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Top 12 Uncertainties Hovering Over Healthcare

Cheryl Clark, for HealthLeaders Media, November 21, 2011

How aggressively the states and the federal government choose to push back on those increases will be a trend that will become apparent next year. And if they are aggressive, health plans many push those costs on to the shoulders of hospitals and physicians with lower value contracts, limiting their ability of providers to continue the practice of shifting the cost of caring for the underinsured.

Nate Kaufman, of Kaufman Strategic Advisers, says the increased scrutiny states and federal agencies are giving on rate review of healthcare premiums, "is one of the biggest issues out there now."

7.  Who Will Lead CMS? 

With partisan politics apparently precluding the permanent appointment of Donald Berwick, MD, as CMS administrator, he is expected to leave the agency by year's end.  The expected heir is his principal deputy, Marilyn B. Tavenner, former Virginia Secretary for Health and Human Services and former HCA Group President.

Also unclear are the fates of HHS Deputy Administrator Steve Larsen, CMS Chief Medical Officer Patrick Conway, MD, and acting director of the new Center for Medicare and Medicaid Innovation, Richard Gilfillan, MD, who left his post as president and CEO of Geisinger Health Plan. These men helped Berwick steer the agency through some of its most controversial program launches.

8. The Patient-Centered Outcomes Research Institute
Now well underway, this 21-member panel enabled by the Affordable Care Act and appointed by the General Accountability Office will make recommendations about the evidence of effectiveness medications, diagnostics, medical devices and even types of surgery and other "health practices." By 2014, PCORI's budget may grow to more than $500 million, according to an August commentary in the Journal of the American Medical Association.

The organization has already started the process of giving out money for research, and although it is precluded from using cost in its calculations or recommending that a treatment be covered, many health leaders are certain that will be the ultimate result. If, for example, PCORI says that a particular medication reduces symptoms only 3% of the time but causes nearly intolerable side-effects in most of those, such a conclusion will undoubtedly influence decisions about whether the drug should be covered.

Keckley says that in talking with his clients, "PCORI is a stealth player in healthcare. But they're not getting nearly as much attention as you'd think." 

9.  Meaningful Use
CMS is expected to issue rules defining Stage 2 of Meaningful Use for electronic medical records for hospitals and doctors wanting incentive payments in the first quarter of 2012, with a final rule several months later, to be ready for implementation by Oct. 1. However hospitals hope that implementation will be delayed one year, says the AHA's Don May.

"Meaningful use is a very big deal for hospitals," May says, because there's $4 billion in incentive payments for doctors and hospitals. The Stage 2 criteria are feared because CMS is expected to significantly increase the percentage of clinicians who, for example, are using computerized physician order entry to meet the meaningful use requirements.

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6 comments on "Top 12 Uncertainties Hovering Over Healthcare"


Janice (11/30/2011 at 1:52 PM)
I agree with Lanay - having coded and reviewed thousands of records in my career, patient non-compliance is a major reason especially for CHF readmissions. Patients are adequately trained during the admission but it is too easy to slip back into old habits when they go home. What makes non-compliance easy is that many of the CHF patients may be on low incomes, and eating appropriately, which is a major player in CHF, may be next to impossible. Patient non-compliance should be excluded from the readmissions for CHF (there is a ICD-9-CM code for it).

Kandi O'Brien (11/29/2011 at 10:59 PM)
It is great to see that the government wants to [INVALID] measures to prevent harm. However, the affects of some of these measures excludes a lot of common situations. Ex: 30 day rule. Most of these PTA have multiple chronic issues and they have totally separate issues that land them in the hospital. The entire visit /week stay shouldn't be denied when there was no wrong doing in relation to the initial treatment. There also should be more regulation on insurance companies. They are making money every year while everyone else faces cuts. Increases for our tax rates have to be approved, maybe the increase for premiums should have a similar plan. Having worked on both sides I am confident that there is a middle ground, however, the wrong people aren't usually at the table to make those decisions.

Lanay (11/29/2011 at 5:48 PM)
In addition to that which is listed regarding readmission for selected illnesses they need to consider patient non-compliance with treatment that directly leads to the readmission.