One point that became clear with the Senate Finance Committee's vote Tuesday on the healthcare reform legislation was that this was just a short stop along a long path—and far more needs to be done as a reform proposal moves toward the Senate Floor.
President Obama, when congratulating the panel for its 14-9 vote to approve the bill, said "a critical milestone" was reached "in the effort to reform our healthcare system." However, he added that the "bill is not perfect."
"We have a lot of difficult work ahead of us. There are still significant details and disagreements to be worked out over the next several weeks as the five separate bills from the Senate and the House are merged into one proposal," he said.
House Majority Leader Harry Reid (D-NV) similarly noted in a statement that the bill's passage represented another "critical step toward bringing real change to our broken health insurance system." Reid will be involved in reconciling the Senate Finance bill with the Health, Education, Labor and Pensions (STEP) Committee bill.
While all but one Republican on the Senate panel voted against the bill, they all expressed desires to see healthcare reform legislation passed—and can be expected to contribute to the debate when it extends to the Senate floor, possibly as early as the end of this month.
When meeting with reporters after the vote, Finance Committee ranking minority member Charles Grassley (R-IA) said, "I'm not going to stand still and say that a vote against this bill is a vote against the status quo. There are so many things that we can do, and when we go to the floor, we will be there telling people how we can change the status quo.
So here is what is likely to emerge in the full Senate debate:
Public insurance option. Even if a public option is including in a reconciled bill (the STEP bill has a public option), debate will likely ensue. For instance, Sen. Jay Rockefeller (D-WV) plans to reintroduce an amendment that calls for a public plan that would pay providers based on Medicare rates for two years and would be administered by an office within the Department of Health and Human Services.
Sen. Charles Schumer (D-NY) has an amendment that would have "no legislative advantage"—specifically, provider rates would be established competitively and no "federal infusion of federal dollars" if a plan did not make it the first time around.
Sen. Olympia Snowe's (R-ME) suggestion for a "trigger plan" also could come into play as a compromise in which nonprofit agencies would offer health insurance in instances in which private insurers could not cover 95% of the people in their regions with plans costing no more than about 15% of the individual's or household's annual income.
Tort reform. Several Republicans on the Finance Committee cited the Congressional Budget Office response to a query by Sen. Orrin Hatch (R-UT) that total national healthcare spending could drop by about 0.5% or $11 billion if tort reform was enacted by 2010.
Medicaid. Several Finance Committee members questioned if Medicaid would be able to sustain an influx of new enrollees in the states and if enough healthcare providers would be available to take care of that population. Sen. Mike Enzi (R-WY) said in discussions on Tuesday that 40% of the providers in his state do not accept Medicaid patients.
First, the good news. The percentage of the population suffering hip fractures has declined and fewer people are dying from them.
Now, the bad news. Patients who do fracture their hip and live to tell about it are more likely to have more co-morbidities, such as heart failure, pulmonary disease, and diabetes.
For example: the percentage of hip fracture patients living with congestive heart failure nearly doubled, from around 13% to more than 25%, between 1986-1988 and 2003-2005. And the percentage of patients with diabetes and hip fracture increased from 9.6% to 25% for men and more than 19% for women.
And patients with hip fracture are also more likely to have diabetes.
Those are findings from a study published in today's Journal of the American Medical Association by researchers at the University of Calgary, Alberta, Harvard University, and the University of Michigan School of Medicine and Public Health.
The authors wrote that there has been a distinct shift in hip fractures after 1995, when hip fractures decreased in both men and women.
"Why these trends have occurred is not entirely clear," the authors wrote, noting that it occurred after the release of bisphosphonate drugs, such as alendronate and risedronate.
Another possibility is in the emphasis on lifestyle change among older Americans, such as more people taking calcium and vitamin D supplements, "avoidance of smoking, regular weight bearing exercise, an awareness of falls, and moderate alcohol intake."
Also, they said, "publicity and physician education and awareness of osteoporosis and fragility fractures" have also increased since 1995, "which may be a contributing factor."
The authors noted that there also has been a reduction in mortality from hip fractures, but most of the decrease occurred before 1998. After 1998, they said, very little change occurred in mortality for either sex.
