Looking Beyond Premiums & Secretary Burwell Response

Earlier this summer, the I AM (Still) ESSENTIAL coalition sent a letter to HHS Secretary Burwell alerting her of various access-to-care issues patients have experienced during their first year of enrollment in qualified health plans. Signed by 333 patient organizations, the letter outlined key areas of concern including limited benefits (particularly related to prescription medications and provider networks), high cost-sharing, and lack of transparency and uniformity. In her response received last week, the Secretary addresses some of the issues that we raised.

As we look forward to year two, we are eager to review the 2015 qualified health plans when the open enrollment period begins on November 15th. The I AM (Still) ESSENTIAL coalition and the patients we represent, especially those living with chronic health conditions, are anxiously awaiting plan details. We will be examining plans closely this year, beyond simply focusing on premiums, to ensure that the 2015 plans are better for patients than those in 2014.

Below is a list of questions that we will be asking as we review the plans. Finding answers to these questions will be the best way to determine if the concerns that we detailed in our letter to Secretary Burwell have been addressed.

1.       Have prescription drug formularies narrowed or expanded?

  • Plans must include the greater of at least one drug per class or the number of drugs in each class as contained the state's benchmark. In 2014, some plans exceeded the benchmark requirements while others simply met the minimum drug coverage requirement. Some plans did not include combination therapies.

2.       Have medications approved over the past two years been added to the formularies?

3.       Have deductibles decreased or increased, including separate prescription drug deductibles?

  • Some plan deductibles were as high as the maximum patient out of pocket costs, which means that the plan would only begin to pay for costs after the beneficiary has spent $6,300 for an individual.
  • According to a RWJF study, exchange plans had an average combined medical and prescription deductible of $2,763 in 2014. Among the plans with a separate prescription drug deductible, the average was $933.

4.       Are plans utilizing co-insurance instead of co-pays, and if so, at what percentage?

  • An Avalere study found that 59 percent of Silver plans on exchanges across the nation use coinsurance for consumer cost-sharing on the specialty tier.
  • The analysis also found that 23 percent of plans have coinsurance rates of 30 percent or more on the highest formulary tier.

5.       Are plans utilizing discriminatory practices by placing certain classes of drugs all on high tiers and does this include generics?

  • The ACA prohibits issuers from using "benefit designs that have the effect of discouraging the enrollment in such plan by individuals with significant health needs". In 2014, some plans placed all drugs, including generics, in a certain class on the highest cost-sharing tier.

6.       Are patients able to access complete drug formularies and provider networks easily?

  • In 2014, users of plan websites found it difficult to locate complete lists of drugs that the plan covered or a directory of medical providers in each plan's network.
  • For 2015, CMS is requiring plans to list one single web address with complete plan formularies and provider directories without a consumer having to log on.

7.       Are patient cost-sharing and utilization management policies clearly defined? Is utilization management being more widely used?

  • In 2014, consumers found it difficult to determine how much they had to pay for their medications. CMS will be requiring plans in 2015 to include tiering information.
  • The use of co-insurance makes it even more difficult for patients to determine their out of pocket costs.  An analysis by Avalere of exchange plans found that plans on the exchange were more likely to use utilization management techniques than employer plans.
  • CMS has said they will be reviewing plans "that are outliers based on an unusually large number of drugs subject to prior authorization and/or step therapy requirements in a particular category and class."

Angela Ostrom

Chief Operating Officer

Epilepsy Foundation

301/918-3766

aostrom@efa.org

 

Carl Schmid

Deputy Executive Director

The AIDS Institute

202/669-8267

cschmid@theaidsinstitute.org

 

Andrew Sperling

Director of Federal Legislative Advocacy

National Alliance on Mental Illness

703/244-7893

Andrew@nami.org

Can Trauma Spur Creativity?
After His Devastating Loss, a Man Finds Healing
Through Writing

Can an emotional trauma flip a switch in the creative brain? Does profound loss offer a new perspective from which to peer into one's soul?

For LeRoy Flemming, author of the "Timelightenment" series (www.timelightenment.biz/) and volume one of "Soulsplitting," the answer is a resounding yes! And, there's psychological research supporting this idea.

