Call it an admission that Congress simply can't perform one of its most important duties—controlling the purse strings. That's the undertone of what President Obama was saying when he sent a letter to Sens. Max Baucus and Ted Kennedy proposing that MedPAC be empowered to determine Medicare reimbursement to providers. Though the letter covered many areas of the healthcare reform debate, it suggests that MedPAC be elevated to an executive-level agency, under which its recommendations would automatically be adopted unless opposed by a joint resolution of Congress.
While the move would raise troubling questions about the separation of powers under our Constitution, it would not be unprecedented. Obama cites the similarities of the proposal with Defense Base Closure and Realignment Commission, which was charged with determining which military bases to close over the past couple of decades. Under its watch, more than 350 bases have been closed since 1989 to save money on operations and maintenance.
Healthcare and the military don't have much in common on first glance, but the same issues that prevent members from making tough decisions on military bases that bring huge dollars to their congressional districts are also in operation in healthcare. Every member of Congress has a hospital or two in his or her district—not to mention dozens of other businesses that depend on Medicare's largesse. Seeing those hospitals close or seeing other businesses suffer because of payment cuts is politically unpopular.
So even if it no longer makes sense to provide a payment pool that keeps every hospital, physician practice or ancillary provider solvent, Congress has a tough time implementing these decisions. That's why every year they roll back many of MedPAC's toothless recommendations. However you feel about the annual double-digit physician reimbursement cut MedPAC suggests, Congress makes a mockery of the commission not only by rolling back the cut but also by annually increasing payments, generally by a small percentage.
So much for leadership, but aside from that, it seems like a good idea. Congress can police the more draconian of recommendations, but could only overturn MedPAC's recommendations in a fairly blunt way. That power would encourage MedPAC to be more circumspect about its recommendations, because they will have a better chance of actually being enacted. Still, I have my doubts that Congress would willingly give up so much power to the executive branch unless a true crisis is at hand. I think we're there, but despite the rhetoric on healthcare reform, I'm not sure Congress agrees.
What should healthcare leaders take from this? Slowly but surely, government leaders are beginning to treat the healthcare cost problem as seriously as it deserves to be treated. The letter's not the only evidence. Legislation introduced May 20 by Sen. Jay Rockefeller (D-WV), chair of the Senate Finance Health Care Subcommittee, echoes the president's letter in that it calls for MedPAC to have new authority to implement Medicare payment policy. As proposed under the bill, MedPAC would be renamed the Medicare Payment and Access Commission and given new powers, such as determining payment rates for physicians and hospitals.
If this idea has any legs, Congress should change the way MedPAC's board is structured. For one, the commission's 17 members are part-time, and are generally active hospital administrators and physicians. They're appointed for three-year terms by the comptroller general, who himself is appointed by the president to a 15-year term.
In an article by my colleague Janice Simmons, Robert Berenson, MD, who advised Rockefeller on the bill, suggests that full-time officials who no longer have any conflicting interests should staff a new MedPAC, to fully represent the public's interest. Currently, Berenson told Simmons, Congress doesn't get a balanced view of the big picture surrounding the healthcare cost problem.
"You get a concerted effort by affected stakeholders presenting one point of view to Congress—and nobody essentially on the other side," he says.
If the proposal were to be adopted, we should be careful not to consider it a panacea to the unsustainable healthcare cost problem. Never underestimate Congress's ability to undermine any sensible idea about controlling costs and limiting spending. When it comes to lobbyists, Congress continues to demonstrate an inability to say the word "no."
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Earlier this week, the University of Medicine and Dentistry of New Jersey agreed to pay the federal government $2 million to settle a whistleblower lawsuit alleging that it bilked Medicaid in a double-billing scheme that started in 1993 and ended in 2003, according to the Department of Justice.
The settlement was the second time UMDNJ paid the government for the double-billing scheme. The first was in 2005 when the hospital paid $4.9 million to the state of New Jersey to settle criminal charges.
In the end, UMDNJ ended up paying nearly $7 million total for the scheme, but, according to Marcella Auerbach, managing partner at Nolan & Auerbach, the hospital could have avoided the lengthy and costly litigation and saved millions, if it had acted differently.
According to Auerbach, a former federal prosecutor who now exclusively represents whistleblowers in healthcare fraud cases, UMDNJ's in-house attorney discovered the hospital and its physicians were billing for the same services back in 2001—before any whistle was blown. The lawyer brought the issue to the hospital's attention, but the management looked the other way, and continued to double-bill for the three years following the warning, he says.
