens,” says Torres. But, he adds, “it’s time the local government started thinking about a Plan B.”

Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation, and not affiliated with Kaiser Permanente.

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FEMA Report Acknowledges Failures in Puerto Rico Disaster Response

By admin | July 17, 2018

FEMA acknowledged for the first time it failed to properly prepare for last year’s hurricane season and was unable to provide the support victims needed in the wake of an unprecedented season of catastrophic storms, according to an internal report released this week by the federal agency.

Most of the shortcomings focused on the response to Hurricane Maria in Puerto Rico, and many of those outlined in the report — a lack of key supplies on the island before the storm, unqualified staff, and challenges with delivering emergency supplies — were detailed in a recent FRONTLINE and NPR documentary Blackout in Puerto Rico, slated to re-air July 17.

The FEMA report found that its warehouse in Puerto Rico was nearly empty when Hurricane Maria hit last September, without cots or tarps, and very low levels of food and water, as most of the supplies had been rerouted to the U.S. Virgin Islands following Hurricane Irma.

It also found the agency as a whole had been understaffed going into the hurricane season, leading to personnel shortages as well as problems with “workforce certification.” FRONTLINE and NPR examined internal documents that found nearly half the staff on the island after the storm was “untrained” or unqualified.”

By the time Maria hit Puerto Rico, the report found, most specialized disaster staff had already been deployed to the other storms.

The initial response was also hampered by huge communication challenges, the report said. Almost 95 percent of cell towers were down after the storm. But FEMA did not have enough working satellite phones to adequately spread to the island’s leadership, making it difficult to get a handle on the scope of the damage.

As emergency supplies arrived, the report found FEMA faced a major hurdle: it lacked visibility into what was being shipped by other government agencies or private sector partners, further hampering response decisions.

“Shipping containers often arrived in Puerto Rico labeled simply as ‘disaster supplies,’ requiring FEMA staff to unload and open containers to determine their contents,” the report stated.

The report also found FEMA struggled to track supplies from the mainland to the island and through distribution, saying the agency experienced “business process shortfalls.” FRONTLINE and NPR found serious flaws with many of the agency’s supply contracts. 

According to the report, the agency had not prepared enough supply contracts in advance and ran out of key items like tarps before Maria even hit. The result was a flood of new contracting that overwhelmed agency staff. In each of the three years before 2017, FEMA’s contracts totaled $1.3 billion. But in responding to the three storms, FEMA issued more than $3.9 billion in contracts.

That lack of planning proved one of the agency’s biggest stumbling blocks to the response. The report found that the last FEMA disaster planning assessment for Puerto Rico was from 2012 and “underestimated the actual requirements in 2017.” In particular, the plans “did not address insufficiently maintained infrastructure (e.g., the electrical grid)” or the “financial liquidity challenges” facing the bankrupt Puerto Rican government.

FEMA’s report also acknowledged that the agency should have better anticipated the need for federal intervention on the island. The report said that in 2011, a separate report on a FEMA preparedness exercise in Puerto Rico “anticipated that the territory would require extensive federal support in moving commodities.”

One of the most critical of those commodities in the weeks after the storm were generators. But the agency didn’t have enough and was unable to quickly acquire more. While the agency ultimately installed more than 2,000 generators on Puerto Rico — a record number — FEMA only had 695 generators in stock when Maria hit and only had 31 on the island three days after the storm.

FEMA administrator Brock Long acknowledged in a foreword to the report that FEMA had work to do to improve its disaster response capability. “With this report, FEMA and the emergency management community have an opportunity to learn from the 2017 Hurricane Season and build a more prepared and resilient Nation,” Long wrote.

https://www.pbs.org/wgbh/frontline/article/fema-report-acknowledges-failures-in-puerto-rico-disaster-response/

 

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¿Qué es la diabetes y cómo se puede prevenir?

By admin | June 26, 2018

Más de 30 millones de personas en los Estados Unidos tienen diabetes y su incidencia ha alcanzado proporciones epidémicas en la comunidad hispana.

 OPINIÓN
JAIME R. TORRES,  Presidente de Latinos por Equidad en el Cuidado de Salud.

La diabetes es una enfermedad en la que el nivel de glucosa sanguínea (también conocida como azúcar en la sangre) sube demasiado. Más de 30 millones de personas en los Estados Unidos tienen diabetes, y la mayoría de esas personas tienen el tipo 2. Antes, la diabetes tipo 2 era más común en las personas mayores de 45 años, pero ahora las personas más jóvenes, incluso los niños, tienen la enfermedad, debido a que muchos tienen sobrepeso o son obesos.

