Cost-sharing is one of the most studied aspects of the Medicaid program. Over three
decades of research overwhelmingly establish that heightened copayments make it harder
for beneficiaries to afford medical services, while premiums make it harder for eligible
individuals to enroll and maintain coverage. The adverse consequences of cost sharing
include poorer health and increased use of high-cost services like emergency rooms.
Leighton Ku & Victoria Wachino, The Effect of Increased Cost Sharing in Medicaid: A Summary of Research Findings (2005), available at http://www.cbpp.org/cms/?fa=view&id=321.
100,000 people lost Medicaid coverage in Missouri because of less generous eligibility
standards, higher premiums and the expansion of copayments to nearly all Medicaidcovered services and prescription drugs. After Missouri cut Medicaid, the number of uninsured individuals increased, hospitals became burdened with more uncompensated care, and revenue shortfalls forced community health centers to charge patients more and obtain larger state grants.
Stephen Zuckerman et al., Missouri’s 2005 Medicaid Cuts: How Did They Effect Enrollees and Providers?
HEALTH AFF (online ed. Feb. 2009), available at
http://content.healthaffairs.org/content/early/2009/02/18/hlthaff.28.2.w335.full.pdf+html.
Medicaid cost sharing adds to families’ financial hardship, forcing difficult choices between
necessary health care and other basic necessities.
Thomas M. Seldon et al., Cost sharing in Medicaid and CHIP: How Does It Affect Out-of-Pocket Spending? 28 HEALTH AFF. W607 (online ed. 2009), http://content.healthaffairs.org/content/28/4/w607.full.
Nominal copayments are associated with significant reductions in the use of clinically
important drugs. When the Oregon Medicaid program implemented copayments for
prescription drugs, set at $2 for generics and $3 for brand name drugs, utilization of
prescription drugs declined by 17%. Reduction in prescription drug use was observed in
every therapeutic category studied with the greatest reductions occurring for drugs treating
depression and respiratory disease.
Daniel Hartung et al., Impact of a Medicaid Copayment Policy on Prescription Drug and Health Services
Utilization in a Fee-for-Service Medicaid Population, 46 MED. CARE 565, (2008) available at
http://www.ncbi.nlm.nih.gov/pubmed/18520310
A dramatic reduction in Medicaid enrollment occurred in Oregon after the state imposed
new copays, ranging from $5 for an outpatient physician visits and $250 for an inpatient
hospital admissions, and new premiums ranging from $6 to $20 a month. Those who left
the program because of the heightened cost sharing had inferior access to needed care,
were significantly less likely to visit a primary care physician, and used the emergency room
more often than those who left the program for other reasons.
Bill Wright, et al., The Impact of Increased Cost Sharing on Medicaid Enrollees, HEALTH AFF. (online ed.,
July/August 2005), available at http://www.healthaffairs.org/RWJ/Wright.pdf.
The Oregon Medicaid program’s copayment policies did not provide the expected cost
savings because individuals skipped preventive care and used more costly hospital
emergency care. Neal T. Wallace et al., How Effective Are Copayments in Reducing Expenditures for Low-Income Adult Medicaid Beneficiaries? Experience from the Oregon Health Plan, 43 HEALTH SERV. RES. 515 (2008), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442363/.
Women living in areas with lower median incomes were disproportionately affected by cost
sharing and more likely to forgo breast cancer screening than women from more affluent
areas. An analysis of Medicare plans also found that breast-cancer screening rates, among
women who should be screened according to clinical guidelines, were 77.5% in full coverage
plans, compared to only 69.2% in cost sharing plans.
Amal Trivedi et al, Effect of Cost Sharing on Screening Mammography in Medicare Health Plans, 358 NEW
ENG. J. MED. 375 (2008), available at http://www.nejm.org/doi/full/10.1056/NEJMsa070929#t=article
Patients in low-income areas are significantly more sensitive to increases in drug
copayments than patients from high- or middle-income areas. Increased drug copayments
make it more likely that low-income patients will be unable to adhere to medication
instructions, worsening health disparities. A 10% increase in copayment for certain drugs
(statins) decreased medication adherence by more than 12% for patients living in an area
with a median household incomes of less than $30,000 compared with a decrease of less
than 2% for patients living in areas with a median income of more than $62,000.
