Medicare to Tie Physician Pay to Quality, Cost

April 24th, 2012

Approximately 20,000 physicians in four Midwest states recently had a sneak peak at their financial future. According to Kaiser Health News, they were e-mailed links to Medicare reports detailing the amount their patients cost on average as well as the quality of the care they provided.  Additionally, the reports showed how Medicare spending on each doctor’s patients compared to their peers in Kansas, Iowa, Missouri and Nebraska.

The so-called “resource use” reports, which Medicare eventually plans to distribute to doctors nationally, are one of the most visible phases of the government’s efforts to enact a complex and delicate although little-known proviso of the Patient Protection and Affordable Care Act (ACA): paying more to doctors who provide quality care at lower cost to Medicare, and cutting payments to physicians who add to Medicare’s costs without improved results.

Requiring providers to pay closer attention to cost and quality is seen as crucial if the nation is to succeed at controlling its healthcare spending — currently more than $2.5 trillion a year.  It’s also vital to Medicare’s solvency.  Efforts are already underway to transform the way Medicare pays hospitals, physicians and other providers who agree to work together in accountable care organizations.  This fall, Medicare – which covers 47 million seniors and disabled people — will fine-tune hospital reimbursements based on quality of care.  It plans to take cost into account as early as next year.

But applying these same precepts to doctors is much more difficult, experts agree. Doctors see far fewer patients than do hospitals, so making statistically accurate assessments of doctors’ care is much harder. Comparing specialists is tricky, since some focus on particular kinds of patients that tend to be more costly.  Properly assessing how a physician impacts costs must include not just the specific services provided, but also care other providers may give.

“It may be the most difficult measurement challenge in the whole world of value-based purchasing,” said Dr. Donald Berwick, the former administrator of the federal Centers for Medicare and Medicaid Services (CMS).  “We do have to be cautious in this case.  It could lead to levels of gaming and misunderstanding and incorrect signals to physicians that might not be best for everyone.”

Dr. Michael Kitchell, a neurologist and chairman of the McFarland Clinic in Ames, IA, predicted that the Medicare reports “will be a huge surprise to almost every physician.”  That’s because the calculations of how much those doctors’ patients cost Medicare not only include the services of the individual doctor but of all the physicians who provided any treatment to the patient.  Kitchell said his own patients typically saw 13 other physicians.  “You’re a victim or a beneficiary of your medical neighborhood,” Kitchell said.  “If the primary-care doctors are doing the preventative screening tests, you’ll get credit for that, but if you’re in a community where the community doctors are doing a poor job, you’re going to look bad.”

Medicare officials are attempting to improve the way they measure physicians as they follow the ACA’s directive to phase in the new payment system, called a Physician Value-Based Payment Modifier, which is scheduled to begin in 2015.  At first, it will apply solely to physician groups and some specialists selected by the government; by 2017, the payment change is intended to apply to most if not all doctors.  The assessment “is a very important change we’re putting into place, one where we’re going to need a lot of feedback and deliberation,” said Jonathan Blum, CMS’s deputy administrator. “We’re not blind to the challenges that are coming toward us.”  Although the program is still being worked out, it will become reality for many doctors in January, because CMS wants to base its 2015 bonuses or penalties on a doctor’s patients’ outcomes during 2013.

Private insurers may decide to use a formula similar to Medicare’s, said Paul Ginsburg, president of the Center for Studying Health System Change.  Medicare’s ultimate method of judging and paying physicians could become “a valuable asset for private insurers, with a tool that will be somewhat bulletproof, that physicians won’t attack because they’ve been part of the process of developing them.”

Getting physician support might not be a peace of cake, said Margaret O’Kane, president of the National Committee for Quality Assurance.  “Doctors are a very powerful political segment,” she said. Additionally, “Patients are not behind this agenda.  The public is very scared about managing costs.”

Dana Gelb Safran, who measures quality for Blue Cross Blue Shield of Massachusetts, doubts it will be possible for the government to judge individual doctors.  “There really are very few measures that we can reliably evaluate on the individual doctor level,” she said.  “When they move forward with the value-based modifier, there is going to have to be a way to allow physicians to identify other physicians with whom they say they practice and who they say they share clinical risk for performance.”

John Driscoll

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Sebelius Asks Civil Right Activists to Defend the ACA

April 23rd, 2012

Secretary of Health and Human Services Kathleen Sebelius has asked civil rights activists to help defend the Patient Protection and Affordable Care Act (ACA), noting that the healthcare law faces an “enemy” whose goal is to set American health policy back half a century.  The remarks come two months before the Supreme Court is expected to issue a ruling that could strike down the law.