La diabetes puede llevar a problemas tales como enfermedades del corazón, ataque al cerebro, pérdida de la visión, enfermedades de los riñones y daño a los nervios. Una de cada cuatro personas no sabe que tiene diabetes.

La diabetes ha alcanzado proporciones epidémicas en la comunidad hispana. Las primeras etapas de la diabetes pueden no causar ningún síntoma. Esta enfermedad es una silenciosa asesina en nuestra comunidad. Debido a que la diabetes puede ser una condición peligrosa y potencialmente mortal, es importante que se diagnostique lo antes posible

Muchas personas logran evitar los problemas que la diabetes puede causar a largo plazo, tomando los cuidados adecuados. Colabore con su equipo de profesionales de la salud para lograr los niveles de glucosa sanguínea, presión arterial y colesterol indicados para usted.

¿Qué es la prediabetes?

Se calcula que unas 84 millones de personas en los Estados Unidos mayores de 20 años tienen prediabetes. Por lo general, antes de desarrollar la diabetes tipo 2, las personas tienen “prediabetes”. Esto quiere decir tienen niveles de glucosa en la sangre más altos de lo normal, pero aún no lo suficientemente altos como para llamarse diabetes. Las personas con prediabetestienen más probabilidades de desarrollar diabetes dentro de 10 años y son más propensas a tener un ataque al corazón o al cerebro.

Tome pasos pequeños para prevenir la diabetes

Pero la buena noticia es que la diabetes puede ser controlada, y en muchos casos prevenida si se hacen simples cambios en nuestro estilo de vida. Se ha comprobado que la prevención de la diabetes es posible y es muy poderosa. De acuerdo con el Programa Nacional de Educación en la Diabetes, estudios demuestran que las personas con alto riesgo de desarrollar diabetes pueden prevenir o retrasar el comienzo de la enfermedad perdiendo del 5% al 7% de su peso, si tienen sobrepeso. Esto quiere decir de 10 a 14 libras para una persona que pesa 200 libras. Hay dos cosas claves para el éxito:

  • Hacer por lo menos 30 minutos de actividad física de intensidad moderada cinco días a la semana.
  • Comer una variedad de alimentos que sean bajos en grasa y reducir el número de calorías que consume por día.
La diabetes es una enfermedad peligrosa pero no tiene por qué arrebatarle la vida a nuestros seres queridos. Con ayuda médica, y la cooperación de la familia usted puede garantizar que esa persona con diabetes que usted conoce, pueda –paso a paso — tener una muy buena y larga vida.
***
Dr. Jaime R Torres, es presidente de Latinos por Equidad en el Cuidado de Salud, una organización que trabaja para impulsar la equidad en salud en nuestro país.

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Harvard study estimates thousands died in Puerto Rico because of Hurricane Maria

By admin | May 30, 2018

Washington Post-

 Miliana Montanez cradled her mother’s head as she lay dying on the floor of her bedroom here, gasping for air and pleading for help.

There was nothing her family could do. It took 20 minutes to find cellular reception to make a 911 call. Inoperative traffic signals slowed down the ambulance struggling to reach their neighborhood through crippling congestion.

Ivette Leon’s eyes bulged in terror as she described to her daughter the tiny points of light that appeared before her. She took one last desperate gulp of air just as paramedics arrived. Far too late.

More than eight months after Hurricane Maria devastated Puerto Rico, the island’s slow recovery has been marked by a persistent lack of water, a faltering power grid and a lack of essential services — all imperiling the lives of many residents, especially the infirm and those in remote areas hardest hit in September.

A new Harvard study published Tuesday in the New England Journal of Medicine estimates that at least 4,645 deaths can be linked to the hurricane and its immediate aftermath, making the storm far deadlier than previously thought. Official estimates have placed the number of dead at 64, a count that has drawn sharp criticism from experts and local residents and spurred the government to order an independent review that has yet to be completed.

The Harvard findings indicate that health-care disruption for the elderly and the loss of basic utility services for the chronically ill had significant impacts, and the study criticized Puerto Rico’s methods for counting the dead — and its lack of transparency in sharing information — as detrimental to planning for future natural disasters. The authors called for patients, communities and doctors to develop contingency plans for such disasters.

Researchers in the mainland United States and Puerto Rico, led by scientists at the Harvard T.H. Chan School of Public Health and Beth Israel Deaconess Medical Center, calculated the number of deaths by surveying almost 3,300 randomly chosen households across the island and comparing the estimated post-hurricane death rate to the mortality rate for the year before. Their surveys indicated that the mortality rate was 14.3 deaths per 1,000 residents from Sept. 20 through Dec. 31, 2017, a 62 percent increase in the mortality rate compared with 2016, or 4,645 “excess deaths.”

