Faced with the pluses and minuses, doctors often don't agree on how to screen for cancer, the Los Angeles Times reports. "Organizations send us their guidelines hoping for our endorsement," said Doug Campos-Outcalt, MD, who heads the development of clinical practice guidelines for the American Academy of Family Physicians, an organization representing about 94,000 primary-care doctors. Those guidelines, he told the Times, are frequently in conflict with one another.
As Democrats tout the American Medical Association's endorsement of their healthcare overhaul, critics are pointing to their sidestepping of a monopoly that sends millions into the trade group's coffers each year. The AMA holds the exclusive rights to the medical billing codes that doctors are required to use when they submit bills to insurance plans. It is a monopoly that critics say gets in the way of making healthcare less expensive and potentially more effective, the Chicago Tribune reports.
Massachusetts has approved plans by Weymouth-based South Shore Hospital to add two stories and 60 beds in a $52 million project that comes on the heels of construction of its $89 million cancer treatment center and new parking garage. The project was the only major hospital expansion approved by Massachusetts this fiscal year, the Boston Globe reports.
The Mayo Clinic, often cited by the Obama administration as a model for high-quality, cost-effective healthcare, generally supports key provisions of the legislation approved by the Senate, but one Mayo official called for more aggressive steps to change how care in the U.S. is paid for. "The concerns are whether the legislation will be strong enough to change the incentives in the system today, which are mostly around paying for volume" and not for "value" of care, Jeffrey Korsmo, executive director of health policy center at the Mayo Clinic, told the Wall Street Journal.
The plight of two kidney transplant patients who contracted a brain infection from an organ donor is prompting health officials to re-examine their policies on using people with certain neurological conditions as donors, the New York Times reports. The organ donor had had seizures and a brain disorder initially thought to be an autoimmune disease and not transmissible. The real cause of his illness turned out to be a rare, usually fatal infection, but the mistake in diagnosis was not recognized until the transplants were done and the two recipients had become critically ill. The case highlights the lack of a national policy on whether to bar people with poorly defined neurological disorders as donors, the Times reports.
Although patients may not be aware of their presence, sales representatives have become fixtures in operating rooms across America, the Washington Post reports. As Washington tries to find new economies in healthcare, salesmen in the operating room serve as simple reminders that medicine is a business, with all the potential that entails to promote efficiency, boost sales, and extract profit. But the Post asks whether they should be there at all.
It took a lot of debate, discussion, disagreement, and discourse, but the Senate approved its healthcare reform bill, the Patient Protection and Affordable Care Act (HR 3590), Thursday morning 60-39 along a straight party line vote.
But a long and complicated process lies ahead for this bill and the House bill (HR 3962), which was approved last month, as they are reconciled into a new bill to be presented back to each chamber.
After a short winter break—the House reconvenes Jan. 12 and the Senate Jan. 19—representatives from each body will meet in a conference committee to iron out differences between the bills. Tentatively, the aim was to have a bill prepared and passed before President Obama presents his State of the Union address in late January or earlier February, but many have speculated that the process could take much longer.
The House bill, with a cost estimated by the Congressional Budget Office at $1.1 trillion over the next decade, is projected to cover 36 million individuals by in 2019—about 96% of legal residents. The Senate bill, with an estimated cost of $871 billion over 10 years, is projected to cover about 31 million people, or 94% of legal residents.
Representatives Henry Waxman (D CA), Charles Rangel (D NY), and George Miller (D CA), the chairmen of the three committees with jurisdiction over health policy in the House, said in a statement on Thursday that they "are committed to producing a final bill that incorporates the best reforms for middle class families, small businesses, seniors, and our fiscal health [and] stays true to the values of our members."
The bills have a number of issues in common, such as establishing new rules requiring insurers to accept all individuals and employers that apply for coverage (known as guaranteed issue), eliminating rescissions, and preventing carriers from setting premiums based on health status.
Here's a look at 10 issues that they will need to reconcile:
1. Insurance exchanges. While the exchanges in the states would be open to small businesses and to individuals without access to employer coverage, different phase-in periods for other businesses appear in the bills.
The House bill calls for federal operation of the exchange, and offers states an option to create exchanges that are subject to federal guidelines. The Senate bill calls for states or regions to operate exchanges using federal guidelines. In the Senate bill, a health insurer's participation in the exchanges will depend on performance. For instance, insurers that increase their premiums before the exchanges begin will be excluded.
2. Public insurance option. Despite weeks of debate, the public insurance option was dropped from the final Senate bill. The House bill contains a public insurance option that requires the Health and Human Services (HHS) secretary to negotiate rates with healthcare providers as private insurers currently do.
