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Illinois Dodges Disaster on Supreme Court's Obamacare Ruling

The following originally appeared on Crain's Chicago Business.


Illinois just dodged a bullet with the outcome of King v. Burwell. If the Supreme Court had ruled against subsidies being challenged in the case, working people and families in the state collectively would have lost more than $49 million a month to help purchase health insurance.

In its decision, the court affirmed the legality of the provision of premium tax credits under the Patient Protection and Affordable Care Act in all states, whether they established their own health insurance marketplace or used the federal marketplace. On average, working poor and middle-class Illinoisans are getting $211 monthly to help pay their health insurance premiums. A different decision would have meant a 169 percent increase in out-of-pocket expense on the average premium.

Recent data by the Kaiser Family Foundation show nearly 73 percent of the remaining uninsured in Illinois eligible for Get Covered Illinois, the state's health insurance marketplace—roughly 597,473 people—live and work in metropolitan Chicago. In the Chicago area, more than 100,000 of the remaining uninsured reside in areas where English is not the predominant spoken language. While concise data are not available of how many of the uninsured are working, American Community Survey data indicate that as many as 62 percent of the uninsured in Illinois are working at least part time and more than likely work for small businesses.

The most recent year for which U.S. Census data on businesses are available, 2012, show 314,199 business establishments in Illinois. However, 94 percent of these companies employ fewer than 50 employees and thus are not required to provide health insurance via the ACA. Cook County alone accounts for 41 percent of the state's total small businesses.

NOW WHAT?

Now that the King v. Burwell decision has put the legality of subsidies to rest, Illinois needs to get busy enrolling the remaining 597,473 uninsured individuals eligible for a path to coverage in the Get Covered Illinois marketplace. Of these uninsured, 283,629 are eligible for a tax credit or subsidy.

It's a matter of economic security for our residents and for Illinois' economic environment. The math tells us that the business community—especially small businesses—needs to be at the heart of efforts to enroll the remaining uninsured. Crain's and Health & Disability Advocates surveyed small businesses last fall and learned that Chicago-area companies still face increasing health care costs; are confused by the requirements of the ACA; and are unlikely to enroll themselves and their employees online. In fact, more than 80 percent of those surveyed said they shop for health insurance for themselves and their employees using health insurance brokers and agents.

Now that federal funding for ACA assisters and navigators is ending, a public-private partnership for enrollment in Get Covered Illinois is critical. We need to double down on engaging health insurance brokers and agents. While the state did an amazing job in enrolling 633,757 adults in Medicaid as part of ACA, Illinois ranked well behind others in marketplace enrollment, coming in 20th out of 37 states that operate marketplaces using HealthCare.gov.

Get Covered Illinois is key to helping Illinois businesses thrive, enabling them to better attract and retain talent. The marketplace also encourages entrepreneurship by ending the reliance of individuals on larger employer-sponsored coverage.

A strong ACA marketplace is a win-win for the business community and the state. We urge Springfield, City Hall and county governments to make enrollment of the remaining uninsured a top priority and engage the business community, health insurance brokers and agents in the process.

Barbara Otto                                          
CEO                                                        
Health & Disability Advocates           

Erica Salem
Director of Strategic Health Initiatives
Health & Disability Advocates

What Really Happens After Enrolling in Medicaid Managed Care?

Health & Disability Advocates (HDA) is monitoring the rollout of the Medicare-Medicaid Alignment Initiative (MMAI) and has heard from frustrated case managers working with consumers who are confused about the enrollment process and their rights. In response, HDA developed an enrollment timeline that explains what new enrollees can expect from Managed Care Organizations (MCOs) and plan representatives upon enrollment. To produce the timeline, HDA researched the MMAI demonstration contract developed by the State of Illinois and approved by the Center for Medicare and Medicaid Services (CMS)  HDA also solicited input from health plans on whether their on-the-ground practices were accurately reflected in the timeline.