In role-playing, veterans who've endured trauma resulting in PTSD "were better able to represent the boundary between reality and the role-playing, to immerse themselves in the scene, to enact identifiable characters consistent with their setting, and produce complex and interactive scenes that told a coherent story," compared to non-PTSD vets, according to researchers Robert Miller and David Johnson.

The non-PTSD group created more stereotyped, and unimaginative scenes, despite a higher education level and greater role-playing experience, the two wrote.

"I was never diagnosed with PTSD, but I know profound emotional trauma can trip all kinds of coping mechanisms in the brain and soul, including creativity," Flemming says. "When I suddenly lost my mother, it was a profound, life-altering shock. She was fine when I saw her last - Dec. 25, 1999 and she died on Jan. 1. That's what started me writing."

His mother was, by far, the most stabilizing and inspiring person in his life, he says, and losing her rocked him to his core. Rather than seeming abstract, the larger questions in life became the most important, and that's when he knew he had to write.

"I didn't have much of a background in writing," he says. "But since her passing, I've been in close contact with a part of my soul that has spawned several books, all of which have helped me heal."

The creativity caused by pain is a cycle, "because the creative process has significantly healed me," he says. "I'm not surprised that creativity increases within those who've suffered; it makes sense."

How does a grieving individual make something good out of a heart-wrenching loss? Flemming offers perspective.

•  Don't force it. One of the last things a grieving person needs is an assignment they don't want. Grief is a process that entails a host of negative emotions: denial, confusion, anger and more. Prescribing creative therapy to oneself or another before one is ready for it can backfire.

•  Let it flow naturally. We are all unique individuals and, though we know in the backs of our minds that we'll someday face the loss of a loved one, we can't predict how we'll handle it.

"Grieving and creativity actually share some traits," Flemming says. "Both are processes, and both prompt individuals to express feelings in their own terms. When creativity can be used in conjunction with the grieving process, the catharsis can be profound."

•  You have many options. When a person is desperate for an outlet, he or she will often gravitate toward what he knows. A onetime aspiring painter, for instance, may return to that familiar and comforting form of self-expression.

"But the mind can be unpredictable; it may be that gardening is the process that is most therapeutic for a grieving person, even though she never pulled a weed or planted a seed in her life," Flemming says. "In other words, be open to where your intuition guides you. As most grieving people understand, life doesn't always work out as planned. Be open to helpful new possibilities."

About LeRoy Flemming

Leroy Flemming is a graduate of Alabama State University, a Historically Black College and University (HBCU) in Montgomery, Ala. He always wanted to show people that with spiritual guidance you can make things happen. Through his determination and inspiration from his Creator, he completed his five-part series of novels, "Timelightenment," (www.timelightenment.biz/), in hopes of demonstrating to the children of this world that they can dream big, and accomplish those dreams. Though inspired by many people, his biggest influence comes from his mother, who said shortly before she passed away, "Son, I may give out, but I never give up!" Flemming recently completed volume one of his new series, "Soulsplitting."

November 10, 2014

TRICARE and Military OneSource are co-hosting a webinar to educate TRICARE beneficiaries about the resources available to them to quit using tobacco products. The webinar, scheduled from Noon - 1:00pm EST, will take place on Thursday, Nov. 20, also known as the Great American Smoke Out. To sign up, go to https://www2.gotomeeting.com/register/296946266.

Read more at: www.tricare.mil/CoveredServices/BenefitUpdates/Archives/11_10_14_GASOWebinar.aspx.

For people with atrial fibrillation (Afib), the fear of having a stroke is very real. Afib raises a person's risk for stroke five times, according to the National Stroke Association. It's a scary statistic, especially as Afib prevalence continues to rise. Understanding the connection between Afib and stroke can help patients better manage their condition and recognize other factors that could put them at even greater risk.

"A stroke prevention strategy of some kind is required for anyone with Afib, no matter how many symptoms you have or how many risk factors you have," said J. David Burkhardt, MD, electrophysiologist at the Texas Cardiac Arrhythmia Institute at St. David's Medical Center in Austin.

