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From the Los Angeles Times

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Red tape hampers care for patients who are poor and disabled

Such patients qualify for Medicare and Medicaid, but bouncing back and forth between state and federal agencies can increase medical costs and reduce their quality of care.

by Anna Gorman, Los Angeles Times

November 13, 2011

M.C. Kim had four heart attacks in as many years. Each time, he left the hospital not knowing why his heart had failed.

When he tried to enter a cardiac rehabilitation program to learn how to reduce the odds of having more heart trouble, the Medicare office told him to call Medicaid. The Medicaid office told him to call Medicare. In the end, he said, both denied coverage.

"I was like a pingpong ball," said Kim , 51, who lives in Los Angeles. "Nobody wanted to take responsibility."

So Kim kept returning to the emergency room, racking up expensive medical bills for taxpayers.

Kim and other patients like him are among the nation's sickest and poorest residents, and their high-cost medical care places an untenable financial burden on states and the federal government. Because he is poor and disabled, he qualifies for both the federal Medicare program and the state-federal Medicaid program, called Medi-Cal in California.

These patients — 1.1 million in California alone — are some of the country's priciest government healthcare consumers. Called dual eligibles, they accounted for close to 40% of Medicaid spending in California in 2009, nearly $10 billion, but constitute only about 15% of enrollees. Nationwide, the nearly nine million dual eligibles have similarly disproportionate outlays and cost roughly $250 billion annually in Medicare and Medicaid funds.

Now, as federal officials look for ways to control costs under healthcare reform, they are zeroing in on millions of patients like Kim. But system reform is a sensitive issue.

"It's a much more fragile population," said Casey Young, who works for AARP in California. "It is always concerning when the motivation is cost savings and not improving care."

The government spends so much on dual eligibles because of their illnesses: multiple sclerosis, cerebral palsy, Alzheimer's disease and other debilitating conditions. The expenditures also are high because patients bounce between the two plans and often receive unnecessary, duplicative and poorly coordinated services. They cycle through emergency rooms, hospitals and nursing homes more than other Medicare or Medicaid enrollees, according to the Kaiser Family Foundation.

The result, healthcare officials and other experts say, is not only inflated expenditures but also gaps in medical treatment for the most vulnerable patients: the elderly, poor and disabled.

"When beneficiaries have to navigate two programs separately, it is no surprise that the care they receive is often inefficient and ineffective," Health and Human Services Secretary Kathleen Sebelius said in a speech in Washington, D.C., in September. "We can dramatically improve health outcomes and reduce costs for dual eligibles if we do a better job coordinating their care."

Bertha Poole, who is covered by both Medicare and Medicaid, said her problems navigating both programs have been small but extremely frustrating. Poole, a quadriplegic, lives on her own in an apartment equipped with special chairs and lifts. She relies on an aide to help her bathe, eat and dress.

When a wheel fell off her shower chair, it took nearly a year for her to convince Medi-Cal, California's version of Medicaid, to fix it. "It sounds frivolous until you need it," she said.

Dual eligibles typically qualify for Medicaid because they are poor and for Medicare because they are either elderly or disabled. Medicare pays for most doctor visits and hospital stays. Medicaid pays for what isn't covered under Medicare, including long-term care at nursing homes.

Each program has tried to shift costs to the other. A federal study last year found that leads to higher bills for taxpayers, as well as lower-quality patient care. Among the problems driving up spending, the study said, are unneeded hospitalizations.

One often-cited example of the financial tug of war involves nursing homes. If a dual eligible in a nursing home gets pneumonia and is treated there, for example, Medicaid picks up the bill. But if the person is transferred to a hospital, Medicaid doesn't have to pay. Medicare does.

"Patients get shuttled from one bed to the next and sometimes fall on the floor in between," said Joe Baker, president of the Medicare Rights Center.

Kim, the heart patient, said better coordination might have prevented him from going to the emergency room roughly 20 times in the last six years.

"I appreciate the programs, but they are in such disarray," he said. "There is so much red tape."