Sebelius described the ACA as an crucial weapon against racial disparities that have long meant higher infant mortality rates, shorter life spans and limited access to medical services for minorities.  “The enemy is at the door and we know that they would like to dismantle these initiatives,” Sebelius told the annual convention of the National Action Network, a civil rights group led by the Reverend Al Sharpton.  “Healthcare inequalities have been one of the most persistent forms of injustice,” she said. “Now is not the time to turn back.”

Civil rights advocates and the minorities they often represent form a key segment of the Democratic base, especially if the Supreme Court strikes down Obama’s signature domestic policy achievement.  Research shows that low-income Americans, including many minorities, have significantly less access to medical care and suffer higher rates of childhood illnesses, hypertension, heart disease, AIDS and other diseases.

Designed to bring healthcare coverage to more than 30 million uninsured Americans, the ACA has become a pet target for Republicans mainly because of an `individual mandate that requires most Americans to have healthcare insurance by 2014.  “We’ve got folks who are committed to undoing…the important initiatives that we’ve made in the last few years,” Sebelius said.  “Frankly, they want to go back and undo Medicare and Medicaid from the mid-1960s.  They want to roll us back years and years.”

The House of Representatives voted recently to partially privatize Medicare and convert Medicaid to a block-grant program for states, although the legislation is likely to be stalled in the Senate.  “I’m here to ask you to help,” Sebelius said.  “If we can begin to close the disparities in health, we begin to close disparities in other areas, too.”

Sebelius asked religious leaders, health advocates and other minority leaders to help the Obama administration educate the public about the healthcare law’s many benefits. The law, which becomes fully effective on January 1, 2014, has already benefited minorities by extending private insurance coverage to young adults, providing free preventive services for those with insurance and prohibiting coverage denials for children with pre-existing conditions.

Donna Jarmusz

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CMS Chooses 27 Medicare Shared Savings Program ACOs

April 18th, 2012

As the nation waits for the Supreme Court to rule on the Patient Protection and Affordable Care Act (ACA), a key provision that will transform the delivery of healthcare is moving ahead.  According to Kaiser Health News, the Obama administration announced that 27 health systems have been designated as Accountable Care Organizations (ACOs) in Medicare’s Shared Savings Program, which offers financial incentives for physicians, hospitals and other healthcare providers to create more integrated healthcare delivery.  The new ACOs will serve an estimated 375,000 individuals in 18 states.

ACO supporters say they improve care for Medicare beneficiaries and slow rising costs by altering the incentives that affect how physicians and hospitals operate.  Experts cite as models such respected health systems as the Mayo Clinic and the Geisinger Health System of Pennsylvania.  Rather than being paid for each service, ACOs reward providers that manage chronic disease and meet certain quality standards, including reducing hospital admissions and emergency room visits.  If they improve care while holding down costs, the systems can share in the savings.

CMS is reviewing another 150 applications seeking to enter the program, suggesting that the Shared Savings Program is succeeding.  The program is “off to a very phenomenal start,” said Jonathan Blum, a CMS deputy administrator.  “We are on track to fundamentally transform the (Medicare) fee-for-service program.”

Late last year, the Department of Health and Human Services (HHS) chose 32 organizations to participate in an advanced version of the Medicare program.  These “pioneers” have made significant progress in developing the ACO model, with many already largely functioning as ACOs.  During their first two years the pioneers will assume more risk, but with a greater potential reward.  Although hospitals were expected to lead the ACO field, Blum noted that the majority of ACOs are physician-led organizations.  He also said many of the organizations are working with private health insurers to serve patients not in the Medicare program.

Chas Roades, chief research officer at the Advisory Board Company in Washington, D.C., warned that as the ACOS take off and “people actually start to deliver care in a different way, it’s messy and complicated.  There will be successes and failures, and it may go slower than policy-makers would like it to.”  According to Roades, it’s important that CMS create some way for the pioneer ACOs to share their data and best practices.  “It’s a slow ramp but everyone will be watching very closely to see how these early ACOs succeed,” Roades said.

Under the shared savings program, ACOs must meet 33 quality measures relating to care coordination and patient safety, appropriate preventive health services, improved care for at-risk populations and the patient experience of care – while reducing the costs of care.  ACOs that meet the standards will be eligible to share in the program’s savings.

“We are encouraged by this strong start and confident that by the end of this year, we will have a robust program in place, benefitting millions of seniors and people with disabilities across the country,” said CMS Acting Administrator Marilyn Tavenner.

Regarding the anticipated Supreme Court ruling, Emily Brower, an executive director with Atrius Health, operator of a pioneer ACO in Massachusetts, said “It’s not changing anything for us.  This is a model of care we’ve been trying to evolve into since before the pioneer program existed.  We’ll continue making investments, and if the law is overturned, we’ll be asking where the return on investment is for us, if not in shared savings.”

