Trump Administration Restarts Obamacare Program That It Suspended Two Weeks Ago

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Insurers will be relieved, and markets will avoid a big hit.

The Trump administration says it is restarting a key Affordable Care Act program, a little more than two weeks after announcing its suspension.

At the time, the administration said it was stopping the program, known as “risk adjustment,” in order to comply with a federal court ruling. Critics questioned that explanation, noting that the administration had options that would allow the program to keep operating, and suspected yet another effort by President Donald Trump and his allies to sabotage Obamacare.

Now the administration has gone ahead and used one of the available options. And that’s a big deal, because of the critical role risk adjustment plays in keeping insurance markets stable.

Risk adjustment is basically a set or payments that flow back and forth among insurers ― in this case, among the carriers that sell coverage to small businesses and directly to individuals. Insurers that end up with lots of relatively healthy customers put money into the program, while insurers with relatively sick customers get money out of it.

The idea is to make sure carriers aren’t making extra profits simply by finding ways to attract the healthiest beneficiaries ― say, by constructing doctor networks or pharmacy formularies that patients with cancer, HIV or other serious diseases would try to avoid. The federal government calculates the amounts, collects the contributions and makes the payouts.

Each year, billions of dollars go through the Affordable Care Act’s version of the scheme, with some insurers paying large sums and others receiving them. But some insurers have sued the federal government, arguing that the existing system doesn’t treat them fairly. In one of those cases, a lower level federal judge in New Mexico sided with the plaintiffs and declared the formula invalid, at least until the federal government could explain its rationale. The Trump administration subsequently asked the judge to reconsider his ruling.

Not too many observers paid attention to the court decision until early July, when the Center for Medicare and Medicaid Services (CMS), which administers the risk adjustment program, announced it was halting payments until the courts cleared up the legal ambiguity.

National Consumer Voice: Emergency Preparedness

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Federal Guidance

Emergency Preparedness and Response: Model Policies and Procedures for State Long-Term Ombudsman Programs
Preparing for and responding to emergencies that affect individuals living in long-term care facilities requires coordinating the work of many. While Long-Term Care Ombudsman programs are not first responders, they can play an important role in emergency planning and response. Ombudsman programs can resolve complaints, protect rights, and promote access to services for residents before, during, and after emergencies and disasters. This document was procuded by the Administration for Community Living to assist in developing polices and procedures for State Long-Term Care Ombudsman programs regarding Emergency Preparedness.

Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
The rule was published on September 16, 2016 and is effective as of November 15, 2016. The regulations must be implemented by affected entities by November 15, 2017. The regulations require nursing facilities to be in compliance with all federal, state and local emergency preparedness requirements.

CMS Emergency Preparedness Final Rule Crosswalk
These tables represent a visualization of the association between the CMS Emergency Preparedness Final Rule Conditions of Participation and existing regulatory and accreditation standards. This crosswalk is intended to serve as a “Quick Reference Guide” and not as interpretive guidance or instructions on how to achieve compliance. Specific questions on individual facility compliance must still be directed to AOs, surveyors, and Centers for Medicare and Medicaid Services (CMS). This crosswalk is a product of Yale New Haven Health System Center for Emergency Preparedness and Disaster Response’s (YNHHS‐CEPDR) and has not been reviewed or approved by the CMS or by any AO. 

CMS Emergency Preparedness Rule: Resources at Your Fingertips

This document provides links to numerous related resources applicable to a variety of providers and suppliers related to the Emergency Preparedness Rule.


Investigation Sought in Minneapolis Ketamine Trials

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Ethics of consent-less study of prehospital agitation treatment questioned.

Following revelations last month about two controlled trials of ketamine for treating severe agitation -- with drugs injected by first responders without the patients' individual consent -- the consumer group Public Citizen and dozens of independent physicians are calling for a federal investigation.

The Minneapolis Star Tribune newspaper published a series of stories in June detailing the trials, which were the first quasi-randomized studies comparing ketamine with traditional medications (i.e., haloperidol and midazolam) used to sedate agitated patients in emergency settings. The trials had been approved under a "waiver of consent" process, under which the investigators said risks were minimal; they also consulted beforehand with community groups, including patients in a homeless shelter under treatment for substance abuse.

Public Citizen is now hoping to make a federal case out of it. Their letter, dispatched just after midnight Wednesday, called on the FDA and the Department of Health and Human Services' Office for Human Research Protections to "immediately launch formal compliance oversight investigations."

