Tuesday, January 15, 2019

Free enterprise healthcare growing even in Mass.

Urgent care centers, walk-in clinics that treat a range of pressing medical issues, are proliferating in crowded shopping centers and along busy roads across the state, especially in affluent suburbs. One 2-mile stretch of Route 9 will soon have four urgent care centers, the newest next to a Chipotle and a Staples in Natick. Chestnut Hill has three within a 15-minute drive, and Cambridge, four.

But no companies have rushed to open urgent care centers in Dorchester, Roxbury, or other lower-income neighborhoods in Boston.

The explosion of the urgent care industry is reshaping the health care landscape in Massachusetts and across the country. A state commission counted 150 urgent care centers last year, up from 18 in 2010. And more are coming this year.

The centers lure patients with convenience: They don’t require appointments, and they typically are open until 8 or 9 p.m., and on weekends. They promise to treat almost any non-life-threatening medical issue — at a fraction of the cost of hospital emergency rooms, and without the long wait.

What they don’t tend to prioritize is care for the poorest. Most firms operating urgent care centers report that only a small percent of their business comes from patients on Medicaid, known here as MassHealth.

And it remains unclear what effect these centers have on the overall health care marketplace. Do they help contain spending by diverting patients from emergency rooms? Or do they add to costs by encouraging new visits?

But at two of Massachusetts’ largest urgent care operators, American Family Care and CareWell Urgent Care, just 11 percent and 2.5 percent, respectively, of patients are on MassHealth.

In another type of walk-in medical clinic that provides more limited services and is located in CVS stores, just 5 percent of patients are on MassHealth.

MassHealth patients, meanwhile, still rely heavily on chaotic and expensive hospital emergency departments, though in some urban neighborhoods, community health centers offer expanded hours for urgent medical needs.

Even the national urgent care lobbying group acknowledges the disparity.

It estimates that 30 to 40 percent of centers refuse to treat Medicaid patients, saying the public program has onerous requirements and does not pay enough to cover their costs.

“We are not trying to cherry-pick, but we have to be sustainable,’’ said Dr. Gene Green, president of South Shore Health, the parent company of South Shore Hospital that recently bought six Health Express urgent care centers. About 2 percent of the centers’ patients are covered by MassHealth.

Some hospital systems, such as Cape Cod Healthcare, are building their own urgent care centers as part of a strategy to attract and retain patients in their networks. Compared with competitors, Cape Cod Healthcare sees a relatively higher share of MassHealth patients at its urgent care locations — about 20 percent. “That’s our population,” chief executive Michael K. Lauf said. “Do I think the odds are stacked against us [financially] because we do that? Yes.”

MassHealth pays health care providers much less than commercial insurers. CareWell, for example, said it receives an average of $74 for each urgent care visit from a MassHealth patient; commercial insurers pay CareWell at least double that — an average of $150 to $200 per visit.

That gap is one factor that pushes some providers to target middle- and high-income patients. An analysis by the state’s Health Policy Commission found that 58 percent of urgent care centers and 72 percent of CVS’s MinuteClinics are located in ZIP codes where residents earn above the median income.

“They are going to get a higher reimbursement by getting people with commercial insurance. Therefore, it’s in their financial interest to be in communities with higher-income patients with commercial insurance,” said Dr. Ateev Mehrotra, a professor at Harvard Medical School who studies walk-in clinics.

Massachusetts now has 59 MinuteClinics, up from 46 five years ago.

A CVS spokeswoman said the company selects locations based on a variety of factors, including store size and regulatory requirements. Jim Brennan, area executive for American Family Care in Massachusetts, said his company’s method for choosing urgent care locations is proprietary.

But executives generally search out retail centers with heavy pedestrian and car traffic, and neighborhoods with busy families consisting of two working adults and teenagers who play sports — and face sports injuries.

“Those people value their time,’’ American Family Care spokesman William Koleszar added. “We want it to be as easy to come to urgent care as it is to pick up their dry cleaning.’’

While AFC executives said their urgent care centers in low-income communities like New Bedford “do very well,’’ they said the state makes it harder for lower-income people to use them.

For those enrolled in MassHealth managed care plans — about 1.2 million people — the state generally will not pay for an urgent care center visit unless the patient has a referral from a primary care doctor.  [Which defeats the purpose of an urgent care facility]

Urgent care companies say the referral rules are dated and burdensome and prevent them from treating larger numbers of low-income patients. They want the rules lifted.

“We can be turning away dozens of [MassHealth] patients a day because we don’t have referrals,” said Shaun Ginter, chief executive of CareWell, which operates 16 urgent care centers in Massachusetts, from Worcester to Peabody to South Dennis.

