The distraught wife paced the exam room, anxious for someone to come and tell her about her husband. She’d brought him to the emergency department that afternoon when he complained about chest discomfort.
Sophia Hayes, 27, a fourth-year medical student at the Oregon Health & Science University, entered with a quiet knock, took a seat and asked the wife to sit, too.
Softly and slowly, Hayes explained the unthinkable: The woman’s husband had had a heart attack. His heart stopped. The intensive care team spent 45 minutes trying to save him.
Then Hayes delivered the news dreaded by doctors and family members alike.
“I’m so, so sorry,” she said. “But he died.”
The drama, played out on a recent Friday afternoon, was a scene staffed by actors and recorded by cameras, part of a nerve-wracking exam for Hayes and 143 other would-be doctors. OHSU officials say they’re the first medical students in the U.S. required to pass a tough new test in compassionate communication.
By graduation this spring, Hayes and her colleagues must be able to show that, in addition to clinical skills, they know how to admit a medical mistake, deliver a death notice and communicate effectively about other emotionally and ethically fraught issues.
It’s a push started in the last two years by Dr. Susan Tolle, director of the OHSU Center for Ethics in Health Care, who wants to improve the way doctors talk to patients, especially in times of crisis.
Tolle has seen doctors who don’t make eye contact, those who spout medical jargon and still others who appear to lack basic compassion for patients and their families.
“They’ll stand in the doorway and say something like, ‘You need to call a funeral home,’” Tolle said.
Part of the problem is that, in the past, aspiring doctors were taught too little, too late about difficult communication and its nuances, said Tolle.
“My generation of faculty were not taught,” she said. “I had history-taking, but it was more about, ‘How long have you had chest pain?’ I did not have [instruction in] how to give bad news.’”
At Tolle’s urging, the OHSU officials revamped the medical school curriculum to include new lessons in — and standards for — communication, ethics and professionalism woven through the coursework, said Dr. George Mejicano, the senior associate dean for education.
“Most of the emphasis has been on the simplest aspects of communication,” he said. “The whole idea here is, how do you tell someone they have a life-threatening or even a fatal illness? How do you tell someone, ‘I’ve actually made a mistake?’”
OHSU isn’t the only center to focus on communication. All medical schools and residency programs in the U.S. are required to include specific instruction in communication skills to gain accreditation, according to Lisa Howley, senior director of strategic initiatives and partnerships for the Association of American Medical Colleges, or AAMC. Residents are required to prove competency in order to graduate from training and be eligible for board certification for individual practice. And there’s been a larger effort nationwide to help practicing doctors learn to talk to patients about dying.
But Dr. Mark Siegler, director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, who closely follows communication issues, said he believes OHSU’s approach is new.
“So far as I know, there is no other school in the U.S. that has any such standard,” said Siegler. “No other program has both a teaching effort and an evaluation effort.”
Hayes, the OHSU medical student, said she and her fellow students were nervous before the recent exam. But the practice with “standardized patients” — actors trained to portray people undergoing medical care — was crucial to understanding the right way to talk to families in a real-world situation.
“You realize you have this horrible information they don’t have yet,” she said.
Tolle wants to improve the way doctors talk to patients, especially in times of crisis. (Jordan Sleeth/Courtesy of the Oregon Health & Science University)
Hayes did quite well and passed the test, Tolle said. So did most of the other OHSU medical students. But several — she wouldn’t say exactly how many — will need remedial coaching and testing before graduation.
Some of those students failed to introduce themselves properly or to find out what the family member had already been told, Tolle said. Instead, they bluntly announced they had bad news and quickly added that the patient was dead.
“You watched the screen and it looked like you hit [the spouse] with a truck,” Tolle said. “It comes across as incredibly uncaring.”
In real life, such botched conversations can have far-reaching effects. Mary George-Whittle was just 24 when her father had emergency open-heart surgery in 1979. When the surgeon emerged from the operating room to face the family, his message was jarring.
Mary George-Whittle’s parents, Louie and Ella George, in the early 1970s. (Courtesy of Mary George-Whittle)
“He blurted out that Dad had died, that he had too little to work with, that Dad’s veins were like working with the veins of a turkey,” recalled George-Whittle, now 63 and retired after a career as a chaplain in Oregon. “He told us he had Dad’s blood all over him.”