The federal health reform law created new offices to coordinate care between Medicaid and Medicare and help states identify ways to curb costs. Earlier this year, California and 14 other states were awarded $1 million in federal grants to test ways to make those improvements.

In a trial effort set to begin in 2013, California plans to begin shifting several hundred thousand dual eligibles into managed care plans to serve all their healthcare needs.

Currently, the vast majority of the state's dual eligibles are in health plans in which doctors and hospitals bill patients on the basis of services provided, meaning costs often soar quickly, healthcare experts say.

Managed care plans would reduce spending, state officials say, and make it easier for patients with complex health needs to get required care without receiving duplicate treatments or unnecessarily landing in nursing homes or hospitals.

"What we are trying to say is, 'You don't have to do this alone,' " said Jane Ogle, a deputy director in the state's Department of Health Care Services. "And when we help you manage this, there are naturally going to be some savings."

L.A. Care, the nation's largest public not-for-profit health plan, has proposed taking on some of those patients in Los Angeles County. "It's overdue to find a system of coordinated care for these folks," said Howard Kahn, the plan's chief executive. "We have got to get the costs of these public programs under some level of control."

Dual eligibles and advocates for seniors and the disabled have mixed views about managed care's ability to make things better. Some say having one place to go for medical care would be a huge improvement. Others worry that it could become harder to choose doctors.

Shelly Jerald, whose 27-year-old son Andre is developmentally disabled and enrolled in Medicare and Medicaid, said she has to handle all of his doctor appointments and bills. Recently, she had to make repeated calls to ensure that a bill from an eye doctor was paid by the right program. "If we could just talk to one person, that would make it easier for us lay people," she said. "It's so frustrating."

But Carla Cleveland, 49, a dual eligible who has diabetes, arthritis, chronic pain and a history of pituitary tumors, fears that she will lose access to her doctors under managed care. Cleveland said she already struggles to get high-quality doctors to accept Medicare and Medicaid patients.

"I am just fearful about what is going to come," she said.

http://www.latimes.com/news/local/la-me-healthcare-duals-20111114,0,4986631,print.story

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California

Formerly homeless, they know whereof they speak

Residents of apartments operated by the Skid Row Housing Trust studied storytelling, learned public speaking — all with the aim of sharing what it's really like to be living on the street.

by Nita Lelyveld, Los Angeles Times

November 13, 2011

Don't just walk by quickly, looking straight ahead.

If you notice a person living on the street, don't pretend you don't.

That's what Victor Rodriguez chose to say to a group gathered downtown one evening last week to hear from people who once were homeless and who know how it feels not to be seen.

Rodriguez, 52, now lives in the Dewey Hotel Apartments, operated by the Skid Row Housing Trust, which develops and manages affordable housing in an effort to provide homes for the homeless.

He is one of a group of the trust's residents who signed up this year to be trained as Trust Ambassadors.

They studied storytelling, learned public speaking — all with the aim of sharing their hard-earned wisdom far and wide. To those who have never been homeless, they can speak about how quickly it can happen. To those who are homeless, they can talk about ways to climb out and regain security.

"We created this program because we're often asked at the trust to provide information about skid row and about homelessness downtown, and for a long time we felt that we were doing an injustice by speaking for the community when we knew that we had so many residents who were very capable of speaking for themselves," Molly Rysman, the trust's director of external affairs, said in introducing the evening's program at the Last Bookstore at 5th and Spring streets.

On this night, in a part of downtown where the poor and the privileged very much coexist, the speakers stood on a low wooden stage before an audience of about two dozen.

In a crisp beige shirt and beige trousers, Rodriguez gripped the microphone with both hands, speaking into it low and confessionally.

He grew up in the suburbs, went to Catholic school, got himself a job at the telephone company. Then he lost the job and the slide began.

"Everything was good and then it all shattered," he said — and he became one of the people passers-by walk by on skid row.

"Take time to give somebody a chance, give somebody some dignity. Say hello. Say good morning," Rodriguez said. And as he spoke, support from the room — "Mmm-hmmm," "That's right" — washed over his words in warm waves.

