Primary Votes Matter: Vote

 

By:  Cynthia Marcotte Stamer, Publisher, Solutions Law Press, Inc.; Executive Director, PROJECT COPE:  Coalition on Patient Empowerment & Coalition for Responsible Healthcare Policy; Managing Shareholder, Cynthia Marcotte Stamer, P.C., a Member of Stamer Chadwick Soefje PLLC.

With tomorrow’s “Super Tuesday” March 1, 2016 primary elections set to define the Presidential, Congressional and state and local candidates that Americans in November will chose from to lead U.S. policy, Americans concerned about health care or other critical policies need to make time to vote as well as participate in our political process through their own responsible political action  and encouraging other to do the same.  Voting in the upcoming March 1 or other Primary Election in your state is a particularly valuable opportunity to meaningfully influence the direction of our government by helping pick the candidates that will qualify to participate in the general election in November, as well as provide input on other key local issues on your ballot.

As Obamacare and other reforms continue to reshape our health care choices and wallets as other policies key to promoting and maintaining the health, prosperity, education, and freedom of our nation, every American should seize the opportunity to provide their input to elected officials.  While providing input or feedback on an ongoing basis to policy leaders also is important, too many Americans fail to take advantage of the most important and most easily accessible opportunity to participate – VOTING!

Contrary to the unfounded “my vote doesn’t count” claims of many Americans, voters that vote actually still decide who are candidates are and which of these candidates get elected to serve Americans.

In today’s tightly contested primary and general elections where increasingly are decided by margins of 5 percent or less of those voters who actually vote, every vote matters. In fact,  it is the very small number of Americans who actually bother to cast a ballot who actually pick our leaders and set the political agenda.  Sadly, the majority of eligible American voters don’t vote in primary or general elections.  Since very few Americans vote and elections are decided by the majority of Americans that actually vote, the power of the vote cast by any voter is much greater than most Americans realize and nowhere is this more true than in primary elections and caucuses.

Primary voting provides the best bang for the buck to voters looking to maximize the power of their vote.  Voters that vote in primaries in fact exercise extraordinary power both because their votes determine the slate of candidates on the ballot in the general election and because the extraordinary low voter turnout percentage means their individual vote carries more weight than in elections with higher voter turnout.  Take the current presidential primaries. According to United States Election Project Statistics, only 8.2% of eligible Republicans voted in the Nevada primary election on February 23, 2016; more than 90% of Republican voters didn’t participate.  Similarly, the February 1, 2016 Iowa Caucus was decided by the votes cast by only 15.7% of the eligible voters. More than 84% of Iowa voters didn’t participate.  See http://www.electproject.org/2016P.  Accordingly, just by showing up to vote, primary voters carry tremendous weight versus other election and the ballots cast by those voters carry on through the general election by deciding which candidates make the ballot in the general election.

The bottom line, your vote in the upcoming March 1 or other primary matters a lot more than you think.  Flex your political muscle in your March 1 or other upcoming primary election by voting.  Your vote will carry tremendous weight in deciding not only who lives in the White House for the next four years, but also the leaders who will represent you in Congress and state and local offices that exercise more direct, day-to-day influence over your lives and your finances.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

Do you have ideas about how to improve the understandability of medication warnings or research findings for patients or other ideas about how to improve healthcare or health care policy?  Share your ideas in the  PROJECT COPE: Coalition On Patient Empowerment LinkedIn Group.  If you have knowledge, experience or other resources that could help patients, families, communities, or the government better understand or cope with  Asperger’s or other health care conditions, costs of care, or other challenges affecting Americans and the American health care system, we encourage you to get involved and share your insights.

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through PROJECT COPE: Coalition On Patient Empowerment.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of PROJECT COPE.