“Our results indicate that the official death count of 64 is a substantial underestimate of the true burden of mortality after Hurricane Maria,” the authors wrote.

Carlos R. Mercader, executive director of the Puerto Rico Federal Affairs Administration, said in a statement Tuesday that the territorial government welcomes the new Harvard survey and looks forward to analyzing it.

“As the world knows, the magnitude of this tragic disaster caused by Hurricane Maria resulted in many fatalities,” Mercader said. “We have always expected the number to be higher than what was previously reported.”

He said such studies — including a forthcoming George Washington University probe into hurricane fatalities — will help Puerto Rico better prepare for disasters and prevent the loss of life.

Maria, which caused $90 billion in damage, was the third-costliest tropical cyclone in the United States since 1900, the Harvard researchers said.

They also said that timely and accurate estimates of death tolls are critical to understanding the severity of disasters and targeting recovery efforts. And knowing the extent of the impact “has additional importance for families because it provides emotional closure, qualifies them for disaster-related aid and promotes resiliency,” they said.

The researchers noted that the Centers for Disease Control and Prevention says that deaths can be directly attributed to storms such as Maria if they are caused by forces related to the event, whether it is flying debris or loss of medical services.

“The worst part was knowing I could do nothing to help her,” said Leon’s daughter, Montanez, a 29-year-old mother of two. “Knowing she didn’t die peacefully means I will never have closure.”

The uncounted

Puerto Rico’s government faced immediate scrutiny after initially reporting that 16 people had died as a result of the storm, which strafed much of the island Sept. 20. That number more than doubled after President Trump visited in October, when he specifically noted the low death toll. The number kept rising until early December, when authorities said 64 had died.

The official toll included a variety of people from across Puerto Rico, such as those who suffered injuries, were swept away in floodwaters or were unable to reach hospitals while facing severe medical conditions. One was a person from the city of Carolina who was bleeding from the mouth but could not reach a hospital in the days after the storm. After arriving, the patient was diagnosed with pneumonia and died of kidney failure. Another, from Juncos suffered from respiratory ailments and went to the hospital — only to be released because of the coming storm. That person later returned, dead.

The new study indicates there probably were thousands more, like Leon, who died in the weeks and months that followed the storm but were not counted. Their deaths have long raised questions about the manner and integrity of the Puerto Rico government’s protocols for certifying hurricane-related deaths.

Gov. Ricardo Rosselló’s administration did not immediately release mortality data, nor did officials provide much information publicly about the process officials were using to count the dead. But officials and physicians acknowledged privately that there were probably many, many more deaths, and bodies piling up in morgues, across the island.

After pressure from Congress and statistical analyses from news organizations that put the death toll at higher than 1,000, Rosselló enlisted the help of George Washington University experts to review the government’s death certification process. He promised that “regardless of what the death certificate says,” each death would be inspected closely to ensure a correct tally.

“This is about more than numbers,” Rosselló said at a news conference in late February. “These are lives — real people, leaving behind loved ones and families.”

Lynn Goldman, dean of GWU’s Milken Institute School of Public Health, expects an initial report to be released in coming weeks. The school’s findings will include the first government-sponsored attempt by researchers and epidemiologists to quantify Hurricane Maria’s deadliness. Experts are assessing statistical mortality data and planned to dive into medical records and to interview family members of those who have died.

Some cases are obviously storm-related, Goldman said, such as someone dying after a tree branch falls on his head while clearing debris, or someone who suffers a heart attack during the storm and is unable to get help. But death certificates bearing the phrase “natural causes” will require further investigation.

The Center for Investigative Journalism in Puerto Rico has gone to court in an effort to seek the island’s mortality data for the months since November, the last month the government of Puerto Rico shared mortality data publicly. The Puerto Rico Institute of Statistics also announced in recent weeks that it would perform an independent death count and use subpoena powers to retrieve the data.

Spokesman Eric Perlloni Alayon said in a statement that the government is still trying to verify the death toll and does not plan to release any new data.

The Harvard researchers reported that there are several reasons the death toll in Puerto Rico has been drastically underestimated. Every disaster-related death, they said, must be confirmed by the government’s Forensic Sciences Institute, which requires that bodies go to San Juan or that a medical examiner travel to the local municipality.

