Comments on: PREVENTIVE HEALTH FOR CHILDREN WILL HELP TO CONTROL COSTS by Sean Palfrey, MD http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/ CommonHealth Sun, 21 Mar 2010 23:33:49 +0000 http://wordpress.org/?v=2.9.2 hourly 1 By: Family Income Benefit Insurance http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-10626 Family Income Benefit Insurance Mon, 15 Feb 2010 10:20:24 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-10626 what a fantastic informative blog! Many Thanks what a fantastic informative blog! Many Thanks

]]> By: Mike Critelli http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-5445 Mike Critelli Thu, 13 Dec 2007 02:27:25 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-5445 I agree with your comments, but would go further. I think we need to get the broadest possible reach for preventive screenings and immunizations for people of all ages, not just children. We need to eliminate all barriers, only some of which are cost-related. For example, access is a barrier for many adults because screenings done by physicians are not available after-hours, and the availability of walk-in clinics open after regular working hours is very uneven around the country. We also have to recognize that many people need specially tailored messages delivered by particular channels to get them to go for screenings, so we need a more tailored outreach program. Obviously, we also need to recognize that there are language barriers for many individuals, and we need individuals who can communicate the need for screenings and immunizations to them. However, your comment is directionally completely on target. I agree with your comments, but would go further. I think we need to get the broadest possible reach for preventive screenings and immunizations for people of all ages, not just children. We need to eliminate all barriers, only some of which are cost-related. For example, access is a barrier for many adults because screenings done by physicians are not available after-hours, and the availability of walk-in clinics open after regular working hours is very uneven around the country. We also have to recognize that many people need specially tailored messages delivered by particular channels to get them to go for screenings, so we need a more tailored outreach program. Obviously, we also need to recognize that there are language barriers for many individuals, and we need individuals who can communicate the need for screenings and immunizations to them. However, your comment is directionally completely on target.

]]> By: Norma http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-4779 Norma Fri, 26 Oct 2007 19:16:33 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-4779 In response to Ann E. Malone, Thank you for your concern. We don't need laws we need health care and human decency toward fellow man. Too bad there aren't more like you up at Beacon Hill. In response to Ann E. Malone,
Thank you for your concern. We don’t need laws we need health care and human decency toward fellow man. Too bad there aren’t more like you up at Beacon Hill.

]]> By: Ann E Malone, RN http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-4776 Ann E Malone, RN Fri, 26 Oct 2007 18:16:20 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-4776 "Everybody" in the above comment is the key word. It befuddles me as to why more of the good people of this state, Sean Palfrey and Deval Patrick included, do not see guaranteed coverage for everyone as a reasonable goal. It has a logical place as part of our social obligation to each other, our social contract. Where is the call for health reform change beyond the preventive healthcare needs of children or the very poor, or beyond the inadequate punative individual mandate and other feeble pieces of the Chapter 58 law? Children and the poor as groups are deserving, yes, but isn't everyone deserving of healthcare? Wouldn't it be cheaper to streamline the financing in an equitable rational manner to guarantee health coverage for everyone? Cost control must occur hand in hand with reforms in access and quality, too. Does Sean Palfrey cease caring about young people once they have their 18th birthday? I think not. The money we currently allow to be wasted on layers and layers of bureaucracy and paper-pushing and means-tested "eligibility requirements" that come with having so many different private and public health programs and insurance products is appalling. And it is obscene in the face of so many unmet health needs. Tragically, the new state law just makes the bureaucracy and waste worse. Are regular people -- voters -- and our politicians so cowed by the wealth and power and slick PR of insurance companies that we will not stand up as citizens in a supposed-democracy to demand what every other civilized industrialized nation on this planet already has -- real universal healthcare for EVERYONE? All this gobbledygook of EPSDT and the silver bronze and gold bs of the connector and its sub-connectors and on and on and on is more than a dissapointment. It is revolting to me as a nurse, as a mother, and as a citizen. We can and must do better. Yes, change is hard, especially when it requires re-directing funds away from some entities such as Blue Cross Blue Shield, Tufts HMS, and the Harvard Pilgram-UnitedHealthcare hybrid, MegaLife, etc, to other more valuable healthcare entities such as primary care providers, community health workers and health centers, nutrition and exercise programs. These changes absolutely can be undertaken and accomplished if the political will exists. It is not rocket science. It is basic human decency and the obligation of a civilized society. It is having the political courage to undertake what is right. This situation begs the following questions: What kind of Commonwealth do we want to be? Who among our leaders, or other citizens, will lead us in having an open public dialogue about Massachusetts health care reform and who will begin these urgently-needed improvements? See http://www.Masscare.org/about or http://www.Healthcare-Now.org to get involved. “Everybody” in the above comment is the key word.

It befuddles me as to why more of the good people of this state, Sean Palfrey and Deval Patrick included, do not see guaranteed coverage for everyone as a reasonable goal. It has a logical place as part of our social obligation to each other, our social contract. Where is the call for health reform change beyond the preventive healthcare needs of children or the very poor, or beyond the inadequate punative individual mandate and other feeble pieces of the Chapter 58 law?

