More about Affordable Care Act

The federal website created by the Affordable Care Act is working better, but it's not yet perfect. That's the gist of Monday's story in the Charlotte Observer. I wrote it after talking with six Charlotte-area experts -- three insurance agents and three "navigators" who have been trained to help enroll consumers into insurance plans in the online marketplace.

That assessment of the status of enrollment -- by the people who are using the website -- drew criticism from one reader who called it a "puff" piece and referred me to some other recent stories about the roll-out of the new health care law.

I'll pass them along for the benefit of others who may have missed them.

The New York Times' Robert Pear wrote a piece about how premiums may be low on the health exchange, but other insurance costs can be high.

On Sunday, Chris Wallace of Fox News interviewed Ezekiel Emanuel about President Barack Obama's promise that Americans could keep their doctors and their insurance plans.

I'll add a couple of my own suggestions:

A week ago, the Times also published an interesting piece about what went wrong with the website and how slowly administration officials responded to the catastrophe.

The Observer was among the first to report -- on Nov. 7 -- about the phenomenon of consumers receiving letters from insurance companies announcing cancellation of their current health plans and suggesting new plans that would cost much more. This was what started the outcry by those who claimed Obama had broken his promise that you could keep your current plan if you like it.

Former JAMA editor: Hospitals are dangerous places

Dr. George Lundberg, past editor of the Journal of the American Medical Association, has long been an advocate for patient safety.

In 1994, he published the seminal article by Dr. Lucian Leape, "Error in Medicine," and was criticized by AMA members who did not believe it and called for Lundberg's termination.

"Whose side are you on?" they asked.

Lundberg replied, "The side of science, truth, and all patients."

He recounts this experience in a new article for his blog, At Large At Medscape, at www.medscape.com.

Here's an excerpt:

"Hospitals are dangerous places. I no longer work in a hospital, and I try never to go to hospitals even to visit, unless, of course, I or my family were to become really sick and would obviously stand to benefit from hospitalization. I feel almost the same about surgicenters, free-standing emergency rooms, and urgent care facilities."

Myths about Obamacare

I spent an hour today listening to a webinar for journalists writing about the roll out of the Affordable Care Act, also known as Obamacare.

The speaker was Angie Holan, editor of PolitiFact, a publication that checks claims about all things political, including both critical and complimentary claims about the health care overhaul.

Earlier this year, PolitiFact published an article about 16 Myths About Obamacare.

A couple of highlights: There are no death panels. And Muslims are not excluded.

Cholesterol guidelines: More on statins

New guidelines about cholesterol levels and treatment were supposed to clear things up, but I'm just more confused.

Should I be taking statin drugs every day just because my LDL cholesterol number is high, which is "bad," and even though my HDL cholesterol is also high, which is "good."

Under these new guidelines, nearly half the U.S. population would be using statins to stave off heart attacks and strokes, according to Dr. Nortin Hadler, a UNC Chapel Hill professor of medicine and microbiology/immunology.

In a recent article for Scientific American, Hadler and his co-author remind us that these drugs are not without potential side effects and will offer no substantive benefits to many.

The article, entitled "How Clinical Guidelines Can Fail Both Doctors and Patients," says the authors of the new guidelines "were faced with robust data that demonstrates a correlation between cholesterol level and clinical outcomes over time. But despite the substantive science behind the connection, the correlation is weak. The guideline neglects to emphasize this fact."

Hadler, widely known for writing books such as "Worried Well" and "Citizen Patient," is skeptical about much of the treatment that medical doctors recommend today, including such broad prescribing of cholesterol-fighting drugs.

Here's is a link to the piece co-authored by Hadler and Dr. Robert McNutt, a former editor at the Journal of the American Medical Association  and the Journal of General Internal Medicine. McNutt is a professor of Medicine at the University of Wisconsin and Rush University Medical Center.

Remember to figure health care costs in retirement

How much money does it take to retire?

Partly, it will depend on your health.

The New York Times recently probed this question through the story of Jeff Strack, a 61-year-old Charlotte sales manager who is considering retirement.

Fidelity Investments estimates that the average married couple retiring this year at age 65 will need $220,000 to cover health costs throughout retirement, the Times story said. That figure is less than last year’s estimate of $240,000 because of lower-than-expected Medicare spending, Fidelity said. Also, people have cut back on medical care during the lackluster economy, and increases in payments to doctors and health plans have slowed under the Affordable Care Act. But the number is still daunting.

The Times also quotes the Employee Benefit Research Institute, which estimates that a married couple retiring in 2013 at age 65 with traditional Medicare (with a prescription drug plan, a generous supplemental plan and median drug costs) will need $255,000 to have a 90 percent chance of having enough money for health care costs throughout their retirement.

Maternity coverage: Men have babies, too

Under the Affordable Care Act, certain essential benefits are required to be provided by every health insurance plan, and that's why some people are getting letters from their insurers notifying them that less comprehensive insurance plans are being cancelled.

Many people in their 50s and 60s have been asking why they have to pay for benefits they don't need, such as maternity coverage.

Here's a story from the Los Angeles Times that tackles that question.

Kaiser estimates 684,000 North Carolinians are eligible for insurance premium subsidies

A new report from the Kaiser Family Foundation estimates that 684,000 North Carolinians will be eligible for tax credits if they buy coverage through the Affordable Care Act marketplace next year. 

Estimates for each state reflect demographic information, including how many lack insurance now, their income levels, or buy their own coverage now and their income levels, as well as whether each state is expanding its Medicaid program.

Here is a link to the full report that includes a table showing each state’s data.  

There is also ZIP-code-specific calculator that can estimate the premiums and tax subsidies people might get if they purchased coverage on the exchange – based on relevant information such as ZIP code, age, family size and income.  

The federal premium subsidies, in the form of tax credits, are designed to help low- and moderate-income people buy private health insurance. 