The Coalition and its PROJECT COPE arise and run on the belief that health care reform and policy must be patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining PROJECT COPE: Coalition On Patient Empowerment and by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, and/or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2016 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

OIG Says CMS Mismanaged HealthCare.gov ACA Federal Marketplace Implementation

The Centers for Medicare & Medicaid Services (CMS) and other public and private organizations should use key lessons for the successful design and deployment of website and other operating systems revealed in a report of the findings of the Department of Human Services (HHS) Office of Inspector General (OIG) investigation into what lead to the notoriously poor launch and other problems in the Healthcare.gov health insurance marketplace website and operating system that the Patient Protection & Affordable Care Act (ACA) directed HHS to establish and administer to facilitate the purchase of private insurance by citizens living in states that declined to establish a state health insurance marketplace in response to ACA.

According to just released OIG Report OEI-06-14-00350, “many missteps” committed by the Department of Health & Human Services (HHS) and its Centers for Medicare & Medicaid Services (CMS) lead to the widespread crashes of the Healthcare.gov website and other widespread problems with the Healthcare.gov enrollment tools necessary for millions of Americans to enroll in new health insurance coverage options created as part of the ACA.  The report not only helps to explain what went wrong, but also provides key insights for HHS as well as other public and private organizations of common management issues that often derail the design and deployment of website or other technologies required to execute key organizational goals.

Problems in the completion and operation of the Healthcare.gov website at its launch on October 1, 2013 and for some time created significant challenges for U.S. families residing in states that elected not to sponsor a state-sponsored health insurance marketplace in response to the ACA. Among other things, HealthCare.gov users attempts to use the Healthcare.gov website were disrupted by a host of website outages and technical malfunctions. After corrective action by CMS and contractors, HealthCare.gov performance improved and facilitated health plan enrollment for millions of consumers. The problems at launch raised concerns about the effectiveness of CMS management of the Federal Marketplace. The findings set forth in the report resulted from an OIG study conducted to gain insight into CMS implementation of the Federal Marketplace, focusing primarily on HealthCare.gov.

The report details the results of OIG’s review and analysis of the chronology of events and identifying factors that contributed to the Healthcare.gov website’s breakdown at launch, its recovery following corrective action, and implementation of the Federal Marketplace through the second open enrollment period based on interviews of 86 current and former HHS and CMS officials, staff, and contractors involved with the website and OIG’s review of “thousands of HHS and CMS documents,” including management reports, internal correspondence, and website development contracts.

Based on this review and analysis, OIG found that “HHS and CMS made many missteps throughout development and implementation that led to the poor launch of HealthCare.gov.” According to the report, the “most critical” misstep was “the absence of clear leadership, which caused delays in decisionmaking and a lack of clarity in project tasks.” The report also criticized HHS and CMS for:

  • Devoting too much time to developing policy, which left too little time for developing the website;
  • Failing to properly manage its key website development contract;
  • Allowing CMS’s organizational structure and culture to create poor coordination between policy and technical work and otherwise to hamper progress; and
  • CMS continuing to follow a “failing path despite signs of trouble” and “making rushed corrections that proved insufficient.

While highly critical of the initial mismanagement, OIG also complimented HHS and CMS for quickly learning and using certain key lessons for more effectively managing major technology projects to respond to and start correcting deficiencies in the Healthcare.gov site.  These core practices include:

  • Leadership. Assign clear project leadership to provide cohesion across tasks and a comprehensive view of progress.
  • Communication. Promote acceptance of bad news and encourage staff to identify and communicate problems.
  • Alignment. Align project and organizational strategies with the resources and expertise available.
  • Execution. Design clear strategies for disciplined execution, and continually measure progress.
  • Culture. Identify and address factors of organizational culture that may affect project success.
  • Oversight. Ensure effectiveness of IT contracts by promoting innovation, integration, and rigorous oversight.
  • Simplification. Seek to simplify processes, particularly for projects with a high risk of failure.
  • Planning. Develop contingency plans that are quickly actionable, such as redundant and scalable systems.
  • Integration. Integrate policy and technological work to promote operational awareness.
  • Learning. Promote continuous learning to allow for flexibility and changing course quickly when needed.

