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Blogs and Articles

More Options Necessary to Meet Electric Demands

By: Kenneth J. Reuter, Jr.

Influential voices who have the ears of policy makers are advocating solar and wind generation to provide electricity supply to meet our country’s demands.  But it is important to respect the fact that technology must drive electric generation supply solutions, not government mandates.  This same notion also applies to the demand side of electricity as well.  For example, mandating EV’s by a certain date is also misguided.  Electric supply and demand must evolve and be driven by available and under-development technology. We also need to understand that our electric grid currently lacks the capability and stability to support a rapid, forced transition. Facts and science must shape our path forward to transition to our electric energy future. This article focuses on how best to address electric generation to support future US demand.

The US generates electricity from four sources distributed approximately as follows: Natural Gas (40%), Renewables (22%), Coal (20%) and Nuclear (18%) with coal as the most polluting.  As solar and wind technology emerge and evolve, we are expanding their deployment.  Both are renewable and neither emit pollution.  As beneficial as these emerging renewable sources have become, they will not solve the growing and massive US demand for a reliable supply. Generation cannot be dependent on daily amounts of sun and wind.  Primary generation must be supplied by predictable, reliable, and cost-effective power plants also known as base-load plants.  We know that coal is the most problematic with respect to pollution.  Clean coal and scrubbing solutions are under refinement.  But there are better solutions that can be further expanded or in development that show great promise.

If we want to meet the very aggressive goal of zero emissions by 2050, coal is not the answer.   It is, however, abundant, and inexpensive.  China’s reliance on coal gives them a huge economic competitive advantage over the US.  As a result, China is also by far the world’s single largest polluter. We are in a global competitive environment and cost is very important to ensure our competitive place in the world economy.

Natural gas, by a wide margin, produces a fraction of pollutants than that of coal by a wide margin does.  And when designed in Combined-Cycle (CC) configuration, meaning using that fuel to spin a generator and then capturing the heat emitted to spin another generator, is very cost-effective producing significantly lower pollutants to the atmosphere.

In highly populated coastal environments, wind has been proposed as a source of electric generation. If you   compare the cost of building a Combined-Cycle (CC) natural gas plant versus an Offshore Wind Farm, (OSW).  A 600 MW CC natural gas plant can be built for approximately $750 Million.  A 600MW Offshore Wind Farm costs in excess of $2 Billion and with much higher maintenance costs.  And remember, all these costs are built into the rate base which drives cents per KW at the meter.  The US has been expanding natural gas CC plants and decommissioning plants that are coal fired.  We have seen greater than a 65% drop in overall emissions from 2005 to 2019 and a 32% drop in CO2 emissions shifting from coal to natural gas. We need to continue the transition from coal to natural gas.

In order to provide consistent base-load electric power to meet future demand we must also revisit nuclear! Nuclear power is clean, emits no pollutants and can run base-load full power for extended periods without the need for refueling.  Most operators elect to refuel every 18-24 months. Nuclear technology is safe, effective and by far the cleanest, most efficient and the most non-polluting answer for us to reach our goal of Zero Carbon Emissions by 2050.

Small modular reactors (SMRs) are advanced nuclear reactors that have a power capacity of up to 300 MW per unit, which is about one-third of the generating capacity of traditional nuclear power reactors. SMRs, which can produce a large amount of low-carbon electricity, are:

  • Small – physically a fraction of the size of a conventional nuclear power reactor.
  • Modular – making it possible for systems and components to be factory-assembled and transported as a unit to a location for installation.
  • Reactors – harnessing nuclear fission to generate heat to produce energy.

Many of the benefits of SMRs are inherently linked to the nature of their design – small and modular. Given their smaller footprint, SMRs can be sited on locations not suitable for larger nuclear power plants. Prefabricated units of SMRs can be manufactured and then shipped and installed on site, making them more affordable to build than large power reactors, which are often custom designed for a particular location, sometimes leading to construction delays. SMRs offer savings in cost and construction time, and they can be deployed incrementally to match increasing energy demand.

No one generation solution is the answer.  The right answer?  All of the above, driven by technology, is the right mix of generation to meet both the growing US demand for electricity and strive to reach a Zero carbon emissions goal by 2050.

Kenneth J Reuter, Jr., has a BS In Economics and Business from the University of Delaware and  an MBA in International Finance from Northeastern University. He has worked for the past 40 years in the electric industry dealing with all methods of generation, transmission, and distribution. He has held positions as an engineer, Director, VP and CEO in global energy companies. He continues to consult globally through his business, Resilience Energy, LLC. 

 

 

 

 

 

Hospital Price Transparency in Delaware: The Ideal and the Reality

By: Dr. Stacie Beck

You usually know what you are going to pay for purchase before you buy. That makes sense. But have you ever tried to determine how much a medical procedure is going to cost before you undergo anesthesia? It can be frustrating.

Well, at last, the federal government has come to the rescue – sort of. The Center for Medicare & Medicaid Services (CMS) now requires hospitals to post all their prices in a machine-readable file (for the highly computer literate) and a selection of “shoppable services” (essentially, non-urgent procedures) in a consumer-friendly format (for the rest of us).

We compared the CMS ideal and the Delaware reality by pricing three procedures that may be familiar to readers: a colonoscopy, vaginal delivery of a baby without complications and a simple cardioversion. The third is an electric shock administered externally to the chest while under anesthesia to restore a regular heartbeat to a patient with a heart flutter.