Children and the poor as groups are deserving, yes, but isn’t everyone deserving of healthcare? Wouldn’t it be cheaper to streamline the financing in an equitable rational manner to guarantee health coverage for everyone? Cost control must occur hand in hand with reforms in access and quality, too.

Does Sean Palfrey cease caring about young people once they have their 18th birthday? I think not.

The money we currently allow to be wasted on layers and layers of bureaucracy and paper-pushing and means-tested “eligibility requirements” that come with having so many different private and public health programs and insurance products is appalling. And it is obscene in the face of so many unmet health needs. Tragically, the new state law just makes the bureaucracy and waste worse.

Are regular people — voters — and our politicians so cowed by the wealth and power and slick PR of insurance companies that we will not stand up as citizens in a supposed-democracy to demand what every other civilized industrialized nation on this planet already has — real universal healthcare for EVERYONE?

All this gobbledygook of EPSDT and the silver bronze and gold bs of the connector and its sub-connectors and on and on and on is more than a dissapointment. It is revolting to me as a nurse, as a mother, and as a citizen. We can and must do better.

Yes, change is hard, especially when it requires re-directing funds away from some entities such as Blue Cross Blue Shield, Tufts HMS, and the Harvard Pilgram-UnitedHealthcare hybrid, MegaLife, etc, to other more valuable healthcare entities such as primary care providers, community health workers and health centers, nutrition and exercise programs. These changes absolutely can be undertaken and accomplished if the political will exists. It is not rocket science. It is basic human decency and the obligation of a civilized society. It is having the political courage to undertake what is right.

This situation begs the following questions:

What kind of Commonwealth do we want to be?

Who among our leaders, or other citizens, will lead us in having an open public dialogue about Massachusetts health care reform and who will begin these urgently-needed improvements?

See http://www.Masscare.org/about or
http://www.Healthcare-Now.org to get involved.

]]> By: David Freels http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-4771 David Freels Fri, 26 Oct 2007 13:12:53 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-4771 Dr. Palfrey's recommendation to follow EPSDT's "template" is far more of a bullseye to improve healthcare than he realizes. In fact, it is such a perfect bullseye that the three-tiered system he describes is totally pointless because of the mandates required by EPSDT, as found at US 42 § 1396d(r)(5), which requires every state Medicaid agency to provide: "(5) Such other necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan." You'll notice (a) EPSDT doesn't say "medically necessary," but in fact EPSDT creates a circumstance wherein a treatment and/or service becomes defined as "medically necessary" by whether or not it is "necessary...to correct or ameliorate" the disease/condition. To only allow treatments and/or services categorized as "medically necessary" is an escape clause for insurance companies to avoid paying for of truly beneficial modalities that may not be the the standard of medical practice or which may even be considered experimental and investigational. In EPSDT, which is the standard for children's healthcare, the only thing relevant is whether or not something is "necessary to correct or ameliorate." A closer look at EPSDT confirms this position. EPSDT's primary mandate is to "correct." Correct is another word for CURE. If you cure disease this obviously saves the healthcare system a tremendous expense while ensuring the patient remains a productive member of society. How many insurance policies exist that promise to provide the insured with whatever is necessary to achieve a cure? None. Zero. Let's suppose there exists a cure for cancer or stroke or cerebral palsy. If it's a cure, how could it not be "medically necessary?" It can only be not medically necessary if it's not the “the standard of medical practice” or if it's categorized as "experimental and investigational." EPSDT hurdles all these political excuses for denial by virtue of whether or not something is "necessary to correct or ameliorate." An even closer look at EPSDT supports this position, which ultimately makes EPSDT the ultimate patient's bill of rights. EPSDT mandates an all-encompassing umbrella for "necessary health care, diagnostic services, treatment, and other measures." What does "and other measures" mean? It means whatever it takes to get the job done. EPSDT also mandates coverage for "defects"; this means birth defects--the ultimate pre-existing condition, which means, under the EPSDT template there is no such thing as a ban on treatments and/or services for pre-existing conditions. Let's keep looking. Insurance is notorious for avoiding coverage if something is a mental problem and not a physical problem or if something is a physical problem and not a mental problem. Under Palfrey's ingenious EPSDT template, that kind of hair-splitting is irrelevant because EPSDT mandates coverage for "defects and physical and mental illnesses and conditions..." And "conditions." That means it doesn't matter what it is; whatever the IT is, the patient gets whatever is necessary to correct or ameliorate IT. This all-encompassing intention is absolutely confirmed with the final EPSDT mandate of "whether or not such services are covered under the State plan." How many insurance companies declare in their policies to do whatever it takes to cure your disease--even if that cure is not covered by the insurance policy? None. I'm with Palfrey. Let's make EPSDT the “the standard of medical practice” for everybody. Dr. Palfrey’s recommendation to follow EPSDT’s “template” is far more of a bullseye to improve healthcare than he realizes. In fact, it is such a perfect bullseye that the three-tiered system he describes is totally pointless because of the mandates required by EPSDT, as found at US 42 § 1396d(r)(5), which requires every state Medicaid agency to provide: “(5) Such other necessary health care, diagnostic services, treatment, and other measures to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State plan.” You’ll notice (a) EPSDT doesn’t say “medically necessary,” but in fact EPSDT creates a circumstance wherein a treatment and/or service becomes defined as “medically necessary” by whether or not it is “necessary…to correct or ameliorate” the disease/condition. To only allow treatments and/or services categorized as “medically necessary” is an escape clause for insurance companies to avoid paying for of truly beneficial modalities that may not be the the standard of medical practice or which may even be considered experimental and investigational. In EPSDT, which is the standard for children’s healthcare, the only thing relevant is whether or not something is “necessary to correct or ameliorate.” A closer look at EPSDT confirms this position. EPSDT’s primary mandate is to “correct.” Correct is another word for CURE. If you cure disease this obviously saves the healthcare system a tremendous expense while ensuring the patient remains a productive member of society. How many insurance policies exist that promise to provide the insured with whatever is necessary to achieve a cure? None. Zero. Let’s suppose there exists a cure for cancer or stroke or cerebral palsy. If it’s a cure, how could it not be “medically necessary?” It can only be not medically necessary if it’s not the “the standard of medical practice” or if it’s categorized as “experimental and investigational.” EPSDT hurdles all these political excuses for denial by virtue of whether or not something is “necessary to correct or ameliorate.” An even closer look at EPSDT supports this position, which ultimately makes EPSDT the ultimate patient’s bill of rights. EPSDT mandates an all-encompassing umbrella for “necessary health care, diagnostic services, treatment, and other measures.” What does “and other measures” mean? It means whatever it takes to get the job done. EPSDT also mandates coverage for “defects”; this means birth defects–the ultimate pre-existing condition, which means, under the EPSDT template there is no such thing as a ban on treatments and/or services for pre-existing conditions. Let’s keep looking. Insurance is notorious for avoiding coverage if something is a mental problem and not a physical problem or if something is a physical problem and not a mental problem. Under Palfrey’s ingenious EPSDT template, that kind of hair-splitting is irrelevant because EPSDT mandates coverage for “defects and physical and mental illnesses and conditions…” And “conditions.” That means it doesn’t matter what it is; whatever the IT is, the patient gets whatever is necessary to correct or ameliorate IT. This all-encompassing intention is absolutely confirmed with the final EPSDT mandate of “whether or not such services are covered under the State plan.” How many insurance companies declare in their policies to do whatever it takes to cure your disease–even if that cure is not covered by the insurance policy? None. I’m with Palfrey. Let’s make EPSDT the “the standard of medical practice” for everybody.