Writing for the e-Care Management blog, Vince Kuraitis is unimpressed.  “I had been anticipating this announcement as a defining moment for Medicare’s thrust into accountable care.  My expectations had been that we would see either:  Boom — a big splash of new Medicare shared savings ACOs announced, including big name hospitals and medical groups that were starting large scale ACOs, perhaps with hundreds of thousands of patients.  Bust — no one showed up at the party.  Providers would have concluded that Medicare ACOs were too risky, bureaucratic, and high effort.  This isn’t the defining moment I thought it would be.  But that defining moment might be just around the corner.  Medicare’s announcement included a mention that they have 150 more Shared Savings ACO applications waiting in the wings.  Is the boom around the corner?”

John Driscoll

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Physician Groups Go After Unnecessary Medical Tests

April 17th, 2012

America’s physicians are embarking on an initiative to cut healthcare costs by ordering fewer unnecessary tests and treatments for their patients.  Nine prominent physician groups released lists of 45 common procedures they say are often unnecessary and may even harm patients. According to Kaiser Health News, “The move represents a high-profile effort by physicians to help reduce the extraordinary amount of unnecessary treatment, said to account for as much as a third of the $2.6 trillion Americans spend on healthcare each year.  Each of the societies, representing both primary care doctors and specialists, picked five procedures that medical evidence shows have little or no value for certain conditions, and which they say should be questioned by patients and their doctors.  The list includes such common practices as routine electrocardiograms for patients at low risk for heart disease, and antibiotics for mild sinus infections.”

Dr. Donald Berwick, formerly the Medicare administrator, called the campaign “a game changer.  This could be a turning point if it’s approached with energy,” Berwick said.  “Here you have scientifically grounded guidance from a number of major specialty societies addressing a very important problem, which is the overuse of ineffective care.”

“We need to use this opportunity to raise awareness that sometimes overtreatment or testing can be harmful,” said Glen Stream, president of the American Academy of Family Physicians, one of the nine participating physician groups.  The Choosing Wisely campaign comes amid efforts – some called for in the Patient Protection and Affordable Care Act (ACA) – to compare the effectiveness of treatments and to change payment incentives to physicians and hospitals to reward quality and penalize inefficiency.  But efforts to slow medical spending growth tend to be political, giving rise to fears of healthcare rationing or death panels.  “Anytime you are recommending against a test or treatment, people wonder ‘is it for some economic interest?’” Stream noted.

Among the nine groups backing the initiative are the American College of Cardiology and the American Society of Clinical Oncology.  The effort is being spearheaded by the American Board of Internal Medicine Foundation (ABIM). Together, the participants represent nearly 375,000 physicians.

Writing in Time, Alice Park says that “Each of the nine professional groups has come up with five tests or procedures that it believes doctors and patients overuse routinely. The American Gastroenterological Association, for example, is recommending against repeat colonoscopies within 10 years of a normal result from a first colonoscopy for patients with no family history of colon cancer.  The American College of Physicians is advising against using MRI to image patients any time they complain of generalized low back pain, and heart experts say doctors should stop using stress echocardiograms in routine check-ups for patients who don’t have chest pain or other risk factors for heart disease or heart attack.”

One of the initiative’s goals is to make people “feel empowered to go to their doctor and say, ‘Do I really need this test?’” said Christine Cassel, president of the ABIM and the group’s foundation. John Santa, an internist and the director of the Health Ratings Center for Consumer Reports, said, “I think it’s courageous of cardiologists, internists and family physicians to suggest reducing services that they know generate income for some of their members.  I’m sure some of their members won’t be happy.”

According to Dr. Steven Weinberger, CEO of the American College of Physicians, “Most of us feel something like $750 billion or so could be eliminated from the system that we spend on healthcare.”  Weinberger said that unneeded diagnostic tests almost certainly account for $250 billion annually.  “I talk about this a fair amount around the country, and invariably physicians come up to me and recount their own anecdotes about overuse and misuse of care.”

John Driscoll

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Healthcare Employment on a Strong Growth Trajectory

April 16th, 2012

Healthcare employment will continue to grow much faster than employment in general, with the number of jobs in home care and other ambulatory settings expected to grow by more than 40 percent by 2020, according to a new study from the Center for Health Workforce Studies (CHWS) at the State University of New York at Albany.

Recent statistics from the Department of Labor focus on an expected hiring shift away from hospitals, as the system emphasizes preventive care and fewer admissions, said Jean Moore, CHWS director.  “For a long time, acute-care services tended to trump everything else, and that seems to be changing,” Moore said.  “There’s a growing awareness that it’s penny-wise and pound-foolish not to pay attention to preventive and primary care.”