By learning from these lessons, OIG reports that CMS took corrective action and is using these lessons to address problems with Healthcare.gov and to improve its operations and services.  OIG notes that after the launch, CMS and contractors pivoted quickly to corrective action, reorganizing the work to improve execution. Key factors that contributed to recovery of the website included adopting a “badgeless” culture for the project, wherein all CMS staff and contractors worked together as a team, and a practice of “ruthless prioritization” that aligned work efforts with the most important and achievable goals. CMS recovered the website for high consumer use within 2 months, and adopted more effective organizational practices.

OIG calls on CMS to continue progress in applying lessons learned from HealthCare.gov to avoid future problems and to maintain improvement across the agency.  In response to the report and these recommendations, CMS concurred with OIG’s call for continued progress, stating that it will continue to employ the lessons learned and that since OIG’s review, it has implemented several initiatives to further improve its management.  As CMS works to improve Healthcare.gov, other public and private organizations should leverage the lessons learned from CMS’ experience to improve their own technology and IT design and implementation.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

What do you think about the status and direction of the U.S. health care system and its reforms?  Do you share Dr. Koriwchak’s concerns?  Have other concerns?  Do you have ideas about how to improve the understandability of medication warnings or research findings for patients or other ideas about how to improve healthcare or health care policy?  Share your ideas in the  PROJECT COPE: Coalition On Patient Empowerment LinkedIn Group.  If you have knowledge, experience or other resources that could help patients, families, communities, or the government better understand or cope with  Asperger’s or other health care conditions, costs of care, or other challenges affecting Americans and the American health care system, we encourage you to get involved and share your insights.

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through PROJECT COPE: Coalition On Patient Empowerment.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of PROJECT COPE.

The Coalition and its PROJECT COPE arise and run on the belief that health care reform and policy must be patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining PROJECT COPE: Coalition On Patient Empowerment and by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, and/or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2016 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.

 

Physician Feedback To CMS On Health Care Reforms

Solutions Law Press, Inc. is delighted to share the following reprint of An Open Letter To Andly Slavitt, Acting Administrator, CMS e from Michael Koriwchak, M.D.,  Vice President, The Docs 4 Patient Care Foundation 

Many of us physicians reacted like starving prisoners when the Commandant announces that there will be extra cockroaches for dinner.”

An Open Letter to Andy Slavitt, Acting Administrator CMS

Feb 18, 2016 07:50 am | By: Dr. Michael Koriwchak

Mr. Andrew Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
Washington, D.C..

Dear Mr. Slavitt:

No doubt you were surprised at the strong, widespread reaction to your comments regarding the Meaningful Use Program as part of your speech to the JP Morgan Healthcare Conference several weeks ago. Your quote regarding the hearts and minds of physicians was particularly noteworthy. After decades of Federal regulatory hostility towards physicians, some of us doctors were pleasantly surprised – even shocked – to hear you acknowledge:

– physicians exist beyond just being another cog in the healthcare machine.
– physicians actually have hearts and minds.
– physicians’ opinions might have value to you.
– programs that are poorly designed distract physicians from patient care.
– CMS aspires to a “cultural focus on listening and learning”

Many of us physicians reacted like starving prisoners when the Commandant announces that there will be extra cockroaches for dinner. Though the news was small, many of us were overjoyed.

But most of us (60% by a recent survey) reacted differently. The majority of us understand the political savvy of saying something controversial about your enemy. Such a move can create a useful distraction, driving the enemy to argue amongst themselves while you continue with work that you would rather we didn’t notice…and that is exactly what has happened. Like an octopus squirting ink into the water you have created an effective smokescreen to let you spend the next few months coding Meaningful Use into MACRA without any interference from us.

So the purpose of this letter is to ask the question: Which of the above interpretations of your comments is correct? What are your intentions?