Michael Chernew et al, Effects of Increased Patient Cost Sharing on Socioeconomic Disparities in Health
Care, 23 J. GEN. INTERN MED. 1131, (2008), available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2517964/?tool=pubmed
Because low-income families live on slim margins, even nominal copayments lead to unmet
medical needs. Families, outreach workers, and providers in Washington State all reported
that immigrant families had significant difficulty paying for prescription drugs when new
copayments were imposed.
Mark Gardner & Janet Varon, Moving Immigrants from a Medicaid Look-Alike Program to Basic Health in
Washington State: Early Observations (May 2004) available at www.nohla.org/pdf-downloads/Moving-
Immigrants-from-a-Medicaid-Look-Alike-Program-to-Basic-Health-in-Washington-State-Early-
Observations.pdf.
A Utah study found that instituting a Medicaid copayment of $2 per prescription led to 13%
of enrollees not filling their prescriptions because they couldn’t afford the co-pay. When
enrollees started getting charged $3 copayments for doctor visits, 11% of enrollees did not
to go to the doctor because they couldn’t afford it.
Office of the Executive Director, Utah Department of Health, Medicaid Benefits Change Impact Study,
UTAH PUBLIC HEALTH OUTCOME MEASURES REPORT, (December 2003), available at
http://health.utah.gov/hda/reports/MedicaidBenefitsChangeSummary.pdf.
When a prescription coinsurance and deductible cost-sharing policy was introduced in
Quebec, Canada, the use of essential drugs decreased by 14% for welfare beneficiaries. This
caused emergency room visits to increase by 78% and serious adverse health events to
increase by 88%.
Robyn Tamblyn, et al., Adverse Events Associated with Prescription Drug Cost-Sharing among Poor and
Elderly Persons, J. AM. MED. ASS’N (online ed. January 2001), available at http://content.healthaffairs.org/content/18/2/201.long
Elderly and disabled Medicaid beneficiaries who reside in states that charge copayments
have lower rates of prescription drug use. The primary effect of copayments is to reduce
the likelihood that beneficiaries will fill their doctors’ prescriptions. This burden falls
disproportionately on beneficiaries in poor health.
Stuart B, Zacker C., Who Bears the Burden of Medicaid Drug Co-payment Policies? HEALTH AFF. (online ed., March/April 1999) available at http://content.healthaffairs.org/content/18/2/201.long.
Caps placed on prescription drugs in the New Hampshire Medicaid program increased the
cost of mental health services by a factor of more than 17, compared to the savings in drug
expenditures, because beneficiaries were more likely to be admitted into hospitals or
nursing homes.
Steven B. Soumerai et al., Effects of Medicaid Drug-Payment Limits on Admission to Hospitals and Nursing
Homes, 331 NEW ENG. J. MED. 1072 (1991), available at
http://www.nejm.org/doi/full/10.1056/NEJM199110103251505
The imposition of $1.00 copayments for services in California in the 1970’s caused affected
Medicaid beneficiaries to reduce their use of necessary care, decreasing immunizations by
45%, Pap smears by 21.5%, and obstetrical care by 58%.
As described by Julie Hudman and Molly O’Malley, Health Insurance Premiums and Cost-Sharing: Findings
from the Research on Low-Income Populations, (March 2003), available at
http://www.kff.org/medicaid/upload/Health-Insurance-Premiums-and-Cost-Sharing-Findings-from-the-
Research-on-Low-Income-Populations-Policy-Brief.pdf.
Friday, February 24, 2012
Suspension of weekly HIV meetings during CRISIS
Copy of letter sent earlier today.
2/24/2012
Margaret Wolfe, MPH
Assistant Secretary
Family Health, Integrated
Services and Health Promotion
Puerto Rico Department of Health
Dear Margaret Wolfe,
On 2/7/2012, some members and representatives of PSPS and APPIA met with the PR-DoH Sec. Lorenzo Gonzalez, Frank Diaz Exec Dir of ASES, along with officials of Triple S, and you, regarding several very serious SHIP issues, for the last time, with no restart date.