“As the United States prepares for its next hurricane season, it will be critical to review how disaster-related deaths will be counted, in order to mobilize an appropriate response operation and account for the fate of those affected,” the authors wrote.

‘Natural causes’

Many families here are awaiting clarity on what happened to their loved ones when “natural causes” became the only explanation. That is what was written on Leon’s death certificate. The Puerto Rico Department of Justice’s Yamil Juarbe said in a statement that it is customary for local officials in these cases to review bodies for any signs of trauma and talk to relatives to learn about the deceased’s medical history. That information is collected and sent to the central office of the Forensic Sciences Institute.

Leon’s family said that her name was misspelled on the death certificate and that her death was incorrectly attributed to diabetes; they say she did not have any known chronic diseases. Officials later corrected the documents.

After falling ill while delivering donations to people who lost their homes in a nearby city, Leon sought treatment at Auxilio Mutuo, a private hospital in San Juan. The hospital never lost water service or electricity, said hospital spokeswoman Sofia Luqui, and the 600-bed facility experienced higher-than-usual patient volume after several other hospitals were forced to close.

Leon was diagnosed with diverticulitis and was sent home with prescription drugs, but she did not improve. Montanez said that at 7 a.m. the following morning, her father summoned her to the family home because Leon was short of breath. She died not long after.

Montanez tried for days to have an autopsy performed, but she said no government agency or private medical organization had the capacity to conduct one. Per her wishes, Leon was cremated a few days later in a rushed ceremony because the funeral home was damaged by the storm and was facing an influx of bodies.

Montanez stays awake many nights replaying her mother’s last days. She tries to remember the woman who loved to make wry jokes, who gave each of her neighbors a whistle to call for help in an emergency during the prolonged blackouts, who organized trick-or-treating by lantern light for the children in the barrio after the hurricane.

But mostly Montanez thinks about the storm. The darkness. The lack of services.

“Everything failed. From Day One, everything was failing,” Montanez said. “There are many stories like ours.”

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Coordinated Care Is More Than a Buzzword for Hospice Providers

By admin | May 10, 2018

April 24, 2018

 

By Edo Banach, JD
President and CEO

National Hospice and Palliative Care Organization

 

As much as we talk about “coordinated care” in health care today, it is regrettable that most people still contend with an uncoordinated, inefficient and stressful system at the end of life.

Often, health care professionals are singularly focused on eliminating illness and find themselves ill-equipped to provide the comfort and guidance needed when a person’s illness requires care rather than, or in addition to, a cure. Families who don’t know that there’s an alternative stand helplessly by as the last months of life get swallowed up by costly, sometimes unnecessary treatments that can hurt more than they help.

Health care consumers and policymakers must be aware that it doesn’t have to be this way. In an increasingly broken and fragmented health care system, hospice care – the nation’s first coordinated care model – shows how health care should and can work at its best for patients at the end of life.

A grassroots movement that began over 50 years ago, the success of the hospice model led to its adaptation into Medicare in 1982 — a mere four years after it began as a demonstration program. Today, an estimated 1.7 million Americans receive hospice services each year, with 1.4 million Americans choosing to utilize hospice through their Medicare benefit.

Expert medical care, pain management, emotional and spiritual support services are all provided and tailored to the patient’s and family’s needs. Hospice caregivers represent a comprehensive, interdisciplinary team of physicians, nurses, social workers, chaplains, volunteers and other professionals that ensures the patient is cared for beyond just his or her medical needs. Hospice respects the dignity of the patient’s life, honors his or her choices and provides a care plan reflective of a patient’s values. This philosophy of care is illustrative of hospice’s legacy and commitment to the best care for every hospice patient.

It’s a system that thrives because hospice providers understand how to balance the patients’ wishes with their health care needs – and coordinate care accordingly. This investment in care actually saves Medicare money – by one estimate, as much as $2,300 per patient — not at the expense of the patients, but rather by allowing the patients and their caregivers to guide decisions that can reduce their use of hospital-based treatments, resulting in fewer complications and side effects.

Despite more than 35 years’ success in the Medicare program, inevitable changes in our health care system could threaten hospice’s effective, original system of coordinated care. A rash or untested policy shift could lead to care delays, limitations on patients’ ability to select their preferred provider or a loss of autonomy for the hospice medical directors.

Change is inevitable and can often be good, but it must be incremental change that does no harm and respects patient and caregiver choice for more, rather than less, options for addressing serious illness.

While the goal of hospice care is not to save lives, it is still often called “lifesaving” by patients’ families. After experiencing the confusion and frustration of fragmented care, many are overwhelmed by the quality, compassion and personalized service that hospice care delivers. The hospice model exemplifies these principles of quality, compassionate and personalized care that beneficiaries, payers, policymakers and their constituencies want.