The Ideal

              The CMS requires that a common price list of 70 shoppable services (or as many as the hospital provides) to be posted. An additional 230 or more, totaling 300 services, chosen by the hospital, must also be posted, reflecting the most common procedures done at the hospital based on local demographics or hospital specialization. Of the three procedures we considered, two (colonoscopy and vaginal delivery) are on the required list and one (cardioversion) is not.

The format can be either a cost estimator tool or a ‘flat file’ with links prominently displayed on the hospital website. The hospital is not allowed to require you to set up an account, use a password or any personal identifying information to access the list.  Four prices should be displayed: the cash price, the payer-specific price, and the minimum and maximum prices negotiated by the hospital with all its payers. ‘Payer’ usually means a health insurance company. Medicare/Medicaid prices are not required to be displayed because they are publicly available elsewhere, although CMS encourages these to be included.

Hospitals must identify and include ancillary services, such as laboratory tests, radiology, drugs, anesthesia services, etc., it provides as part of a shoppable service. Beware: hospitals differ in the ancillary services that are included. Moreover, their negotiated contracts with payers could differ in ancillary services that are included. Though not required, CMS ‘strongly encourage(s) and recommend(s), …(hospitals) indicate any additional ancillary services that are not provided by the hospital but that (hospitals) know the patient is likely to experience as part of the primary shoppable service, and to indicate that such services may be billed separately by other entities involved in the patient’s care’ that are not employed by the hospital.

CMS helpfully suggests a format for each situation, as depicted below.

If all ancillary services are included in the contract negotiated with Health Insurer X:

If ancillary services are included but negotiated separately by the hospital with Health Insurer Y, then:

If only some ancillary services are included by hospital in its contract with Health Insurer X:

While a health insurance plan member may be able to request an estimate of total cost from the insurer, the self-paying patient must be savvy enough to request the cost of all services: those provided by the hospital and those billed separately. The latter requires the patient get the contact information of those the hospital has contracted with (e.g., pathology and/or anesthesia practices, etc.).

The Reality

The hospitals surveyed here are: Christiana Care, Bay Health, Beebe, Chester County-Penn Medicine, and UM Upper Chesapeake Medical Center.

The good news is that all have links to a cost estimator tool on their main websites. However, they are mostly buried under obscure headings, sometimes at the top or bottom of the page in small print, e.g., Billing and Financial Information (Bayhealth) or Resources (Beebe). Christiana Care buries it the deepest, and one has to know whether a colonoscopy or vaginal delivery is an in-patient or out-patient, medical or surgical service. Upper Chesapeake’s link for ‘guests’ is inoperative.

It is important in most cases to have the billing (CPT or DRG) code rather than the procedure name. For example, there are several types of colonoscopies. Most cost estimator tools include statements that certain services may be billed separately, such as physician and anesthesia, but are not specific by procedure. No name or contact information for these outside services is listed, despite being contracted by the hospital, except for Bayhealth in an online brochure.

Few follow CMS’s suggested formats. Below the colonoscopy (CPT 45378) estimate for a self-paying patient is shown for our sample hospitals.

Christiana Care:

It appears that all ancillary services are included in the self-pay price but this is not clear. The cost of vaginal delivery (CPT 59400) without ancillary services is $4,430 and no estimate is provided for a cardioversion (CPT 92960)

Bayhealth

It is not clear what ancillary services are included from this estimator tool. No estimate was available for vaginal delivery and cardioversion costs $1737.

Beebe

No estimate was available for vaginal delivery and cardioversion costs $652. Again, it is not clear what specific ancillary services are included for each procedure from this estimator tool.

Chester County Hospital (Penn Medicine)

Penn Medicine provides estimates specific to each location (here Chester County Hospital) whereas Christiana Care and Bayhealth do not. However, it was easier to find the flat file than the estimator tool. Notice that the prices appear to be far apart for the cash-paying patient from each source. No estimate was available for vaginal delivery and cardioversion costs $688. The latter estimate was available in the ‘flat file’ but not the estimator. There were three entries under cardioversion (CPT 96920) with prices ranging from $1264 to $4477.

UM Upper Chesapeake Medical Center The cost estimator tool is unavailable to non-patients. Only the rather useless chargemaster list is accessible as a machine-readable file.

Conclusions

The CMS has made a valuable advance in health care price transparency. However, our local industry is dragging its feet in obeying the spirit as well as the letter of the law. All the hospitals here list phone numbers for patients to get more precise estimates, however this does not fulfill the intent of the regulation. The ideal is for information to be conveniently available for comparison shopping. Other industries with multiple and complex inputs, e.g., construction, education, etc. have achieved this. The health care industry can too.

Dr. Stacie Beck is an Associate Professor of Economics at the University of Delaware. She has a BS in economics from Boston College and a PhD in economics from the University of Pennsylvania. She has been published in many peer review journals and currently serves as an editorial board member of Eastern Economics Journal.

 

 

 

Health Care Commission: Lack of Independence from the Governor

By: Alexandre Kittila

The Delaware Healthcare Commission (DHCC) is the executive authority on healthcare in the state of Delaware. When it was established in 1990, the founding legislation stated that the Commission shall “serve as the policy body to advise the Governor and General Assembly.” To meet the DHCC’s important duties, members are “to collaborate with other state agencies and the private sector, to initiate pilots, and to recommend policy changes to the Governor and General Assembly.”