Since 1/12/2012 we agreed on weekly meetings to discuss complaints brought to Sec Gonzalez’ and this groups attention, understanding this to be the forum for solutions.
For the most part, these are barriers to HIV treatment and care under the current SHIP, “mi-salud” particularly to our community, aprx- 20,000 within hospital and other clinical settings, where we are not properly care for, abused, and left to die or terminally discharged. To which the Sec responded “We are working on a couple of things with them (Hospital Ass. Of PR), I will handle it.”
While specialized AIDS Service Organizations with clinics providing primary care, have been waiting over a year for certifications and contracts from SHIP, in order to get paid for care like other Community Health Centers (330).
But, even more alarming is the primary health care in general, of 1.5 million federally indigent recipients.
Beneficiaries of the state’s Medicaid program with previous eligibility and how after the states petition to expand coverage to include an additional 100,000 with cost sharing measures, approved by CMS, effective since 11/1/2011, have negatively impacted care deliverables, at the local level data is being wrongfully interpreted between Medicaid and the Insurance Company generating co-pays for this population.
The Secretary responded “We can have a Medicaid-Tech, re-evaluate each case individually, because I doubt that there will 1,000 persons that will qualify for co-pay exemption”.
The jurisdiction has become an obstacle in accessing care to the chronically ill, elderly, and poor population.
On the 2/7/2012 meeting, Dr. Lorenzo Gonzalez was not present due to a suppose duty of “reviewing a piece of legislation”, in fact, he sneaked out of the building.
Even without his presence, I stated towards the ridiculous re-evaluations “This is not an acceptable solution, you guys created a systematic problem that requires a systematic solution, we do not need to decide whether to take our blood pressure, mental health, diabetes or HIV medicines nor the added stress this causes.”
I also questioned “how many more patients needed to die before something gets done?” regarding hospital care. I also stated that “At the very latest on our next weekly meeting, we expected to have copy of an administrative order from the PR-DoH Sec to the members of the of Hospital Association in Puerto Rico, stating that they have to ensure compliance with state licensing and federal guidelines.”
We are still waiting for your prompt response to these issues, some of the points were aired in the local media since before the 11/1/2011 and the commencement of the meetings, if in fact HIV is a priority for this administration, as we know this is but the tip of the iceberg.
As I send you this, I got word of the Sec. making time to speak at an activity of the SJ EMA, were he is pretending to do great things for our community regarding our rights.
Sincerely,
Anselmo Fonseca
VP / Co-Founder
Pacientes de SIDA pro Politica Sana
787-948-8890
propoliticasana@gmail.com
"Celebrando 13 años sirviendo a la comunidad"
2/24/2012
Margaret Wolfe, MPH
Assistant Secretary
Family Health, Integrated
Services and Health Promotion
Puerto Rico Department of Health
Dear Margaret Wolfe,
On 2/7/2012, some members and representatives of PSPS and APPIA met with the PR-DoH Sec. Lorenzo Gonzalez, Frank Diaz Exec Dir of ASES, along with officials of Triple S, and you, regarding several very serious SHIP issues, for the last time, with no restart date.
Since 1/12/2012 we agreed on weekly meetings to discuss complaints brought to Sec Gonzalez’ and this groups attention, understanding this to be the forum for solutions.
For the most part, these are barriers to HIV treatment and care under the current SHIP, “mi-salud” particularly to our community, aprx- 20,000 within hospital and other clinical settings, where we are not properly care for, abused, and left to die or terminally discharged. To which the Sec responded “We are working on a couple of things with them (Hospital Ass. Of PR), I will handle it.”
While specialized AIDS Service Organizations with clinics providing primary care, have been waiting over a year for certifications and contracts from SHIP, in order to get paid for care like other Community Health Centers (330).
But, even more alarming is the primary health care in general, of 1.5 million federally indigent recipients.