Surgical and medical management of hip fracture patients has improved over the last 20 years, "including care maps to improve timely surgical intervention, improved surgical devices, and movement toward replacement arthroplasty, combined with a push for earlier weight bearing exercises may have reduced mortality by improving mobilization," they wrote.
Hospitals seeking to reduce their operative complication rates should make sure their attending surgeons get at least six hours of sleep between the time they last performed an operation.
That's one of the conclusions from a study by a team at Brigham and Women's Hospital in Boston led by Jeffrey M. Rothschild, MD, of the Division of General Medicine. The study is published in today's Journal of the American Medical Association.
Rothschild's team found a 2.7-fold increase in complications among post-nighttime surgical procedures performed by attending physicians with sleep opportunities of less than six hours compared with those performed by attending surgeons who got more rest the night before.
The study compared 919 surgical and 957 obstetrical post-nighttime procedures with 3,552 and 3,945 control procedures respectively between January 1999 and June of 2008.
They found complications occurred in 6.2% of the post-nighttime procedures when surgeons had sleep opportunities of six hours or less, compared with 3.4% complication rate when surgeons had more than six hours sleep.
"These data suggest that attending physicians, like residents and nurses, may be at increased risk of making errors when sleep deprived or working extended shifts," the authors wrote.
In a media briefing Tuesday, Rothschild said the study findings "raise the importance of professionalism and the need for physicians to step up to the plate. If they feel tired or they find a colleague is tired, to find another way to approach this problem."
Complications measured included surgical site infections, bleeding, organ injury, wound failure, neural damage, and fracture/dislocation.
The study was launched to look into the issue of attending physician and surgeon fatigue. In the past, there have been studies linking resident fatigue with higher incidence of medical errors, including percutaneous needlesticks and lacerations and post-call motor vehicle crashes.
However, the authors wrote, "Less is known about the effects of extended-duration work shifts on the performance of attending physicians." To their surprise, they did not find a higher risk of complications for surgeons and obstetrician/gynecologists who performed procedures the preceding night (procedures that began or ended between midnight and 6 a.m.), compared with surgeons who did not work the preceding night.
The key was in the amount of sleep they got between surgeries, factoring in the time it takes after a surgical procedure to wash up, get dressed, drive home, relax and get to sleep, and then drive back to the hospital to begin a new surgical day.
The authors wrote that because of concerns about their professional development, "attending physicians may be less likely to acknowledge the potentially harmful effects of extended work shifts than trainees. Some attending physicians may also be less inclined than residents to postpone electively scheduled surgical procedures even when they are aware of the possibility of decreased alertness from insufficient overnight sleep.
Rothschild suggested hospitals and surgeons look at five strategies to reduce the times when surgeons go back into the operating room after fewer than six hours sleep.
If possible, avoid scheduling elective procedures following overnight on-call responsibilities
Use hospital-based physicians to cover overnight emergencies
Consider cancelling or postponing elective procedures when the risks are high or when colleagues feel the risks are high
Use teamwork, including backups, to assist or relieve fatigued physicians
Consider using caffeine if the surgeon must perform lifesaving procedures
Cheryl Clark is a senior editor and California correspondent for HealthLeaders Media Online. She can be reached atcclark@healthleadersmedia.com.
Senator Olympia J. Snowe, Republican of Maine, cast her vote with Democrats as the Senate Finance Committee approved legislation to remake the U.S. healthcare system and provide coverage to millions of the uninsured. With Snowe's support, the committee backed the $829 billion measure by a vote of 14 to 9, with all the other Republicans opposed. With its vote, the Finance Committee became the fifth and final Congressional panel to approve a sweeping healthcare bill. The action will now move to the floors of the House and the Senate, where the healthcare measures still face significant hurdles.
Although many of the healthcare reform details are still up in the air, there are a few changes to the healthcare system found in all bills under consideration—expanding coverage, bolstering primary care, and tracking quality data, for instance. Medical practices can and should start preparing early to strategically prepare for a transformed healthcare system, David Gans, vice president of innovation and research for the Medical Group Management Association, said at the MGMA's annual conference on Tuesday.