A substantial addition to that mission occurred in 2022, when the legislature granted additional authority to the Commission to “be responsible for establishing and monitoring the State of Delaware Health Care Spending.” Giving the Commission direct control over establishing pilot programs and affecting spending, grants what was an advisory board much more influence than the term “commission” would lead you to believe.

A real concern is not the establishment of the DHCC, nor its duties, but, rather, the fashion in which its board members are selected, and who is selected to serve. An executive commission separate from the branches of the Delaware government to establish pilots and spending could encourage decisive action and less entanglement in the bureaucracy; in its current state, however, it simply works as an extension of the Governor’s power over the healthcare industry in Delaware. Separation of the commission from the influence of bureaucrats in our government is crucial to ensure its proper function and fidelity to the goal of meeting the health care needs of Delawareans.

There are eleven members of the Commission. They are: the Insurance Commissioner, a representative of the Speaker of the House, a representative of the President Pro Tempe, the Secretary of Finance, the Secretary of Health and Social Services, the Secretary of Services for Children and Youths, and five individuals who are chosen by the Governor. Therefore, fully eight out of the eleven members are directly selected by the Governor. This compromises the independence of the Commission and can lead to the Commission becoming simply a rubber stamp for the Governor’s preferred policies and spending priorities.

If we truly want the best outcome for Delaware citizens who seek health care, the Commission should be a think tank to consider how we can best provide timely access and quality care at a fair and reasonable price. That is, the best way to spend the taxpayers’ money.

There is potential for independence of the Commission from the Governor in a provision of the Delaware Code that requires that “no more than 3 of the Commission members appointed by the Governor shall be of the same political party.” Of course, in Delaware, for nearly a decade now, the leadership of the House and Senate, and the Insurance Commissioner, have all be of the same political party as the Governor, And, given that the three cabinet members are appointed by the Governor, they will likely be of the same political party.  So, while the law may seem to create balance, consider that, even adhering to this requirement, the balance of the Commission could be 9-2. And, even if the Speaker of the House, the President Pro Tempe of the Senate, and the Insurance Commissioner are all of the opposite party of the Governor, and two of the five individuals selected by the Governor are of the opposite party, the balance would still be a majority of the Governor’s party, 6-5.

So, has the government followed their own laws? Currently, the cabinet members and government officials holding the designated positions are all members of the Democrat Party, and 4 of the 5 persons named by the Governor are Democrats, the only exception being the former Democrat mayor of Lewes, Theodore Becker, who is now registered as a “NO PARTY.” There clearly is no balance.

Additionally, many members of the Commission have a vested interest in the outcome of the decisions the Commission makes because they are affiliated with a health care provider or service in Delaware.  The Commission is mandated, in 16 Del. C.  §9903(e)(3) to act “in such a way that fosters creative thinking and problem solving.” A commission in which a nearly singular policy affiliation reigns does not “foster creative thinking”, but rather becomes an echo chamber effect, not receiving or considering competing or alternative viewpoints.

An executive authority on healthcare is not inherently a bad idea but the fact that nearly every member serves, for all practical purposes, at the pleasure of the Governor makes it dangerous. It allows the Governor and the government a more heavy hand into places it ought to be restrained. The Commission needs to be nonpartisan and independent, and motivated by the best interests in meeting the health care needs of our citizens.

So, what would be the best solution?  Perhaps we should make the five Commission members currently chosen by the Governor, selected and voted on by the General Assembly. Perhaps adopt an ethics rule to eliminate self-interest. Maybe allow a single selection by the Governor, other than his cabinet members, similar to the ones for the President Pro Tempe and the Speaker of the House.

All of those ideas will improve the Commission’s ability to meet the statutory mandate. But the most important takeaway is that since the DHCC is meant to be for the people, it should also be by the people. Establishing the DHCC in a more balanced structure will not only lead to more ideas, but also better ideas, hopefully leading to better healthcare for everyone in the state of Delaware.

.Alexandre Kittila is Senior at Tower Hill School. Kittila served as an intern for A Better Delaware in the summer of 2023.

Consolidation of Healthcare Services and Financing in Delaware: The Inherent Risk of Monopoly

By: Christopher Casscells, M.D.

Delaware is a small state, both by size and population. As our elderly population grows and the state’s economy shrinks, a larger percentage of our economy will be dedicated to healthcare because, necessarily, older people require more healthcare. None of this is disputable.

Delaware residents have limited choice of providers, especially of hospital systems: only Bayhealth, Beebe, Christiana and St. Francis are options. Christiana is dominant, and the others generally co-exist. Delaware’s certificate of need laws discourage further outside competition from entering the marketplace.

A predictable result of the implementation of the Affordable Care Act (Obamacare) is the trend of consolidation of healthcare providers, nationally. There are fewer and fewer independent practices, as they are bought up or driven out by the hospitals. Again, policy drives that result, as the hospitals are paid a larger premium by Medicare, Medicaid and private insurers for exactly the same service provided by an independent practitioner. So, the trend is toward a day when all healthcare is delivered by hospitals and their employees.

The issue looms large for Delaware patients.  In most places, patients still have choices between competing large systems, and oversight is in place to screen for price-setting collusion between these entities.