The finished product outlines important points for case managers and their clients to consider.

One Day Changes Everything

Consumers who are enrolled in a managed care plan after the 12th day of the month will not see their coverage start until the month after next. This is relevant for consumers choosing a specific managed care plan in order to see a particular provider or specialist in that plan’s network. Submitting paperwork after the cut-off date means consumers would have to wait longer than expected for necessary treatment. Helping consumers submit required documents in a timely manner can guarantee they are connected to the medical treatment they need, which promotes continuity of care.

Stratification Sets Up Future Contact Standards

Once enrolled in a plan, all enrollees can expect to complete a Health Risk Screening within 60 days. The screen collects information on the enrollee’s physical and mental health conditions and identifies their current medical providers. This is what IlliniCare’s Health Screen looks like. Health plans use the screen to establish intensity of services and frequency of contact with Care Coordinators by stratifying the enrollee as low, moderate or high risk.

Enrollees stratified as low risk will receive annual follow-ups from their Care Coordinators while those stratified as moderate or high risk will have quarterly follow-ups. Moderate and high risk enrollees will also complete a Health Risk Assessment and create an Individualized Care Plan within 90 days. These enrollees will help form their own Interdisciplinary Care Team of healthcare providers that meets quarterly to review the Individualized Care Plan.

The Care Coordinators’ Role

Care Coordinators focus on enrollees’ healthcare needs by connecting them to necessary tests, doctors and treatment. They also facilitate information sharing among providers by leading the Interdisciplinary Care Team. Addressing enrollees’ medical needs is their priority. Care Coordinators direct less attention to linking enrollees to social supports, like housing and public benefits.

It’s also important for case managers to know that Care Coordinators must manage a substantial caseload of up to 600 enrollees. Caseloads include a blend of low, moderate and high risk enrollees, with each risk level weighted differently.

Understanding what a care coordinator can—and cannot—be expected to do is advantageous to case managers. When roles are clearly recognized, case managers know how care coordinators can be used as a resource. And in what instances an alternative referral would be more appropriate. This establishes a stronger professional relationship between case managers and care coordinators, which ultimately benefits the enrollee.

Case managers and Care Coordinators are on the front lines of healthcare reform and fostering solid working relationships between these two players will be a critical component of the success or failure of these efforts. Knowing what case managers and their clients can expect from managed care plans can lay the foundation for a strong relationship that supports the health of individuals while also furthering the goals of healthcare reform.

Bryce Marable MSW
Health Policy Analyst
Health & Disability Advocates


People With Disabilities Who Opt Out of ‘Voluntary’ Wellness Programs Will Pay the Price, and the EEOC’s Okay With That.

The following originally appeared on the American Civil Liberties Union's Speak Freely Blog.

Voluntary wellness programs at work can provide benefits to employees, but employers are increasingly adopting “voluntary” wellness programs that unfairly burden workers with disabilities the most of all. Worse, the Equal Employment Opportunity Commission seems to think that’s okay, undermining core antidiscrimination protections it used to defend.

Here’s why.


Imagine a woman living with rheumatoid arthritis and severe depression who, under doctor’s care, has finally returned to work. Her medications — a corticosteroid and an antidepressant — have triggered weight gain. Now imagine this woman facing her employer’s “wellness activities:” She is instructed to fill out a detailed questionnaire about her medical conditions; she is weighed and pronounced overweight; she is told to lose weight. Oh, and the program is voluntary — but if she doesn’t comply, she will have to pay hundreds of dollars more in annual health care premiums. 

This imaginary example is all too real: Persons with disabilities risk discrimination and stigma if their employers gain access to their private medical information. And disabled workers are far more likely to have a condition targeted by wellness programs, such as high blood pressure, high blood glucose, or being overweight. 

Historically, the Americans with Disabilities Act has provided employees with disabilities some protections against overly intrusive and punitive wellness programs. The EEOC has maintained, sensibly, that voluntary medical examinations and inquiries cannot impose penalties on employees who decline to participate. 

