Fight Expected Over Georgia Bill To Repeal States Certificate-Of-Need Requirements

Meanwhile, in other state legislative news, a provision in Kansas' temporary budget is linked to the state's support of an interstate health care compact, and California lawmakers are weighing a $2.4 billion tax package on the state's managed-care organizations.

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A selection of opinions on health care from around the country.

State Highlights: After Settlement, Tufts Health Plan Revises Autism Treatment Policies; Mass. Home Health Agency Cuts Staffers

News outlets report on health issues in Massachusetts, Illinois, Indiana, Florida, Utah, Iowa and California.

Rep. Fitzpatrick: Permanent Birth Control Device Linked To More Fetal Deaths Than Previously Reported

In a conference call with reporters, Rep. Mike Fitzpatrick, D-Pa., alleged this harm and other adverse events. He also charged that physicians who performed the procedure received illegal kickbacks.

Based On Latest Enrollment Numbers, Covered California Now 'Running In Place'

Also regarding Covered California, the exchange may require its health plans to pay broker commissions to try to avoid discrimination against higher-cost consumers. Meanwhile, in Minnesota, MNSure data indicates exchange shoppers are getting older.

Viewpoints: Michelle Obama On Changing The Mental Health Conversation; S.C. Paper Endorses Kasich

A selection of opinions on health care from around the country.

California Marketplace May Require Insurers To Pay Agent Commissions

California's health exchange may require its health plans to pay sales commissions to insurance agents to keep insurers from shunning the sickest and costliest patients.

Covered California is working on a proposal that would force the plans to pay commissions effective next year, said Executive Director Peter Lee. The proposed rules could apply to regular and special enrollment periods, and would leave the specific commission amount or percentage up to insurers, he said.

The issue is expected to be discussed Thursday at Covered California's monthly board meeting.

Regulators in other states have warned insurers about altering commissions in a way that discriminates against higher-cost consumers, but Lee said Covered California may be the first exchange to adopt specific rules.

Health insurers typically pay agents a flat fee or a small percentage of the monthly premium. If companies want to restrict enrollment and avoid some sicker patients, they can try to do so by reducing the incentive for agents to sell their policies across the board or at certain times.

Lee said it has become apparent to him that some insurers are trying to avoid sicker customers by slashing their payouts to agents.

"When one health plan says during special enrollment, for instance, we won't pay commissions, they are hoping insurance agents won't sell them and they will sell sick people into another plan," Lee said. "We aren't going to let the old games of risk selection happen under the Affordable Care Act."

The health law banned underwriting and required insurers to accept all applicants regardless of their medical history.

Even after the open enrollment period has ended, people can sign up if they experience a qualifying event such as marriage, a birth or loss of employer coverage. Health insurers have criticized government rules for this special enrollment as too lax, essentially inviting consumers to wait until they get ill to sign up.

Nationwide, several major health insurers have cut or eliminated broker compensation as they reported financial losses in exchange markets. Industry officials have said the moves aren't discriminatory but rather a prudent business response to higher-than-expected medical costs in the individual market.

A spokeswoman for the California Association of Health Plans said her group won't weigh in on Covered California's proposal, leaving the decision up to individual insurance companies. Anthem Inc., California's largest for-profit health insurer, also declined to comment on it until more details are known.

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This issue began attracting more attention in November after industry giant UnitedHealth Group Inc. announced substantial losses on exchanges across the country and pulled back on marketing, including payments to agents.

Lee said he immediately contacted UnitedHealth, which just joined Covered California this year, and advised the company to keep paying commissions in the state.

A spokesman for UnitedHealth said the company didn't make any changes to broker commissions in California this year. It has said it will decide by midyear whether to continue selling in Obamacare marketplaces.

Lee also weighed in at the federal level in a letter last month. He urged Health and Human Services Secretary Sylvia Burwell to consider setting a minimum commission and to forbid divergence in compensation between open and special enrollment.

The issue is significant because, despite all the hype about government-run websites making the purchase of health insurance easier, many consumers still turn to an insurance agent for help. In Covered California, insurance agents accounted for more than 40 percent of enrollment last year, compared to the roughly 30 percent of people who signed up on their own online. There were 14,624 certified insurance agents working with the exchange as of last month.

