At the height of the fall's swine flu surge, hospitals across the Chicago area banned children from entering because they are prolific carriers of the H1N1 virus and posed a threat to patients, particularly those in high-risk categories. Now, as H1N1 cases wane but experts warn of another possible spike, some hospitals are wrestling with the question of whether, and when, to lift the restrictions, the Chicago Tribune reports.
Unionized employees at four community hospitals in the Massachusetts-based Caritas Christi Health Care system have ratified a new four-year contract that will give them a 3% raise and a bonus on Jan. 1. The nearly 3,000 workers, represented by Local 1199 of the Service Employees International Union, stand to receive another 4% pay hike next October and additional raises of at least 2% in the third and fourth years of the contract, the Boston Globe reports.
A new Massachusetts policy requiring crowded hospital emergency rooms to accept all patients delivered by ambulance has not worsened conditions, as some doctors had feared. According to an analysis by state public health officials, the average time patients spent in 75 of the state's emergency rooms remained about the same since the rules went into effect in January 2009. Patients who were admitted to the hospital spent between 5 and 5 1/2 hours in the emergency room, while patients who were sent home spent about 2 1/2 hours, the Boston Globe reports.
By 2019, the number of uninsured could be reduced from an estimated 57 million to 24 million under the current Senate healthcare reform bill. However, the accompanying additional demand for services that would accompany this expansion would be difficult to meet initially with existing health provider resources—leading to "price increases, cost-shifting and/or changes in providers' willingness to treat patients with low-reimbursement health coverage," according to a Dec. 10 memo compiled by Richard Foster, the Centers for Medicare and Medicaid Services (CMS) chief actuary.
The memo also notes that while net Medicare savings are estimated at $493 billion for the next decade, some of those savings may be unrealistic. For instance, the Senate reform bill would add "permanent annual productivity adjustments" to price updates for most providers--such as hospitals, skilled nursing facilities, and home health agencies—using a one-year average of productivity gains throughout the economy.
While the payment update reductions could provide "strong incentives" for all providers to improve their efficiency in providing services, "it is doubtful that many could improve their own productivity to the degree achieved by the economy at large," the memo noted.
Over time, this could cause Medicare rates to grow more slowly and "in a way that that was unrelated to the providers' costs of furnishing services to beneficiaries," according to the memo. This would mean that for those providers for whom Medicare "constitutes a substantial portion of their business," they could find it in the long run difficult to remain profitable.
And without legislative intervention, they could possibly end their participation in the program—thus jeopardizing the care of Medicare beneficiaries. Simulations by the Office of the Actuary also show that about 20% of Part A providers could end up becoming unprofitable, as well.
Caritas Christi, Massachusetts' largest community-based healthcare system, and the Service Employees International Union announced a first-of-its-kind labor agreement Friday that partially indexes pay hikes to reimbursement rates at four hospitals in the Bay State.
The four-year contract—which was ratified by 90% of the workers—also provides benefits and education opportunity improvements for nearly 3,000 members of local 1199SEIU at the hospitals, which includes access to the local's Training and Upgrading Fund—the largest joint labor-management training and education fund in the country.
Caritas and SEIU officials said in a joint media release that the contract underscores their shared mission to ensure improved funding and care delivery throughout the health system.
"Providing greater workforce stability and enhanced training and education programs, and the creation of a collaborative approach to problem-solving will allow us to continue to offer access to quality care in the communities we serve," said Caritas Christi CEO Ralph de la Torre, MD.
The contract is the first of its kind in Massachusetts that partially indexes select wage increases to hospital reimbursement rates. The contract immediately brings the hourly wages of the lowest-income employees at the four hospitals to $12.62. Additional across-the-board raises for all 1199SEIU members are scheduled for Jan. 1, 2010 (3% plus ratification bonus), Oct. 1, 2010 (4%), Oct. 1, 2011 (2% guaranteed plus another increase based on hospital reimbursement rate), and Oct. 1, 2012 (2% guaranteed plus another increase based on hospital reimbursement rate).
The agreement affects workers at St. Elizabeth's Medical Center in Brighton, Carney Hospital in Dorchester, Norwood Hospital in Norwood, and Good Samaritan Medical Center in Brockton. Workers at three of the four hospitals voted to join 1199SEIU after Caritas Christi signed a Free and Fair Elections accord with union members in January. Workers at Good Samaritan had previously joined SEIU.
"When caregivers achieve economic security, it's not just good for workers and their families, it's also good for patients," said 1199SEIU President George Gresham. "It's good for the community, and ultimately good for the health system when the work of caregivers is recognized and they have a voice."