To qualify for tax credits, people must earn between 100 and 400 percent of the federal poverty level (that's $23,550 and $94,200 annually for a family of four). They must also not be eligible for affordable coverage from an employer or from Medicaid or Medicare. People who are not lawfully present in the country or who are incarcerated are not eligible for tax credits. 

In states that expand Medicaid under the Affordable Care Act,  uninsured residents with incomes up to 138 percent of the federal poverty level will qualify for Medicaid. In states that do not expand, uninsured residents between 100 percent and 138 percent of the federal poverty level generally will be eligible for tax credits, but those with lower incomes generally will be left without assistance. 

The new analysis estimates that about 29 million people nationally are potential customers for the exchange, including currently uninsured people and those who buy private insurance on their own now through the existing markets for non-group insurance. People who buy coverage also will face deductibles and other cost-sharing, depending on the plan they chose, though some of those who are eligible for tax credits will be eligible for additional assistance with their cost-sharing.

Success on the Affordable Care Act website

On Friday, 25 days after enrollment opened on the Affordable Care Act website, a staffer at North Carolina MedAssist helped her first client get far enough to compare health insurance plans and find out about eligibility for a premium subsidy.

"One down and 80,000 to go," said Lori Giang, executive director of MedAssist, a Charlotte-based free pharmacy for low-income people.

That's the estimated number of Mecklenburg County residents who will qualify for premium subsidies in the new health insurance marketplace -- if they can ever get through.

Because of malfunctions, millions of people across the country have been unable to enroll.

Until Friday, trained navigators at MedAssist and other agencies across North Carolina haven't been able to get far enough in the online process to help clients compare insurance plans or determine their eligibility for subsidies.

MedAssist has six staffers and 10 volunteers who have been trained to help consumers buy insurance through the online insurance marketplace. "I want to be able to put them to work," said Susan Royster, MedAssist's associate executive director.

Appointments for a free face-to-face meeting with a navigator are available by calling toll-free 1-855-733-3711.

Friday's successful client, who asked not to be named, is a 60-year-old Mecklenburg resident with a household income of less than $23,000 a year. That is 200 percent of the federal poverty level.

MedAssist navigator Nicole Stanfield helped the client through the process, leading to the news that the client is eligible for a monthly premium subsidy of $552, or $6,624 per year, from the federal government. The client was "overjoyed," Giang said.

The client is able to choose from 28 private insurance plans. The lowest-cost "bronze" plan would have a $12 a month premium after the subsidy. The highest-cost "platinum" plan would have a monthly premium of about $280 after the subsidy.

The client hasn't yet chosen a plan but is reviewing them to make sure the final choice will have the right network of doctors and hospitals and will cover the necessary prescription drugs.

Royster said she shared the news with other agencies in N.C. Community Care Networks, a consortium of organizations that received a federal grant earlier this year to train navigators and application assistants. None had been able to get as far as Stanfield had with Friday's client.

"They were all excited,"  Royster said. "It's only taken 25 days."

No fines if you enroll for health insurance by March 31

A few weeks ago, I wrote that the deadline to sign up for health insurance under the Affordable Care Act -- without getting a fine -- was actually Feb. 15, not March 31 as has been advertised.

But the Obama administration this week announced it will delay imposing penalties for six weeks so that people can safely enroll through March 31. 

The healthcare.gov website has malfunctioned since enrollment opened Oct. 1, but the White House said the delay is not linked with those website problems. Rather, officials said it's a clarification of the law's intent.

The law currently requires that by Jan. 1 most people must have health insurance, and allows enrollment through March 31.  It also allows consumers to be without coverage for less than three consecutive months without a fine.

But to have insurance by March 31, consumers would have to choose a policy by Feb. 15 to allow enough time for their enrollment to be processed so coverage would start March 1. Most insurance coverage begins on the first of the month.

With the new administration announcement, consumers can wait until March 31 to enroll and not face fines.

Here's an article from the Kaiser Health News: 

http://www.kaiserhealthnews.org/Stories/2013/October/23/administration-adjusts-deadline-for-health-law-coverage-penalty.aspx

Charlotte physician named Eisenhower Fellow

Dr. David Callaway, director of the Division of Operational and Disaster Medicine at Carolinas Medical Center, is one of eight U.S. citizens who will be studying abroad next year as USA Eisenhower Fellows.

Dr. David Callaway

The announcement came recently from Retired Gen. Colin L. Powell,  chairman of Eisenhower Fellowships.

Callaway is board-certified in emergency medicine and holds a master's degree focused on national security from Harvard's Kennedy School of Government. During his fellowship, Callaway will examine the impact of the Syrian crisis on the healthcare system and the international security policies of Turkey and Jordan. He will also work with local leaders to identify opportunities for health innovation in crisis zones.

He will travel on an intensive four- to five-week individualized professional program. While abroad, he will meet with experts in business, academia, government and nonprofit institutions working in the areas of health technology, health policy, innovation, national security and public 
policy. 

Eisenhower Fellowships is a private, nonprofit, nonpartisan organization seeking to foster 
international understanding and leadership through the exchange of information, ideas, and 
perspectives among leaders throughout the world. 

Established in 1953 as a birthday tribute to President Dwight D. Eisenhower, the organization has sponsored more than 2,000 Fellows from 108 countries. 

For more information,  www.efworld.org.

Enrollment deadline really Feb. 15 for Affordable Care Act

When enrollment in the Affordable Care Act's new online insurance exchanges opened Oct. 1, those in the know assured everyone there was plenty of time.

Although you have to enroll by Dec. 15 to get insurance starting Jan. 1, the law says the uninsured have until March 31 to be covered and avoid paying a fine.

But it turns out that really isn't true.

The Christian Science Monitor broke the news last week that, because of technicalities in the insurance world, the real deadline if Feb. 15.