Hospitals also are expected to keep hiring — nearly one million between now and 2020 — for a growth rate of 17 percent – as baby boomers age and need more inpatient care.

Physicians’ offices and other healthcare professionals are projected to hire 1.4 million people by 2020, a 36 percent increase.  The number of home health care jobs will soar by 872,000 – that’s an 81 percent growth rate.  The total number of ambulatory-care jobs will grow by 2.7 million by 2020, or 44 percent.

According to Kaiser Health News, healthcare is projected to be a growth industry, even if the Supreme Court strikes down the Patient Protection and Affordable Care Act (ACA).  “One of the things I wasn’t expecting was how much growth there was even during the recession,” Moore said.  “I would have expected some tempering of the growth.”

Although total U.S. employment declined by two percent between 2000 and 2010, healthcare employment rose 25 percent — demonstrating the sector’s expanding share of the economy.  By 2020, nearly one of every nine American jobs will be in healthcare.  When you consider that four million new health jobs will be created and people retiring from existing ones, more than seven million new workers will be needed.  That includes more than one million nurses.

According to the report, administrative healthcare jobs were cut during the economic slump from 2008 to 2010, a time when providers added nursing and other clinical positions.  Recent reports suggest that hospitals are hiring additional administrative staff to keep up with the increased regulation required by the ACA.  “They may be rehiring the people they had to let go when times were tight,” Moore said.

Healthcare employment totaled 14.19 million in October of 2011, an increase from the 13.88 million a year earlier, according to the Bureau of Labor Statistics.  Hospital jobs increased by 84,000 during the same time period.  Ambulatory services — physician offices, outpatient clinics and home health agencies added more than 173,000 positions.

Demand is strongest for general practitioners, nurse practitioners and physician assistants at private practices, community clinics, hospitals and long-term care facilities.  Demand also is high for physical therapists.  Some analysts predict that the shortage of physical therapists will increase as healthcare reform goes into effect.  Fewer uninsured Americans translates to a greater demand for physical therapy.  In response, medical schools are expanding and developing physical therapy training programs.

If anything, the physical therapist shortage will worsen, because in 2000, 15.6 percent were between the ages 50 and 64; 10 years later, 32 percent were in that age bracket, according to a report from the American Physical Therapy Association (APTA).  Unemployment among physical therapists remains remarkably low: In 2010, only 0.4 percent — one in 250 — of physical therapists were jobless.  “Nobody knows how accountable-care organizations and medical homes will shake out, but healthcare reform in general will decrease the number of uninsured, which will increase demand for physical therapists,” said Marc Goldstein, senior director of research for the APTA.  “Physical therapy programs are being developed or expanded, so the current level of 6,000 graduates annually should creep up.”

A survey by Sullivan, Cotter and Associates, Inc., a nationally-recognized compensation and human resource management consulting firm, over the last year, nearly 75 percent of respondents reported they increased their physician staffing levels; adding an average of 12 specialists and nine primary-care physicians to their staffs.  Another 75 percent said they plan to increase their physician staffs and mid-level providers over the next year.  “These data are consistent with the labor market shift in physician employment that has been occurring over the past few years,” said Kim Mobley, practice leader for physician compensation.  “We expect this trend to continue for some time.  This shift in the labor market has resulted in what has become a highly competitive market for physicians as organizations and physicians align to provide services in a high quality, more efficient manner.”

Donna Jarmusz

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When Uninsured Have Dental Pain, They Often Head to the ER

April 11th, 2012

Greater numbers of Americans , especially those who lack insurance coverage, are turning to the emergency room for routine dental care.  This choice frequently costs 10 times more than preventive care and offers far fewer treatment options than a dentist’s office.  The majority of these ER visits are to treat toothaches that could have been avoided with regular checkups but went untreated, often due to a shortage of dentists, particularly those who treat Medicaid patients.

The number of ER visits nationally for dental problems increased 16 percent from 2006 to 2009, and a report from the Pew Center on the States states that the trend is just getting started.

In Florida, more than 115,000 dental patients visited the ER in 2010, costing more than $88 million.  That included more than 40,000 Medicaid patients, a 40 percent increase when compared with 2008.  Many ER dental visits involve repeat patients seeking additional care.  In Minnesota, nearly 20 percent of all dental-related ER visits are return trips because emergency rooms generally are not staffed by dentists.  They are equipped to offer pain relief and medicine for infected gums but not much more.  Because many patients can’t find or afford follow-up treatment, they return to the emergency room.  “Emergency rooms are really the canary in the coal mine.  If people are showing up in the ER for dental care, then we’ve got big holes in the delivery of care,” said Shelly Gehshan, director of Pew’s children’s dental campaign.  “It’s just like pouring money down a hole.  It’s the wrong service, in the wrong setting, at the wrong time.”