Nearly 40 years later, she and her 11 siblings can still remember the shock.
“The impact that that still has is like PTSD,” she said. “The experience gets caught up in how poorly the news was given.”
This year’s test is a first step, Tolle said. It will be reviewed and refined for future classes. Students who need help will get it. At the same time, OHSU faculty will be offered sessions to help improve their communication skills so they can model what students are taught.
The long-term goal is to raise the bar across the profession, said Tolle, who’s had some practice shifting paradigms. She’s the co-creator of the Physician Orders for Life-Sustaining Treatment, known as POLST, a document credited with revolutionizing end-of-life instructions across the U.S.
In the same way, Tolle said, the culture of communication among doctors can change, too, starting with the latest generation.
“Our biggest goal is not to do a kind of ‘gotcha’ thing for the current medical students,” she said. “It’s to find where the pieces are missing.”
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The Trump administration has advised Idaho that its plan to allow insurance policies that fall short of Obamacare standards could result in penalties for insurers. But another strategy might yet fly.
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No, you can’t.
That’s what federal officials told Idaho regulators and the state’s governor late Thursday regarding the state’s plan to allow insurers to sell health plans that fall short of the Affordable Care Act’s requirements.
But the letter from the Trump administration letter did offer an alternative: Tweak your plan a bit to make them qualify as “short-term” policies. These alternatives — which are exempted from ACA rules, including those barring insurers from rejecting people with preexisting medical conditions — offer coverage for a limited time.
“On the one hand, they’re saying they’re going to enforce the ACA,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities. But, the Health and Human Services Department also seems to say, “if you want to roll back protections for people with preexisting conditions, we have some ideas for you,” she added. “And that concerns me.”
Idaho’s approach, announced in January, would have allowed insurers to offer “state-based” insurance plans that did not include some of the law’s consumer protections. A few weeks later, Idaho Blue Cross jumped in with five “Freedom Blue” state-based plans it hoped to sell.
Regulators in other states were watching the Idaho situation. Its move was viewed either as a brazen effort to flout federal law or an innovative attempt to stabilize the market. Regardless, it meant the Trump administration had to take position: Enforce the ACA or look away.
Here are four key takeaways from the decision and how it may play elsewhere.
1. States and insurance carriers can’t ignore federal law.
Although the letter commended Idaho’s effort to “address the damage” caused by the ACA, it said the proposed state-based plans would violate at least eight of its provisions, including its ban on setting annual or lifetime caps, charging sick people more than those considered healthy or excluding coverage for preexisting conditions.
Thursday’s letter noted that if such plans were sold in Idaho, insurance carriers might face significant financial penalties. Experts said they would be surprised if insurers wanted to take that risk.
“It’s one thing for the state to take on CMS, but quite another for carriers,” said Jan Dubauskas, general counsel for the IHC Group, which sells short-term health insurance nationally. “When I heard that, I thought, ‘This is the end for state-based plans.’”
By midafternoon Friday, Blue Cross of Idaho had not issued any comment.
But Idaho Gov. Butch Otter, a Republican, was upbeat, saying the letter from Centers for Medicare & Medicaid Services Administrator Seema Verma “was not a rejection of our approach” but “an invitation … to continue discussing … what can and cannot be included in state-based plans.”
The timetable going forward is not immediately clear, although both federal regulators and state officials say they are willing to talk about alternatives. Getting new short-term plans on the market would also require insurers to consider their options, modify the plans and come up with new premium rates.
2. Short-term plans get another boost.
Dubauskas and others said the Idaho decision could increase interest in short-term plans.
Such policies have been sold for years, meant as a stopgap for people between jobs. They’re less expensive than ACA plans, mainly because they can reject people with health conditions or exclude coverage for such conditions and have other limitations. Most of the plans don’t cover mental health and substance abuse treatment, few cover maternity care, and some don’t include prescription drug coverage. They generally can’t be renewed, meaning consumers must reapply and answer medical questions each time their policies expire.
The Obama administration, fearing that short-term plans would suck relatively healthy people out of the ACA market, limited them to 90-day terms. The Trump administration, however, has proposed allowing short-term plans to last for up to a year. These final rules aren’t expected for at least another two months.
Ironically, Idaho Insurance Director Dean Cameron had in January promoted the more robust “state-based” plans — like those the Blues insurer wanted to sell — as an alternative to short-term coverage.