Although open enrollment runs through the end of March, individuals are  required to be insured all year in 2014, and the IRS will forgive only brief coverage gaps of less than three consecutive months. (Some people will qualify for exemptions to this rule, such as if they have very low incomes.)

So people need to be covered by insurance in March. And to do that, they'll need to enroll by Feb. 15.

According to the Monitor: "Most companies start their policies on the first of the month, and so to be covered on March 31, one has to buy insurance that starts on March 1. To get insurance that starts on March 1, one has to sign up by around Feb. 15."

I called the Kaiser Family Foundation to find out more. Senior fellow Karen Pollitz said it's worth noting that people who enroll later than Feb. 15 might face only a partial penalty because the penalty is assessed for coverage months.  

Take someone whose income would mean they'd draw a $95 fine for not having insurance next year. If they enroll on Feb 16, coverage will take effect April 1. That means that person will have had a three-month coverage gap. Pollitz said the penalty would be 3/12 x $95, or $23.75.

By the way, the federal government's enrollment website, www.healthcare.gov, still isn't working properly. But a new feature popped up last week that allows consumers to window shop for plans without having to create an account. Without an account, you can't see if you're eligible for a subsidy or how much, but you can get an idea of the number of plans and their before-subsidy costs.

Kaiser's state-specific subsidy calculator  can provide estimates..

Consumer Reports also has launched an interactive tool for consumers.

And here's another from WebMD.

Affordable Care Act website still not working for Charlotteans

Charlotte area consumers ready to search for health insurance on the new federal exchange are still not able to do so.

"We've had to cancel any appointments we've had," said Lori Giang, executive director of North Carolina MedAssist, one of three Charlotte agencies that received money to train "navigators" to help consumers.

The federal exchange, also called the marketplace, is at www.healthcare.gov.

Madison Hardee, a lawyer with Legal Services of the Southern Piedmont, said she is keeping appointments but hasn't been able to enroll clients online. She's helping some of them to fill out paper applications or apply through the North Carolina e-PASS website -- nc.epass.gov -- which is used to enroll clients in other medical assistance programs offered by the state, such as food stamps or Medicaid.

The federal exchange website hasn't been working properly since Oct. 1, the first day of enrollment.
But Hardee said she has heard that some consumers have been able to enroll through the toll-free number, 1-800-318-2596.

"We plan to try that with the next appointment," Hardee said.

For enrollment assistance from navigators and certified application counselors:
--North Carolina MedAssist: 704-536-1790, www.medassist.org.
--Legal Services of the Southern Piedmont: 704-376-1600, www.lssp.org.
--C.W. Williams Community Health Center: 704-405-9510, www.cwwilliams.org.

After Oct. 14, you can make appointments for one-on-one enrollment assistance navigators and application counselors by calling 855-733-3711.

Novant Health will have financial assistants available at two workshops for walk-in visitors: 1-5 p.m. Nov. 6 at the BB&T building, 108 Providence Road in Charlotte, and 3-7 p.m. Nov. 14 at the Salisbury Civic Center, 315 S. Martin Luther King Jr. Ave. S., Salisbury.

Blue Cross and Blue Shield of North Carolina will open two Charlotte stores near the end of October. One will be near Northlake mall, at 9325 Center Lake Drive., and the other in Whitehall Commons, near S. Tryon Street and I-485. It will also have a kiosk at Concord Mills.

New 'lean and mean' co-op health plans threaten the 'bigs'

As enrollment in the Affordable Care Act rolls out this week, it's interesting to see how varied the insurance offerings are in different states.

North Carolina has only two insurance options, Blue Cross and Blue Shield of North Carolina and Coventry Health Care of the Carolinas. South Carolina has four: BlueCross BlueShield of South Carolina, BlueChoice, Coventry Health Care of the Carolinas and Consumers' Choice Health Plan. That latter is a newly created nonprofit cooperative, which doesn't exist in our state.

In this article for the Center for Public Integrity, Wendell Potter, a former Cigna executive-turned-whistle blower, suggests this is the "beginning of the end of the health insurance industry as we know it." And he refers to co-op plans like the one in South Carolina.

Here's an excerpt:

"One of the things apparent right off the bat is that some of the best deals will be offered by nonprofit health insurers, including the brand new co-op plans that will be available in about half the states. These plans will be lean and mean. They won’t have the enormous overhead costs of the big for-profit insurance corporations that I used to work for, and they won't have to charge extra for coverage just to satisfy the profit demands of shareholders. They won’t have shareholders.

"If you’re wondering why Aetna, Cigna, Humana and UnitedHealth Group, four of the biggest for-profits, are not planning to participate in many of the marketplaces, it’s because they know they cannot be competitive and still satisfy the profit expectations of their shareholders.

"Before long both Wall Street and Main Street will catch on to the idea that the big for-profits are bloated Goliaths that can and will be taken down by the new Davids of the insurance world. The value proposition held out by the bigs for years — that their armies of underwriters, marketers and 'medical management' specialists are essential — will be blown to smithereens.

"The bigs have to know this, and it explains why we are seeing some of their desperation tactics. Like the letter Aetna is sending to some of its policyholders encouraging them to renew early this year so they can avoid the 'big changes' that are on the way."  

Terrie Hall, anti-smoking advocate, dies

Terrie Hall, a Lexington, N.C., grandmother who appeared in one of the most startling anti-smoking commercials you'll ever see, died Monday, 13 years after being diagnosed with mouth cancer.

Terrie Hall

She was 53, and had appeared in one of eight national "Tips from Former Smokes" TV ads sponsored by the Centers for Disease Control and Prevention as part of a $54 million anti-smoking campaign.

But Hall's ad was by far the most popular. Last year, when I first wrote about her, her video on the CDC website had garnered 749,000 views - more than twice that of the others.

In the Associated Press article about Hall's death, Dr. Tom Frieden, CDC director, called her a "public health hero... She may well have saved more lives than most doctors do."