Until now.

The EEOC has recently proposed new regulations and guidance language on wellness programs that would allow employers to implement wellness programs that add up to 30 percent of the cost of the employee’s health insurance to an employee’s health care bill. Based on the average annual premium, this translates to an extra cost for disabled employees of about $1,800 per year, either because they don’t want to answer questions that could expose their disability to their employer or because they cannot meet the health goal

The EEOC describes these programs as “voluntary,” but workers with disabilities are the least likely to be able to afford additional health care premiums. According to the U.S. Census Bureau, median household income for people with disabilities is less than half of household income for people without disabilities: $25,974 compared to $61,103. At the same time, there is little evidence that these programs are effective. 

If the EEOC is going to allow employers to charge workers hundreds more each year, it needs to be sure important privacy and disability protections are in place.

Three safeguards matter the most. First, the EEOC needs to provide guidance language that workers with disabilities have the right to request a reasonable accommodation waiver from a wellness program, so that their medical status can be taken into account in their ability to comply. The guidelines should also protect disabled workers’ privacy, so that their decision to join or not join the wellness program doesn’t broadcast the details of — or even the existence of — their medical condition to their employer. Finally, disabled workers should rest assured that the guidelines protect them from disability-based discrimination in the workplace, such as harassment of employees who cannot comply with “normal” health standards. 

Comments on the proposed regulations are due this Friday, June 19, 2015. Tell the EEOC not to permit employers to subject their disabled workers to a Hobson’s choice: Submit to the prescribed wellness activities, or pay hundreds more each year. The EEOC should instead insure that workers with disabilities can opt out of these programs without penalty. 

Claudia Center
Senior Staff Attorney

Redoing Redes: Strengthening Communication Procedures in the Illinois Medicaid Redetermination Project

The Illinois Medicaid Redetermination Project (IMRP) is erroneously suspending vital medical care for people who remain eligible. Since the rollout of the IMRP in early 2013, the program has been plagued by inadequate communication from the state that leaves consumers confused and ultimately without healthcare. Consumers report that they are not receiving the required notices by mail and when they call with questions, frontline state staff cannot provide answers. Because of the state’s ineffective communication protocols and inadequate employee training, rightful Medicaid beneficiaries are in the precarious situation of being unable to fill their prescriptions, go to the doctor or receive treatment. The purpose of the IMRP is to save state dollars by trimming the Medicaid program of those who are no longer eligible, not cut people who still deserve services.

Letters Lost in the Mail

Medicaid beneficiaries are cut simply because they never received their redetermination notices in the mail. For example, Health & Disability Advocates worked with a mother whose child had been dropped from Medicaid because IMRP sent the notice to a non-existent address. The fact that IRMP sent the letter to an incorrect address on the same street where the family lived suggests that it was a clerical error. In this situation, a young adult dealing with serious mental illness could not access medication and treatment, because the state, not the individual made an error. Sudden lapses in care can pose serious consequences for people who rely on these supports for their physical and mental health.

This is not an isolated instance. A survey of case managers working with older adults and people with disabilities found that the IMRP fails to adequately notify people of their redetermination responsibilities and inform them when they are bounced from the program. Many get the bad news when they attempt to fill prescription or go to the doctor and are told that they are no longer covered. People deserve clear communication from the state telling them they are no longer covered and the steps to get reinstated.

Confused and Not Covered

Even in cases where Medicaid recipients do receive notices, many consumers find the letters are hard to understand and filled with jargon. Given that the intended audience has never before been required to submit to annual redeterminations and may also have lower literacy levels, the letters must be crystal clear. Reports from case managers suggest the letters are confusing.  One case manager surveyed noted “clients do not understand what documents they need to submit with the form and whether they need to submit anything.” With the potential for people to lose their health coverage, the consequences of this confusion are severe.