With more than 13,000 employees serving more than 600,000 patients annually in 85 communities, Caritas Christi is the 10th largest employer in Massachusetts.1199SEIU United Healthcare Workers East is the largest healthcare union in the nation, and represents more than 340,000 healthcare workers in Massachusetts, New York, Maryland, New Jersey, and Washington, DC.
Requests for medical records are already arriving in hospital mailboxes following the approval of the first set of issues for complex RAC review earlier this week.
Connolly Healthcare was approved to audit a number of DRG validation issues in the following Region C states: Alabama, Colorado, Florida, Georgia, New Mexico, North Carolina, Oklahoma, South Carolina, Tennessee, and Texas.
One hospital in southern Alabama has already received a number of documentation requests for various issues. Two of the hospitals in their system received a total of 38 requests in the past few days auditing the following DRGs:
MS-DRG 163 (Major chest procedures with MCC)
MS-DRG 164 (Major chest procedures with CC)
MS-DRG 167 (Other respiratory system OR procedures with CC)
MS-DRG 207 (Respiratory system diagnosis with ventilator support 96+ hours)
MS-DRG 329 (Major small and large bowel procedures with MCC)
MS-DRG 394 (Other digestive system diagnoses with CC)
MS-DRG 432 (Cirrhosis and alcoholic hepatitis with MCC)
MS-DRG 871 (Septicemia or severe sepsis without MV 96+ hours with MCC)
MS-DRG 872 (Septicemia or severe sepsis without MV 96+ hours without MCC)
MS-DRG 981 (Extensive OR procedure unrelated to principal diagnosis with MCC)
MS-DRG 983 (Extensive OR procedure unrelated to principal diagnosis without CC/MCC)
MS-DRG 987 (Non-extensive OR procedure unrelated to principal diagnosis with MCC)
MS-DRG 988 (Non-extensive OR procedure unrelated to principal diagnosis with CC)
MS-DRG 989 (Non-extensive OR procedure unrelated to principal diagnosis without CC/MCC
Another Alabama hospital reported receiving their first documentation requests Tuesday. Their hospital is in the process of gathering together the requested documentation. In addition, their RAC team, which includes HIM, case management, nursing, compliance, finance and other staff members, plans to meet next week to look at the requested documentation and related process.
Alabama, however, is not the only state with providers reporting RAC documentation requests. A six-hospital system in Tennessee received 57 requests as of Wednesday. The hospital worked diligently prior to the start of the RAC program to prepare, and so far, it has paid off.
Certainly, now that Connolly Healthcare has been approved to audit for DRG validation, other providers across Region C should begin to see their first documentation requests in the near future, if they haven't received them already.
A model of the health system of the future has come screaming out of the Dakotas like a winter blizzard. Who would've thunk it? Sanford's superstar CEO Kelby Krabbenhoft thunk it, that's who.
It's being called the largest rural healthcare system in the country, and is well on its way to being fully integrated—a term that means physicians and management are on the same page regarding financial and quality goals. Sanford Health-MeritCare will operate in six states: North Dakota, South Dakota, Minnesota, Iowa, Nebraska, and Oklahoma, with 17,400 employees and more than 800 physicians, 70 specialty areas in medicine, and 29 hospitals over 1,600 beds serving more than 2 million people in the service area. The combined annual net revenue is $2 billion.
As such, it's well-prepared for the future of healthcare reimbursement and accountability. For someone with such clout, Krabbenhoft is unassuming and humble about his role. In a physician-driven leadership team, he is among very few non-physicians in those roles at the institution, and he likes it that way.
I spoke with Krabbenhoft recently, and as I reviewed the interview, I came up with four reasons the merger should pave the way for a more accountable healthcare if other systems can follow Sanford-MeritCare's lead.
Integration
Its focus on an integrated model (that is, a largely employed physician staff) will give it leverage and the integration needed to achieve ambitious quality targets.
"I've lived as the CEO of a system that didn't have any aligned physicians. None. And I would go farm rather than go back there. It's like trying to get anything done through the United Nations. Building the integrated model in its purest form, as we've tried to do, perfectly situates us for any reform, because we're going to be able to answer their questions, whoever 'they' are—major payers and government. We can speak to quality, amalgamating outcomes on any platform, whether it be by DRG, case, or by procedure. We can speak economically and clinically with a united physician backbone in the organization. Being that large and covering that many patients has put us in a great position to talk of reform where it's not a battle with reformers. We can produce value that from a payment standpoint, which they'll be appreciative of," says Krabbenhoft.
Physician leadership
Other than Krabbenhoft, physicians control most of the leadership positions. Some 93-95% of its revenue comes from employed physicians.