Agents welcomed Covered California's proposal and said they look forward to a debate about what would constitute fair compensation.

"If this issue isn't addressed, we're on a downward path to zero commissions," said Michael Lujan, president of the California Association of Health Underwriters and a co-founder of Limelight Health in San Francisco. "There is a clear need for in-person assistance, and that is being threatened."

In and outside the exchange, agent commissions have been on a steady slide for years. Lujan said he estimates commissions have been reduced by 60 to 70 percent in the individual health insurance market during the past three years.

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.

State Highlights: States Takes Step To Address Rape Kit Backlogs; Ky. Official Paints Grim Picture Of Health Spending

News outlets report on health issues in Kentucky, Oklahoma, Kansas, Colorado, California, Connecticut, Maryland, North Carolina, Massachusetts, Michigan and Florida.

Insurers And Medicare Agree On Measures Tracking Doctors' Quality

The federal government and the insurance industry released on Tuesday an initial set of measures of physician performance that they hope will reduce the glut of conflicting metrics doctors now must report.

The measures are intended to make it easier for Medicare, patients, insurers and employers to assess quality and determine pay.

America's Health Insurance Plans, or AHIP, which represents most insurers, said it was encouraging insurers to add these into contracts it strikes and renews with doctors and hospitals. Medicare already uses some of the measures in its payment programs and plans to add the others, officials said.

Right now, doctors have to report different metrics to each insurer, adding to the paperwork they face and making it hard for anyone to provide a reliable assessment of their overall performance. One study by AHIP analysts of 23 health plans counted 546 distinct measures. Sometimes doctors have to report multiple measures that assess the same thing, such as how many patients' diabetes improved, because each insurer has its own metric.

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"Everywhere you go in health care people ask for one thing: simplify, simplify, simplify," said Andy Slavitt, acting administrator of the U.S. Centers for Medicare & Medicaid Services. The new measures, he said, "will reduce needless complexity for physicians."

The panel of government and insurance officials released seven groups of measures, each tailored to a type of care: cardiology, gastroenterology, HIV and hepatitis C, oncology, obstetrics and gynecology, orthopedics, and primary care. Core measures for other types of care are still being evaluated, and the sets can change as new metrics are developed.

Carol Sakala, an executive at the National Partnership for Women & Families, a consumer-oriented nonprofit, called the measures a "good start" but said "we must continue this work and fill crucial measure gaps," including ways to get patients' perspectives on whether their care produced a satisfactory result.

Primary care doctors now must report between 50 and 100 measures to multiple insurers, said Dr. Douglas Henley, CEO of the American Academy of Family Physicians. "As you can imagine, that creates a lot of chaos and confusion as well as administrative burden and complexity," he said on a conference call announcing the measures.

The new set has 21 metrics for primary care doctors. "This represents a huge step forward," he said. But if insurers do not consistently adopt them, he said "this effort will be for naught."

The primary care core measures include ones that gauge whether patients' blood pressure, depression and blood sugar levels were controlled; whether diabetic patients' eyes and feet were examined; whether women were appropriately screened for cervical cancer and breast cancer; whether doctors unnecessarily screened females under 21 for cervical cancer; whether doctors screened patients for obesity and came up with a treatment plan and a follow-up visit.

Those measures are also designed for use in some of Medicare's new experiments in paying doctors proactively taking care of patients, including through accountable care organizations.

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A selection of opinions on health care from around the country.

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A selection of opinions on health care from around the country.

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A selection of opinions on health care from around the country.

State Highlights: Calif. Health Plan Tax; Newborn Deaths At Philadelphia Hospital

News outlets report on health issues in California, Pennsylvania, Massachusetts, Tennessee, New York, the District of Columbia, Illinois, Missouri and Virginia.

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A selection of opinions on health care from around the country.

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Study Finds No Harm In Allowing Surgeons-In-Training To Work Longer Shifts

Patients suffered no extra harm when doctors training to be surgeons were allowed to work longer shifts, a study released Tuesday concludes, adding to a push to relax the strictest limits on resident hours.

The New England Journal of Medicine study comes as the Accreditation Council for Graduate Medical Education is reassessing requirements that prevent residents from working extremely long stretches or back-to-back shifts. Those rules were enacted in 2003 and strengthened in 2011 amid concerns that sleep-deprived residents were more likely to make serious errors.