Gans advised medical practice managers to monitor the public discussions about healthcare reform and pay attention to the timelines included in proposed legislation. Beyond that, however, he suggested taking the following steps to prepare for some of the potential changes:
1. Evaluate payer mix and contracts. Pointing to Massachusetts as a case study, Gans predicted that a significant effort to expand the number of Americans with insurance would create virtually "unlimited demand" for physician services. On the one hand, that could lead to more physician shortages and pressure on practices. But it would also increase practices' leverage when negotiating contracts with insurers, he said.
Physicians will have more room to pick and choose the best contracts because of the high demand for their services. "You may have operating leverage you never had before," Gans told attendees.
2. Focus on copays and patient education. Many of the newly insured won't be familiar with the basic workings of health insurance—copays, premiums, and eligibility requirements. The onus will be on medical practices to educate new patients about their financial responsibilities when visiting a physician. Additionally, practices should evaluate new collection strategies and technologies in order to collect the revenue they are owed, Gans advised. Practice payment policies should be published in clear language for distribution to new patients, he said.
3. Evaluate new covered services. Healthcare legislation will likely require certain services to be covered in all insurance policies, such as imaging and screenings, radiation and chemotherapy, mental health, and substance abuse. Practices need to evaluate their current offerings to determine if the practice could provide additional covered services. In particular, healthcare reform could bring about a significant focus on preventative services, and many practices should be able to adapt to capture that reimbursement.
4. Consider pilot programs and medical homes. Although the percentages differ, each healthcare reform bill promises to increase payments to primary care and focus on chronic care and patient-centered treatment options. Medical groups should begin evaluating their potential to qualify as a patient-centered medical home or offer advanced chronic disease management and monitoring services, Gans said. They may also want to participate in Medicare pilot programs, as there are often financial bonuses for those who do.
5. Start collecting data. Comparative effectiveness may be the sleeping tiger of healthcare reform, Gans said. It is one of many ways that reform could increase the emphasis on health data collection, and practices should review their internal data collection, tracking, and reporting procedures now. Electronic health records help with this process, and practices may want to consider the timeline for taking advantage of the $44,000 available per-physician in federal dollars to encourage EHR adoption.
Senate leaders and White House aides will meet October 14 to try and reconcile competing health bills, a day after the Senate Finance Committee voted to approve legislation. Senate Democrats have already held some preliminary discussions about blending the bills, and the White House lobbying team is already fully deployed across the Capitol, reports the New York Times.
Attacks on the leading Democratic reform plan by the insurance lobby left little doubt that the White House and the nation's insurance companies have abandoned any real hope of forging a compromise. And as the Senate Finance Committee approved a 10-year, $829 billion bill to remake the healthcare system, Obama's top advisers and the insurers moved into a more intense stage of conflict, reports the Washington Post.
Beginning in February 2008, each time a patient at Cedars-Sinai Medical Center in Los Angeles received a CT brain perfusion scan, the dose displayed would have been eight times higher than normal. No standard medical imaging procedure would use so much radiation, which one expert said is on par with the levels used to blast tumors. The U.S. Food and Drug Administration and Cedars-Sinai has revealed that 206 stroke patients who received scans at the hospital were overdosed with radiation. Now doctors and safety experts around the country face the question: How did the problem go undetected for 18 months?
Two of Minneapolis-St. Paul, MN, areas biggest medical groups will collaborate in a seven-year effort to slow the rise of medical costs. HealthPartners and Allina Hospitals and Clinics announced that they plan to try out new payment formulas to reward quality and improve patient satisfaction, ultimately producing lower costs in the area. Allina is the Twin Cities' biggest clinic and hospital group. HealthPartners is the state's third-biggest health insurer and also has a chain of clinics.
While Texas employers shunned health maintenance organizations as an insurance option for workers during the last decade, a study shows a slight increase in HMO enrollment. The Texas Health Market Review, an annual publication of Minneapolis-based health economist Allan Baumgarten, found that enrollment in Texas HMOs increased 3.9% in 2008 and 7% in 2007, primarily because of Medicaid, Medicare, and the state's Children Health Insurance Plan.