Delaware’s size, both geographically and in population, limits those “remedies”. There is very limited choice of hospital and provider, especially, regionally, in some of our rural areas.

Additionally, in Delaware, there is limited choice of health insurers. The state is dominated by Highmark Blue Cross Blue Shield (BCBS), a Pennsylvania company that acquired BCBSDelaware over a decade ago. Highmark is effectively the only health insurance company in Delaware. Highmark manages portions of Delaware’s sizable Medicaid and Medicare patient population in addition to being the sole health insurance contractor for the State of Delaware, its employees, and retirees. The State is the largest employer in Delaware. Several other entities have tried to make a go of it, including Aetna, Principal, Coventry, Cigna, Care First, US Healthcare and United Healthcare, to name a few, but none has been able to compete. There should be competition, however, Delaware law requires a minimum of 3 choices of health insurer, but the Delaware Insurance Commissioner simply ignores the mandate.

And, even with multiple hospitals, our choices are shrinking. Increasingly, there are “collaborations” between Highmark and Christiana Care, Beebe and BayHealth. Delaware policy leaders need to take note. In Pennsylvania, Highmark ‘collaborated’ with the Allegheny Hospital System in PA before taking over and creating a vertical monopoly which successfully competes against other insurers, hospital systems and combinations. While a system like Pittsburgh’s UPMC in Western Pennsylvania might be able to compete with that large a competitor, Delaware has no other competitive choices. If left unchallenged, a vertical monopoly would worsen an already less than ideal situation.

There are those that argue that such a collaboration would lead to economies of scale with better access, lower cost, and higher quality. But those metrics have been the goal of the Delaware Healthcare Commission for well over a decade, and the only result has been the steady worsening of all three metrics. According to Forbes Advisor, Nov. 2022, Delaware already has the 8th highest cost per capita of healthcare in the nation. Our wait times in Emergency Departments are dismal, and securing an appointment with a provider is increasingly difficult. Those advocates need to be asked to account for these results, in spite of the increasing consolidation of the healthcare marketplace.

Regardless of the intentions of those responsible for the oversight of the state’s health policy, the Department of Health and Human Services, the Insurance Commissioner, and the Healthcare Commission, they must be more vigilant to protect the options patients have for care.

History has demonstrated consistently that monopolies in a service industry are ill-advised. Delaware policy makers need to prevent further consolidation, bring more insurance options to Delaware citizens, and prevent a vertical monopoly that will adversely affect precisely those goals our policy makers are seeking to achieve.

Dr. Christopher Casscells, MD, Policy Director, Center for Health Policy, Caesar Rodney Institute. Dr. Casscells was one of Delaware’s leading Board-Certified Orthopedic Surgeons. He graduated from the University of Virginia School of Medicine and did his residency at Yale-New Haven Hospital. After a distinguished 30-year medical career, Dr. Casscells retired from practicing in January 2020.

Medicare Advantage Plans: Are We Doing Our Best for Our Seniors?

By: Glenn Brown, DPT, PT, MMSc, ATC

Medicare provides health insurance coverage for 65 million people in the United States.  But Medicare has changed, and today, over 30 million seniors, (nearly 51%) are covered under a Medicare Advantage Plan. The number of Special Needs Plans available has doubled since 2018.  Even government retirement packages are looking at Medicare Advantage as an alternative. It is well known that in Delaware, state retirees are facing a considerable battle over being forced into a Medicare Advantage Plan as opposed to the promised benefits of traditional Medicare and supplemental insurance coverage.

Given the increasing popularity of Medicare Advantage, we must consider how and if this transition in the Medicare market is beneficial to both patients and providers.  Significantly, we must consider the impact of the rising percentage of the Medicare market share captured by for-profit companies versus nonprofit, or government plans.  Currently, for-profit insurers account for 72.9% of all Medicare Advantage plans, with an annual growth rate of over 11%.

Medicare Advantage plans purport additional benefits and coverages for subscribers compared to traditional Medicare. These plans boast lower prices for prescription drugs and lower premiums with expanded coverage options such as vision, fitness, telehealth, hearing, and dental benefits. Despite these additional bells and whistles, beneficiaries in Medicare Advantage and traditional Medicare reported similar rates of satisfaction with their care. Regarding affordability, a slightly smaller number of beneficiaries in traditional Medicare with supplemental coverage than Medicare Advantage enrollees reported having cost-related problems.

However, many Medicare Advantage plans create cost and convenience issues for subscribers. These include limited network coverage, high out-of-network costs, prescription drug formularies that do not include their needed medications, preauthorization, and utilization management processes that can lead to delays in care and administrative burdens for both patients and healthcare providers. In my practice, Highmark Medicare Advantage subscribers encountered an unexpected increase in out-of-network copayments. These copayments, which previously were 20% co-insurance payments, now range from $35-$50 per visit depending on the plan selected by the subscribers.

While there are pitfalls for subscribers in Medicare Advantage, the challenges it creates for providers are so great that many providers are unwilling to accept their fee schedules and billing/reimbursement policies. Large provider groups are leaving the Medicare Advantage market because of low reimbursement and prior authorization hassles.  Providers also experience much greater complexity in the billing and collection process which involves greater resources allocated to obtain payment for services. They expose themselves to greater financial risk because of the increase in complexity and the risk of unpredictable plan changes, including reimbursement rates, utilization management programs, and other billing and collections process burdens.