If your comments are sincere then consider this letter a warm introduction to the group of rapidly growing, grass-roots full time practicing physicians whom this letter represents. Over the past few years we have acquired the policy expertise and political skills to be effective leaders and collaborators with you to bring truly meaningful improvements to America’s health care. Realize that the leaders of organized medicine with whom you currently work – including the AMA , whose membership represents less than 15% of practicing physicians – do NOT represent the “hearts and minds” of physicians that you profess to seek. If you mean what you say then we are reaching out to you.

If, on the other hand, your comments are nothing more than political subterfuge, then this letter serves as a warning. We are not buying the political offal that you are selling. This physician group will use all of its intellectual, financial and political resources to make it far more difficult for you to destroy what is left of health care in America.

The choice is yours. We look forward to hearing from you.

Michael Koriwchak, M.D.
Vice President,
 The Docs For Patient Care Foundation

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

What do you think about the status and direction of the U.S. health care system and its reforms?  Do you share Dr. Koriwchak’s concerns?  Have other concerns?  Do you have ideas about how to improve the understandability of medication warnings or research findings for patients or other ideas about how to improve healthcare or health care policy?  Share your ideas in the  PROJECT COPE: Coalition On Patient Empowerment LinkedIn Group.  If you have knowledge, experience or other resources that could help patients, families, communities, or the government better understand or cope with  Asperger’s or other health care conditions, costs of care, or other challenges affecting Americans and the American health care system, we encourage you to get involved and share your insights.

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through PROJECT COPE: Coalition On Patient Empowerment.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of PROJECT COPE.

The Coalition and its PROJECT COPE arise and run on the belief that health care reform and policy must be patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining PROJECT COPE: Coalition On Patient Empowerment and by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, and/or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2016 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.


 

 

 

 

Health care Quality: Different Meaning For Care Vs. Coverage

By:  Cynthia Marcotte Stamer, Publisher, Solutions Law Press, Inc.; Executive Director, PROJECT COPE:  Coalition on Patient Empowerment & Coalition for Responsible Healthcare Policy

American patients and their families need to be careful about mindlessly making health care choices for themselves or their family in reliance on healthcare “quality” data or guidance by private health plans and insurers, Medicare, Medicaid, or other government payers, and other public and private entities that allow the cost of care to shade their valuation of the quality of care.

The value of quality data – regardless of its source – in determining the quality and value of a proposed plan of care inherently depends upon how well a patient’s actual circumstance fits the assumptions upon which the quality analysis and conclusions rest.  Different treatment plans often impact differently patients diagnosed with the same condition for a variety of reasons.

Patients and their families making health care decisions for themselves or a loved one generally should use a two step approach when making health care provider or treatment decisions:

Patients and their families attempting to make decisions about the treatment plan for a patient affiliated with a life threatening or major chronic illness rightly should work with their health care provider to critically evaluate the options based first solely on the particular needs of the patient first without regard to cost, and then separately evaluate how cost barriers to securing the best treatment for the patient may require compromises or other tradeoffs.

When working with physicians and other health care providers, patients and their families need to understand the role and proper use of quality data – whether used by health care providers to determine care pathways, medical peer review, licensing boards or other quality assurance agencies enforcing quality standards for health care providers, or payers like Medicare, Medicaid, or other government payers or private insurers, self-insured health plans or other nongovernmental payers.

Because each patient’s medical and other circumstances are unique, very few patients fit cleaning the assumptions built into the clinical or payment pathways used to determine quality for a cost or medical efficacy determination.  In essence, each patient considered individually is an outlier at some level.  While these individual deviations have little material effect on the efficacy of proposed treatments in some instances, disregard of unique characteristics of the physical, emotional, psychosocial or other status of the patient significantly undermines or changes the likely efficacy of treatment. The assessment of the care and treatment needs and options of a patient without regard to cost inherently allows the patient, his family and his treatment team to evaluate the best interests of the patient, taking into account the unique physical, emotional, psychosocial and other realities of that patient.