The fact that UMDNJ knew about the double-billing, knew it was illegal, and continued to do it, is what makes the case so interesting. According to Auerbach, the hospital could have saved millions if it ceased double-billing and came clean to the government through a self-disclosure.
"It's a bet," Auerbach says. "They are betting on the fact they won't get caught."
However, UMDNJ hit one too many times and ended up going bust. The man who busted the hospital is Steven Simring, MD, who will collect $801,000 for his efforts.
Based on the details of the case, Auerbach was not surprised to see a doctor blow the whistle on the hospital. Evidence shows that there were many discussions about the double-billing in which doctors expressed concern. Auerbach says it comes as no surprise that Simring would come forward and blow the whistle rather than risk being prosecuted himself.
Auerbach, who has extensive experience in whistleblower cases, says the gambler's mind-set is common in whistleblower cases. Rather than play by the rules and fess up, many facilities try to sweep problems under the rug and pretend they never happened. Some even go one step further. Auerbach says many times concerned employees will raise a compliance concern only to be handed a pink slip for their trouble, which raises another legal problem.
"These people are fired for bringing points up," Auerbach says, "Then they come to us and they have two claims."
Auerbach says this case can be seen as a message to healthcare leaders. The DOJ is saying take any compliance concerns presented by employees or legal council very seriously and, when appropriate, self-disclose. The alternative is a lengthy, expensive, public whistleblower case.
Nurse practitioners in New York State will be able to practice independently if a bill drafted by the Nurse Practitioners Association of New York passes through the state Senate.
Currently, NPs in New York State are required to have written collaborative agreements with physicians. The extent of that relationship is determined by the physician and NP, and the two parties do not need to practice in the same location, explains Tom Nicotera, director of membership and public affairs at the Nurse Practitioners Association of New York.
The collaborative agreement, does, however, mandate that physicians review NPs' charts every 90 days. But, again, the level of chart review is determined by the physician and NP. "It could be one, it could be 20," says Nicotera.
The Nurse Practitioners Association of New York drafted the bill to accomplish two goals. First, under the current collaborative agreement model, if a physician leaves practice, retires, or dies, any NPs who practice with that physician must stop seeing patients immediately. "This disrupts patient care," says Nicotera. This bill would allow NPs to practice independently; therefore, they would not be subject to changes in a physician's practice.
Second, explains Nicotera, fewer medical students are choosing primary care careers. However, the majority of NPs are involved in primary care, thus helping to fill the gap. "The more autonomous NPs are—the fewer barriers there are for them to see patients—the better off we are," Nicotera says.
The Medical Society of the State of New York opposes the bill, claiming that it poses a patient safety issue, particularly when it comes to NPs treating complex patients.
NPs' training consists of graduate level education and state certification, according to the American Academy of Nurse Practitioners. Physicians must achieve graduate level education and go through three to four years of a residency program (some also choose to participate in a fellowship, which adds another two to three years to their training). Although physicians and NPs do many of the same tasks day-to-day, the difference in training may be enough to negatively affect patient outcomes, the society argues.
"Clearly, NPs are an integral part of the healthcare team, and they manage non-complex patient care in a physician's office very well," says Liz Dears, Esq., senior vice president at the Medical Society of the State of New York, who says her son often sees a nurse practitioner and she is pleased with the care he receives. "But we have concerns about the quality of care they provide to chronically ill patients."
The definition of NPs' roles is broad and changes from practice to practice, and that demands a relationship with a physician, adds Gerard Conway, Esq., senior vice president and chief counsel at the Medical Society of the State of New York.
In addition to patient safety concerns, the Medical Society of the State of New York opposes the bill for fear that it would create healthcare silos. "We should be working not for one type of practitioner to be independent from the others, but integration. We don't think anyone, including NPs, should be carving out separate practices," says Conway.
Nicotera, however, says that the bill was not intended to build silos. Rather, it was created to provide New Yorkers with greater access to healthcare. "There are medically underserved populations in just about every county in New York. We really need to be able to take care of our patients."
He also says that the bill will not affect NP-physician relationships. NPs will continue to collaborate with and refer to physicians when necessary. "Removing the statutory collaborative agreement won't change their practices. Collaboration is a fact of life when you're in healthcare."
New Yorkers might have to sit tight a while longer to see the outcome of this bill. Only a handful of days remain in this legislative session, and recent leadership changes within the Senate will most likely push the decision to the next legislative session, says Nicotera.