]]> By: Norma http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-4769 Norma Fri, 26 Oct 2007 10:38:10 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-4769 Nick, I have been reading this blog for months and so far all I read is phoney concern, and threats and insults. So don't look for any answer to real questions. Like, why are the lawmakers at the State House treating the uninsured like criminals? Why do they call this "affordable" insurance? Why do they call this"Universal" health care? Why are the lying to the Nation that the citizens are all insured? The lawmakers did not have to MANDATE this so called health care reform, they have to FORCE it's own citizens to buy into bogus insurance plans. The citizens of this State need to wake up and petition out each and every lawmaker on Beacon Hill.We the people should have some say on the corrupt politics that went on at our exspense.The lawmakers caved into the Insurance Lobbyist and we have to pay the price? I refuse to buy into phony insurance plans! Nick,
I have been reading this blog for months and so far all I read is phoney concern, and threats and insults. So don’t look for any answer to real questions. Like, why are the lawmakers at the State House treating the uninsured like criminals? Why do they call this “affordable” insurance? Why do they call this”Universal” health care? Why are the lying to the Nation that the citizens are all insured? The lawmakers did not have to MANDATE this so called health care reform, they have to FORCE it’s own citizens to buy into bogus insurance plans. The citizens of this State need to wake up and petition out each and every lawmaker on Beacon Hill.We the people should have some say on the corrupt politics that went on at our exspense.The lawmakers caved into the Insurance Lobbyist and we have to pay the price? I refuse to buy into phony insurance plans!

]]> By: NICK http://commonhealth.wbur.org/practicing-physicians/2007/10/preventive-health-for-children-will-help-to-control-costs-by-sean-palfrey-md/comment-page-1/#comment-4767 NICK Fri, 26 Oct 2007 09:17:01 +0000 http://www.wbur.org/weblogs/commonhealth/?p=246#comment-4767 THIS IS SUCH A GREAT IDEA! HAVE YOU EVER THOUGHT ABOUT MAKING CERTAIN SCREENINGS REQUIRED FOR ADULTS. I AGREE THAT PREVENTION NEEDS TO OCCUR EARLY ON. THIS SHOULD GO THROUGH YOUR WHOLE LIFECYCLE. COMMENTS? THIS IS SUCH A GREAT IDEA! HAVE YOU EVER THOUGHT ABOUT MAKING CERTAIN SCREENINGS REQUIRED FOR ADULTS. I AGREE THAT PREVENTION NEEDS TO OCCUR EARLY ON. THIS SHOULD GO THROUGH YOUR WHOLE LIFECYCLE. COMMENTS?

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