The Senate bill instead has a provision in which multi state private insurance plans would be offered under contract with the federal Office of Personnel Management, with at least one of the plans being a nonprofit entity.
3. Medicaid expansion. Under the House bill, Medicaid would be expanded up to 150% of the federal poverty level (roughly $16,245 for a family of four). The House bill provides 100% federal financing of Medicaid expansions through 2014, and then 91% financing beginning in 2015.
In the Senate bill, the rate of eligibility is 133%. It would provide 100% federal financing of Medicaid expansions between 2014 and 2016. By 2017, most of the states would share in the cost of expanded coverage.
4. Financial assistance. For individuals with low or moderate incomes, subsidies would be available in the House bill on a sliding scale to offset the premium costs for plan enrollees living above 133% of the federal poverty level. Above that level, premium contributions would be capped at no more than 1.5% of income for those living at 133% of poverty to no more than 12% of income for those at 400%.
The Senate bill requires those families above the poverty level to contribute no more than 2% of income; this increases to no more than 9.8% of income for those at three to four times the poverty level.
5. Physician care. The House bill calls for a 5% increase in fees for primary care services, and a 10% increase in those areas with shortages. The Senate bill calls for a 10% increase for primary care physician fees, along with the fees for general surgeons practicing in areas with shortages.
6. Paying for healthcare. The Senate bill includes a Medicare payroll tax increase of 0.9% (to 2.35%) for individuals earning more than $200,000 or families making more than $250,000. A tax also is included on high-cost or "Cadillac" plans: a 40% tax is proposed for employer sponsored health coverage that exceeds $8,500 a year for individuals and $23,000 for families. The Senate also raises the threshold for deducting medical expenses from 7.5% to 10%.
In the House bill, the tax rate for high income families would be increased, with a 5.4% income tax surcharge on individuals with incomes over $500,000 and families with incomes over $1 million.
7. Mandated coverage. Under both bills, most Americans will be required to have coverage or face paying penalties. But some differences still exist. Under the House bill, individuals would have to have coverage by 2013 or pay up to 2.5% of their income; the penalty, however, could not surpass the average cost of a plan found in the exchanges.
In the Senate version, which would take effect by 2014, the penalty for not having coverage is $95 in 2014 or 0.5% of an individual's income—whichever is higher. This penalty would climb in 2016 to $750, or 2% of income—up to the cost of the cheapest health plan.
8. Employers. In the House bill, large employers would be required to offer coverage to their employees and contribute at least 72.5% of the premium cost for single coverage and 65% of the premium cost for family coverage of the lowest cost plan; or pay 8% of payroll into a health insurance exchange trust fund.
The Senate bill requires companies with 50 or more full time employees who do not offer coverage to pay $750 per employee to a trust fund if at least one employee obtains subsidized coverage through the exchange.
The House bill exempts small businesses with payrolls of less than $500,000. The Senate bill exempts firms with less than 50 employees from providing or contributing to coverage.
9. Health and wellness. Both bills call for establishing a fund to provide resources for community based prevention programs, childhood obesity programs, and other similar public health programs. The Senate bill, though, creates a new annual wellness visit, including a health risk assessment and personalized prevention plan, for Medicare beneficiaries.
10. Abortion language. The House bill has strict language: plans in the insurance exchanges that accept federal subsidies could not provide abortion services at all. The Senate bill would permit insurers operating in the new exchanges to offer abortion services, but enrollees would have to write separate checks for the abortion coverage.
HHS announced it is targeting $38 million for additional grants to support the training and development of a skilled health IT workforce.
Authorized under the $787 billion American Recovery and Reinvestment Act, the two new grants will award $32 million to establish university-based certificate and advanced degree health IT training programs, and $6 million to develop a health IT competency exam.
These latest awards, together with the recently announced $80 million in workforce program grants for the Community College Consortia and Curriculum Development Centers, recognize the need to develop a health IT workforce to support the meaningful use of health IT, said David Blumenthal, MD, HHS' national coordinator for health IT.
"To realize the widespread adoption of EHRs and achieve the vision of a transformed health system that health IT can facilitate, the workforce needs to be expanded and properly trained to facilitate rapid uptake of health IT by healthcare providers," Blumenthal said in a media release. "The workforce development program is expected to generate highly skilled professionals in key roles to meet 85% of the estimated need for expansion of the health IT workforce, who will in turn support healthcare providers and hospitals implement and maintain electronic health records and use them to strengthen the delivery of care."
The two new grant programs are titled: Information Technology Professionals in Health Care: Program of Assistance for University-Based Training Programs and Competency Examination for Individuals.
