Expectations are high this year that Congress will finally reach an agreement to overhaul the way Medicare pays doctors for services, scrapping a method that's been the target of criticism for more than a decade. If that happens, experts say, Medicare beneficiaries will see changes in how health care is provided, with an increased emphasis on coordinated care and preventive services. "We're optimistic that there are a lot of opportunities in this to help make people healthier, more satisfied with their care and bring down costs," said Dr. Joseph Craft III, a cardiologist at Mercy Clinic Heart and Vascular and president of the St. Louis Metropolitan Medical Society.
In the midst of the sweeping transformation taking place in health insurance, the company that served as an illustration of why an overhaul was necessary could end up benefiting most from the new federal health care law. Just a few years ago, the health insurer WellPoint outraged its customers — and regulators — by proposing an increase of nearly 40 percent in some of its annual premiums. Now, WellPoint has captured a large portion of the government money being spent on Medicaid, the federal-state health care program for the poor, and can gamble on the new insurance marketplace because of protections offered by the federal government in the early days of the law's introduction.
An influential senator is demanding copies of contracts and conflict-of-interest policies from the National Quality Forum after allegations that kickbacks were paid to influence its patient safety guidelines. Sen. Charles Grassley cited "serious concerns" about how the Quality Forum vets its expert advisers and suggested the group may have endorsed a drug for a use the government hasn't approved. "This case calls into question NQF's due diligence and its obligation to prevent conflicts of interest or recommendations that violate officially approved uses," Grassley, R-Iowa, said in a letter to Dr. Christine Cassel, president of the nonprofit group, whose guidelines are widely adopted by health care providers.
With the midterm elections fast coming into focus, politics in Washington will remain consumed by health care for months to come. Democrats worry that the flagging support for expanding health care insurance may not recover soon enough from its botched introduction. Republicans are leaving no stone unturned in search of Obamacare horror stories to stoke further discontent. This political theater, however, has little relevance to the actual delivery of medical services. For that, the debate that matters has been taking place far from the klieg lights, in a remote courthouse in Idaho, where less than two weeks ago a district judge sided with the Federal Trade Commission and ordered the unwinding of the merger between one of the state's biggest hospital systems and its biggest independent network of doctors.
At San Francisco General Hospital, less than 3 percent of patients who come to its adult medical clinic are responsible for 35 percent of all admissions. In Oakland, just 5 percent of patients in Alameda Health System's Highland Hospital account for 50 percent of hospital "days," meaning a sliver of the population racks up the bulk of the hospital's long, costly hospitals stays. But a growing trend of "hot spotting" - using sophisticated data mapping to zero in on the chronic "super-users" of health services - is taking hold, spurred in part by provisions in the federal Affordable Care Act that financially reward efforts to help keep patients healthier and out of the hospital.
When you go to a drive through for fast food, you know exactly what it will cost you at the next window. But right now, if you're in need of a hospital outpatient procedure, it's like a fancy restaurant with no prices on the menu. The Heritage Valley Health System plans to change that. "Hospitals and health care have become more retail," said Dan Murphy with Heritage Valley Health System. With hospitals in Sewickley and Beaver, heritage valley will begin posting prices for 25 common outpatient procedures – doctors' costs would be extra.