No patient or family should suffer needlessly at the end of life – and that includes either physically or emotionally. America is getting older, but members of the hospice and palliative care community are prepared to meet the growing need for more hospice care. And we are ready to do so in a way that is driven by our patients and their families.

Doing so demands that any health care reform allows hospice to continue to build on our successful foundation – and expand our patient and family-centered model across the care continuum. Protecting that continuity is essential to care for all patients with serious, advanced and life-limiting illness.

Rather than just trying to make hospice more like the rest of the health care system, how about making the rest of the health care system more like the original coordinated care model? Coordinated care should be more than a popular health care buzzword. It should be the driving force for all health care everywhere – just as it currently is for hospice.

It’s the model and philosophy that have driven hospice’s success and changed lives for the better. It is a model that we will continue to fight for and for policies that support peace, comfort and quality at the end of life.

https://www.nhpco.org/press-room/press-releases/op-ed-coordinated-care

 

 

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Puerto Rico’s Oversight Board Certifies Fiscal Plan: What are the Implications for Medicaid?

By admin | April 27, 2018

April 24, 2018 Edwin Park

As I have previously written, a robust and resilient Medicaid program is essential to Puerto Rico’s long-run recovery from the devastation of Hurricanes Maria and Irma.  Its residents disproportionately rely on Medicaid for their health coverage due to their low incomes and relative lack of access to private insurance.  For example, 62 percent of children in Puerto Rico — and 48 percent of its residents overall — were enrolled in Medicaid in 2016.  Moreover, after the hurricanes, there is a significant risk that more residents of Puerto Rico will likely become eligible for Medicaid in coming months — offset to some degree by the effects of overall population decline due to outmigration — and the average medical needs of beneficiaries may also increase.  Congress recognized the important role Medicaid is playing in the post-hurricane recovery by enacting critically needed temporary financial assistance for the Medicaid programs of Puerto Rico and the U.S. Virgin Islands as part of the Bipartisan Budget Act of 2018 in February.

On April 19th, the Financial Oversight and Management Board of Puerto Rico certified the Commonwealth of Puerto Rico’s fiscal plan, which includes a major overhaul of the island’s Medicaid program Mi Salud.  While much of the fiscal plan’s Medicaid provisions focus on delivery system reforms to improve quality and lower costs as well as lower prescription drug costs, other provisions raise substantial concerns.  Among the key takeaways from the certified fiscal plan:

Clearly, the most troubling aspects of the fiscal plan’s Medicaid proposals are its proposals to potentially increase beneficiary cost-sharing and further cut benefits.  If eventually implemented, they would place many low-income beneficiaries in Puerto Rico at risk of foregoing needed services and treatments, even though their health needs are likely to be greater in the aftermath of the hurricanes.

The fiscal plan includes these damaging potential Medicaid cuts because of the federal funding shortfalls Puerto Rico will face after the temporary Medicaid funding increase expires on October 1, 2019.  That’s why Congress should consider permanent Medicaid financing changes to sustain and strengthen the Medicaid programs in Puerto Rico as well as the U.S. Virgin Islands and the other U.S. territories over the long run.  Such improvements would help ensure that Puerto Rico maintains and expands Medicaid coverage for its low-income residents, continues to improve access to and quality of care and strengthens its severely stressed and damaged health care system.  It would also make its Medicaid program far more resilient and responsive in the event of another hurricane or other natural disaster.

 

Edwin Park is a Research Professor at the Georgetown University McCourt School of Public Policy.

 @EdwinCPark

 

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How is health care in Puerto Rico after Hurricane Maria? No one knows.

By admin | April 20, 2018

 April 18

Mekela Panditharatne is an attorney at the Natural Resources Defense Council

In Puerto Rico, locals say the best way to know whether someone died because of Hurricane Maria is to turn up at a morgue or funeral parlor rather than consult official sources.

Six months after Maria hit, the hurricane’s death toll is still a subject of controversy. After seismic investigations by the island’s Center for Investigative Journalism and the New York Times late last year showing that the true death count was probably several times higher than the official toll — more than 1,000 hurricane-related deaths, compared with the 64 deaths reported at the time — the Puerto Rican government asked a team of experts at George Washington University to review the numbers. But insufficient details were collected about causes of death by the island’s Demographic Registry. And as months go by, it becomes harder to trace the families of the deceased and ask questions about how a death occurred.