IMRP’s own data reveal their communication shortcomings. According to May’s Medicaid redetermination numbers, 81% of cancellations are due to a lack of response. Being cancelled doesn’t mean a person is ineligible. In fact, a substantial portion of these clients should still be receiving services.  Of those dropped, 1/3 were reinstated within three months.  In FY 2015 alone, this translates into 238,025 people being incorrectly cut from Medicaid, and this number could be even higher. People who are less frequent healthcare users may learn of their cancellation when they attempt to schedule a doctor’s appointment. With people who deserve Medicaid cut from the program, the IMRP is not achieving its main objective of reducing state expenditures by eliminating those who no longer qualify. Cutting eligible people will actually result in higher costs. Without access to primary medical treatment, people will resort to more costly emergency room care for conditions that could have been managed or even prevented.

Matters get worse when consumers call state workers for clarification, because frontline staff members are often not fully informed themselves. In the above-mentioned case of the mother fighting for her son’s coverage to be reinstated, her interaction with the IMRP hotline was unhelpful and hurtful. The representative said there was nothing more she could do and blamed the family. Stateline workers should be fully trained to provide answers; anything less only increases confusion and frustration.

The Path Forward

The state must develop plain-language notices that explain redeterminations and their importance while outlining the specific steps to keeping coverage. This would not be a new undertaking. State officials have previously brainstormed ways to create simple, more consumer friendly forms. Unfortunately, the furor around budget deficits and service cut threats has drowned out the push for clear communication standards. Even worse, continuing to deemphasize this issue will leave many rightful Medicaid recipients suddenly without coverage. Communication protocols and state staff should support individuals in maintaining their vital connection to healthcare, not create hurdles that effectively jeopardize emotional and physical health. State officials must restart the discussions on clear notices and broaden the conversation to include improved training for frontline staff. These reforms will go a long way towards supporting the IMRP’s original objective of eliminating wasteful spending while also keeping those who still deserve coverage connected to care.


Bryce Marable MSW
Health Policy Analyst

Joint Commission Mandates Armband to Identify Patients With Too Many Armbands.

Oakbrook Terrace, IL --  Hospitals are up in arms again after The Joint Commission (TJC) on Monday started requiring all patients with too many armbands  to be flagged with an armband for having too many armbands. Mark Chassin, President and Chief Executive Officer of TJC, applauded his organization for taking  action against his organization's failed policies.

"I'm proud The Joint Commission is finally  taking a stand against The Joint Commission for continuing to ignore all the unintended consequences of their regulations," said Dr. Chassin.

Doctors and nurses have been telling authorities for years that too many patient armbands are a safety hazard, but those complaints had fallen on deaf ears until last week when 87 year old ICU patient Pat Swanson of Denver, Colorado  underwent emergent bilateral upper extremity amputations at Great Scotts Medical Center shortly after 52 armbands cut off circulation during an anasarca storm.

"After a root cause analysis, we  determined the PROBABLY A PALLIATIVE CARE CANDIDATE  armband placed an hour before the event finally took her arms over the edge," said Dr. Steven Johnson, the Hospitalist on duty when this tragic but totally foreseeable event occurred.

"When she was admitted 24 days ago, she only had three arm bands, but if you do the math, she gained just over 2 armbands per day in the ICU that nobody noticed. In retrospect, the patient telling us 'My arms are too heavy with armbands to lift a spoon and eat' should have clued us into an emerging problem, but we were too busy filling out FMLA papers for multiple family members everyday to head her cry for help," said Dr. Johnson.

In the last four years, The Joint Commission says the average number of patient armbands has skyrocketed from 3 to over 17, as more and more patient characteristics demand armband worthy status, adversely affecting everyone in the hospital.  Nursing students are constantly pulling the code blue cord in an abundance of caution after being unable to palpate a radial pulse.  Medical students have no idea what  pronator drift is anymore.  Phlebotomists are being  retrained to perform bedside  carotid cut-downs for routine blood draws.  Even administrators are overwhelmed with committees trying to solve the excessive armband problem.
Too many armbands?  There's an armband for that!