Because the appropriateness of a proposed treatment plan inherently depends upon how closely the patient’s situation fits the underlying assumptions upon which the conclusions drawn from the quality data rests, patients and their families first should investigate and evaluate the needs of the patient and the care options available for treatment from a purely health care perspective without regard to cost based on the unique situation of that patient.   Review of these assumptions with the patient’s physician and other health care team helps determine not only whether the “standard” treatment fits the patient, but also what the patient and his caregivers need to be prepared to deal with the realize the benefits of the treatment proscribed and the likely effects of compromise or deviation from those expectations.  This analysis not only helps ensure the effectiveness of the plan of treatment but also reduces the risk that the patient will be hurt or his care or recovery undermined by the administration of a treatment plan that doesn’t fit the patient or performances that the patient or those supporting him in his care cannot reliably deliver.

Just as patients and their families should carefully question and evaluate assumptions underlying the quality and efficacy data behind treatment recommendations made by health care providers for the treatment of the patient, they also must carefully evaluate the health care “quality” determinations and decisions made by the public or private health plan that covers the patient.  Patients and families need to resist the urge to mindlessly accept without question the increasingly common practice by of private insurers and Medicare and other government regulators of accusing or suggesting that physicians or other health care providers are engaged in overprescribing, “fraud” or other bad medicine because the health care provider prescribes or delivers care supported by the medical quality literature in light of the needs of the patient which exceeds or deviates from the generic, one size fits all care plan selected by a payer to fit the cost containment goals of the payer.

Patients and their families need to understand that quality decisions by public or private payers for purposes of deciding what and how much treatment a payer will pay for inevitably both minimize the importance of the unique needs of the patient and adjust their notions of quality to fit the budget and profitability standards the of the payer based on the premiums or taxes the payer collects to fund the promised benefits.  These are statistical actuarial questions targeted on the amount of dollars that the payer is willing to spend for the dollars collected.  It is not unusual for a government payer such as Medicare or a private payer to try to limit the care that the insurer pays for to care that is less expensive without regards to the unique needs of a particular patient.  The outlier needs of particular patients have little value and receive little or no consideration in this analysis generally.  Consequently, it is not unusual for a Medicare, Medicaid, a private insurer or health plan or other payer to decline or resist paying for certain treatments that a physician orders in an effort to tailor care to the unique needs of a patient when the needs of the patient don’t fit the assumptions underlying the coverage design of the payer.

At the end of the day, patients and their families concerned about getting the best outcome for the patient should inform themselves and actively work with their physician and other health care providers, their health plans and other sources to familiarize themselves not only with the treatment needs and options of the patient, as well as the underlying assumptions behind the quality and efficacy findings underlying these treatment options.  By evaluating the assumptions required to achieve the reported treatment efficacy, patients and their providers can promote better care decisions and outcomes by helping their provider to anticipate and address the unique care needs of the patient, can better determine when and if to make tradeoffs in care for health care coverage or other cost or nonmedical reasons and can help improve the effectiveness of the care plan by better anticipating and arranging to meet the assumptions required to support the optimal outcome.

About Project COPE: The Coalition On Patient Empowerment &  Coalition on Responsible Health Policy

Do you have ideas about how to improve the understandability of medication warnings or research findings for patients or other ideas about how to improve healthcare or health care policy?  Share your ideas in the  PROJECT COPE: Coalition On Patient Empowerment LinkedIn Group.  If you have knowledge, experience or other resources that could help patients, families, communities, or the government better understand or cope with  Asperger’s or other health care conditions, costs of care, or other challenges affecting Americans and the American health care system, we encourage you to get involved and share your insights.

As American leaders continue to struggle to deal with these and other mounting problems impacting the U.S. health care system, the input of individual Americans and businesses and community leaders is more critical than ever.  Get involved in helping to shape improvements and solutions to the U.S. health care system and the Americans it cares for by sharing your ideas and input through the Coalition For Responsible Health Care Policy  and exchanging information and ideas for helping American families deal with their family member’s illnesses, disabilities and other healthcare challenges through PROJECT COPE: Coalition On Patient Empowerment.