Medicare Advantage plans give the perception of being an appealing alternative to traditional Medicare.  These plans promise additional benefits and cost savings, but they also come with a range of disadvantages. These disadvantages include limited network coverage, higher out-of-pocket costs, geographic and prescription drug restrictions, and the potential for plan changes and disruptions.  Additionally, a growing number of Medicare subscribers are covered by “for-profit” companies.  Recent evidence indicates that “for-profit” consolidated companies result in elevated physician charges and costs. Prudent and forward-thinking decision-making must occur now. We must drive more of these plans back to traditional Medicare or at least force them to operate in a manner similar to traditional Medicare.  Failure to do so will result in these profit-driven companies creating a system that transfers greater costs to those on a fixed income and greater limitation of provider access for a population that has notably more serious conditions and/or multiple medical issues. We owe it to our seniors to create a system that properly cares for them versus a system that sees only the GOLD in the “Golden Years”.

Glenn Brown DPT, MMSc, ATC, SCS is the co-owner of CORE Physical Therapy in Dover.  Dr. Brown has been in clinical practice for 38 years as a physical therapist and athletic trainer and has been a Sports Certified Specialist since 1993.  Dr. Brown currently serves as the Legislative Chair of the Delaware Chapter of the American Physical Therapy Association.

 

Are Certificate of Need Laws Relevant in Delaware’s Healthcare Marketplace?

By: Jane Brady, Chair, A Better Delaware

You may have never heard of a Certificate of Need (CON) if you do not work in healthcare in Delaware. Yet, these requirements within CON regulations can affect your access to, and the cost and quality of, patient care you receive.

The law adopting a Certificate of Need requirement, now called a Certificate of Public Review in Delaware, was intended to improve access, costs, and the quality of care for patients, generally in hospitals and nursing homes. The law has failed to achieve those goals.

A Certificate of Need is a regulation that requires healthcare providers to get permission from the state before adding or expanding the type of services they offer or before acquiring expensive equipment, building new facilities, or expanding existing ones. Upon passage of an Act of Congress, certificate of need laws were passed by 49 of the 50 states in the early 1980s.

Over the intervening years, research has shown that the goals the laws sought to achieve were not reached, and many states now have repealed the certificate of need statutes. In fact, even Congress repealed the law that compelled states to adopt a certificate of need law – in 1986!! Yet, like many other states, Delaware still has the requirement in place. It should be repealed.

There have been studies of the impact of certificate of need laws. The Kaiser Family Foundation did a study that found that states that have certificate of need requirements had 11% higher healthcare costs than states that did not have it. An additional study by George Mason University found that there were 30% fewer hospitals per 100,000 residents in states that had a certificate of need requirement. Additionally, rural areas, with smaller, localized populations, were more poorly served.

Certificate of need laws are structurally flawed. They limit competition. They allow the state to pick “winners” and “losers,” with the existing facilities having the political connections and favor to “win.” The certificate of need restricts who can participate in competing for your healthcare choices and as a result, there is no incentive to be innovative or even cost-conscious when they appeal to you as you make your health care choices. When businesses compete for you to choose their services, they will try and find the most cost-effective way to give you a product that you want, when you want it. Without competition, there is no need to be responsive to your demand for a specific service or to be more cost-effective. You get what they have decided to provide at the price they decide to charge.

Importantly, access includes timeliness. Recently, CMS, the company that manages Medicare and Medicaid nationally, conducted a study of emergency room wait times in all 50 states and the District of Columbia. Delaware ranked 47 out of 51, with an average wait time for emergency room services of over three hours.

It is good governance to eliminate certificate of need laws. Since the laws were passed, the government has taken a much larger role in providing health care.

In an attempt to assure continuing use of these competition – limiting laws, advocates claim they are necessary for more effective care for indigent patients. It was not one of the original stated goals of the legislation but has been used to try and justify retaining these laws on the books. However, if you wish to help the indigent access health care, and most would accept that is a desirable social goal, the best course is to require the expenditure of public funds for that purpose to be transparent and accountable. Currently, the way reimbursements are being made, the hospitals effectively become a smokescreen, and the public cannot discern easily where and how the money is being spent.

The absurd argument some of those who favor using certificate of need laws to help fund indigent services argue is that if you restrict the amount of healthcare available, the healthcare providers who are lucky enough to be in the market can charge higher rates to the people with private insurance, and that will subsidize the care for poor patients without any insurance.  Maybe a day long ago when providers actually decided what health care would cost.

Now, Medicare and Medicaid have changed the economic environment in which healthcare is provided and costs are highly regulated. In truth, Certificate of Need laws are now essentially outdated for any purpose. Delaware should repeal the laws providing for a Certificate of Public Review, our equivalent of a Certificate of Need, and allow the health care providers of our state compete fairly to provide the public, timely, the quality health care they need and want.

Jane Bady serves as Chair of A Better Delaware.She previously served as Attorney General of Delaware and as a Judge of the Delaware Superior Court.

 

Healthcare Challenges Should be a Priority

By: Dr. Greg DeMeo, D.O., Advisory Board Member, A Better Delaware

For more than 20 years, the American Medical Association (AMA) has warned of a pending physician shortage. Many practitioners suggested this was nothing more than a marketing ploy to drive membership. Sadly, the AMA was correct, and there are shortages of medical doctors throughout the country, in some areas, severe. The occurrence of the pandemic has exacerbated and likely accelerated the problem. Access to care for both insured and uninsured individuals has become quite difficult.