For example, in 2009, 56 percent of children enrolled in Medicaid received no dental care.

Visiting ERs for dental treatment “is incredibly expensive and incredibly inefficient,” said Dr. Frank Catalanotto, a professor at the University of Florida’s College of Dentistry.  Preventive care such as regular teeth cleaning can cost $50 to $100, as opposed to $1,000 for emergency room treatment that may include painkillers for aching cavities and antibiotics from resulting infections, Catalanotto said.  Infections can be dangerous, particularly in young children, who often have fevers and suffer from dehydration from preventable dental conditions.  In Florida 200 children were hospitalized in 2006 for those types of infections.  The recession has only worsened the trend, according to Catalanotto.  When someone in the family is laid off, dental tends to take a back seat to food and other necessities.

The Wisconsin Hospital Association has estimated that 32,000 patients with dental problems visit hospital ERs every year. The fees paid to dentists by state health programs such as BadgerCare Plus are the fifth-lowest in the country, according to a report by the Pew Children’s Dental Campaign.  Raising the fees paid to dentists is not likely in the short term given the state’s budget, said Matt Crespin, associate director of the Children’s Health Alliance of Wisconsin, an affiliate of Children’s Hospital and Health System.  “That’s why some of those innovative models have to be looked at,” according to Crespin.

Pekin Hospital in central Illinois has seen a significant increase in ER patients with “very poor dental health,” said Cindy Justus, the hospital’s ER nursing director.  They include uninsured patients and drug abusers, and many are repeat patients.  “There’s just not a lot of options” for them, Justus said.  Shortages of dentists, most notably in rural areas, are part of the problem, Gehshan said.

In Illinois’ Cook County, — which includes Chicago — ER dental visits rose nearly 77,000 between 2008 and 2011.

The cause of the problem is too little financing for dental care in the healthcare system. “And when you lose adult dental coverage like California did in 2009, that creates an even bigger problem,” Gehshan said.  “We do have a safety net, and it’s not big enough,” she said.  In fact, she said, California’s dental care system can only handle about 70 percent of the need in the state, and that’s if the system were actually at full capacity.

Amazingly, 25 percent of all California children have never been to a dentist.  As a result, when those children and their parents end up in the emergency room, using time and resources that could be better spent on non-dental emergencies, that costs California’s taxpayers money, Gehshan said.

Donna Jarmusz

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Don’t Text and Treat: How Mobile Technology Is Distracting Physicians

April 10th, 2012

Dr. Henry Feldman, nicknamed the iDoctor, of Boston’s Beth Israel Deaconess Medical Center is a hospitalist and programmer who is constantly armed with an iPhone and iPad.  According to Kaiser Health News, mobile technology has helped Feldman become a better, faster physician.  “It lets me do everything I could do if I was sitting at my desktop at the patient’s bedside, and actually some things I couldn’t easily do,” he said.  According to Kaiser Health News, this includes showing patients impressive apps, diagrams, medical records and even photos from their own surgeries.  Beth Israel, one of Harvard Medical School’s teaching hospitals, is one of the most technically sophisticated hospitals in the nation, particularly in terms of mobile technology.

A somewhat different viewpoint is offered by Dr. John Halamka, the hospital’s chief information officer who helped make Beth Israel electronically advanced.  Halamka warns that mobile technology has a serious downside — it can distract doctors from patient care.  Physicians who carry mobile devices often receive texts, e-mails, Facebook messages, tweets and other notifications that automatically appear on the screen, he said.  Because the vast majority of smart phones and tablets are personal devices, the problem can be virtually impossible for hospitals to control.  “I think all of us who use mobile devices have what I will call continuous partial attention,” Halamka said.  “We’re engaged in our work but at the same time we’re checking that e-mail or we’re glancing at that instant message.”

Last winter, Halamka wrote a case study for the federal Agency for Healthcare Research and Quality about an incident in which a 56-year-old man was admitted to have his feeding tube replaced.  A team of doctors decided to stop giving the patient a blood thinner, but as one of the residents was entering the new order into her smart phone, she got a text about a party.  Because she was busy responding, she never completed the drug order.  It wasn’t a minor mistake; the patient almost died.  “If you forgot to pick something up at grocery store, it’s an inconvenience,” according to Halamka.  “If you forgot to stop a blood thinner, it can result in significant harm.”