Afib occurs when the heart's upper chambers (atria), which push blood to the lower chambers (ventricles), beat irregularly. "Instead of the blood being pushed forward by the heart pumping, it's just swirling around in the heart and can clot easily," said Marcie Berger, MD, FACC, a cardiac electrophysiologist at Froedtert Memorial Lutheran Hospital and the Medical College of Wisconsin in Milwaukee. Clots can travel and cut off blood flow to the brain, causing a stroke.

Besides an irregular heartbeat, a person with Afib "can have additional risk factors making a stroke even more likely," said Dr. Berger.

Most doctors use a tool known as the CHADS2 score to evaluate patients' stroke risk based on the following criteria:

  • Congestive heart failure. Heart failure occurs when blood isn't being pumped efficiently to the rest of the body, resulting in fluid retention and congestion. If the heart isn't pumping at full capacity, the risk of clotting increases. "Diminished heart function is a risk factor for Afib itself as well as stroke, and it's more common in older patients," said Dr. Burkhardt.
  • High blood pressure. When the force of blood against the arteries is too high, it can cause damage to the arteries over time. "It becomes a double whammy, where you have high blood pressure as well as atrial fibrillation increasing your stroke risk," said Ralph L. Sacco, MD, professor and chairman of neurology at the Miller School of Medicine at the University of Miami.
  • Age: 75 or older. The median age among people with Afib is 67 years old in men and 75 years old in women, according to the U.S. Centers for Disease Control and Prevention. "In older adults, a new Afib diagnosis is usually due to age-related changes in the electrical system of the heart," said Dr. Berger. Changes in the heart and blood vessels are common with age, and reduced circulation increases the risk of blood clots forming.
  • Diabetes. People with diabetes are nearly four times more likely to have a stroke, according to the National Stroke Association. People with uncontrolled diabetes are more prone to have high cholesterol, and plaque build-up in the arteries can block blood flow to the brain.
  • Stroke or transient ischemic attack. Someone who's had a stroke is many times more likely to have another than someone who's never had one. According to the American Heart Association, a person who's had one or more TIAs, or "mini-strokes," is 10 times more likely to suffer a stroke.

The American Academy of Neurology recently issued an updated guideline recommending oral anticoagulants, or blood thinners, to prevent stroke in Afib patients. Guideline lead author Antonio Culebras, MD, of SUNY Upstate Medical University in Syracuse, NY, noted, however, that "doctors will need to consider the individual patient's situation in making a decision whether or not to use anticoagulants, and which one to use, as the risks and benefits can vary for each person."

Some stroke risk factors, such as age and family history, can't be controlled. But, "if we can address those controllable factors earlier in the disease process, hopefully we can work to reverse this growing trend," said J. Brian DeVille, MD, FACC, FHRS, medical director of electrophysiology at Baylor Health Care System in Dallas.

Many of the same lifestyle changes that help manage Afib can also reduce stroke risk, such as maintaining a healthy weight, exercising, and quitting smoking. The key is coming up with a prevention plan that a patient can commit to for the long run.

As Burkhardt points out, "once you're diagnosed with Afib, stroke prevention is a consideration forever."

Last Updated: 03/11/2014
Clinton, IA - Clinton and the Clinton County Sherriff's Office, will be coordinating the American Medicine Chest Challenge in Clinton, Camanche and DeWitt.
The event will take place on November 8, 2014 in communities across the country. This initiative will challenge residents to take the Five-Step American Medicine Chest Challenge:
· Take inventory of your prescription and over-the-counter medicine.
· Secure your medicine chest.
· Dispose of your unused, unwanted, and expired medicine in your home or at an American Medicine Chest
Challenge Disposal site.
· Take your medicine(s) exactly as prescribed.
· Talk to your children about the dangers of prescription drug abuse.
To help combat this growing threat to our nation's children, we are hosting the American Medicine Chest Challenge (AMCC) on November 8, 2014. Residents can find a local collection site on www.americanmedicinechestchallenge.com or dispose of their medicine at home, following the guidelines on the site.
The most recent National Survey on Drug Use and Health shows prescription medicines to be the most abused drugs by Americans, other than marijuana and found that 70% of people who abuse prescription pain relievers say they got them from friends or relatives. A recent study on drug use by teens by the Partnership for a Drug Free America (PDFA) found that one in 9 children are abusing prescription pain relievers to get high.
"This Challenge will raise awareness about the dangers of abusing prescription drugs and reduce the availability of potent drugs that lead kids down a path to addiction,'' explained American Medicine Chest Challenge Chief Executive Officer Angelo M. Valente.
"With the American Medicine Chest Challenge we are calling on residents to see their medicine cabinets through new eyes -- as an access point for potential misuse and abuse of over-the-counter and prescription medicine by young people," explained Valente.
The American Medicine Chest Challenge has gained the national support of PhRMA, The Partnership at DrugFree.Org, the Generic Pharmaceutical Association and the American College of Emergency Physicians.
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This November 15th, Get Covered Illinois and TPQC will host a Kick-Off Enrollment Event for Rock Island County residents to get insurance under the federal health law. This event is scheduled for Saturday, November 15th:

9:00am - 3:00pm at 1830 6th Avenue, Moline, Il.

This is an open invitation for all Rock Island County residents to learn more about their expanded options for health insurance coverages. There is no cost for attendees and there will be great give away prizes and snacks for all. Illinois certified counselors will be available to help with questions, concerns and portal navigation.

The Affordable Care Act's first open enrollment period drew what officials call the "low-hanging fruit" of the uninsured population: the sick and those who knew the law requires everyone to have insurance.

This year, the TPQC and the State of Illinois are targeting people who often need a thorough explanation and several face-to-face meetings to understand their options. With a shorter enrollment period and a stiffer penalty for going without insurance, the state is intensifying its efforts to get the enrollment message out.
The law's second open enrollment period runs from Nov. 15 through Feb. 15, half as long as last year's enrollment period. The penalty for not having insurance will increase in 2015 to $325 or 2 percent of annual adjusted income, from $95 or 1 percent of income in 2014.

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World-renowned Expert Shares 5 Helpful Tips

Whether it's Mom, Dad, Grandma or Grandpa - or your spouse - the "holiday quarter" can present special challenges for families with a loved one suffering from dementia.

"We have an expectation that loved ones should never change from the person we've perceived them to be for years, but everyone changes significantly over an extended period, especially those diagnosed with dementia," says Kerry Mills, a sought-after expert in best care practices for people with dementia, which includes Alzheimer's. November is Alzheimer's Awareness Month.

"Dementia encompasses a wide range of brain diseases, which means it's not the fault of a Grandma if she has trouble remembering things or gets flustered. Empathy for what she's experiencing on the level of the brain will help your relationship with her. Do not expect her to meet you halfway to your world; you have to enter her world."

Spouses have a particularly difficult time coping with their partner's dementia, Mills says. A spousal relationship is a team and is central to the identities of both people. So, while you're paying special attention to a parent's or grandparent's condition, extend it to his or her spouse, she says.

Families tend to have a hard time coping with a loved one's dementia during holiday gatherings. Mills, coauthor with Jennifer A. Brush of "I Care, A Handbook for Care Partners of People with Dementia," (engagingalzheimers.com), offers tips for how to interact with a loved one - say, Grandma - whose brain is deteriorating.

•  Do not get frustrated. "First, do no harm" - the excellent maxim taught to medical students, is also a great first principle for those interacting with Grandma, who may be experiencing a level of frustration and anxiety you cannot comprehend adequately. She simply doesn't have access to certain details, but she is still a conscious and feeling person who has plenty to offer. If you get frustrated, she'll pick up on it.

•  Dedicate someone to Grandma during the gathering. Of course, loving families will want to include Grandma in the group, but be careful not to overwhelm her with attention. Her brain, which has trouble processing some information, could use assistance - a liaison to help her process things. Grandpa could probably use a break; her son or daughter may be the best handler during a gathering.

•  Give Grandma purpose; give her a task in the kitchen. Keep Grandma, who may've been prolific in the kitchen in the past, engaged! Simple tasks, such as mashing potatoes or stirring gravy, may be best. Engage her in conversation about the food. If it's Grandpa whose suffering dementia, include him in a group. Give him a cigar if the other men are going outside to smoke. Engage him in a conversation about football, which may allow him on his own terms to recall details from the past.