Delaware, like many states, has varying access to health care, depending on your location. Located in New Castle County, ChristianaCare, the largest health care system in the state, enjoys a favorable national reputation. Kent County is much more rural, but also enjoys a large medical system, BayHealth. Sussex County has challenging demographics that, while slowly changing, are mostly Medicare and Medicaid insured populations. That County’s healthcare needs are supported by Bebee Medical Center.

In all regions, however, and in all specialties, physicians are in short supply. Most critically affected are Primary Care Medicine, Women’s Health, and medical specialties such as Cardiology and Neurology.

Women’s Health Care has always been a medical specialty in which Delaware physicians have practiced at a very high level. ChristianaCare has always enjoyed a strong residency training program in Women’s health and graduates 7 residents per year in the specialty. However, on average, about 50% of those graduates go on to further train in sub-specialty practice and leave the area after graduation.

Even prior to the pandemic, it was difficult to secure an appointment in a reasonable period of time for well women visits. New patients often had to wait 2 or 3 months for an appointment, although pregnant women and patients with perceived gynecologic problems were seen in a more timely manner.

The pandemic truly took a toll on medicine. Physicians in all specialty areas have retired or left the practice of medicine in numbers that have never been seen before. Consider that, as well as the natural aging of the workforce, and the prediction of the AMA is simply coming to fruition. This has left healthcare for women in Delaware at a crisis level. Presently wait times for well women visits can easily approach a year if you are lucky enough to get an appointment. Many women need to seek care in Emergency Rooms and Urgent Care Centers. This reduction in the work force and the demand, that simply exceeds what medical practitioners can meet, have contributed to the access to care issue.

But there are other issues that have led to this crisis. Delaware has limited competition in certain areas of business directly related to healthcare, such as insurance. This limited competition directly correlates to the increased cost of care, as well as limited access.

As a practical matter, all healthcare is paid for by insurance, whether commercial or government funded. Medicare, which is a federally funded and administered program, essentially establishes reimbursement rates for Medicaid and commercial insurance. Unfortunately, physician reimbursement rates under Medicare have increased by just 8% over the past 22 years, while hospital rates as well as rates for skilled nursing facilities have increased by over 60% in the same time frame.

Delaware, with limited options and with Highmark as its largest commercial insurer, provides little opportunity for physicians to negotiate. In some instances, Highmark pays consistent with Medicare and in almost all cases, Highmark tends to reimburse towards the lower end of the scale.

While New Castle County is fortunate to enjoy ChristianaCare as its major hospital system, this benefit comes with a double-edged sword. ChristianaCare, with its vast scope, power, and wealth, clearly dominates the healthcare marketplace for the entire state and has the leverage to benefit from “preferred” reimbursement rates under the state Medicaid system – to the detriment of private practice physicians in our communities. In addition, ChristianaCare’s size enables it to control competition regarding the development of new ambulatory surgical centers as well as free standing specialty hospitals. Finally, Highmark and ChristianaCare have initiated numerous joint ventures, which allows them to disqualify community-based physicians in favor of hospital employed physicians. What does disqualify mean?

As a result of the disparity in reimbursement increases, physicians are unable to compete with the hospital system for new hires. Over the past 10 years, hospitals have enjoyed the increased control and revenue stream that employing additional physicians brings. In addition, these physicians are highly likely to refer patients to hospital- owned facilities for any additional treatment, which further closes the loop on fair competition. In our community, ChristianaCare has aggressively gone into the marketplace and offered very high starting salaries to recent graduates. This business model even further reduces access. Clear data exists that shows hospital employed physicians see many fewer patients per day than private practice physicians.

All in all, the unfair reimbursement practices supported by government policies are slowly, but surely, decreasing access to care at all insurance levels. Hospitals take advantage of their size and scope to further benefit from this broken system. Legislators need to make better and informed decisions about competition, fair reimbursement, and referral for profit in order to give everyone who needs a doctor, better access to health care and at a reasonable cost.

Dr. DeMeo is the medical director of Christiana Care’s Labor and Delivery Department and represents The American College of Obstetricians and Gynecologists at the national level where he focuses on issues related to Medicare reimbursement. 

 

 

 

The Discipline Crisis in Schools Has Serious Consequences

By Beth Conaway, Advisory Board Member, A Better Delaware

Public schools ensure that all students have access to a free education. As a result, they are the cornerstone of America’s future. However, our public schools are facing unprecedented challenges with teacher shortages, academic achievement, and negative school environments. Current school discipline practices play a huge role in these challenges.

Prior to Covid, schools began introducing administrators and teachers to the concept of restorative practices. Restorative practices attempt to strengthen relationships between teachers/students and student/student. Popular examples of restorative processes include affective statements (telling a person how you feel) community-building circles, small impromptu conferencing, and setting classroom agreements or norms. (Panorama Eduction Services). Teachers and administrators are trained that for students impacted by trauma and toxic stress, consequences that are not exclusionary or disciplinary in the traditional manner can be more effective in changing the behavior. Trauma based discipline states that the response or intervention for a misbehaving student needs to focus on the specific student’s needs and base the consequence on an incrementally more punitive rubric or leveled response to behaviors. The idea is to seek out the intervention that will change the behavior, not simply automatically assigning a specific response from a predetermined menu.