But Massachusetts Health and Human Services Secretary Marylou Sudders said she is concerned about MassHealth patients going to urgent care centers that are not connected to larger health systems; encouraging treatment there would be “antithetical’’ to the state’s plan to manage care for MassHealth patients by requiring them to stay within specific networks of health care providers. [Typical Leftist authoritarianism]

State officials are considering licensing urgent care centers. “They are a growing part of health care. We need to take a prudent look,’’ Sudders said.

MinuteClinics began opening in Massachusetts more than a decade ago and are already regulated by the state, which requires them, for example, to provide a list of primary care doctors for customers who don’t have one.

Urgent care centers are still new enough to Massachusetts that the state has no official definition for them, nor specific rules for how they operate or what illnesses they can safely treat.

While most states do not specifically license urgent care centers, their oversight has grown with the expansion of the industry.

Urgent care centers can range from small offices staffed by nurse practitioners to large facilities run by emergency physicians, with expensive imaging equipment and blood-testing laboratories. Their hours vary.

Some centers are set up as doctor’s offices and charge similar prices, while others are licensed as hospital outpatient facilities and charge additional hefty fees that often come as a surprise to patients.

“There still needs to be education about what kinds of services urgent care centers actually provide to the community, and who can actually access their services,” said Senator James Welch, cochairman of the Legislature’s Joint Committee on Health Care Financing.

Welch and Mariano expect lawmakers to work on health care legislation this session that includes regulations on urgent care.  [More of those lovely Fascist regulations]



A New Bill Would Rein in Executive Overreach and the Administrative State. But Does Congress Really Want That Power?

This week saw the reintroduction of the Regulations from the Executive in Need of Scrutiny (REINS) Act. Sponsored by Sens. Rand Paul (R–Ky.), Chuck Grassley (R–Iowa), Joni Ernst (R–Iowa), Todd Young (R–Ind.), and Ted Cruz (R–Tex.), the REINS Act tackles two major libertarian priorities: reducing burdensome regulations and reining in executive power. By passing it, Congress would reassert its role as a check on both runaway presidents and the administrative state.

As a joint statement released by the senators introducing the bill explains, the bill would require "that Congress affirmatively approve every new 'major rule' proposed by the Executive Branch before it can be enforced on the American people, as opposed to the status quo, where regulations ultimately take effect unless Congress specifically disapproves." (A "major rule" is defined as "a regulation that may result in an economic impact of $100 million or greater each year.")

This would be a welcome change. With active affirmation rather than passive consent, there would be much more scrutiny over the rules imposed on Americans and far fewer regulations would pass muster. Grassley is right when he says that "even when well-intended, government regulations are all too often ineffective, counterproductive or even outright harmful." He's also right that "more needs to be done to reclaim the rightful role of Congress as the lawmaking body of government."

But why wasn't this bill passed during the past two years of united Republican government? If we're to take Republican rhetoric at face value, the REINS Act should've sailed through Congress and landed on the president's desk post-haste. But when it was introduced under united Republican government, it went nowhere. That speaks to an enduring, bipartisan problem of reliance on the executive branch.

As Yuval Levin wrote in Commentary last year, "Members of Congress are happy to complain about the other branches, but they are not inclined to use the enormous power at their disposal to restrain those competing institutions and reassert their own." Instead, "Broad delegations of power in statutes have let presidents wield what are properly legislative authorities, and intentionally vague legislation has empowered judges to fill gaps that legislators should never have left open."

The depressing fact is that most members of Congress have become allergic to accountability. Politically, it's far easier for congressional Republicans to point to the deregulation agenda pursued by the Trump administration than to go on the record with votes on specific regulations, many of which would inevitably be controversial.

Essentially, our legislators don't want to legislate because it makes the business of getting reelected more of a burden. The failure to codify the REINS Act is a perfect example of the broader issue.

In this case, that congressional dysfunction led to a missed opportunity for substantive regulatory reform. While it's good that the REINS Act has been reintroduced, a component bill is not likely to pass the House now that it is controlled by the Democrats. To the extent that the Trump administration has rolled back the federal regulatory regime—a success that has been overstated—any progress can easily be erased by a future president.

Until Congress reasserts its constitutionally mandated authority as the foremost federal branch, we aren't likely to see much in the way of sweeping regulatory reform. And reliance on the executive is, unfortunately, a bipartisan scourge.



George Will: A fluent fool

He makes the elementary mistake of mistaking style for substance.  Trump is not gentlemanly enough for him

Some Will-speak:  “In one of contemporary history’s intriguing caroms, European politics just now is a story of how one decision by a pastor’s dutiful daughter has made life miserable for a vicar’s dutiful daughter. Two of the world’s most important conservative parties are involved in an unintended tutorial on a cardinal tenet of conservatism, the law of unintended consequences, which is that the unintended consequences of decisions in complex social situations are often larger than, and contrary to, those intended.”