Beneficiaries of the state’s Medicaid program with previous eligibility and how after the states petition to expand coverage to include an additional 100,000 with cost sharing measures, approved by CMS, effective since 11/1/2011, have negatively impacted care deliverables, at the local level data is being wrongfully interpreted between Medicaid and the Insurance Company generating co-pays for this population.
The Secretary responded “We can have a Medicaid-Tech, re-evaluate each case individually, because I doubt that there will 1,000 persons that will qualify for co-pay exemption”.
The jurisdiction has become an obstacle in accessing care to the chronically ill, elderly, and poor population.
On the 2/7/2012 meeting, Dr. Lorenzo Gonzalez was not present due to a suppose duty of “reviewing a piece of legislation”, in fact, he sneaked out of the building.
Even without his presence, I stated towards the ridiculous re-evaluations “This is not an acceptable solution, you guys created a systematic problem that requires a systematic solution, we do not need to decide whether to take our blood pressure, mental health, diabetes or HIV medicines nor the added stress this causes.”
I also questioned “how many more patients needed to die before something gets done?” regarding hospital care. I also stated that “At the very latest on our next weekly meeting, we expected to have copy of an administrative order from the PR-DoH Sec to the members of the of Hospital Association in Puerto Rico, stating that they have to ensure compliance with state licensing and federal guidelines.”
We are still waiting for your prompt response to these issues, some of the points were aired in the local media since before the 11/1/2011 and the commencement of the meetings, if in fact HIV is a priority for this administration, as we know this is but the tip of the iceberg.
As I send you this, I got word of the Sec. making time to speak at an activity of the SJ EMA, were he is pretending to do great things for our community regarding our rights.
Sincerely,
Anselmo Fonseca
VP / Co-Founder
Pacientes de SIDA pro Politica Sana
787-948-8890
propoliticasana@gmail.com
"Celebrando 13 años sirviendo a la comunidad"
ADAP Advocacy Association Cautions that Hospitalized Patients Living with HIV/AIDS in Puerto Rico going without Medications;
Local Advocates Call on Officials to Provide Proper Health Management & Treatment
WASHINGTON, D.C. (February 24, 2012) - The ADAP Advocacy Association, also known as aaa+, today joined local advocates in Puerto Rico calling for better health management and treatment of patients living with HIV/AIDS who are hospitalized and going without their anti-retroviral (ARV) medications. The dire circumstances facing these patients was first brought to light by two organizations, AIDS Patients pro Sane Policy and the Permanent Assembly of Persons Infected and Affected with HIV/AIDS (APPIA).
"The ADAP Advocacy Association is concerned whenever people living with HIV/AIDS are being denied access to care and treatment, and our colleagues in Puerto Rico have sounded the cautionary alarm," said Brandon M. Macsata, CEO of the ADAP Advocacy Association.
The news media outlet el Nuevo Dia reported earlier this week that patients were not being provided their ARV medications, and in some cases the family was being asked to provide them. The original posting can be viewed online at http://www.elnuevodia.com/otroatropelloalospacientesconvihsida-1188292.html.
"What is really needed to end these senseless deaths is the political will and true commitment first do no harm," argued Anselmo Fonseca, spokesman for AIDS Patients pro Sane Policy. "Dealing with humans as numbers, really affects me, 30 years into this epidemic no one should be dying from lack of treatment."
According to Fonseca, advocates in Puerto Rico spoke with officials from the office where these alarmingly high death stats were generated in an attempt to understand their source, but this inquiry only made things worse. While doctors document the cause of death, often they leave out the primary diagnosis of HIV/AIDS due to stigma, at the families request, even after death and only put the complications.
He further said, "These number can be even more alarming, but based on the practice of averages, we can guesstimate that approximately 400 deaths occur annually."
To learn more about the ADAP Advocacy Association, or the crisis in Puerto Rico, please contact Brandon M. Macsata by phone at (305) 519-4256 or email at info@adapadvocacyassociation.org.