Last year, she also received the Surgeon General's Medallion, one of the highest honors in public health.

Hall was a lifelong smoker, having started when she was 17.

"I wanted to be like my friends, " she told me last year. "All of them were smoking. That just seemed to be the thing to do. It made me feel grown up."

She was up to two packs a day in 2000, when a sore throat led to diagnosis of mouth cancer. She continued to smoke during radiation therapy.

Her sore throat got worse, and her voice deteriorated. A year later, at age 40, she was diagnosed with throat cancer and had surgery to remove her larynx. She had a permanent stoma, or hole in her throat, and a voice prosthesis that had to  be replaced every few years.

Until she got the "hands-free" device that she demonstrated in the ad, she used to put her thumb over the stoma to close off the air before she could speak. 

In the CDC public service announcement, Hall, a slender, bald woman with a deep, scratchy voice speaks directly at television viewers.

"I'm Terrie and I used to be a smoker.

"I want to give you some tips about getting ready in the morning."

For a moment, the screen shows a photo of lovely, youthful Terrie from 1978, when she was a senior at Forbush High School in East Bend.

Then you watch as the adult Terrie puts in her false teeth, dons a long blond wig and inserts a device into the permanent hole in her neck.

"Now you're ready for your day, " she says.

When I spoke to her on the phone last year, her voice was hard to understand at first. But she said she had no trouble relating to laryngectomy patients in the hospital or to students at high schools and middle schools across the state. 

"Some kids cry. Some kids get scared, " she said. "Some kids feel sorry for me. Some kids say, 'I'm never gonna smoke.' "

People recognized Terrie almost everywhere she went. "You're that lady on TV, " they'd say. 

Some added: "When I saw your commercial, I threw away my cigarettes."

But Terrie didn't want people to feel sorry for her. 

"I thank God every day that I'm here (and) that I can talk and get the message out, " she said last year. 
"I was killing myself smoking ... I just hope I save lives."

Former Charlotte woman refuses to let cancer block career and family goals

It was July 2009, and Morgan Thompson was 26 and living her dream, working for Redbook magazine in New York City, when a surgeon delivered shocking news.

“It’s lymphoma.”

A swollen lymph node, just above her left collarbone, had turned out to be malignant – Hodgkin’s lymphoma.

Thompson

Thompson burst into tears. Then, she turned to her family and friends for support. She was told by doctors that, if she had to get cancer, this was the kind to get because the cure rate is high, 90 percent or better.

But after six months of chemotherapy and a stem cell transplant, her scans still showed the presence of cancer cells. Her disease was more aggressive than most, and four years later, she continues treatment, taking experimental drugs as part of a clinical trial.

Now 30, Thompson will tell her story Friday at a fundraiser for the Belva Wallace Greenage Cancer Foundation. The Charlotte-based group was created in 2010 by Belva Greenage, a two-time cancer survivor, former bank executive and publisher of Today’s Charlotte Woman.

Thompson’s mother, Linda Lockman-Brooks, a Charlotte marketing executive, became friends with Greenage when both worked at Bank of America. Lockman-Brooks admired the way Greenage handled her disease and turned to her for advice and comfort when her daughter was diagnosed.

“One of the first calls I made was to Belva,” Lockman-Brooks said. “She was really my safe place.”

This spring, when Greenage was planning her fifth annual “Coffee & Conversation” program, she invited Thompson to be a speaker. She wanted someone young to talk about “claiming your best life,” Lockman-Brooks said. Coincidentally, Thompson’s new job as associate merchandising director with Seventeen magazine, would be bringing her to Raleigh this week. She accepted the invitation.

Other speakers will be Moira Quinn, also a cancer survivor and senior vice president for communications at Charlotte Center City Partners, and Dr. Russell Greenfield with Greenfield Integrative Healthcare.

“I want my daughter to live the best life she can live,” said Lockman-Brooks, who will be in the audience with her husband Wil Brooks, a State Farm insurance agent.

“These are the cards she’s been dealt, but I’m so pleased that she’s living her best life, and she’s taking care of herself. That’s the best message for me.”

In an interview, Thompson acknowledged there have been times over the years when she felt defeated. But she refused to let cancer define her. A 2004 journalism graduate from UNC-Chapel Hill, she continues to pursue her career goals and also married Ross Thompson on June 4, 2011, while in the midst of chemotherapy.

Cancer “is just a part of my life now,” Thompson said. “I think about it, but my life is so full that I don’t dwell on it.

“This is an awful thing that has happened to me, but I won’t let it keep me from reaching for my dreams.”

For more information:
The Belva Wallace Greenage Cancer Foundation "Coffee & Conversation" event is Friday 7:30 to 10 a.m. at the Charlotte Convention Center. Tickets are $40 at www.belvascancerfoundation.org.
For information about Thompson’s journey, read her blog: http://beatingcancerwhilestayingfabulous.blogspot.com/

When is 'cancer' not cancer?

In a recent article, Dr. George Lundberg, editor of Medscape General Medicine, cautioned that doctors and patients should distinguish between cancers that will likely be aggressive and "cancers" that will not.


Here is an interesting excerpt:

"Pathologists never can really predict how any one cancer will behave. But after many decades of matching histologic patterns with the natural history of diseases, we are actually pretty good at predicting which lesions will be really bad actors and which seem likely to lie around indolently.

"Starting about 1965, I practiced and taught that 'When you say cancer, you are saying a mouthful. Be very careful. By that diagnosis, you, the pathologist, are giving any clinician license to treat that patient and his or her cancer with whatever treatment might then be in vogue, including cutting it out, shooting ray guns at it, or poisoning the cancer and the patient.'
"...We are learning more every day that cancer is many different diseases, even thousands or tens of thousands of different diseases.
"For a long time, it made sense to try to eradicate all cancers, as early and as completely as possible..But, as with many exuberant efforts, this one got out of control. Many lesions that were called 'cancer' really were not cancers at all in behavior, and this fact began to be recognized in large numbers of patients. These unfortunate victims have experienced massive psychological and physical harm and costs without any clear benefits achieved by finding and treating their 'noncancers.' 