"At one point we had 17 committees - all working independently and without communication - each trying to come up with a solution that nobody else liked, resulting in 17 other committees to sort it all out," said Dr Johnson.

What came out of these painful meetings was nothing short of genius at Great Scotts Medical Center. "We hired a hospital seamstress to convert  all those armbands into one giant sash for the women and a handsome fashion belt for the men.  Patients love it and it's a great conversation piece for family.  Plus, as an added bonus, we have the highest satisfaction scores in the universe! Thank you Joint Commission for being so helpful," said Dr Johnson.


Complete list of 52 armbands removed from Pat Swanson.

  1. Swanson With an O
  2. Already Outlived Life Expectancy
  3. Don't Code Her, She Won't Know The Difference
  4. Allow Natural Life Support
  5. Risk of Talking Alot
  6. Risk of Family Filling Out Poor Patient Satisfaction Survey
  7. Looks Older Than Her Stated Age
  8. Ambiguous Name Alert
  9. Suspected  Female
  10. Hard of Understanding
  11. Hits On Young Male Doctors
  12. Likes To Talks About Her Bowels
  13. POA Is A Physician
  14. Doesn't Believe In Flu Shots
  15. Family Googles Everything
  16. Thinks Most Doctors and Nurses Are Too Young
  17. Risk of Asking Lots of Questions
  18. Reads Every Consent Word-For-Word
  19. Family Wants Lawyer To Review All Documents
  20. Wants a Comfortable Death With Everything Done
  21. No Known Drug Allergies
  22. Allergic to All Antibiotics - Anaphylaxis
  23. Allergic To  Wasps, But Not Bumble Bees
  24. Has Two Daughters Who Never Leave The Room
  25. Thinks She's The Only Patient In the Hospital
  26. OK To Go Outside and Smoke
  27. Has Lots of Great Stories If You Have a Free Moment
  28. Wants Everything Taken Care Of While She's Here
  29. Found Cheating at Crossword Puzzles
  30. Should Be In a Nursing Home
  31. Can't Remember If She Has Dementia Or Not
  32. When She Yells 'Bill', Just Say 'Yes,'
  33. Doesn't Like To Be Called Honey
  34. It's Fakeasia, Not a Stroke
  35. Frail like a Babby Bunny
  36. That's Not a Wig You See
  37. Was Perfectly Healthy Until A Week Before Getting Sick
  38. Has Appointment at Mayo Clinic After Discharge To Figure This Out
  39. Disappoints Easily
  40. Not Really a Fighter
  41. Loves a Good Foley
  42. QHS = 4 PM
  43. Rides Call Light Like a Rodeo Champ
  44. 12/10 On The Pain In My Ass Scale
  45. Direct Eye Contact Should Be Avoided
  46. OK To Incubate 
  47. Gown and Glove Encouraged
  48. On Family Meal Plan
  49. Dilaudid 2 MG IV Push Preferred
  50. Dysphagia 7 Diet
  51. Probably a Palliative Care Candidate
  52. Too Many Armbands



Memorial Day Also Remembers Veterans Who Lost Their Life In a VA Hospital.

VA Hospitals -  Memorial Day is a time to remember our service men and women who died while serving in the armed forces, but it's also a time to pay respect to the thousands of veterans who die every day in our VA hospitals all across the country.

Billy Smith and his family are using today to remember World War II Veteran Granpa Jim, shot 17 times in war, who passed away three years ago at their local VA hospital after undergoing routine bunyan surgery and never making it out alive.  "We dropped him off for a routine surgery and we never heard from him again," said Billy, who says the VA still has no record of him ever getting admitted in the first place.