•  Use visual imagery and do not ask yes-or-no questions. Again, asking someone with Alzheimer's to remember a specific incident 23 years ago can be like asking someone confined to a wheelchair to run a 40-yard dash - it's physically impossible. Don't pigeonhole her. Direct Grandma in conversation; say things to her that may stimulate recollection, but don't push a memory that may not be there. Pictures are often an excellent tool.

•  Safety is your biggest priority. Whether during a holiday gathering or in general, Grandma may commit herself to activities she shouldn't be doing, such as driving.

"She's been driving for decades, and then she develops a memory problem, which not only prevents her from remembering her condition, but also how to drive safely," Mills says. "This major safety concern applies to any potentially dangerous aspect to life."

"Currently, there's a stigma with the condition, but I'd like to change the baseline for how we regard dementia," Mills says. "As with other medical conditions, Alzheimer's should not be about waiting to die - patients often live 15 years or more after a diagnosis. It should be about living with it."

About Kerry Mills

Kerry Mills, MPA, is an expert in best care practices for persons with dementia both in the home and in out-of-home health care residences and organizations. She is a consultant to numerous hospitals, assisted livings, hospice, home care agencies, senior day care centers and nursing homes. In her twelve-year career in health care, she has served as executive director and regional manager for numerous long-term dementia facilities. She is an outspoken advocate for persons with dementia, lecturing in Hong Kong, Canada, China, Europe and the United States. Her book, coauthored with Jennifer A. Brush, "I Care," (engagingalzheimers.com), is the 2014 Gold Award Winner of the National Mature Media Awards.

During November, dLife® celebrates Diabetes Champions - a group of people we identified as going above and beyond in the world of diabetes to inform, motivate, and inspire others to better self-manage their diabetes life.

Starting November 1, read their stories and enter to win each week's grand prize personally selected by the featured Diabetes Champions. The more times you enter, the greater your chance is to win. Read more.

The current session of Congress has left many important issues unresolved. Critical legislation is languishing in committees and vital budgetary decisions have yet to be made. With such inaction it's easy to assume this session of Congress is over.

But it's not!

In the coming weeks Congress will be focused on developing next year's federal budget. Let them know that increasing funding for Alzheimer's research should be their TOP PRIORITY.

Urge your members of Congress to provide an additional $200 million in Alzheimer's research funding.

Tour Day Part of Alzheimer's Awareness Month in November

 

DAVENPORT, IA (October 30, 2014) - Senior Star at Elmore Place is partnering with the creators of the Virtual Dementia Tour® (VDT), Second Wind Dreams®,to support national Take the Tour Day, November 6, to help build support for Alzheimer's Awareness Month in November.

Taking the VDT® is important as, according to the Alzheimer's Association website, every 69 seconds someone in the United States is diagnosed with Alzheimer's.  The VDT® is a creative tool that helps people understand the challenges of those facing dementia.  The VDT® guides participants through completing everyday household chores while facing some of the same challenges those with Alzheimer's encounter - blurred vision, difficulty hearing, interrupted concentration and more.

Each tour takes about 15-20 minutes and is led by the experienced associates of Senior Star at Elmore Place.  Associates at Senior Star provide compassionate and innovative care to those facing Alzheimer's making this team well prepared to address participants' questions.

This real-life experience is also important as persons first diagnosed with a form of dementia are often cared for by a family member.  The VDT® experience is an eye-opener for caregivers to better understand the challenges those with Alzheimer's face.

Tours are being conducted on November 6 at 9 a.m., 11 a.m. and 1 p.m.  Each tour is limited to 16 participants.  To take the VDT®, RSVP no later than November 5 by calling 563.484.5114.  If you're unable to participate on this date, call 563.484.5114 to arrange a private tour with the associates of Senior Star.

For more information about Senior Star at Elmore Place or to tour the community, call 563.484.5114.

About Senior Star at Elmore Place

Senior Star at Elmore Place, a Senior Star community, features 236 modernly decorated apartments spanning across 20 acres of beautifully landscaped property with many customized amenities to offer its residents three distinctive living experiences:  independent living, assisted living and memory care.  For more information, visit www.seniorstar.com.

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