"Cure rates from aggressive therapy on those 'indolentomas' are 100%. But, so would the outcomes have been of nondiscovery---100% cure of nondisease."

Lundberg thanked Dr. Laura Esserman of the University of California-San Francisco and the National Cancer Institute for "recently having forcefully called this mass discrepancy of professional and public behavior to the forefront of our consciousness. Ceasing to name lesions that are most likely indolentomas by that fearsome word 'cancer' is the first step. Almost any patient who hears the word 'cancer' applied to their pathologic findings experiences their hair catching on fire." 

In an interview with National Public Radio, Esserman, a breast cancer surgeon, said: "Many of these precancerous lesions are not going to go on to become cancer. I don't think we should label it as cancer. I think we should call it a 'ductal lesion.' I think people would be much more willing to be calm about it."

Charlotte heart specialists work 'virtually' with Belize counterparts

Heart specialists from Carolinas HealthCare System have been to Belize many times to assist with surgeries and other medical care.

But on Tuesday, they didn't even have to leave Charlotte to help their colleagues in Central America.

From a conference room at Carolinas Medical Center, Dr. Francis Robicsek, vice president of Carolinas HealthCare's International Medical Outreach Program, launched a "virtual communication portal" with the Karl Heusner Memorial Hospital in Belize City.

The portal will enable cardiologists in Belize to consult with cardiologists from Sanger Heart & Vascular Institute in real-time on complex cardiac cases. 

At a demonstration Tuesday, Robicsek, Dr. Paul G. Colavita, Sanger president, and Dr. Geoffrey Rose, Sanger vice president, spoke with cardiologists in Belize through the portal.

It was the second portal of its kind launched by Carolinas HealthCare System in Central America. The first 

was launched in February 2012 with the Guatemalan Institute of Cardiology and Cardiac Surgery.

Since 2011, cardiology and surgical teams from Sanger have traveled to Belize every month to assist with cardiac catheterizations, open heart surgeries and stents. To date, more than 100 catheterizations and nearly 15 open heart surgeries have been performed on Belizean patients.

Dr. Paul Colavita, left, and Dr. Francis Robicsek demonstrated the virtual portal with Belize City physicians Tuesday at Carolinas Medical Center.

 Dr. Geoffrey Rose addresses health care providers and administrators at Carolinas Medical Center in person as medical personnel and administrators from Belize (visible on the screen) listen and interact through the "virtual portal." 

Affordable Care Act: Figuring out who's eligible for subsidies

With about a month left before enrollment begins in the new health insurance exchanges, the Kaiser Family Foundation has provided details that can help individuals determine what plans they might want to purchase and how much they might receive in federal subsidies.

Enrollment starts Oct. 1, and until then, consumers probably won't have enough information to make their choices. But don't worry. Enrollment lasts until March 30, 2014. That's six months to figure everything out.

People can begin to get familiar with the types of insurance plans that will be available. They're called bronze, silver, gold and platinum, with bronze plans having the lowest premiums and the most cost-sharing (through deductibles and copays) and platinum plans having the highest premium with the least cost-sharing.

Most people will not pay the "sticker prices" for health insurance premiums because they'll qualify for subsidies, Kaiser officials said.

Federal subsidies are available for individuals and families whose incomes are between 100 percent and 400 percent of the federal poverty level. An individual at 100 percent of the FPL would earn $11,490 a year, a family of four would earn $23,550.  An individual at 400 percent of the poverty level would earn $45,960, a family of four would earn $94,200.

I've included below the Subsidy Calculator provided by the Kaiser foundation.
If you need more information, click here to link to the Kaiser foundation website.

Or click here for McClatchy coverage of the Affordable Care Act.

Better hospital price transparency coming next year

A North Carolina law requiring hospitals to provide public pricing on 140 medical procedures and services went into effect Wednesday, when it was signed by Gov. Pat McCrory.

But don't expect more transparency for a few more months.

Spokespersons for Carolinas HealthCare System and Novant Health, which operate eight hospitals in Mecklenburg County, said the actual posting of charges isn't required until March 31 for inpatient procedures and June 30 for outpatient procedures.

Both systems say they'll be submitting data to the North Carolina Department of Health and Human Services in advance of those dates. The state will publish the information on its DHHS website.

The new law also prevents hospitals, in certain situations, from putting a lien on a patient's residence to collect on unpaid medical bills. That provision takes effect Oct. 1. Hospitals will also be required to submit their charity care policies to DHHS for publication on the state website.

"Transparency is a good first step to fixing things, " said Sen. Bob Rucho, a Matthews Republican who led the push for the changes.

The law, which received bipartisan support in the legislature, came about after a series of articles in the Observer and The News and Observer of Raleigh last year explored how the growing market power of hospitals has driven up prices.

The stories revealed soaring profits at nonprofit hospitals, seven-figure executive salaries, and efforts by hospitals to sue uninsured patients delinquent on their bills or to turn over the accounts to collection agencies.

"For too long, North Carolina patients have been in the dark on what they can expect to pay for common medical procedures when they are admitted to a hospital," McCrory said in a news release. "This new law gives patients and their doctors pricing information so they can make an informed financial decision with regard to their health care."

Earlier this year, the federal government published a database on the cost of 100 common hospital procedures and services across the country. The newspapers' review of hospital pricing in North Carolina found that, in three-fourths of the services examined, the highest price was triple or more compared to the lowest price for the same procedure. For example, the price for implanting a pacemaker in North Carolina ranged from $22,000 to $75,000, according to the federal database.