These mistakes are symptomatic of a broader trend. Recently, the island’s Institute of Statistics has found itself at the unlikely epicenter of a public outcry, as the cash-strapped local government considers ending the independent agency’s tenure. Now sidelined from participating in Maria’s maligned death count, the institute has historically played a critical role in correcting tendencies by local agencies to underreport health risks.

Last month, I traveled to Puerto Rico to get a handle on what doctors are seeing on the island now, six months after the storm. Doctors there say that poor data collection and underreporting are hiding a health crisis whose true scale eclipses official accounts.

The problems are particularly acute for chronically ill patients. Wendy Matos, a physician who supervises nearly 470 doctors as the executive director of the University of Puerto Rico’s faculty practice plan, said that her clinics are seeing increases in cardiac arrest and intracranial hemorrhage (bleeding inside the skull), more waterborne and infectious disease and swelling numbers of suicides since Maria.

Matos, whose doctors comprise the largest network of specialists and subspecialists on the island, also said her medical clinics have lost track of what has happened to tens of thousands of patients since the hurricane. From Sept. 1 to Dec. 31, doctors at Matos’s clinics saw nearly 25 percent fewer patients than they had the previous year — just under 91,000, down from about 117,000 patients in a comparable period in 2016. Some of these high-risk patients have left the island. Others are struggling to access care, immobile or unable to travel the long distance to San Juan on deteriorating roads. Some have died.

These issues, doctors think, either aren’t fully reflected in data put out by Puerto Rico’s Department of Health, or fail to surface because data on disease and injury isn’t being published at all.

An example: Under federal Centers for Disease Control and Prevention guidelines, Puerto Rico, like other states and territories, must publish weekly reports on influenza outbreaks. In January, officials on the island claimed thatinfluenza cases had not reached epidemic proportions. But doctors told me that diagnoses were artificially low because influenza test kits weren’t readily available after the storm. In February, several deaths were investigated for their possible connection to the influenza virus.

How frequent and severe have other health conditions been after Maria? The answer isn’t fully known because the numbers simply aren’t yet published. That’s typical in Puerto Rico, which periodically publishes annual health data in a lagging fashion, but doctors I spoke with said that after an emergency like Maria, the government should make information more readily available. With parts of the island still without power, though, reporting remains difficult for remote hospitals and health centers.

The testimonial data I collected suggest that Maria did make a dent. Hector Villanueva,  a physician and medical director of HealthPro Med, a federally qualified community health center based in Barrio Obrero, one of the poorest neighborhoods in San Juan, said his staff took over maintaining the island’s vaccine inventory for nearly two weeks after Maria hit, receiving and distributing vaccines from satellite centers across the island. His clinics also saw increases in waterborne and infectious disease in the months after the hurricane hit. Higher rates of mental illness linger.

Federally qualified not-for-profit clinics like Villanueva’s are now faring better than other private health-care providers on the island. Puerto Rico’s health infrastructure is glued together by private health clinics and offices; several of these have shuttered since the hurricane. As these clinicians pack up shop, their patients, set adrift, strain the capacity of an overburdened health system.

Even before Maria, rural and isolated areas in Puerto Rico didn’t have enough doctors and nurses. Specialists were in short supply. The hurricane has left more patients without care, or waiting longer for care. The island’s Center for Investigative Journalism found that after the storm, hospitals’ operational capacity had been overstated by the governor.

In some cases, capacity has still not returned to pre-Maria levels. Villanueva, who oversees a satellite health clinic in the area, told me that there still is no functional dialysis center in Vieques, where residents suspect that poor health outcomes are linked to toxic substances deposited by the U.S. Navy in decades past. To get treatment, dialysis patients must undertake a day-long trip three times a week, typically by boat, to the nearby metropolises of Fajardo or Humacao.

To fix these problems, the Federal Emergency Management Agency and the local government should direct federal aid to outreach tools such as telemedicine and to rebuilding the island’s regional health and water infrastructure. Accurate data collection and analysis, too, is key. Underreporting, or nonreporting, of hurricane-related disease and deaths in Puerto Rico means that resources aren’t being directed where they’re needed.

Meanwhile, the picture of the island’s health crisis is still precariously opaque.