Sharing and promoting the use of practical practices, tools, information and ideas that patients and their families, health care providers, employers, health plans, communities and policymakers can share and offer to help patients, their families and others in their care communities to understand and work together to better help the patients, their family and their professional and private care community plan for and manage these  needs is the purpose of PROJECT COPE.

The Coalition and its PROJECT COPE arise and run on the belief that health care reform and policy must be patient centric and patient empowering.  The best opportunity to improve access to quality, affordable health care for all Americans is for every American, and every employer, insurer, and community organization to seize the opportunity to be good Samaritans.  The government, health care providers, insurers and community organizations can help by providing education and resources to make understanding and dealing with the realities of illness, disability or aging easier for a patient and their family, the affected employers and others. At the end of the day, however, caring for people requires the human touch.  Americans can best improve health care by not waiting for someone else to step up:  Step up and help bridge the gap when you or your organization can. Speak up to help communicate and facilitate when you can.  Building health care neighborhoods filled with good neighbors throughout the community is the key.

The outcome of this latest health care reform push is only a small part of a continuing process.  Whether or not the Affordable Care Act makes financing care better or worse, the same challenges exist.  The real meaning of the enacted reforms will be determined largely by the shaping and implementation of regulations and enforcement actions which generally are conducted outside the public eye.  Americans individually and collectively clearly should monitor and continue to provide input through this critical time to help shape constructive rather than obstructive policy. Regardless of how the policy ultimately evolves, however, Americans, American businesses, and American communities still will need to roll up their sleeves and work to deal with the realities of dealing with ill, aging and disabled people and their families.  While the reimbursement and coverage map will change and new government mandates will confine providers, payers and patients, the practical needs and challenges of patients and families will be the same and confusion about the new configuration will create new challenges as patients, providers and payers work through the changes.

We also encourage you and others to help develop real meaningful improvements by joining PROJECT COPE: Coalition On Patient Empowerment and by sharing ideas, tools and other solutions and other resources. The Coalition For Responsible Health Care Policy provides a resource that concerned Americans can use to share, monitor and discuss the Health Care Reform law and other health care, insurance and related laws, regulations, policies and practices and options for promoting access to quality, affordable healthcare through the design, administration and enforcement of these regulations.

You also may be interested in one or more of the following other recent articles published on the Coalition for Responsible Health Care Reform electronic publication available here, our electronic Solutions Law Press Health Care Update publication available here, and/or our HR & Benefits Update electronic publication available here.

You also can get details about how to arrange for your employees or other communities to participate in training on “Building Your Family’s Health Care Toolkit,”  using the “PlayForLife” resources to organize low-cost wellness programs in your workplace, school, church or other communities, and other process improvement, compliance and other training and other resources for health care providers, employers, health plans, community leaders and others here.

NOTE:  This article is provided for educational purposes.  It is does not provide legal advice, establish any attorney-client relationship or provide or serve as a substitute for legal advice to any individual or organization.  Readers must engage properly qualified legal counsel to secure legal advice about the rules discussed in light of specific circumstances.ANY STATEMENTS CONTAINED HEREIN ARE NOT INTENDED OR WRITTEN BY THE WRITER TO BE USED, AND NOTHING CONTAINED HEREIN CAN BE USED BY YOU OR ANY OTHER PERSON, FOR THE PURPOSE OF (1) AVOIDING PENALTIES THAT MAY BE IMPOSED UNDER FEDERAL TAX LAW, or (2) PROMOTING, MARKETING OR RECOMMENDING TO ANOTHER PARTY ANY TAX-RELATED TRANSACTION OR MATTER ADDRESSED HEREIN.  ©2016 Cynthia Marcotte Stamer, P.C. Non-exclusive license to republish granted to Solutions Law Press.  All other rights reserved.