Restaurant-goers need calorie information sooner, study says

I have appreciated the growing practice of listing calorie information on restaurant menus and vending machines. But Duke University researchers say it's too little too late.

In a study published today, they suggest a better approach: Improve calorie listings on websites and mobile apps so customers can prepare to order healthy items before they arrive.

"If consumers wait until they enter restaurants to make purchasing decisions, it might be too late," said lead author Gary Bennett, an associate professor of psychology and neuroscience, global health at Duke. 

"Particularly for those who are watching their waistlines, it’s important to make plans before stepping through the restaurant doors."

The Food and Drug Administration is working out the final rules for menu calorie labeling as part of the Affordable Care Act.

The Duke study, published on the website of the journal PLOS ONE, assessed the top 100 U.S. chain restaurants’ websites for the availability of and ease of access to calorie information. 

The study, funded by the Duke Obesity Prevention Program, found that only 46.3 percent of the restaurants surveyed had a separate online section identifying healthy eating options. Increasing this feature on restaurant websites could help diners make better choices, researchers said.

Similar research by Gavan Fitzsimons at Duke's Fuqua School of Business has found that including a healthy option on an in-store menu did not translate into healthier eating choices. On the contrary, Fitzsimons found that just seeing the healthier item on an in-store menu tended to make people more likely to eat less-healthy food. (What does that say about human behavior?)

Another Duke study done in King County, Washington, found that adding nutrition facts to menus at one fast-food chain had no effect on consumer behavior in its first year.

Health insurance premiums show 'moderate' growth

Health premiums increased by a "moderate" increase 4 percent in 2013, according to this year's Employer Health Benefits Survey released today by the Kaiser Family Foundation/Health Research & Educational Trust.

Drew Altman, President and CEO of the Kaiser foundation, said the country has been seeing moderate premium increases in health insurance in recent years, especially compared to the years of "startling double-digit increases."

But he said "you can't blame the public" for having a sense that premiums are going up faster than usual because, over time, what people are paying for health care "has so significantly eclipsed the increase in their wages and inflation."

The survey looks backward, not forward, and Altman didn't make a prediction for the future. But he added that people who want to blame Obamacare for "big premium increases" will have a harder time because "there aren’t any big premium increases" this year.

For another view about the slowdown in healthcare spending, Altman referred to an article by Gail Wilensky in the May 31 issue of the Journal of the American Medical Association.

George W. Bush's heart surgery prompts debate about stents

Americans have become familiar with the idea of using stents to open blocked arteries, so when former President George W. Bush underwent stent surgery recently, most people probably viewed the decision as routine.

But there is -- and should be -- a national debate about when to use this expensive therapy.

Here's an excerpt from the blog Health Beat by Maggie Mahar, who quoted Bloomberg News: 

“The discussions have been ongoing since 2007, when the trial known as Courage first found that less costly drug therapy averted heart attacks, hospitalizations and deaths just as well as stents in patients with chest pain. The results were confirmed two years later in a second large trial.

“The debate has centered on both the cost of stenting, which can run as high as $50,000 at some hospitals, and its side effects, which can include excess bleeding, blood clots and, rarely, death. Opponents say the overuse of procedures like stenting for unproven benefit has helped keep U.S. medical care on pace to surpass $3.1 trillion next year, according to the U.S. Centers for Medicare and Medicaid Services.

“ 'This is really American medicine at its worst,' said Steven Nissen, head of cardiology at the Cleveland Clinic in Ohio  . . .  ‘It’s one of the reasons we spend so much on health care and we don’t get a lot for it. In this circumstance, the stent doesn’t prolong life, it doesn’t prevent heart attacks and it’s hard to make a patient who has no symptoms feel better’ . . .

“ 'Stents are lifesaving when patients are in the midst of a heart attack,’ added Chet Rihal, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota. ‘...They allow immediate and sustained blood flow that help a patient recover. For those who aren’t suffering a heart attack, the benefits are less clear   . . . While stents may be used in patients with clear chest pain, there’s no evidence that they prevent future heart attacks.’  A review of eight studies published last year in JAMA (Journal of the American Medical Association) Internal Medicine also found no differences."

How can patients be responsible consumers without knowing costs?

Earlier this week, I posted a reference to the Kaiser Health News article on the proliferation of high deductible health insurance plans and how hospitals have noticed an increase in the number of unpaid accounts as a result.

Reader William Ertel, a Charlotte financial planner, wrote to suggest the problem should be viewed differently.

People should be expected to pay their bills, he said. But how are patients supposed to be responsible consumers if they can’t find out the cost of the services they are buying? 

Ertel said he’s had a high-deductible policy for years, and a health savings account to build up a pot of money to use for medical expenses. But "the novelty of this has disappeared for me," he said.

That's because: “No one at a doctor’s office can tell you what anything costs... In my business (or just about any other) we would say that is crazy!”

When a doctor recommends a test, Ertel said he asks for the cost, and the answer is often, “It depends on your insurance.”

“This is, of course, factually incorrect. My insurance might dictate how much I will pay (which is important) but it certainly should have no bearing on what it costs. Should a (procedure) cost more if I have a (Blue Cross Blue Shield of North Carolina) high-deductible plan or if I am uninsured?

"So the original story about hospitals complaining about high deductible delinquency could easily have been -- Hospitals Are Unable to Tell Patients the Costs."

One of Ertel's relatives recently went to the emergency room, and was released after about an hour. The bill from the hospital said "ER services" for $1,200, which was discounted to $900 based on the insurance contract. It was due within 15 days. And there was no more explanation.

Ertel called the billing office for details. Five days later, he got a list of insurance codes and cryptic descriptions – “none of which could interpreted or understood by an average person,” he said. 

Instead of focusing on patients not paying their bills, Ertel said: “You ought to let people know how poorly medical service providers communicate their fees and provide billing information....Again, I think people should pay what they owe, but hospitals are failing at providing timely information on amounts and explanations. I think this may contribute to the hospital being paid slowly."