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Why America’s Black Mothers And Babies Are In A Life-Or-Death Crisis

By admin | April 16, 2018

NY Times Magazine Feature Article: ‘Black infants in America are now more than twice as likely to die as white infants’
Why America’s Black Mothers And Babies Are In A Life-Or-Death Crisis
The New York Times Magazine 
“‘The answer to the disparity in death rates has everything to do with the lived experience of being a black woman in America.’ When Simone Landrum felt tired and both nauseated and ravenous at the same time in the spring of 2016, she recognized the signs of pregnancy. Her beloved grandmother died earlier that year, and Landrum felt a sense of divine order when her doctor confirmed on Muma’s birthday that she was carrying a girl. She decided she would name her daughter Harmony. ‘I pictured myself teaching my daughter to sing,’ says Landrum, now 23, who lives in New Orleans. ‘It was something I thought we could do together.’ But Landrum, who was the mother of two young sons, noticed something different about this pregnancy as it progressed. The trouble began with constant headaches and sensitivity to light; Landrum described the pain as ‘shocking.’ It would have been reasonable to guess that the crippling headaches had something to do with stress: Her relationship with her boyfriend, the baby’s father, had become increasingly contentious and eventually physically violent.”

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About Half Of Americans Support Single-payer Health Care

By admin | April 16, 2018

New Washington Post-Kaiser Family Foundation poll finds a slight majority of Americans support singlepayer health care approach, with numbers showing glaring partisan divide 

About Half Of Americans Support Singlepayer Health Care
The Washington Post
“As President Trump’s administration tries to chip away at the Affordable Care Act by giving more authority to states to regulate private insurance, a new poll finds a slight majority of Americans support a move in the opposite direction, with everyone getting health insurance from a national government-run program. A Washington Post-Kaiser Family Foundation poll finds a 51 percent majority of Americans support a national health plan, also known as a singlepayer plan, while 43 percent oppose it. Nearly three-quarters of Democrats support a singlepayer health plan (74 percent), while a slightly larger share of Republicans oppose it (80 percent). Independents break the tie, supporting a government-run health-care plan by 54 percent to 40 percent. Support is relatively high among rallygoers, defined as those who have attended a rally or a protest within the past two years. A 61 percent majority of this Democratic-leaning group supports a singlenational health plan. Just under half of non-rallygoers, 49 percent, feel the same way. Those who attended a protest or rally to express their views on the Affordable Care Act in the past two years favor a national health plan by a more than 4-to-1 margin, 79 percent to 18 percent. This group is also overwhelmingly defensive of the ACA, with 85 percent saying they came out to express support for the law.”

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Dialysis Patients are Still Trekking 12 Hours for Care After Hurricane Maria

By admin | April 13, 2018

Left without a hospital, some Puerto Ricans must travel by plane for lifesaving treatment.

Two men sitting inside an airplane. One is looking out a window.
Joe Garcia and Radamés Cabral Trinidad fly back to Vieques after dialysis treatment.Carmen Heredia Rodriguez / Kaiser Health News

VIEQUES, P.R.—As the cry of a rooster heralded the dawn, Joe Garcia, 41, pulled a vial of insulin from the fridge. He filled a syringe and wrapped it in aluminum foil in preparation for the long day ahead.

“I tell him that from here to there, that’ll spoil,” said his mother, Martina Collazo de Jesus, 63, watching the preparations under the fluorescent bulb lighting the family kitchen.

It is a gamble Garcia, who has both diabetes and kidney failure, has taken since Hurricane Maria slammed this Puerto Rican island just east of the main island. More than six months after the storm, Garcia and 13 other Vieques residents must still board a plane three days a week for kidney dialysis on Puerto Rico’s main island.

Hurricane Maria totaled Vieques’s hospital, which housed the island’s only dialysis clinic.

That set off an ongoing crisis for patients with kidney failure like Garcia—who cannot survive without dialysis and for whom the thrice-weekly round trip to a dialysis center in Humacao on Puerto Rico’s main island, including treatment, takes at least 12 hours.

When seriously ill patients like Garcia will again be able to access their lifesaving treatments in Vieques remains uncertain, as federal and local officials and nonprofit groups debate strategy and finances. No one knows when the hospital will be rebuilt, either. And the government and nonprofit organizations continue to punt the responsibility of paying for the flights.

“This is really hard,” Garcia said, as he prepared for his long day of treatment. “I am crazy, crazy, crazy for them to build a clinic here in Vieques.”


Before Hurricane Maria, Vieques, a sleepy island with about 9,350 people and miles of popular beaches along the Caribbean, was once home to a thriving tourism industry.

Since that September storm, residents have relied on generators for electricity, and tarps still serve as roofs for many houses.

The hurricane ravaged Garcia’s home. It tossed the appliances and ripped the metal sheets off, leaving only the wood frame standing. He now lives next door with his mother. The tattoos on his left arm bear her nickname, Tati, alongside the names of his sister and daughter.