To avoid such errors from occurring at Beth Israel, Halamka has implemented policies advising doctors on minimizing distraction on their mobile devices.  The hospital is testing software products that separate the devices’ personal and professional functions and wants to launch the new programs within the next six months.  The problem is that new technology fast outpaces the policies that regulate its use.  “The consumer technology industry is bringing more tech to doctor hands faster than policy can be made,” he said.  “How long did it take to pass laws against texting while driving,” Halamka noted.  “And we had how many people die because they were distracted drivers. There was a lag. I think maybe we’re at that point in healthcare.”

Writing on KevinMD.com, Dr. Kevin Pho “We’re encouraging more doctors to use ‘point-of-care’ apps, which, in theory, should benefit patients. But unaccounted for is the fact that smartphones and tablets carry many other functions that are non-clinical — like Facebook, for instance.  A simple answer, some say, would be to ban non-medical use of smart phone and tablet apps.  But like trying to ban texting and driving, that would be near impossible to enforce.  A better way would be to increase awareness and education of the phenomenon.  I had no idea how bad the problem was.  In medical school and residency, there are few courses on online professionalism.  Perhaps that needs to be part of the curriculum.  We need social media and health 2.0 role models who can teach physicians, residents and medical students not only how to act professional online, but also on appropriate mobile technology use in the clinic and hospital.  The problem is, there are too few of these role models.  In their absence, much of what we do to address this issue will be reactionary, and likely after a well-publicized malpractice case.”

Jonathan Mack, director of clinical research and development with the West Wireless Health Institute, a San Diego-based non-profit that focuses on cutting the cost of healthcare through new technology, believes that distraction from mobile technology “is case by case, but it’s not a huge problem overall.  It’s a learning curve” as hospitals adapt to the new technology.  Hospital administrators should be comfortable calling doctors on bad behavior if they see it and offer training so that they don’t become a barrier to care.

Writing for informationweek.com, Larry Seltzer says that “But of course, like the rest of us, doctors are going to use these devices for non-business reasons from time to time.  Yes, smart phones are especially good distractions, but it’s not like they invented distraction.  If nurses and techs weren’t playing Angry Birds 10 years ago when they had nothing to do, they might have been reading People magazine or doing a crossword puzzle.  Surgeons might not have been making personal phone calls while sewing up patients, but they might have been having personal conversations with others in the room.  What’s the difference?  There are good reasons why doctors and techs might want to access computers or the Internet while working on patients, and there are bad reasons.  These are people who we already entrust with a lot.  It’s just common sense to expect them to use these devices responsibly.”

Jeff Newkirk

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HHS To Step Up Alzheimer’s Research

April 9th, 2012

Federal officials have taken another step toward their goal of better treatment for and even prevention of Alzheimer’s disease by 2025, according to Kaiser Health News. A more comprehensive, draft version of the Obama administration’s national plan to address Alzheimer’s is now available. Experts emphasized expanding and better coordinating disease research, primarily through public-private partnerships.  They also stressed improved preparation for the healthcare workforce, enhancing public outreach and providing Alzheimer’s families with financial and other support.  To achieve these goals, President Obama proposed an additional $106 million in federal funds as part of his 2013 budget.

The Alzheimer’s advisory council provides new specifics about how the money will be used.  For example, they propose creating registries to better direct Alzheimer’s patients into clinical trials, as well as establishing a national inventory of research investments.  On the healthcare side, the council proposes working with private partners to develop evidence-based guidelines for Alzheimer’s care and establishing a national clearinghouse to publicize those recommendations.  Additionally, the council advocates that new healthcare models – such as the medical homes and accountable care organizations promoted by the Patient Protection and Affordable Care Act (ACA) – be analyzed for outcomes among Alzheimer’s patients.

The draft plan, issued by the Department of Health and Human Services (HHS), places top priority on treatment, and focuses on the burden the disease places on families and caregivers.  “Alzheimer’s burdens an increasing number of our nation’s elders and their families, and it is essential that we confront the challenge it poses to our public health,” President Barack Obama said.  The White House plans to divert an additional $50 million this year from HHS projects to Alzheimer’s research, and seeks an extra $80 million in new research funding in fiscal 2013.  “These investments will open new opportunities in Alzheimer’s disease research and jumpstart efforts to reach the 2025 goal,” according to HHS.

Eric Hall, president and chief executive of the Alzheimer’s Foundation of America and a member of the advisory council that has been working with HHS, said the draft proposal addresses many of the panel’s concerns.  “Given the current economic environment that limits much-needed resources and the scientific unknowns of this disease, we believe that defeating Alzheimer’s disease will likely happen in a series of small victories,” Hall said.  He was particularly satisfied that the plan focuses on educating healthcare providers on detecting early signs of cognitive impairment and linking newly diagnosed families with support services.