Charlotte hospital CEO arranges ballet for his wife

Carolinas HealthCare System CEO Michael Tarwater is well known in North Carolina for running one of the largest hospital and healthcare systems in the country.

But recently, we came across an article in The Chautauquan Daily that reveals a side of Tarwater you don't often see.

Tarwater

The July 24 article in the official newspaper of the Chautauqua Institution in New York was headlined "Evening of Pas De Deux: Couple makes trip to Chautauqua to fall in love all over again."

It's about Tarwater's idea to surprise his wife of 27 years, Ann, with a ballet, reliving the first time they met.

The ballet, "At First Sight," was first performed in February in Charlotte by the North Carolina Dance Theater as part of a fundraising gala at the Knight Theater. It was followed by a dance competition featuring local business leaders. The winner was Tarwater and his dance partner from Metropolitan Ballroom.

According to The Chautauquan Daily, Tarwater had approached Sasha Janes, NCDT associate artistic director, in 2012 about creating a surprise for his wife's birthday. The two met secretly for about six months as Janes choreographed the piece based on Tarwater's story. "He added music and dance and made it come to life again," Tarwater told the newspaper.

The newspaper said "At First Sight" was to be performed by NCDT dancers Sarah Hayes Watson and David Morse on the Amp stage at Chautauqua in late July, and the Tarwaters were expected to attend.

Twitter not a place for intimate moments of death

I love Scott Simon and National Public Radio, but I was shocked at his decision to send Twitter posts recently during his mother's final hours.

Having been with my parents and a dear friend as they died, I couldn't imagine stepping out from that sacred time to send an electronic message to hundreds -- or thousands -- of strangers. One of my closest friends died in June, and all I thought about that day was being with her, totally, to let her know, even on a subconscious level, that she was loved and cared for.

Response to Simon's tweets appeared to be overwhelmingly positive. I felt like I was the only person who was bothered by the idea until I read this essay by Kim Triedman, a poet and novelist, on the website for WBUR, Boston's public radio station.

Triedman writes about "what seems to me a disturbing phenomenon in our society whereby our communication technologies are increasingly commandeering what have historically been intimate human experiences."

She notes that the New York Times said Simon did not begin his deathbed vigil with a "project" in mind. And he did not know when he began tweeting that his mother's hospitalization would end in her passing. But he continued, for more than a week, during which time his mother continued to decline.

Triedman stresses that she's not critical of Simon or even of Twitter. "I know the impulse to reach out, to share the burden."

But she adds: "What I am most concerned with here is the fact that technology has once again afforded us a way to distance ourselves from the very substance of our lives -- to put some other 'thing' between us and our loved ones...

"Twitter, I would maintain, is a zone. A place that is decidedly not where you are. A state of mind in which you're always looking out for the next 140 character windfall, something you can scavenge out of this experience and that, like a photographer so intent on a picture that he neglects to take in the scene.

"Wherever it is, whatever it is, it's not a place I want to be when grief comes to call."

News about blood pressure drugs, monitoring

Joe and Terry Graedon of The People's Pharmacy shined a light recently on two pieces of news regarding blood pressure medicines and monitoring.

Anyone taking anti-hypertensive drugs or monitoring blood pressure at home might be interested in reading these items.

The first is about accumulating research which suggests that popular blood pressure drugs increase the risk for serious cancers.

The second discusses research that demonstrates the benefit of home monitoring of blood pressure.

Charlotte hospital executives on list of CEOs to watch

Becker's Hospital Review has included the two executives of Charlotte hospital systems on its newly published list of "130 nonprofit hospital and health system CEOs to know."

Like others on the list, Carolinas HealthCare System CEO Michael Tarwater and Novant Health CEO Carl Armato were chosen based on their "experience and achievements in the healthcare industry, as well as their professional involvement in the communities they serve," according to Becker's, a bimonthly publication about the healthcare industry.

Tarwater

Armato

Tarwater has been with Carolinas HealthCare since 1981, serving as CEO since 2002. In that time, the system has grown to be one of the largest public nonprofit healthcare systems in the country. It owns, leases or manages about 40 hospitals in the Carolinas, including the largest, Carolinas Medical Center in Charlotte.
It has more than 60,000 full- and part-time employees.

Armato has been with Novant Health since 1988, serving as CEO since 2012. Novant, based in Winston-Salem, is a private nonprofit system with 14 medical centers in the Carolinas, Virginia and Georgia. It has more than 24,000 employees in those states.

Other North Carolina hospital executives on the Becker's list include:

Dr. Victor Dzau, CEO of Duke University Health System, Durham.

John McDonnell, CEO of Wake Forest Baptist Medical Center, Winston-Salem.

Tim Rice, CEO of Greensboro-based Cone Health, which is part of Carolinas HealthCare System.

Dr. William Roper, CEO of UNC Health Care System in Chapel Hill.

David Strong, president of Rex Healthcare in Raleigh.

Does malpractice reform work?

A new study by researchers at the Center for Studying Health System Change has found that Medicare patients receive more diagnostic tests and emergency department referrals when treated by physicians who worry about malpractice liability, regardless of whether states have adopted common malpractice tort reforms.

The study findings, published in the August Health Affairs, indicate physicians’ perception of their risk — rather than their actual risk — of malpractice liability predicts their practice of defensive medicine and suggest that traditional malpractice reforms, such as caps on damages, don’t change how physicians practice.

Funded by the National Institute for Health Care Reform, the study breaks ground by analyzing office-based physicians’ concerns about malpractice liability and the actual tests and ER referrals — based on insurance claims data — they ordered for Medicare patients with chest pain, headache and lower back pain. Patients whose physicians reported higher levels of malpractice concern received more services, the study found.