The Smith Family is not alone.  Hundreds of thousands of families use Memorial Day to remember their fallen VA hospital heroes who went in to get routine medical care and ended up paying the price with their lives.

For many families, Memorial Day is a painful reminder of the lack of accountability in the VA system, were employees can't be fired even in the most egregious of circumstances.

Memorial Day honors veterans who lost their lives in a VA hospital
"When I was a resident, I was trying to save the life of my ICU patient crashing on the ventilator, and the x-ray technologist said he wasn't going to come in on a Friday night to do a stat chest x-ray because he lived 30 minutes a way and it was snowing outside," said Dr. Stanley Franklin, an internist who knows how hard it is to get anyone fired from the VA for gross incompetence.  "That place breeds death."

"Then there's the time my MI patient waited six days for a cardiac echo because the echo tech was on vacation for a week.  Oh and then there's that one time my patient bled to death after a nurse stuck him 87 times trying to get an IV started. The list goes on and on."

For many veterans the real war is not on foreign grounds with bombs and bullets, it's fighting for their lives every time they enter a VA hospital.  Please remember to honor your fallen VA patients who gave their lives so some VA employee could instead enjoy a fine potluck lunch.






Staying Against Medical Advice: Top 15 Reasons!

Much has been said about patients who leave against medical advice, but little has been described  about patients who stay against medical advice.  When a hospital setting is no longer appropriate for a patient, a physician will recommend discharge to the next appropriate level of care.  For most well adjusted patients, the hospital is the last place in the world they want to be, but for a select subset of customers,  the hospital is the only place they would like to be.

The average adult probably finds it hard to believe some patients actually want to stay in the hospital longer than necessary, but it's true.

Staying longer than necessary does come with risk, including hospital acquired infections, medication errors and other unspecified iatrogenic badness.  But, try explaining that to the clientele refusing to leave and many doctors risk getting a 4 instead of a 5 on their patient satisfaction experience scorecard.
Staying Against Medical Advice is your right!

Remember, an unsatisfied patient is a hazard to a hospital's health.  With Medicare paying hospitals these days partly based on the patient experience, hospitals and their healthcare providers must walk an often impossible line between doing what's good for the patient and what's good for the patient experience.

In fact, Medicare believes so strongly in a patient's right to refuse discharge and stay against medical advice, they have a form that allows the patient to stay against medical advice and have their discharge decision appealed by some unknown entity with an unknown degree deep within the Medicare Fort.

photo 7dac7e09-65e5-4a26-aff4-e5b0f3752f80_zpsuqaxkt07.png

So why do some patients want to stay against medical advice and risk all the complications of continued hospital care?  Here is a Top 15 List of real quotes from patients who were allowed to stay against medical advice by hospitals fearful of not getting 5/5 on their patient satisfaction scores.

  1. "You have the best Dilaudid of any hospital I've ever been to."
  2. "My daughter ain't going anywhere  until you have her pseudoseizures under control."
  3. "My ride is out of town until Tuesday of next week."
  4. "Someone stole my Oxycotton script and I'm not leaving until you write me another one."
  5. "My husband got admitted to the hospital yesterday and I want to stay here until he goes home too.  Can he stay in my room too?"
  6. "I'm lonely at home and my kids never call."
  7. "The chicken cordon bleu here is amazing."
  8. "I have a call button.  Why would I want to go home?"
  9. "I've been having abdominal pain for 20 years and I'm not leaving until you figure it out."
  10. "My team is playing tonight and I don't have cable at home."
  11. "I'm not going to rehab until I'm strong enough for rehab."
  12. "I'm a squatter.  Get over it."
  13. "My kids don't get back from vacation until next week."
  14. "My water got shut off and I have no way to take a bath."
  15. "You all make me feel so good."
Prepare yourself. Patient is staying against medical advice!

Prepare Yourself. Patient is Staying Against Medical Advice!


UPDATE:  Patient #9 is still in the hospital after 423 days.



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