Since then there has been push back from residency program directors concerned that the rules created new dangers for patients by abruptly forcing interns to leave in the middle of treating a patient or surgery. They also complain the rules interfere with resident education because it is harder for a trainee to follow their patients.

The study released Tuesday conducted a direct experiment by tracking patient outcomes after loosening the rules for doctors in 58 surgical residency programs. It found that their patients did not die or suffer complications any more than at 59 residency programs that did not waver from the current rules.

"We believe the trial results say it's safe to provide some flexibility in duty hours," said Dr. Karl Bilimoria, the main author and a professor of surgery at the Feinberg School of Medicine at Northwestern University in Chicago.

Some previous studies had come to similar conclusions, but this one has been anticipated because of its more rigorous methods. The trial has drawn protests from Public Citizen and the American Medical Student Association, which said researchers put patients and residents at risk by waiving the rules.

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The groups assert that the experiment, funded by the American Board of Surgery, the American College of Surgeons and the accreditation council, was never likely to find a significant difference in patient outcomes, since most elements of patient care -- the physicians, specialists, nurses and other clinical workers -- remained unchanged.

"Research on the deleterious effects of chronic sleep deprivation is just overwhelming," said Dr. Deborah Hall, president of the medical student association. "I'm concerned we're going to walk away from a lot of progress that's been made without overwhelming data [showing] that residents aren't subject to the ordinary limits of human neurobiology."

In an editorial also published in the journal, Dr. John Birkmeyer, chief academic officer at Dartmouth-Hitchcock, a health system in New Hampshire, came to a different conclusion than Bilimoria did. Birkmeyer wrote the experiment's results "effectively debunks concerns that patients will suffer as a result of increased handoffs and breaks in continuity of care."

Rather than roll back the rules on duty hours, he argued that surgeons should find safer ways to treat patients without relying on "overworked" residents.

"To many current residents and medical students, 80-hour (or even 72-hour) workweeks and 24-hour shifts probably seem long enough," Birkmeyer wrote. "Although few surgical residents would ever acknowledge this publicly, I'm sure that many would love to hear, 'We can take care of this without you. Go home, see your family, and come in fresh tomorrow.'"

The research was conducted in the academic year that began in fall 2014. One group of residency programs followed the existing rules, while the other programs were allowed to remove several strictures.

Residents in the experimental group could stay at the hospital longer than 28 hours in a row, the current maximum. They did not have to be given at least eight hours off between shifts. Residents who worked a 24-hour shift no longer had to wait 14 hours before returning to the hospital. And first-year residents could work more than 16 hours in a row, a limit set in 2011.

After analyzing medical records for 65,849 patients in the control group and 72,842 in the experimental group, the researchers found no significant difference in death or complication rates. They also surveyed 4,330 general surgery residents and found that those with the more flexible schedules rated their overall well-being and morale no different than did those with strict rules.

"We're very encouraged by the findings," said Dr. Maya Babu, a neurological surgery resident at the Mayo Clinic and president of the Resident and Associate Society of the American College of Surgeons. "We feel very strongly that flexibility is important to provide opportunities to learn and to have patient ownership, to see patients from the time they're admitted through surgery the next day."

Seven percent of residents exempted from the duty limitations said they left during an operation at least once a month, while 13 percent of those following the rules said they left. Thirty percent of the experimental group said they missed an operation at least once a month, while 42 percent of those with standard rules said they missed one. A third of the test group said they turned a patient over to another doctor in the middle of dealing with them, while nearly half of the control group recalled doing so.

Dr. Michael Carome, director of Public Citizen's Health Research Group, a patient safety advocacy organization, said the study should have objectively assessed the hours residents worked and the effects on their health and patients, rather than rely on surveys. He said the study also did not track whether residents in the control group adhered to the stricter limits on how long they could work.

"The study didn't collect any meaningful data on resident health outcomes," Carome said.

The most major restrictions on resident duty hours put into place in 2003, such as a maximum workweek of 80 hours a week and a minimum of one day off every seven, were not tested in the study and are expected to remain in place.

The paper was scheduled to be presented Tuesday at the Academic Surgical Congress in Jacksonville, Florida. A similar experiment, looking at internal medicine residents, is still in progress.