When researchers compared physicians’ level of malpractice concern with objective state-level indicators of malpractice liability risk, such as whether a state limits economic damages, they found no consistent relationships. In a few cases, referrals and treatments were lower in states with a higher malpractice liability risk.

“Traditional malpractice liability reforms don’t appear to resolve the concerns that drive physicians to practice defensive medicine,” said Dr. Emily Carrier, coauthor of the study.

Past malpractice research has focused on physician self-reporting on hypothetical cases. That generated conflicting results, leading to disagreements about the role of defensive medicine in the overuse of care.

The Health Affairs article, titled “High Physician Concern About Malpractice Risk Predicts More Aggressive Diagnostic Testing in Office-Based Practice,” is is available at www.hschange.org.

Three must-reads in this week's "Sunday Review"

The New York Times "Sunday Review" section carried several must-reads about health issues this week.

On the cover, "Status and Stress," by Moises Velasquez-Manoff, explores the toxic effects on stress for those who feel helpless about their life circumstances. "Even those who become rich are more likely to be ill if they suffered hardship early on."

"The Hype Over Hospital Rankings," by Elisabeth Rosenthal, explores the meaning - or lack of meaning - in all those Best Hospital rankings that marketing departments like to pass along as news.

Frank Bruni's column, "Our Pulchritudious Priesthood," describes the fad among New Yorkers of hiring personal trainers. "What therapists were to the more cerebral New York of yesteryear, trainers are to the more superficial here and now: designated agents of self-actualization, florid expressions of self-indulgence, must-have accessories, must-cite authorities."

Two pioneering health professionals supported each other through cancer

When it comes to getting things done, it’s often the people behind the scenes, as much as the big names in front, who deserve the credit.

That’s true for two pioneering women who shunned the spotlight and whose recent deaths are a great loss for the Charlotte region’s health community.

Donna Arrington, 69, who helped start a regional HIV/AIDS organization in the early years of that epidemic, died May 13 of multiple myeloma.

Donna Arrington

Sharon Dixon, 68, a nurse who helped create Charlotte’s first hospice, died June 27 due to complications from a rare lymphoma – Waldenström’s macroglobulinemia – that she lived with for 20 years.

Arrington and Dixon not only worked together as professionals in fields that often intersected, they became friends. They shared not only their passion for helping people, but their love of animals, and in the end, companionship during treatments for cancer.

In 1990, Arrington became the first executive director of what was then called the Regional HIV/AIDS Consortium. It came “at a time when people were afraid to even touch a person that had AIDS,” recalled Joe Gentry, Arrington’s longtime administrative assistant.

Sharon Dixon

But Arrington, with a supportive board – that for some years included Dixon – helped regional leaders make plans and raise money to help prevent HIV infection and serve people who already had it.

“She had a great ability to put the right people in touch with the right people,” Gentry said. “You wanted the right people at the table.”

One of them was Dr. Bill Porter, a Charlotte oncologist who served a stint as consortium chairman in those early days.

“What I remember is how easy Donna made it for me to sit in that chair and how dependable she was and how confident she was that the work she was doing was terribly important,” he said.

Today, Porter is a physician for Hospice & Palliative Care Charlotte Region, and he also recalls the beginning of that organization in 1978.

“Sharon was present at the creation,” Porter said.

In the early years, Dixon was the only nurse, visiting up to 12 dying patients and their families in their homes.
Later, in administrative roles, she helped hospice grow and thrive. Today it serves 450 patients, has about that many employees and operates two residential centers for dying patients whose symptoms can’t be managed at home.

 “Sharon sort of figured it out – who you needed to talk to, where the money was,” Porter said. “She did all this while she was sick for years with this cancer that finally took her life.”

Dixon’s interest in hospice grew out of childhood experience in Oklahoma. At 17, she took care of her mother who suffered tremendous pain while dying, said Marilyn Morenz, a friend and hospice nurse.
“Sharon never wanted anyone else to experience that kind of suffering.”

In recent months, Arrington and Dixon found comfort in their shared circumstance.

When she felt good enough, Dixon would sit with Arrington through hours of infusion therapy, said Cathy Morelli, Arrington’s partner of 15 years. “Donna in turn would do the same for Sharon....They both did good deeds in their lives and then good deeds for each other as their ends came near.”

When Arrington died first, that was “a really tough loss for Sharon,” Morenz said. “As much as they were able, they were there for each other at the end.”

Outdoor Nation encourages young people to get active

Outdoor Nation has teamed up with Blue Cross and Blue Shield of North Carolina and North Carolina Recreation and Park Association to encourage young people to get outside and get active.

The groups are offering 2013 GO NC! Health Challenge Grants to support initiatives that increase physical activity and promote healthy lifestyles. Grants of up to $7,500 will be awarded for projects from the eastern, central and western parts of North Carolina. They must be based in North Carolina and use outdoor recreation as a way to address health concerns. 

To apply, submit your proposal by Aug. 30. Awards will be announced Sept.18.

Chris Fanning, executive director of the Outdoor Foundation, the organization that started the Outdoor Nation movement, called Outdoor Nation a national initiative that reconnects "millennials" -- also known as Generation Y, born between the early 1980s to the early 2000s.

In the past year, Outdoor Nation has awarded more than $250,000 to youth for projects that reconnect young people with nature. 

“Since 2012, our GO NC! initiative has worked with organizations across the state to increase access to greenways and public bicycles. We’re thrilled to expand this work to support creative and passionate youth who are keyed into new and exciting ways to promote healthy lifestyles in our state,” said Kathy Higgins, BCBSNC vice president of corporate affairs.

The grant program announcement follows the recent Outdoor Nation Signature Summit on the Outdoors. In late June, nearly 200 young people gathered at UNC-Chapel Hill and camped overnight at the 47,000-acre Jordan Lake State Recreation Area to brainstorm and develop projects that get more people outdoors.