After getting the CMS letter, he told the Idaho Statesman newspaper that short-term plans might be easier for the Trump administration to handle legally but could cause consumers more problems than what Idaho had proposed.
Critics fear that consumers will buy such plans without understanding their limitations.
“They might think it’s health insurance like they’re used to, but it’s really not, it’s really very bare-bones,” said Lueck.
3. State reactions will vary widely, creating different rules around the country.
Even if the Trump administration proposal to extend short-term coverage to a full year is finalized, states can set stricter rules.
A handful of states already do.
New York and New Jersey require many of the same rules as the ACA, but insurers wont’ sell short-term plans there.
Four states — Arizona, Michigan, Minnesota and Oregon — limit the length of the plans to 185 days, according to a survey by the Commonwealth Fund and researchers at Georgetown University.
“A small group of largely blue states have some regulation [of short-term plans], but not very many,” said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. “It’s possible that if this rule is finalized we will see more states start to step up and regulate short-term markets.”
Conversely, lawmakers in other states may promote short-term coverage as a lower-cost alternative to the ACA, although people with preexisting conditions may not be able to buy such plans.
“Politically, short-term plans have some appeal because lawmakers can say now there’s a cheaper option out there,” Corlette noted.
4. The increased emphasis on short-term plans could increase premiums.
Actuaries fear that short-term plans — or state-based plans like those rejected in Idaho — would help drive up costs for people who remain in more comprehensive ACA coverage.
That’s because younger and healthier people might be tempted to drop their ACA coverage, leaving a remaining pool of those who are older, sicker and costlier. That, in turn, drives up premiums — affecting millions of Americans who don’t receive subsidies and already struggle to pay.
But just how many people will jump to new, short-term coverage?
The Trump administration has estimated that about 100,000 to 200,000 people with existing ACA coverage would make the shift, while other experts suggest higher numbers.
Christopher Condeluci, a benefits attorney, said it’s unclear which estimates are correct.
The real issue to keep in mind, he said, is that an increasing number of people who don’t get subsidies are already choosing to either forgo coverage or pick an alternative, such as short-term plans.
“People are voting with their feet,” he said. “That cannot be overlooked.”
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As President Donald Trump and congressional Republicans tirelessly try to dismantle the Affordable Care Act, a number of states are scrambling to enact laws that safeguard its central provisions.
The GOP tax plan approved by Congress in the last days of 2017 repealed the ACA penalty for people who fail to carry health insurance, a provision called the “individual mandate.” On Jan. 30, in Trump’s first State of the Union address, he claimed victory in killing off this part of the health law, saying Obamacare was effectively dead without it.
But before that federal action kicks in next year, some states are enacting measures to preserve the effects of the mandate by creating their own versions of it.
Maryland is on the cutting edge with legislation moving through both chambers of the Statehouse.
“We’ve been just struggling since Trump became president with how to protect the ACA in our state,” said Vincent DeMarco, president of the Maryland Citizens’ Health Initiative, a nonprofit organization that has been instrumental in pushing the measure.
Proposals have been discussed or advanced in at least nine states, including California, Washington and Connecticut, and the District of Columbia.
Creating an individual mandate is just one way that states — generally blue states where Democrats control the legislature — seek to ensure what many lawmakers view as key advances made by the ACA don’t disappear.
They’re looking to one another as test cases to see how state-level legislation can either buttress or alter the ACA, according to Trish Riley, the executive director of the National Academy for State Health Policy.
“One state will try one approach, others will try it,” Riley said. “It’s an experiment, and an important one.”
Time is short, since most states have limited legislative calendars and are fast approaching the deadlines for insurers to file their 2019 rate plans.
Passing and implementing these kinds of measures will be tough, said Sabrina Corlette, a research professor at Georgetown University’s Health Policy Institute. But “I think there’s still a window of opportunity for states to do something and have an impact on 2019 premiums,” she said.
Maryland’s Take On The Individual Mandate
Maryland’s effort began last April when the state legislature created the Maryland Health Insurance Coverage Protection Commission “both in response to and in anticipation of efforts at the federal level to repeal and replace the ACA,” according to a report by the state’s legislative services department and the commission itself.