Paul Mitchell, 54, who now lives in the Olympia Hotel Apartments, was homeless for close to 20 years. Most of those years, he told the group, he didn't really understand why.

His father worked. His mother worked. Why was steady work something that slipped out of his grip?

Finally, he said, he found his way to a mental health counselor, who told him there was more going on.

"Try going for weeks and months and years without proper sleep. You'd be a lunatic. You'd be mental," said this tall, dignified man in a black suit. "Your brain is just this thing exploding in water, that doesn't want to work.… Getting therapy and getting help just really helped me out."

Steve Hatter, 52, who is legally blind, spoke of a rootless life that, like other lives, started securely in the suburbs. He described heading west after spinning a Diet Coke can and seeing in what direction its top pointed. One desperate day in Los Angeles, he said, he popped a lot of pills and collapsed in what he thinks was Hollenbeck Park.

Someone saw him fall and called 911, which led to life-saving antidepressants and a roof over his head.

"By having that stability, I could overcome a lot of different things," he said, including being told that his eyesight was failing.

Theresa Winkler said she got back 11 years when she found her way off the streets. She'd been on her own since she was 12 — a prostitute and an addict. She was living in a bush without money to buy a cigarette when she decided she might as well head downtown.

She found the Skid Row Housing Trust, which began to find her help — starting with locating her birth records. She'd thought she was 53. The records showed she was 42.

She got the years back. She got a Social Security card. She got an apartment. She got clean.

As a Trust Ambassador, she says, she has set a new goal.

"I want to speak to women that are just like me and I want to speak to young women, so they don't become what I was."

http://www.latimes.com/news/local/la-me-homeless-ambassadors-20111114,0,7258623,print.story

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From Google News

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Judge: Norway terror suspect is not insane

Anders Behring Breivik is accused of killing 77 people in a shooting rampage

by Per Nyberg - CNN.com

(CNN) -- There is no reason to believe that Norway mass murder suspect Anders Behring Breivik is insane, District Court Judge Torkjel Nesheim said Monday.

There is also no evidence he had accomplices in the bomb and gun rampage in which he is accused of killing 77 people this summer, the judge said.

The judge ordered him held in custody for a further 12 weeks, with visits and correspondence controlled by the authorities for the first eight, and a ban on media for the first four.

More than 500 people packed into a court in Oslo, Norway, to see the suspect's first public appearance, said Irene Ramm, head of press for the Oslo court.

A woman whose daughter was killed in the massacre said she could not understand "how a human being could do something like that."

"That's why I had to be here today. I don't understand, so I had to see, had to be here," said the woman, who was identified only as "Carina" on Norway's TV2. "He looked cold, completely cold," she said.

He was not allowed to deliver a speech he had prepared, the station reported.

Breivik said he did not recognize the authority of the court on the grounds that he opposes the multi-cultural society it is part of, TV2 said.

He was stopped on several occasions when he started referring to himself as Commander of the Knights Templar, a title he used in his 1,500-page manifesto, the station reported.

Until now, the proceedings for Breivik have been held behind closed doors. But on Monday, the families of the victims were able to see Breivik as officers brought him into Oslo City Court with his hands and feet cuffed, the Norwegian Broadcasting Corporation reported.

The hearing was to determine whether to keep Breivik in jail until his trial in the spring.

Survivors return to scene of island rampage

He is accused of killing dozens of people in a bomb attack in Oslo followed by a shooting rampage on nearby Utoya island. Eight people were killed in a bombing in Oslo; 69 young people were killed on Utoya island, in the deadliest attack in Norway since World War II.

The young people were attending a Labour Party youth camp. Most of the 700 campers ranged in age from 16-22, with some as young as 13.

Breivik has pleaded not guilty.

He is described by authorities as a right-wing Christian extremist. The 1,500-page manifesto attributed to Breivik was posted on the Internet and is critical of Muslim immigration and European liberalism.

http://edition.cnn.com/2011/11/14/world/europe/norway-terror-suspect/

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