####
WASHINGTON, D.C. (February 24, 2012) - The ADAP Advocacy Association, also known as aaa+, today joined local advocates in Puerto Rico calling for better health management and treatment of patients living with HIV/AIDS who are hospitalized and going without their anti-retroviral (ARV) medications. The dire circumstances facing these patients was first brought to light by two organizations, AIDS Patients pro Sane Policy and the Permanent Assembly of Persons Infected and Affected with HIV/AIDS (APPIA).
"The ADAP Advocacy Association is concerned whenever people living with HIV/AIDS are being denied access to care and treatment, and our colleagues in Puerto Rico have sounded the cautionary alarm," said Brandon M. Macsata, CEO of the ADAP Advocacy Association.
The news media outlet el Nuevo Dia reported earlier this week that patients were not being provided their ARV medications, and in some cases the family was being asked to provide them. The original posting can be viewed online at http://www.elnuevodia.com/otroatropelloalospacientesconvihsida-1188292.html.
"What is really needed to end these senseless deaths is the political will and true commitment first do no harm," argued Anselmo Fonseca, spokesman for AIDS Patients pro Sane Policy. "Dealing with humans as numbers, really affects me, 30 years into this epidemic no one should be dying from lack of treatment."
According to Fonseca, advocates in Puerto Rico spoke with officials from the office where these alarmingly high death stats were generated in an attempt to understand their source, but this inquiry only made things worse. While doctors document the cause of death, often they leave out the primary diagnosis of HIV/AIDS due to stigma, at the families request, even after death and only put the complications.
He further said, "These number can be even more alarming, but based on the practice of averages, we can guesstimate that approximately 400 deaths occur annually."
To learn more about the ADAP Advocacy Association, or the crisis in Puerto Rico, please contact Brandon M. Macsata by phone at (305) 519-4256 or email at info@adapadvocacyassociation.org.
####
Tuesday, February 14, 2012
Another barrier to patients with HIV/AIDS
They reported that, they are not providing their medicines in hospitals
"Deaths occurred in the last 15 days of people with AIDS in hospitals of Puerto Rico will be due to Lorenzo González", sentenced Anselmo Fonseca. (file)
Patients with HIV/AIDS who are hospitalized are not being provided their maintenance drugs, which violates the Charter of rights of the carriers of the Virus HIV/AIDS, reported two organizations that represent them.
That bill of rights is the law 349, adopted in 2000 and establishes that persons with HIV/AIDS are entitled to adequate and appropriate treatment.
Anselmo Fonseca, spokesman for AIDS Patients pro Sane Policy, and Ivette González, of the Permanent Assembly of persons infected and affected with HIV/AIDS in Puerto Rico (APPIA), said that in more than two meetings with the Secretary of health, Lorenzo González, they have specified problems patients with HIV and AIDS hospitalized are facing.
But they assured that they have not had any reply of the Secretary. Yesterday Health Secretary did not respond to the request for interview on this subject.
"It occurs in both public hospitals and private." On the one hand, they do not provide medications and there is no proper management of these cases in the hospitals. "Are going backwards", said the spokesman of APPIA.
He added that patients with HIV/AIDS do not receive their medicines and treatment in time and as it should be, they are easy prey for opportunistic diseases that can lead to death.
Fonseca abounded in the case of an HIV-positive woman admitted to a hospital - not specified - because her disease progressed to AIDS. Still hospitalized, said Fonseca, the infectologist would not give her medication for her illness. Other patients in other hospitals requires family members to bring medicines rather than provide them in the hospital told Fonseca.
For her part, Gonzalez noticed another woman who was in a hospital - which she also would not pointed out - in where she was operated in the head. That same patient and her families did not learned that she was HIV-positive until they read the documents from the hospital.
Both Fonseca and Gonzalez ensured that these are not the only cases of which they have knowledge.
"Any death that occurred in the last 15 days of people with AIDS in hospitals of Puerto Rico will be due to Lorenzo González," said Fonseca.
"There is a denial by some members of the medical class in treating and handling people with HIV/AIDS." "We don't know how to handle them," said Gonzalez
Original posting news page-
This is a rough translation from Microsoft online with some corrections.