"When a physician joins, they understand our expectations, but we also have a physician covenant designed by the doctors, which forces all to share responsibility on quality. They hold up their end of the bargain, and we'll provide all the institutional and technological support they need. The docs are fully capable of governing themselves and enforcing quality better than any management person," says Krabbenhoft.
No JVs, period
Sanford-MeritCare refuses to do joint ventures, making sure the docs are on a level playing field within the organization.
"If someone doesn't want to play our kind of team ball there are plenty of options out there. Free agency is alive and well in medicine, but I believe those days are coming to an end. Our goals is to be one of the best institutions in the country, and none of those, whether it be Kaiser, Johns Hopkins, Cleveland Clinic—none of those do joint ventures, carve-out deals—none of that stuff, he says."
Huge size, huge goals
The sheer size of the new entity will give it further negotiating clout with insurers and economies of scale. The merger didn't require antitrust review, because the two service areas do not overlap. Health system CEOs should keep that in mind for future acquisition strategies.
"Once a legal team figures out the core business and the relationships between docs, they really start to serve as an M&A center. Our growth has really taken on meteoric proportions lately and it's because the whole team has growth on its agenda," he says.
Many chief information officers have smartphones on the top of their 2009 wish list. The compact mobile devices combine online access to information with PDA (personal digital assistant) functionality, making them perfect for on-the-go clinicians.
According to a report by market-research firm Manhattan Research, the number of physicians who own smartphones will increase from 64% to 81% by 2012. The October 2009 report states that the ability to complete tasks remotely will become even more indispensible to physicians in the future.
The devices are becoming the desktop of the future as hardware improves and applications become more sophisticated and robust. Programs that were formerly only available on desktops, such as PACS (picture archiving and communication system), can now easily fit in a physician's hand.
"We're no longer using it as a reference device, we're using it as a computer replacement," says Henry J. Feldman, MD, chief information architect at Beth Israel Deaconess Medical Center in Boston.
Whether your facility provided you with a smartphone or you purchased one as a gift to yourself, the experts say that you can expect to see some innovative trends in mobile health applications making their way to handheld screens next year.
1. Augmented reality
"Augmented reality" is the latest buzzword for smartphones. It describes the ability of users to view real-world structures using the GPS, camera, compass, and other hardware contained in a smartphone. WIKITUDE World Browser is one example of augmented reality.
The browser presents smartphone users with information about their surroundings, such as nearby points of interest. It works by overlaying information on the real-time camera view of a smartphone.
In healthcare, this may mean that one day patients may be able to point a smartphone at a facility and view detailed information, such as a staff directory, phone numbers, and building maps. They may even be able to take virtual tours. Think of it like a high-tech online information desk.
"It would tell you any information you want to have about a building just by where the phone is pointing," says Mark Laytar, a Web production manager at Baltimore-based University of Maryland Medical Center (UMMC). "It's really interesting."
2. EMR integration
Electronic medical records (EMR) aren't going to stop making headlines. If smartphones have anything to do with the matter, we'll begin seeing applications that integrate a patient's EMR with a physician's smartphone.
PatientKeeper is one such product. The Newton, MA-based company of the same name has developed an application that lets physicians access their EMR systems from a smartphone. Physicians can view a list of patients, a patient summary, lab and test results, medication lists, clinical notes, allergies, and much more.
Naturally, accessing clinical data on a mobile phone will likely raise data security and privacy concerns. Feldman says this problem can be easily solved using encryption technology.
"People have to remember that a smartphone isn't any different than a laptop," he says.
Given the popularity of the application, one can expect EMR companies to develop their own tools in response to this mounting need, especially given the growing number of physicians who are using mobile devices.
3. Image viewing
OsiriX Imaging Software has an open source PACS application available on the iPhone. The company offers free and sophisticated paid versions of the application. Physicians can use the application for PACS tasks they would have ordinarily completed using the OsiriX desktop application.
"It's not a weird sort of hybrid application," says Feldman. "This is a genuine PACS system for your iPhone."
Feldman says he can walk down the hall, run into a colleague, and conduct a consult on the fly by displaying patient CAT scans and animations. It even allows him to annotate images that will sync back to the PACS system.
"It's not diagnostic quality," he admits. "But it's good enough for 90% of what we do."
Feldman says the mobile hospital desktop, a.k.a. "the computer on wheels," is no match for his smartphone, which is always by his side and linked to the hospital network. If he were to use a desktop to conduct a consult, he would need to locate it and wheel the heavy, awkward device where he needs to use it.
"I can do all the things that I normally do on a desktop during my walk down the hall with another physician," says Feldman. "That's a fundamental shift."