For the university-based training program, the national coordinator expects to issue eight to 12 one-time awards for academic programs that rapidly increase the availability of people qualified for specific health IT jobs that require university-level training. The training will emphasize programs that can be completed in one year or less. Awards are for a 39-month project period. Four-year colleges and universities may apply.
For the competency exam program, the national coordinator expects to issue a single one-time award to support the development and initial administration of a set of health IT competency exams. The exams will assess basic competency for individuals trained through short-term, non-degree health IT programs, and for people with relevant experience or other training to demonstrate their competency in health IT workforce roles needed to achieve meaningful use of electronic health information. The award is for two years.
Applications for both grants are due by January 25, and the final awards are expected in March 2010. Information is available at http://HealthIT.HHS.gov/ and www.grants.gov.
Politicians and pundits are opining about the Senate's approval of health reform legislation Thursday morning. Depending on your political slant, the bill is somewhere between a forward step toward improving healthcare and an expensive plan that will lead to more government intrusion.
But what do health leaders think of the final bill? Here are comments from five health stakeholders:
J. James Rohack, MD
President
American Medical Association
"The Senate bill will improve choice and access to affordable health insurance coverage and eliminate denials based on pre-existing conditions. It will increase coverage for preventive and wellness care that can lead to better disease prevention and management, and further the development of comparative effectiveness research that can help patients and physicians make informed treatment decisions. Patients will no longer face lifetime limits on health coverage or higher premiums based on medical conditions or gender.
"While this vote closes one chapter of the legislative process, the hard work is not yet done. The AMA will stay constructively engaged throughout the House and Senate conference process to continue to improve the final bill and assure the best outcome for patients and physicians.
"Important issues that need to be resolved in the House-Senate conference committee include the scope, authority, accountability, and transparency of a payment advisory board. The details of several cost control and quality improvement initiatives also need to be refined so that they do not have unintended consequences for patients and physicians.
"Separate action is needed early next year to permanently repeal the current Medicare physician payment formula to preserve access to care for America's seniors, baby boomers, and military families by creating a stable physician payment system."
Rebecca M. Patton, MSN, RN, CNOR
President
American Nurses Association
"This is a victory for advocates of meaningful healthcare reform. We are poised to see the most significant piece of legislation passed in a generation; legislation that ensures millions of Americans receive coverage, strengthens the nation's preventive and wellness care, and addresses critical shortages in the healthcare workforce."
Karen Ignagni
President and CEO
America's Health Insurance Plans
"Providing all Americans with healthcare coverage is crucial for the country. Health plans support legislative changes that would provide guaranteed access to all Americans, with no pre-existing condition limitations and no health-status-based premiums. These reforms are essential to giving all Americans greater peace of mind and health security.
"At the same time, specific provisions in this legislation will increase, rather than decrease, healthcare costs; reduce coverage options; and disrupt existing coverage for families, seniors, and small businesses—particularly between now and when the legislation is fully implemented in 2014.
"These issues can and should be addressed if healthcare reform is going to fulfill the promise of providing all Americans with guaranteed access to affordable, portable health care coverage."
Ken Johnson
Senior Vice President
Pharmaceutical Research and Manufacturers of America
"We applaud the Senate for taking an important and historic step toward expanding high-quality, affordable healthcare coverage and services to tens of millions of Americans, many of whom are struggling today financially. While considerable work remains to be done in reconciling differences between the Senate and House bills, we remain convinced that comprehensive healthcare reform, if done in a smart way, will benefit patients, our economy and the future of our nation.
"Most importantly, the Senate bill recognizes the importance of medical progress in America. Innovative, cutting-edge medicines have dramatically increased life expectancy rates in the United States and have allowed patients with cancer, heart disease, diabetes and other devastating chronic diseases to live longer, healthier, and more productive lives. We strongly believe that everyone in America should benefit from promising new advances in medical care…
"Our commitment to comprehensive healthcare reform is evident by our $80 billion pledge to reduce healthcare costs over 10 years. To that end, our companies agreed back in June to help most eligible seniors and disabled Americans who hit the so-called 'donut hole' in Medicare Part D cut their out-of-pocket expenses on brand-name medications in half as part of the Senate's healthcare reform legislation. The remainder of our commitment will help the government expand healthcare coverage to millions of Americans."
A. Barry Rand
CEO
AARP
"The bill passed by the Senate makes needed progress to prevent coverage denials due to health status and limit insurance companies from charging older Americans much more for coverage because of their age. It also begins to close the dangerous gap in Medicare drug coverage known as the doughnut hole, and Senate leaders have committed that a final bill will close the gap entirely by 2019, in keeping with the President's pledge.