However, the idea of consequences and disciplinary actions changed along with the introduction of restorative practices. For example, a school may determine that a student is acting out to get attention, so rather than remove the student” to give them what he/she wants” the principal will keep the child in the classroom with or without additional adult support. In a second scenario, when a student is violent or extremely disruptive, an administrator is often brought into the classroom while the teacher takes the rest of the class out of the room. A third common scenario is that the disruptive student is removed for a short time with the administrator to participate in restorative practices and then is immediately brought back to the classroom.

There are several negative results of these actions when done without consequences:

  1. Loss of instructional time for all students leading to poorer achievement.
  2. Stress and anxiety for teachers leading to burnout and lack of teacher retention.
  3. Lack of instructional support from administrators to teachers as they deal with misbehavior rather than supporting the teachers in their instruction.
  4. An increased lack of respect from students to teachers and other students.

Students dealing with trauma and mental health needs are real. However, without disciplinary actions that support teachers and the other students in the classroom, the joy and excitement about teaching and learning will continue to erode. What began as regular instances of students cussing out teachers or acting in deliberate insubordination has escalated to a scenario where teachers are just trying to put out “bigger fires” or prevent them from occurring rather than being able to teach.

As a result, alternative classrooms, environments, and additional mental health supports need to be available to schools to give all students the supportive learning environment essential to their success.

Beth Conaway is a former teacher, who served for 8 years as Principal of the Morris Early Childhood Center and then as Principal of Milton Elementary School for 5 years. She retired after 31 years in the Delaware public school system. She currently teaches graduate courses at the University of the Cumberlands and volunteers in the Indian River School District.

 

Education Funding in Delaware Is Working

By John Marinucci, Advisory Board Member, A Better Delaware

It has become quite fashionable for education advocates and stakeholders to argue that the system of education funding in Delaware is broken. Critics claim that Delaware’s education funding system is convoluted, complex and should be discarded in favor of some other funding mechanism.  But, before we pass judgement and seek to scrap the system, it’s important to establish a foundational understanding of the Delaware Education Unit Funding structure.

Delaware’s Unit Funding structure is entirely formula driven.  Funds are appropriated to school districts and schools based on the number of students enrolled, with three types of funds being received: State funds, Local funds; and Federal funds.  Prior to Federal Covid Relief funds, the level of Federal support was relatively stable and constant, and made up approximately 8% of the funds received by districts.  This remaining, primary funding sources that make up approximately 92% of education funding are State and Local funds.  State funds provided to school districts are appropriated based on the Units Funding system through three funding divisions – aptly named Division I, Division II, and Division III.

Division I funding represents State funds allocated to school districts to fund teacher, administrator, student support personnel, and administrative support salaries.  A formula in Delaware law establishes the number of students that constitute a single funding unit.  That same law establishes the number of units that trigger the “earning” of various school and district level administrators as well as student support personnel.  The larger the number of students enrolled, the more units “earned”, and the more administrators and support personnel “earned” by the formula.  The Delaware statutes also contain pay scales for the various classes of employees that establish the State contribution to that individuals’ ultimate salary. The scale accounts for the incremental increases a teacher can earn based on years of experience and level of education. An individual’s final salary may also include a local salary supplement determined by the board of the local school district.

The Division I funding structure is intended to reward higher levels of education and greater years of experience, giving districts the incentive to hire employees with the highest level of education and the most experience.

Teachers with more experience and seniority may seek a transfer for personal, or other reasons, and often seek transfers into positions and to schools that they perceive as easier or less stressful.  This leaves a vacant position in what can be considered a more difficult position or school, to be filled by a less senior educator, who, of course, is paid less, based on the scale.  This leads to the conclusion that employees in what are perceived to be less desirable schools or positions are paid less than employees in the more desirable positions or schools, which in fact, is true.  To attract and retain the senior, most experienced employees to the most challenging positions and schools, significant incentives must be made available.

Division II funding is allocated to fund the State’s share of all the “stuff” it takes to run an education system, books, curricula, supplies, electricity, heating fuels, etc.  Division II funding is allocated based on the total units “earned” by a school district, based on the assumption, the more students, the more “stuff” is needed.  Division II funds are not intended to cover all of the other education costs, however. Districts are expected to use Local Funds to supplement State Division II funds.

Division III funding is what is known as “equalization” funding.  Division III recognizes that some neighborhoods have greater property wealth and therefore a greater ability to generate local property taxes, the primary source of local funding, and seeks to balance the inequities inherent with the great variations in local property taxes.  Districts with lower property values receive a greater amount per unit than districts with higher property values.

Local Funds make up the third source of funding.  Local funds are the funds collected by school districts generated through local property taxes and are intended to supplement the State and Federal funds.  Each district establishes a school property tax to be assessed on properties within its district boundaries, which must be approved by a referendum vote of the citizens within the district.  The education system in Delaware is established on the fundamental principle of “Local Control” and referenda driven local property tax authority represents the hallmark of that Local Control.

This funding structure provides budget certainty to school districts.  Districts can estimate the funds to be allocated based on their student enrollment, which enables them to better budget and manage their finances.

There is one shortcoming of the education funding structure. Currently, the State has no regular unit-driven funding for technology.  Imagine a school with no computers, no smartboards, no websites, no on-line testing or on-line curricula.  Libraries with no on-line access to perform research.  It’s impossible to conceive of a life without technology in this day and age, yet the State provides ZERO unit-driven funding to support the technology needs of districts, schools and students.  State technology funding that has been provided has been in fits and starts and woefully insufficient.