That’s the elephantine lead of George Will’s recent column, headlined “Today’s Germany is the best Germany the world has seen.” The real story comes way down in paragraph six, where Will explains: “No European nation was as enchanted as Germany was by Barack Obama’s studied elegance and none is more repelled by Donald Trump’s visceral vulgarity.”

So it’s really all about Trump, which should be no surprise for George Will. He was hailed as the “best writer, any subject,” by the Washington Journalism Review and the “dean of conservative journalists” by Andrew Ferguson in an October 2017 Weekly Standard piece titled “The Greatness of George Will.”

“If Trump is Nominated, the GOP must keep him out of the White House,” ran the headline on Will’s April 29, 2016 column, in which he decried “Republican quislings” who were “slinking into support of the most anti-conservative presidential aspirant in their party’s history.” The quislings would “render themselves ineligible to participate in the party’s reconstruction.”

Two months later, Will announced a change in his voter registration to “unaffiliated,” citing Trump’s complaint about a “Mexican” judge. Will said he joined the Republican Party “because I was a conservative, and I leave it for the same reason: I’m a conservative.” In response, Trump tweeted, “George Will, one of the most overrated political pundits (who lost his way long ago), has left the Republican Party. He’s made many bad calls.”

In late June, 2016, Dan McLaughlin of National Review wrote that Will’s column “has kicked up a stir by arguing that voters of all ideological stripes should hand majority control of the Senate and House to the Democrats in November. This is a profoundly bad idea, and Will makes nearly no effort to consider its actual consequences.”

On November 2, 2016, Jonathan Chait noted Will’s ideological fervor but six months later, “none of his expectations has remotely come to pass.” Will’s April column “currently has less resemblance to the pronouncement of a conservative pope than to Will Ferrell in Old School, proclaiming that everybody is going streaking.”

Contrary to the edict of the conservative pope, Trump did win the election. He went on to take down ISIS, call out Islamic terrorism, calm down Kim Jong-un, lower taxes, and usher in an economic boom with economic growth in the 4 percent range. That counted for nothing with the erudite Will, with his PhD from Princeton.

Last May in New York Magazine, Ed Kilgore described Will as “one of the few #NeverTrump figures on the right who has neither wavered nor flagged in his disdain for the 45th president.” In January 2019, nearly three years after he urged the GOP to keep Trump out of White House, and with Democrats panting for impeachment, Will writes of the president’s “visceral vulgarity.” On the other hand, Will hails “Barack Obama’s studied elegance,” a strange statement for a conservative pundit, if he had bothered to study the record.

In 2009, one of Obama’s first acts was to cancel missile defense for U.S. allies Poland and the Czech Republic, both victims of Soviet occupation. That same year, “soldier of Allah” Nidal Hassan gunned down 13 unarmed American soldiers at Fort Hood, Texas, and wounded more than 30 others. The President of the United States, commander in chief of all U.S. forces, called this “workplace violence,” refused to link Islam with any act of terrorism, and in 2012 at the UN proclaimed “the future must not belong to those who slander the prophet of Islam.”

In a deep recession, the president bulked up an already bloated federal government and told Americans if they liked their  health plan they could keep it, one of his many lies. The president cracked down on journalists such as Sharyl Attkisson and James Rosen and deployed the IRS against conservative groups. He deployed powerful forces in the FBI and DOJ to clear his chosen successor Hillary Clinton and frame Donald Trump.

POTUS 44 preserved the Communist dictatorship of Cuba and on his way out the door shipped planeloads of cash to the Islamic state of Iran, still chanting “Death to America.” With this guy, it was “your country, right or wrong.”

In the 2017 Rising Star: The Making of Barack Obama, official biographer David Garrow called Dreams from My Father, POTUS 44’s defining narrative, a work of “historical fiction,” and the author a “composite character.” And like Paul Kengor in 2012, Pulitzer Prize winner Garrow charts the “Communist background” of Obama’s beloved “Frank,” the African American Frank Marshall Davis, who spent his life defending all-white Soviet dictatorships.

After all that, and a lot more, conservative pope George Will hails “Barack Obama’s studied elegance.” So the true back story to Will’s hatred of Donald Trump is gushing admiration for his predecessor. Like Winston Smith in George Orwell’s 1984, conservative George Will had won the victory over himself. He loved Barack Obama.



Wisdom from barmaid Sandy


For more blog postings from me, see  TONGUE-TIED, EDUCATION WATCH INTERNATIONAL, GREENIE WATCHPOLITICAL CORRECTNESS WATCH, AUSTRALIAN POLITICS, and Paralipomena (Occasionally updated),  a Coral reef compendium and an IQ compendium. (Both updated as news items come in).  GUN WATCH is now mainly put together by Dean Weingarten. I also put up occasional updates on my Personal blog and each day I gather together my most substantial current writings on THE PSYCHOLOGIST.

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