A differing perspective was offered by George Vradenburg, chairman of USAgainstAlzheimer’s and an advisory panel member, who said the draft plan does not go far enough.  “This first draft fails to present a strategy aggressive enough to achieve the goal of preventing and treating Alzheimer’s within 13 years,” he said, noting that the plan lacks specific timelines and does not hold any high-level officials accountable for meeting the plan’s goals.

More than five million Americans already have Alzheimer’s or similar dementias, a number that is expected to rise to 16 million by 2050, along with skyrocketing medical and nursing home bills, because the population is aging so rapidly.  “They’ve covered the right topics.  What is needed now is more detail,” said Alzheimer’s Association President Harry Johns.  “There’s real recognition at this point that Alzheimer’s is devastating for not only the individual but for the families and caregivers.”

Jeff Newkirk

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HHS Issues New Rules on Healthcare Insurance Exchanges

April 4th, 2012

The Department of Health and Human Services (HHS) has issued its final rule aimed at implementing state health insurance exchange provisions of the federal healthcare law.  The rule becomes effective 60 days after it is published in the Federal Register.  The regulation outlines details of the exchanges, which are scheduled to launch on January 1, 2014, and offer insurance plan options for individuals and small businesses, as well as federal subsidies for premiums.

The final rule outlines the minimum standards states must meet in establishing and operating their exchanges, such as individual and employer eligibility for enrollment.  The rule also outlines minimum standards that health insurers must meet to participate in an exchange and the standards employers must meet to participate in the exchange.  The regulation offers states “substantial discretion” in how to design and operate their exchanges.  HHS will accept comment on nine sections of the exchange rule, including provisions regarding the ability of a state to allow agents and brokers to assist qualified individuals in applying for advance payments of the premium tax credit and cost-sharing reductions for qualified health plans; Medicaid and CHIP regulations; options for conducting eligibility determinations; and verification for applicants.  This final rule does not address all of the insurance exchange provisions of the Patient Protection and Affordable Care Act (ACA).

“These policies give states the flexibility they need to design an exchange that works for them,” said HHS Secretary Kathleen Sebelius. “These new marketplaces will offer Americans one-stop shopping for health insurance, where insurers will compete for your business.  More competition will drive down costs and Exchanges will give individuals and small businesses the same purchasing power big businesses have today.”

Among the regulations are a guide to set standards for establishing exchanges; setting up a Small Business Health Options Program (SHOP); performing the basic functions of the exchange; and certifying health plans for participation in the exchange; as well as setting up a streamlined, web-based system for consumers to apply for and enroll in qualified health plans and insurance affordability programs.  The announcement is the culmination of more than two years’ work with states, small businesses, consumers, and health insurance plans.  The administration examined models of exchanges; convened numerous meetings and regional listening sessions across the country with stakeholders; and consulted closely with state leaders, consumer advocates, employers and insurers.  To finalize the rules, HHS accepted public comment to learn from states, consumers, and other stakeholders on how to improve the rules; HHS adapted the proposals based on feedback from the American people.

Unfortunately, many state lawmakers are hesitant to move forward with creating the exchanges until the Supreme Court has ruled on the ACA’s constitutionality, according to Joy Johnson Wilson, federal affairs counsel and health policy director at the National Conference of State Legislatures.  “It’s fair to say that legislation has kind of slowed,” Johnson Wilson said, noting that many lawmakers are taking a “wait-and-see approach” in anticipation of the high court’s oral arguments this month.  Legislators do not want to make plans that have to be revisited and revised, Johnson Wilson said.

Despite the ambivalence of some states, they will be given great flexibility in setting up the exchanges. The concept is the eligibility for determining the premium tax credit is going to be done by the exchange…but also in the state-based exchange to allow — whether it’s a web-based broker or a small-business broker or agent — to interact with the exchange in an automated way,” Tim Hill, deputy director in the Centers for Medicare and Medicaid Services insurance-regulation office, said.

“Those are all relationships that are regulated on the state level…to determine the fee structure for how agents or brokers can be compensated for bringing business to the exchange,” Hill said.  “That’s something we’re going to leave to the state.”  Hill said allowing third-party companies or brokers access the exchanges will help inform people about the insurance exchanges.  “There are lots of folks out there who can generate interest and marketing…it’s a source of leverage that we want to leverage if the states choose to,” Hill said.