The 15-member Federal Coordinating Council for Comparative Effectiveness Research, which held its final listening session this week in Washington, heard from many healthcare providers in that session on the challenges of working effectively with data. The council will now evaluate testimony from all three of its sessions and prepare recommendations this month for the White House and Congress on where efforts for comparative effectiveness research should be focused.
Polly Pittman, PhD, executive vice president of AcademyHealth in Washington, DC, said her organization "knows firsthand what challenges can result" from a lack of a common definition of comparative effectiveness research. This occurred in compiling the organization's annual report on the volume and cost of comparative effectiveness research across the United States.
The database sources in the study suggested that cancer treatment was the most common treatment that was the focus of comparative research in clinical trials. However, the study also found that tracking comparative effectiveness was not an easy matter: Existing databases made it difficult to track research by study design.
John Cuddeback, MD, the chief medical information officer of Anceta, the collaborative data warehouse of the American Group Practice Association in Alexandria, VA, suggested that attention should be paid to how physicians can use their electronic health record systems to better extract the "wealth of detailed clinical and process of care data and patient outcome data across the continuum." About 85% of his group's membership now has EHRs, he said.
He said his group supports "a view of comparative effectiveness that goes beyond simply comparing medications, devices, and existing guidelines"—especially when it comes to patients with multiple conditions or comorbidities. Instead, he would like to see movement toward using real world data "in the context of collaborative, rapid cycle improvement" to expand the evidence base for "costly and vulnerable patient populations."
Mark Roberts, MD, an internist, professor of medicine at the University of Pittsburgh Medical Center, and president of the Society for Medical Decision Making, supported continuing investment in the "development and advancement of comparative effectiveness methods themselves and the rigorous training in their use."
But he also specified that, "we cannot relay solely on the randomized control trials to answer complex clinical questions," he said. "The best treatment for an individual patient with a special need or disease simply cannot be determined from the knowledge of the average effect of that treatment in a narrowly defined randomized controlled trial."
For instance, a particular therapy that has a higher five-year survival rate may be "irrelevant" to an ailing grandmother who wants a therapy that maximizes her ability to be alive at her granddaughter's wedding in two months, Roberts said.
"Comparative effectiveness research must develop the ability to account for the important individual differences in physiology and risk faced by patients making decisions about their care," he said. "And it also must account for individual patient preferences."
As President Obama traveled to sell a government-run insurance plan as essential to healthcare reform, Senate negotiators began to explore a possible bipartisan compromise modeled after rural cooperatives. Creating a "public option" to compete with private coverage has emerged as a significant hurdle as Congress begins to debate legislation to restructure the nation's healthcare system. But many lawmakers who are skeptical of a federal plan expressed interest in an alternative proposal to create the member-run healthcare cooperatives.
As President Obama's tries remake the nation's healthcare system shifts into high gear this summer, one thing he wants to do is avoid making the mistakes President Bill Clinton made. And as Clinton watches Obama take on the issue that stymied him 16 years ago, Clinton has concluded that Obama has a better chance than he did, both because of the way the new proposals are structured and because of a national mood that is more supportive of major action.
St. Paul, MN-based Regions Hospital has launched a public campaign to make sure legislators understand the full impact of cutting General Assistance Medical Care, or GAMC. The program, which covers 34,000 Minnesotans earning less than $7,800 a year, will end after July 2010 as part of the governor's plan to close the state's deficit without raising taxes. For Regions alone, that will mean a loss of $36.3 million in reimbursement, and GAMC now accounts for about 5% of the hospital's revenue.
A proposed expansion of Seattle Children's Hospital would reasonably balance the public benefits of the project against protecting the livability and vitality of adjacent neighborhoods, city planners said. In April, Hearing Examiner Sue Tanner ruled that the city's first of evaluation the plan's impacts was inadequate, and planners released a new evaluation May 28 and that report is the basis for the new recommendation. The hospital's plan eventually would result in as many as 600 beds, up from 250 now, and 2.4 million square feet of building space, up from about 900,000.
Former Texas Gov. Bill Clements is giving $100 million to UT Southwestern Medical Center, the largest single gift in the institution's history. The donation comes with no restrictions on its use, a rarity for a gift of such size, medical center officials say. The Southwestern Medical Foundation board will work with UT Southwestern leaders to determine how the money will be spent.
Bayonne Medical Center has decided to end its lockout of union nurses and other healthcare workers, according to a report. The 843-member union has been locked out since 7 a.m. June 9, the majority of their jobs taken over by non-union workers. In ending the lockout of nurses and other healthcare workers, the Bayonne Medical Center has said that it will impose the terms and conditions of the contract offer that the union overwhelmingly rejected.