The commission, chartered for three years, is charged with studying how federal action could affect the state’s health insurance market and Medicaid program and offering recommendations to mitigate any negative impacts. The panel began meeting months before the Maryland General Assembly started its 90-day session in January.
Based on the commission’s initial recommendations, Sen. Brian Feldman and House Del. Joseline Peña-Melnyk introduced the Protect Maryland Health Care Act of 2018, which lays out a framework for preserving an individual mandate in the state.
The federal individual mandate was put in place to make sure that younger, healthier people joined the insurance risk pool, helping to stabilize the market. The idea is that those relatively healthy customers help cover the insurers’ costs for sicker customers’ care, which keeps premium costs manageable for everyone.
The Congressional Budget Office estimated that 13 million people nationwide would become uninsured without the individual mandate. Some will choose to go without insurance or will not be able to find an affordable plan. Insurers could opt to leave local markets because they could not make money covering only sick patients.
Feldman said insurers and health care experts testified before the commission that Maryland’s insurance exchange would collapse in 2019 if the state didn’t act.
“Because of uncertainty at the federal level, it’s going to be up to states in this arena to pick up the slack and to enact legislation that responds to that uncertainty,” he said.
The federal mandate imposed a tax penalty on people who could afford to but chose not to buy insurance, depositing the money in a general Treasury fund.
In Maryland, the penalty fee will effectively be used, according to advocates, as a “down payment” on an insurance policy.
Beginning in 2020, if someone indicates on their taxes that they’re uninsured, the state would use the fine, plus any tax credits from the federal government, to buy an insurance plan for them.
Maryland would match its residents only with plans that cost nothing more than the fine plus the federal subsidy. So, if such a plan isn’t available in a person’s area, the state will hold on to the money in an interest-bearing account until the next open enrollment season. Then, the person has another chance to buy insurance. If at this time they don’t purchase a plan, the state will deposit the money into an insurance stabilization fund.
Politics And Policy On The Ground
Maryland is fertile ground for such health care experiments. The ACA remains popular within the state. Polling commissioned by DeMarco’s group puts the law’s support at 62 percent.
In addition, about 52 percent of Marylanders favored a state-based individual mandate, to make up for the federal provision that was repealed.
Democrats control the general assembly, but Gov. Larry Hogan, a Republican, has not offered a specific position on the issue — rather, he alluded to health reform efforts in his State of the State address. “Let’s develop bipartisan solutions to stabilize [health insurance] rates,” he said.
Ed Haislmaier, a senior research fellow at the Heritage Foundation, expressed skepticism about whether this approach will make a difference. The people who are targeted, he argued, are younger, healthier and generally lower-income. They don’t have insurance because they don’t want it, he suggested.
Jason Levitis, a senior fellow at Yale Law School’s Solomon Center for Health Law and Policy who has been instrumental in helping states craft their own versions of the individual mandate, warned that Maryland’s approach could face administrative challenges.
States that follow an approach more closely modeled after the federal mandate, he said, will have an easier time implementing it because regulators have already had five years of experience enforcing it.
Still, Levitis praised the Maryland plan: “There’s something attractive about the idea there, that you put this money … towards coverage.”
And a sampling of state proposals highlight a common theme.
“All the mandate efforts are based on the federal one,” Levitis said. “The variations are what you put on top, [how states] individually keep track of the money people pay and use it for health care services.”
He pointed to Connecticut as an example. It has two bills pending in its legislature — one that closely mirrors the federal mandate, but with slightly lower fines, and another in which the fines would be deposited into health savings accounts for the individuals.
In New Jersey, a Senate panel advanced a two-bill approach this week that would collect a fee from residents who opt against buying health insurance. These fines would then be used to help pay the health care claims of people who are catastrophically ill.
In the District of Columbia, a health care working group recommended an individual mandate nearly identical to the federal one. The plan would require City Council and congressional approval to become law.
Washington state has convened a group to study how to enforce a mandate, and no legislation has been introduced yet in California.
Meanwhile, Maryland officials also hope to learn from the experiences of other states.
For instance, lawmakers in Maryland are considering the creation of a state-based, basic, low-cost health plan as well as a fund to help insurers cope with the burden of very high-cost patients.
These efforts also come from the work of the commission.
Stan Dorn, a senior fellow with the pro-Obamacare group Families USA, said Maryland “had the foresight to see threats coming and to try to be proactive about it.”
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