Writing on The Hill’s Healthwatch blog, Julian Pecquet notes that “States will have ‘substantial flexibility’ to operate a key provision of President Obama’s healthcare reform law.  The long-awaited final rules expand states’ ability to craft insurance marketplaces that meet their residents’ needs.  This includes allowing states to structure their health insurance exchange in a variety of ways — for example, as a nonprofit entity established by the state, as an independent public agency or as part of an existing state agency.  The final rules also offer each state more time to set up its exchange.  The law requires states to ‘demonstrate complete readiness’ to guarantee they’ll be operational 12 months later.  If states don’t meet the deadline, a federal exchange will take over.  The final rule, however, allows for ‘conditional approval’ if a state is ‘advanced in its preparation’ by January 1, 2013.  In addition, states that aren’t deemed ready for 2014 can apply to operate their own exchange in 2015 or any subsequent year.  ‘HHS may conditionally approve a state-based exchange upon demonstration that it is likely to be fully operationally ready by October 1, 2013, which provides States with flexibility in meeting exchange development timelines,’ according to the regulation.  ‘HHS will provide additional details in future guidance.’”

Jeff Newkirk

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ACA’s Future Unclear As It Celebrates Its 2nd Birthday

April 3rd, 2012

As the Patient Protection and Affordable Care Act (ACA) celebrates its second birthday, the Obama administration reminded senior citizens – one of the most reliable voter blocs — exactly how much healthcare reform has helped them.  Coverage of the “donut hole” in prescription drug plans saved five million seniors and disabled people $3.2 billion.  According to data from the Centers for Medicare and Medicaid Services (CMS), through the first two months of 2012, roughly 103,000 Americans saved $93 million in the donut hole.  “Without the healthcare law, more than 5.1 million seniors would have faced $3.2 billion in higher drug costs,” Health and Human Services Secretary Kathleen Sebelius said.  The donut hole is a gap in coverage for prescription drugs under what is called Medicare Part D.  Part D covers 75 percent of the cost of prescription drugs until total medication spending for the patient hits $2,800.  Then the hole opens, and seniors must pay out of pocket until they have spent $4,550.  After that, Medicare pays about 95 percent of drug costs.

The ACA sent all seniors who hit the prescription drug donut hole a one-time $250 check.  In 2011 and 2012, seniors in the donut hole receive a 50 percent discount on brand-name drugs.  Additionally seniors covered by traditional Medicare received wellness check-ups and screenings for diseases like cancer and diabetes without paying anything out of pocket.  Under the law, the donut hole phases out in 2020.

The seniors’ lobby AARP launched its largest-ever outreach effort with ads and town-hall meetings aimed at defending Medicare and Social Security.  “We’re not leaving it up to chance” that the public hears about the law’s benefits, congressional Seniors Task Force co-chairwoman Jan Schakowsky (D-Ill.) said.  Democrats, Schakowsky said, have made it a “primary organization effort”…”to tell the truth (about the law) over the next several months.”

Writing in The Hill, Julian Pecquet says that “Democrats see the Ryan budget, which is expected to propose replacing Medicare with subsidies for people to buy insurance, as political gold ahead of the November election.  Republicans for their part will spend the week hammering the law’s ‘broken promises’ — higher premiums, employers dropping coverage and the soaring cost of insurance subsidies when compared to the earlier budget window Democrats highlighted when they were debating the law two years ago.  They’re also arguing that the healthcare law hastens Medicare’s insolvency by removing $500 billion from the program to pay for what they call an unsustainable new entitlements.”

In terms of implementing the law to meet the 2014 deadline, the ACA leaves it up to the states to set up health insurance exchanges.  In states that refuse to do that, HHS has the authority to create a federal exchange as a backup — but it could be stretched thin if it has to cover too many states.  At the moment, a number of states are not making plans and the federal exchange could end up covering as many as 15 to 25 states.

Other states are biding their time depending on the outcome of the Supreme Court case — and the elections — to decide what to do next.  There’s an excellent possibility that many of them won’t be far enough along by January of 2013, when HHS has to either certify the states’ exchanges or prepare to run a federal exchange in those states.  HHS has already extended the deadline for states to apply for the grants that will help them run exchanges.  And it’s taking other steps to help states that won’t be ready in time.  But if a lot of states refuse to create the exchanges –and more time won’t help them — HHS will be forced to act.

White House spokesman Jay Carney told reporters that President Obama is looking beyond past battles. “He is focused on a forward agenda right now, and working with Congress and doing the things he can through executive action to grow the economy and create jobs,” Carney said.

Republican leaders, who once accused the president of focusing too much on healthcare and not enough on jobs, now say the White House is moving away from the ACA because of uncertainty over whether or not its individual mandate is constitutional.  In terms of the upcoming Supreme Court oral arguments, Senator Roy Blunt (R-MO) said “I think we’ll win in the end.  Now the question is how long is it until the end.  There’s no question that the president’s plan will not work.”

A differing opinion was offered by Democratic Caucus Vice-Chairman Xavier Becerra (D-CA).  “I think as time goes by more and more people are beginning to support the reform because it starts to apply to them.  The more people see what the ACA does, the more they’re going to like it.”

John Driscoll

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