Study: Doctors’ Texts Can Prod Patients To Take Drugs, But Questions Linger

A spoonful of sugar may make the medicine go down, but that’s hardly useful if a patient doesn’t remember to take it in the first place.

According to a new analysis, there could be a possible solution: text message reminders sent to patients’ phones from the doctor. Researchers found that texts could push people to do better at adhering to their drug regimens and, along the way, save the health system a fair bit of money.

The paper, published Monday in JAMA Internal Medicine, reviewed data from 16 studies, all of which explored whether mobile telephone text reminders sent to patients made them more likely to take their medicine. In total, the studies included in this meta-analysis tracked the behavior of almost 3,000 chronically ill patients, looking at how well they complied with medication regimens, and found the text messages had an impact.

Across the various studies, patients went from having a 50 percent rate of following through on medication to a nearly 68 percent rate.

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On its face, that looks like quite a jump. But readers should view the findings with a degree of caution, the authors noted. They pointed out that several of the studies they examined relied on participants to self-report how faithful they were with their prescription drugs. Since people often misremember or misreport this kind of information, that measure isn’t always the most reliable. In addition, the studies included in the analysis lasted on average about three months, though chronically ill people take their medications for years. Thus, the studies may not have accounted for whether patients eventually experience text message fatigue and consequently paid the reminders less attention. If that is the case, then text messages could initially be effective but, over time, lose their power in helping people take medicine.

“It’s one way to think just sending messages is simple, and people will like it,” said Robby Nieuwlaat, an assistant professor of epidemiology and biostatistics at Canada's McMaster University in Hamilton, Ontario. “But they can also be irritating at some point if you don’t need it.”

That could be a factor, said Laurie Buis, an assistant professor of family medicine at the University of Michigan, who has also researched the subject. But it’s clear people want such reminders. “There is a lot of consumer demand for these types of interventions.”

The paper also compares studies from a host of countries. Two were based in the United States, but others were conducted in China, Spain and Kenya. Some texted patients every day. Others messaged them every week. Still others used strategies like aligning a text message with timing for when patients should take particular doses. Some sent patients reminders that had been personalized. Others didn’t. Those differences could introduce variables that made the texts more or less effective, or they could have introduced other considerations for which the analysis doesn’t account.

Taking medicine is, of course, important — especially for people with chronic conditions, like diabetes or high blood pressure. Chronically ill people are also often on multiple medications, which can be hard to track and easy to forget about.

That means if text reminders do work, they have “the potential to prevent major clinical events such as heart attacks, strokes and premature death,” study co-author Clara Chow wrote in an email. Chow directs the cardiovascular division of the George Institute for Global Health in Sydney, Australia.

Not taking medicine isn’t just bad for your health — it’s expensive, too. Experts estimate patients not complying with their drug regimens cost the United States between $100 billion and $289 billion each year. If text reminders do prove effective, they could offer an easy, low-cost tool to address that problem.

“Text-message based interventions can be delivered at low-cost, they can be easily scaled with computerized message management systems,” Chow said. “So they are likely to be cost effective in health care.”

But the issue of who pays for the text messaging also raises questions.

Texts are cheap to send, but they still aren’t free, Nieuwlaat said. He wrote a commentary analyzing the study. As researchers further probe how helpful they could be, doctors and patients need to think about who would pay for that kind of service and if it’s worth the investment.

“If it’s on the patient side, it has to be acceptable to the patient — maybe they pay a bit more for the text messaging they receive,” he said. If health systems or doctors subsidize text reminders, they’ll “have to think about whether they think it’s worth investing the money, considering the potential benefit.”

There also needs to be more research to better quantify how influential these messages could be, Nieuwlaat added.

For instance, researchers need to study more than just whether patients remembered taking their medicine, he said. Other questions, such as how often pharmacists refilled prescriptions and whether patients get healthier, would be powerful measures.

Meanwhile, even if text messaging is effective, it addresses only one reason people don’t take their medicine, Buis said. Text messages are a good reminder if you forget something, but people often don’t take medicine for other reasons — they can’t afford the drugs or they dislike particular side effects.

Plus, even if almost 70 percent of respondents ended up taking medicine, that isn’t everyone, she said, adding that a more comprehensive strategy is still necessary.

Though it isn’t enough alone, she said, “text messaging can help move the needle.”