"In addition, the Senate bill adds important new Medicare benefits, like free preventive care, and encourages states to provide more home and community-based long-term care services and supports instead of costlier institutional care."
The most notable year in hospital medicine used to be 1996, when the phrase "hospitalist" was first coined in the New England Journal of Medicine. That is the year typically associated with the official birthday of hospital medicine.
Now, another landmark year has dawned. The year 2009 was a milestone for hospital medicine.
Hospitalists now have certification in hospital medicine from the American Board of Internal Medicine, as well as their own designation (Fellow of Hospital Medicine, or FHM, for short) from the Society of Hospital Medicine (SHM).
As the fastest growing medical specialty, hospital medicine includes a field of 30,000 practicing hospitalists in the country, according to SHM. With the newfound certification and designation, hospitalists are increasingly gaining professional recognition in the healthcare world.
Certification in hospital medicine
After years of whispers and held breaths, the American Board of Internal Medicine (ABIM) and the American Board of Family Medicine (ABFM), under the American Board of Medical Specialties (ABMS), in October officially announced a five-year pilot program for focused practice in hospital medicine (FPHM) for general internists.
"This is not only a new kind of credential in hospital medicine, but it is a new kind of credential for the certifying board in that we are credentialing you not based on additional training, but rather based on what you have been doing for a living," said Robert M. Wachter, MD, professor and associate chair of the Department of Medicine at the University of California, San Francisco, and a member of the ABIM board of directors.
FPHM is considered maintenance of certification, rather than a separate certification. In the typical internal medicine maintenance of certification, which most hospitalists go through, physicians must complete a practice improvement module every 10 years. However, those pursuing the new FPHM must complete the more frequent standard of one in every three years. The FPHM criteria include ABFM- and ABIM-developed tools that are specifically targeted at hospitalist practice-based learning.
Just as airline pilots and teachers must recertify every couple of years, physicians might consider more frequent certification, according to Wachter. The new FPHM shows a continued competency and dedication in hospital medicine, he said.
ABIM vs. ABPS: Who's on first?
There's debate, however, on which organization was the first hospitalist certifying board. The American Board of Physician Specialties (ABPS) announced the newly established American Board of Hospital Medicine (ABHM) in January. The new ABHM generated debate among the hospitalist community about its validity as a certifying board, with e-mails and blogs filled with chats about what to expect.
A study in September concluded that the three major board certifying organizations—The ABMS, ABPS, and the American Osteopathic Association's Bureau of Osteopathic Specialists—require the same amount of certification and recertification requirements. The study, which was conducted by The Associated Industries of Florida Service Corporation, compared the three organizations' requirements by medical specialty, including years of required training, exams, documentation, and CME hours; it concluded the boards were essentially equal in the rigor of standards.
The new initials: FHM
In addition to the new options in certification, hospitalists now also can apply for some added letters on the nametag—FHM.
SHM announced the first class of Fellows of Hospital Medicine at its annual meeting in May. The 500-plus hospitalists with this honor are now adding FHM to their bios after MD or DO.
"Employers can look at this designation and know that a physician has special competencies, and it is important to physician colleagues because it demonstrates that we are committed to hospital medicine," says Shaun Frost, MD, FACP, FHM, regional medical director at Brentwood, TN–based Cogent Healthcare, member of the board of directors at SHM, and chair of the SHM membership committee that spearheaded the FHM process.
Just as the FHM designation is an added distinction, it also helps validate the specialty as a whole, according to Jeffrey Greenwald, MD, FHM, member of the hospital medicine unit at Boston Medical Center and associate professor of medicine at Boston University School of Medicine.
"I remember going to a lot of SHM meetings during my first five years as a hospitalist and thinking, ‘Gosh, when is the time going to come when we can stop defending who we are,'" said Greenwald. "In some ways, the FHM is that recognition that hospital medicine is here to stay."
What's to come in 2010?
Next year, SHM will announce the Senior Fellows of Hospital Medicine (SFHM) and Master's of Hospital Medicine (MHM) for nomination- and invitation-only members who have reached high leadership levels of experience.
In addition, applicable hospitalists can look forward to entering the ABIM pilot program in 2010, as well as look for the ongoing results of the FPHM programs.
Karen M. Cheung is an associate editor for HCPro, contributing writer for HealthLeaders Media, and blogger for HospitalistLeadership.com. She can be contacted at kcheung@hcpro.com. Liz Jones, associate editor of Medical Staff Briefing, contributed to this article. She can be contacted at ejones@hcpro.com.