The Blausen Human Atlas is another fine example of an imaging application. It provides point-of-care access to animations of medical treatments and conditions, along with accompanying narration. Users can manipulate illustrations and animations. The added zoom capability lets them explore different parts of the body systems.
"If you're a clinician, you can use the atlases as an educational tool with your patients," says Michelle Snyder, senior vice president of subscriptions at San Mateo, CA-based Epocrates, which markets a popular drug and disease reference application.
4. Mobile health monitoring
Gartner, Inc., an information technology research and advisory company, recently ranked mobile health monitoring—the use of mobile communications to monitor patients remotely—number five in its top 10 consumer mobile applications for 2012. The company's report states that mobile health monitoring has the potential to help governments, care delivery organizations, and healthcare payers reduce costs related to chronic diseases. It also has the potential to improve quality of life in patients.
According to Feldman, Apple has already made it possible to turn an iPhone into a glucometer. Instead of going to their physicians with their diabetes logs, patients may only have to bring a smartphone with them in the future. (You can view a demonstration of this technology at www.youtube.com/watch?v=0lwp2vgxF3I.)
"It frees you from the computer," says Feldman. "Right now, people show up with a glucometer and sometimes I can figure it out, sometimes I can't. All of the sudden, I now have a device that I understand and it's standardized."
Snyder says it is in the best interests of pharmaceutical companies to enter the mobile health monitoring space. If their patients become more compliant, then they will use more of their medications.
She predicts that patients may not be the prime audience for mobile health monitoring applications, since most patients with chronic diseases are older and not as likely to use mobile devices. However, she states that these applications would be helpful to an individual who may be caring for an aging parent.
5. Disease mapping
News outlets are typically the timeliest source of information on the spread of diseases. However, one smartphone application has set out to change that. HealthMap integrates disease outbreak data from news sources, personal accounts, and official alerts and displays them on a Web site.
The project, which is based out of the Massachusetts Institute of Technology (MIT) Media Lab in Cambridge, MA, is funded through a grant by Google.org, the philanthropic arm of Google.
HealthMap, which launched as a Web site over two years ago, has released an application called OutbreaksNearMe, which is available on both the iPhone and Android smartphone platforms. The application provides users with location-based information about diseases using the global positioning system (GPS) available in smartphones.
"We can deliver HealthMap alerts directly to your phone that are particularly relevant to your current location," says project co-founder Carl Freifeld, a PhD student at the MIT Media Lab. "I think having the smartphone application makes it easy for physicians to keep up to date on what outbreaks of diseases are happening in their area so they know what to look for when their patients come in."
While federal, state, and local health departments collect data about diseases, they often conduct a lengthy approval process. By the time information reaches physicians, it may be too late for them to react. By comparison, the information on OutbreaksNearMe gathers real-time data.
"Official announcements are obviously still very important, but in order to be official, it has to go through a vetting process," says Freifeld. "That introduces a time lag."
6. Interactivity
In 2010, look for interactive smartphone applications that allow users to contribute data in addition to accessing it. OutbreaksNearMe has already started incorporating interactivity into its application. Users can contribute knowledge about disease outbreaks in their area using the application. The concept is similar to the iReporter feature that CNN.com uses to gather news tips from the public.
"It's exciting for us, because it's a way to improve our system to get access to even more information. It also allows users to be participants in the HealthMap community rather than be passive recipients of the data we're collecting," says Freifeld.
Another example of this trend comes from UMMC. The hospital garnered much attention when they released Medical Encyclopedia, an application containing approximately 50,000 pages of medical content from A.D.A.M., a creator of health-related information. (For more information on this application, visit www.umm.edu/iphone/.)
"We really didn't know what to expect, but we certainly weren't expecting 1,500 to 2,000 downloads a day, which we've gotten consistently from day one," says UMMC Web site editor Chris Lindsley. "We became one of the most popular medical applications right out of the gate."
The reference application lets users ask experts at the medical center questions about health concerns. While the experts do not diagnose patients online, they do provide them with explanations of diseases and conditions and direct them to sources of additional information.
7. Mobile testing
On-the-go physicians need tools they can take with them as they travel from one patient's room to the next. Expect to find companies releasing more mobile testing applications in 2010. Some applications that have been extremely popular include eye charts, color blindness tests, hearing tests, stress checks, and many others.
Many applications are beginning to leverage the smartphone accelerometer—a device that detects motion. When you turn your phone left or right, the display of a phone with a built-in accelerometer will change from portrait to landscape. For gamers, that means that they can simulate driving a vehicle by simply tilting their phone.