A word of caution – State funds have historically constituted the majority of funds available to school districts. However, recently the trend has been to shift the responsibility for education funding in Delaware from the State to the districts’ local property taxing authority.  Specifically, in State Fiscal Year 2007, the ratio of funding of Delaware schools was 64% State Funds, 28% Local Funds and 8% Federal Funds.  Ten years later in Fiscal Year 2017 that ratio was 59% State Funds, 33% Local Funds and 8% Federal Funds.  A full 5% of the total funding for the respective year has shifted from the State to the districts’ local property taxing authority.  This is alarming since State funding is a much more equitable form of education funding than local funds because it doesn’t matter “what side of the tracks” the kids come from, the funds for their education will be the same.  Local property taxes are very much driven by the relative property wealth of the community from which those taxes are assessed and collected.  And despite equalization funding, intended to lessen those inequities, in fact, some remain.

In conclusion, while the State of Delaware’s Unit Funding structure may be old and may not include vital aspects that were not a consideration when it was first conceived, such as technology funding, the State’s Unit funding structure is clearly an inherently more equitable funding source than local property taxes.  Mind you, local property taxes and local financial participation in education funding play an important role in the complete funding structure, after all, communities must have “skin in the game”, but it is short-sighted to dispose of a funding structure simply because it’s “old”.  The Unit Funding structure in Delaware works.  The Unit Funding structure in Delaware is inherently equitable.  While it does lack the requirement of a regular, periodic review to assure it meets the funding needs of the current education necessities and obligations, the Delaware Unit Funding structure is not fundamentally broken.

John is the former Director of Operations for the Milford School District, Director of Finance for the DOE, and Executive Director of the Delaware School Boards Association.

 

 

 

Expanded Training is Key to Protecting Students

By Dennis Godek, Advisory Board Member, A Better Delaware

As the 2023 school year begins, the safety of our children in a changing world is at the forefront of our thoughts. School shootings have become too frequent, and we must be ever vigilant to try to prevent these incidents and be ready to respond quickly and effectively when they occur. Preventing school attacks requires direct action, and sometimes, the courage to challenge the status quo. Many tend to criticize school and other officials when it becomes evident, after an attack, that an attacker displayed signs of disturbing behavior that may have predicted violence. These same critics often decry the “abuse of rights” when officials investigate and take definitive steps to determine a person’s propensity for violence. We cannot have it both ways. Law enforcement, education leaders and social workers, acting in good faith and with the resources they need, must use the utmost discretion in this pursuit, but the safety of all students must override a hesitancy to act.

The Delaware education system has made improvements in “safety from attack” for all students. Security policies have been reviewed and amended, many schools now have either school resource officers, armed constables, or both, and schools are required to have plans for action in the event of an attack.

Law enforcement in Delaware have been trained to the national standard of tactical response to active assailant incidents for almost 10 years. Law Enforcement and Fire/EMS, statewide, have been training together, again to national standards, for the integrated response to active attacks. That integrated training incorporates the provision of trauma care to victims in as short a time as possible both during, and immediately after, an attack. Along with specific medical treatment, this response has saved many lives after an attack. These training efforts, and the commitment of the agencies involved, are part of an effort to ensure that the horror of an attack like that which occurred in Uvalde, Texas, will not occur in Delaware.

Lessons learned from reviews of attacks across the country are constantly utilized to update response policies. Regardless of the number of victims, the location of the incident, or the number or armament of the offenders, these are complex incidents which require coordinated and precise response by public safety agencies, augmented by pre-planned actions by school officials. The Delaware Emergency Management Agency oversees the Delaware Comprehensive School Safety Program (CSSP) which is responsible for enhancing school security in all public and charter schools through maintenance and development of comprehensive safety and preparedness plans. The CSSP ensures that mandatory drills and exercises are conducted in all schools on an annual basis and works with school administrators on annual updates to school emergency plans. Any new school construction must include specific target hardening. Secure vestibules, hardened glass and windows in certain areas, improved door security, and panic buttons in office areas are some of the requirements.

While difficult for everyone involved, it must be emphasized that parents and family of students are not to respond to the school when learning of an attack. Law enforcement MUST protect the scene from the introduction of more potential victims, the escape of suspects, and provide for the free movement of emergency vehicles. Technology can be utilized to notify parents and family of a reunification location which is away from the scene and will facilitate the most efficient means of reuniting family and students.

The level of accountability for compliance with drills, exercises, plans, and physical plant improvements, must remain high and require vigilance by overseers and diligence by stakeholders. The law enforcement, fire and EMS community of Delaware is committed to do whatever it takes to protect our students.

“It is not enough that we do our best; sometimes we have to do what is required.” – Winston Churchill

Dennis Godek previously served as a New Castle County Police Officer and as Assistant Chief of Career Services at the Christiana Fire Company. He currently serves as Chair of the New Castle County Fire and Ambulance Advisory Board, which is the liaison between county government and the Fire/EMS service in New Castle County. Godek is a founding member of the Delaware Statewide Active Assailant Committee, which includes Law Enforcement and Fire/EMS agencies from across the state. Dennis Godek is a member of the Advisory Board of A Better Delaware.