Before Garcia received his diagnosis of kidney failure two-and-a-half years ago, he worked odd jobs, including as a handyman at a hotel and a manager at a car-rental business.

Puerto Rican government officials have discussed various solutions for restoring dialysis services, including bringing in mobile clinics and finding another building.

Puerto Rico’s health secretary, Rafael Rodríguez-Mercado, said in an interview last month in Washington, D.C., that the department is moving to bring in mobile dialysis units that should arrive within four to six weeks.

“I think this issue is a question of waiting for things to arrive, ‘go with the flow,’ and begin doing them,” said Rodríguez-Mercado.

He also said the government is searching for buildings suitable to house temporary dialysis services in Vieques.

But three weeks later, patients are still taking flights. Luis Emanuelli, the regional vice president of the national dialysis provider Fresenius Kidney Care, said he is aware of the plans for mobile dialysis clinics but is unaware of any time line. Officials with Puerto Rico’s Department of Health and local officials in Vieques did not respond to phone calls seeking information on the status of the dialysis units.

A medical van transports patients from their dialysis appointments to the airport in Ceiba, Puerto Rico. (Carmen Heredia Rodriguez / Kaiser Health News)

The health secretary and Vieques officials have disagreed about who is responsible for coordinating repairs of the ravaged hospital and its infrastructure—each pointing to the other.

Héctor Ortiz Jiménez, the Vieques municipal secretary, says, “All decisions with respect to the hospital correspond to the Department of Health because that is already part of the agreement between the Department of Health and the Vieques municipality.”

Meanwhile, the Federal Emergency Management Agency is collaborating with the territory’s health department and the federal Department of Health and Human Services “to help identify costs for mobile or temporary units that are eligible reimbursement expenses,” the agency said in an email.

It said officials hope to reconstruct buildings that “meet the needs of the community with resiliency for future disasters.”

But the email added that “no long-term solution has been identified yet for any reimbursement costs for reconstruction.”


Multiple groups have stepped up to help transport dialysis patients to a working facility. In the months following the hurricane, the responsibility of paying for this transportation has switched regularly between government and nonprofit organizations. These exchanges have at times left patients and the dialysis provider wondering where funds for the next flight would come from.

First, helicopters coordinated by the federal Department of Health and Human Services carried the Vieques residents to the main island for treatment.

In late October, the nonprofit organization ViequesLove began coordinating the flights, ultimately spending $9,000 in airfare, according to its founder.

Then Americares, a nonprofit, international relief organization focused on health, began paying, ultimately spending $55,000 on flights. The Puerto Rican health department informed Americares that it would shoulder the travel costs for March.

“The most sustainable solution for patients in need of long-term care is to have the local health system coordinate,” says Donna Porstner, the director of media relations for the nonprofit.

But this month, a local nonprofit that specializes in kidney health, the Renal Council of Puerto Rico, has assumed that responsibility. It secured the funding from the foundation Unidos por Puerto Rico, according to Renal Council’s executive director, Ángela Díaz. She says she expects the money will cover transportation for the next five to six months.

The council also asked for funding to rent a building in Vieques that could be retrofitted into a dialysis clinic. The foundation has not made a final decision on that request because it is waiting for the various government agencies to come up with a plan to reestablish services, Díaz says.


Eight hours after getting up in Vieques, Garcia dozed in one of the pink reclining chairs lining the walls of the treatment room in Humacao, still only halfway through his four-hour dialysis treatment.

Tubes full of blood snaked from his left arm and funneled into the machine on his right side. The electronic screen showed an assortment of numbers reflecting blood pressure and the amount of dialysis fluid flowing through the filter. The tattoo of his mother’s name on the same arm peeked out beneath the tangle of plastic.

Some patients from Vieques don’t know how much longer they can take the journey for this treatment.

Beside Garcia sat Radamés Cabral Trinidad, 65, who has threatened to stop dialysis to protest the traveling and the lack of effort to provide local treatment. “I want to die,” he said. “I want to die in Vieques.”

José Lorenzo, the director of operations of the clinic run by Fresenius Kidney Care, says he sympathizes with the Vieques residents’ call to reestablish the clinic as soon as possible. “I’m worried about these patients,” he says, noting the toll the grueling travel takes on their health.

It would be another four hours before Garcia pulled up to his mother’s home, plopped his bag down, and fixed a plate of leftover rice, exhausted. He took off his shirt and checked his blood pressure to make sure it was stable post-travel, post-treatment.

“I’m glad we made it,” he said.

“Thank God,” his mother replied.

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