The letter cited the adverse-event rates from the initial trial as indicating that the risks associated with ketamine were far from minimal, and questioned the method used to determine whether patients were severely agitated (scores of 2 or 3 on the Altered Mental Status Scale). It also said the institutional review board (IRB) that approved the trials, as well as the sponsors and investigators, should be scrutinized.

A ‘civil war’ over painkillers rips apart the medical community

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For Thomas P. Yacoe, the word is “terrifying.”

Leah Hemberry describes it as “constant fear.”

For Michael Tausig Jr., the terror is “beyond description.”

All three are patients struggling with chronic pain, but what they are describing is not physical agony but a war inside the medical community that is threatening their access to painkillers — and, by extension, their work, their relationships, and their sanity.

Two years after the United States saw a record 27,000 deaths involving prescription opioid medications and heroin, doctors and regulators are sharply restricting access to drugs like Oxycontin and Vicodin. But as the pendulum swings in the other direction, many patients who genuinely need drugs to manage their pain say they are being left behind.

Doctors can’t agree on how to help them.

“There’s a civil war in the pain community,” said Dr. Daniel B. Carr, president of the American Academy of Pain Medicine. “One group believes the primary goal of pain treatment is curtailing opioid prescribing. The other group looks at the disability, the human suffering, the expense of chronic pain.”

Pain specialists say there is little civil about this war.

“There’s almost a McCarthyism on this, that’s silencing so many people who are simply scared,” said Dr. Sean Mackey, who oversees Stanford University’s pain management program.

“The thing is, we all want black and white. We don’t do well with nuance. And this is an incredibly nuanced issue.”

Nuance does not matter to people like Tausig, 43, who has been unable to work or socialize since 2008, when the last of his five spinal reconstruction surgeries left him in constant pain.

He last got a taste of life without opioids a few years ago, when his pharmacy’s corporate parent imposed opioid-distribution limits, forcing him to find a new one.

“Those three days were among the worst of my life,” he said. “I wandered the house at night, legs shaking like a whirling mass of putty, sleepless and without respite from the pain.”

Now, with regulators and health industry leaders continuing to bear down on opioids, and the arrival of a new president whose statements indicate that he might further restrict opioid distribution, Tausig’s worries have deepened.

“It’s put the fear of God in me.”

WSJ: As America’s Unpaid Caregiver Network Shrinks, Challenges Add Up

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When a professional home health agency isn’t an option, family and other unpaid caregivers are often asked to pick up the slack.

It’s estimated that more than 34 million people in the United States provide unpaid care to individuals 50 and older. The economic impact of those services is far from trivial. Indeed, unpaid caregivers—largely adult children, siblings, spouses or other family members—provide an estimated $500 billion worth of care service annually, according to estimates.

But America’s network of these volunteer, unsalaried caregivers is shrinking—and at the most inopportune time.

Each day, roughly 10,000 baby boomers turn 65, past studies by the Pew Research Center have found. The ratio of caregivers to care recipients, meanwhile, peaked in 2010 and has been falling ever since.

The Wall Street Journal highlighted the looming care deficit in a new report published Friday.

“Families have fewer children, older adults are more likely to have never married or to be divorced and adult children often live far from their parents or may be caring for more than one adult or their own children,” stated a 2016 study by the National Academy of Sciences.

In effort to keep up the pace of care, families have even resorted to piecing together support networks made up of childhood friends and ex-spouses, The Wall Street Journal reported. It’s unclear how sustainable that strategy is, however.

Additionally, many of those caregivers have been forced to coordinate care from hundreds or even thousands of miles away as jobs have become more mobile and spread out geographically.

There are scores of personal and work-related challenges in taking on the role of an unpaid caregiver, The Wall Street Journal highlighted in its report.

About 68% of caregivers cited the mental and physical time and effort required of the role as a top challenge, while 45% identified the ability to navigate the U.S. health care system as a major obstacle. Another 45% of caregivers identified the changing relationship dynamics as a prominent challenge as well.

Statistics come from a study conducted by Merrill Lynch and Age Wave.

When brought into the care plan, home health agencies often strive to help family members mitigate many of those points. Findings suggest the role of a home health provider may become even more prevalent moving forward.

Besides psychological and social factors, there’s a very real financial toll tied to caring for an aging loved one.

Family caregivers, on average, spend about $7,000 per year on out-of-pocket costs related to caregivers, a 2016 report by AARP determined.