Monday, February 13, 2012
Otro atropello a los pacientes con VIH/Sida
Denuncian que no se les proveen los medicamentos en los hospitales
POP GLORIA RUIZ KUILAN gruiz@elnuevodia.com
A LOS PACIENTES con VIH/sida que son hospitalizados no se les proveen sus medicamentos de mantenimiento, con lo que se violenta la Carta de Derechos de las Personas Portadoras del Virus VIH/SIDA, denunciaron dos organizaciones que los representan.
Esa Carta es la Ley 349, aprobada en el 2000 y establece que las personas con VIH/sida tienen derecho a un tratamiento adecuado e idóneo.
Anselmo Fonseca, portavoz de Pacientes de Sida Pro Política Sana, e Ivette González, de la Asamblea Permanente de Personas Infectadas y Afectadas con VIH/sida de Puerto Rico (APPIA), dijeron que en más de dos reuniones con el secretario de Salud, Lorenzo González, le han precisado los problemas que confrontan los pacientes con VIH/sida hospitalizados.
Pero aseguraron que no han tenido respuesta alguna del secretario. Ayer el secretario de Salud no respondió al pedido de entrevista sobre este tema.
"Ocurre tanto en hospitales públicos como privados. Por un lado, no proveen medicamentos y tampoco hay un manejo adecuado de casos en los hospitales. Estamos retrocediendo", dijo la portavoz de APPIA.
Agrego que en la medida que los pacientes con VIH/sida no reciban sus medicamentos y tratamiento a tiempo y como debe ser, son presa fácil de enfermedades oportunistas que los pueden llevar hasta la muerte.
Fonseca abundo en el caso de una mujer VIH positive ingresada en un hospital -que no precise- porque su enfermedad progreso a sida. Estando hospitalizada, precise Fonseca, el infectologo no le dio los medicamentos para su enfermedad. A otros pacientes la facultad médica de los hospitales les exige a los familiares que traigan los medicamentos en vez de que se los provea el hospital, conto Fonseca.
Por su parte, González dio cuenta de otra mujer que estuvo en un hospital -que tampoco precise- en donde fue operada en la cabeza. Sus familiares y la misma paciente no se enteraron de que ella era VIH positive hasta que leyeron los documentos de alta del hospital
Tanto Fonseca come González aseguraron que estos no son los únicos cases de los que tienen conocimiento.
"Toda muerte ocurrida en los últimos 15 días de personas con SIDA en los hospitales de Puerto Rico será por culpa de Lorenzo González", sentencio Fonseca.
"Hay una negación por parte de algunos miembros de la clase médica en tratar y manejar personas con VIH/Sida. No saber como manejarlos", dijo González.
http://www.elnuevodia.com/otroatropelloalospacientesconvihsida-1188292.html
***********
Esta es sola una, de varias leyes de que se esta violando a nivel local y federal.
Ejemplos- *Daño por Culpa o Negligencia por Impericia Profesional (Malpractice) – Significa cualquier daño ocasionado a un paciente por error, omisión, culpa o negligencia como consecuencia de, o inherentes a, servicios profesionales brindados o que debieron haber sido brindados por un profesional de servicio de salud o un institución de cuidado de salud.
*Los Derechos Civiles en Puerto Rico son aquellos derechos que el Estado le ha garantizado a cada ciudadano a través de la Carta de Derechos de la Constitución del Estado Libre Asociado, a través de leyes y reglamentos y por jurispudencia o interpretación judicial.
Algunos de esos derechos son:
Libertad de expresión, Derecho a la intimidad, Derecho al voto, Derecho a no ser discriminado.
Anoche murió una de estas pacientes.
********************
Llueve y no acampa. ESTA ES NUESTRA VIDA, Toda persona con situacion similar favor de llamarnos al 787-283-8623 o 787-948-8890. / All person with similar situation please call us at 787-283-8623 or 787-948-8890
Gracias, Thank You,
Anselmo Fonseca
VP / Co-Founder
Pacientes de SIDA pro Politica Sana
787-948-8890
propoliticasana@gmail.com
"Celebrando 12 años sirviendo a la comunidad"
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