Healthcare is developing slick applications using this feature. The CobbMeter is one such example. It allows physicians to measure spine curvature angles with surprising accuracy. Instead of using a protractor, physicians can align the side of an iPhone to standard tracings that they use and the position sensor in the phone will display the curvature angle. The precision of the device is 1/10th of a degree.
There are also CPR applications that let users practice CPR motions by pushing their smartphone down to deliver compressions. The applications provide users with feedback on the appropriate amount of force they should use during compressions.
8. Videos
Snyder predicts that 2010 will bring with it a lot more video, particularly for instructional purposes. One company to watch is Durham, NC-based Modality, Inc. They create learning and reference applications for the Apple iPhone and iPod touch.
One of their more popular applications is called Procedures Consult. It helps users prepare for, perform, and test their knowledge of common medical procedures encountered in a clinical setting. It uses videos, animations, illustrations, and text.
According to Snyder, many hospitals are using Modality tools to train student nurses, nurses, and other healthcare professionals.
For more information about Procedures Consult, and other Modality tools, visit www.modalitylearning.com.
9. Guidelines
Although admittedly less exciting, smartphones will soon be able to access clinical guidelines. Organizations don't need to invest a lot of time making guidelines suitable for smartphones, since they typically already have the content developed and on their Web sites.
"Associations are realizing that it's not that hard to get your guidelines into an app for the iPhone," says Snyder. "I think you're going to see more associations, societies, and other organizations developing their guidelines for the iPhone, because that's usually when the clinician wants to look at it—at the point of care. It's the same reason they use ePocrates."
10. Revamped reference apps
In addition to the top nine trends listed in Medicine on the ‘Net this month, you can expect to find enhancements to popular applications like ePocrates and UpToDate (an evidence-based, peer-reviewed information source).
"The reference apps have grown up," says Feldman. "They have connectivity to the Internet. So ePocrates, which used to be a simple textbook, now has intelligence."
For example, if a patient brings a mysterious blue pill to an appointment, the physician can look up the pill in ePocrates and determine what medication it is based on its visual characteristics. The tool can also look up drug formularies based on a patient's health plan.
"A lot of people are taking what they already have and then adding additional features and functionality," says Snyder.
Beyond 2010
In the future, you can expect to find more individuals entering the health informatics industry. According to Feldman, many developers who are releasing smartphone applications don't have a clinical background—and it sometimes shows.
"When I'm on the ward, I work 100 hours a week seeing patients, but at the same time I write a lot of code," he says. "I understand software and system design, but at the same time I understand the clinical care. It's easy to make apps now; it's hard to make them good. If you design these incorrectly, you can kill people."
Smartphones, along with their applications, will continue to evolve in response to the persistent demand for mobile information and tools that solve real-life problems for the growing number of clinicians who will adopt these devices.
The experts predict that the next advance in smartphones may occur when 4G (fourth generation) wireless devices come on the market.
"It basically means that you're going to be walking around with Ethernet speed everywhere," predicts Feldman.
Cynthia Johnson is the editor of Medicine On The 'Net, a monthly newsletter from HealthLeaders Media.
Medical residents often fail to report needlestick incidents, which can put them at risk for blood-borne diseases, a recent study shows.
Of 699 surgery residents surveyed, 59% reported they had been stuck by a needle more than once, according to the report that was published in this month's issue of Academic Medicine. However, about half of those residents failed to report the incident to hospital officials. Not reporting such incidents means that the residents do not receive treatment to prevent infections, such as HIV or hepatitis C.
Study authors said residents do not report the incidents because they are embarrassed and are afraid that they will receive negative evaluations from faculty. It's up to hospital and GME administrators to work together to create a culture in which residents and other healthcare workers feel comfortable speaking up. One way to transmit that message is through a robust IC training program.
Emphasizing the importance of IC training, principles, and expectations from day one is critical to helping residents form good IC habits, says Bruce Polsky, MD, chief of the division of infectious diseases at St. Luke's-Roosevelt Hospital Center in New York City. "If you do not do that, then you're in the position of having to break bad habits."
Although residents at many hospitals receive IC training during orientation, they tend to become lax about certain practices overtime. For example, residents understand the importance of hand hygiene, but it is difficult to get them to put it to practice consistently, he adds.
Tackle this problem by enlisting IC department employees, nurse managers, and unit receptionists to monitor the ward and report residents or veterans who violate hand-hygiene procedures. When a breach occurs, the observer intervenes and corrects the resident. If the monitor does not feel comfortable interceding, he or she can report the issue to an attending physician who then speaks with the resident.
When noncompliance becomes a chronic problem, the information is relayed to the resident's immediate supervisor and then up the chain of command to the program director.
Residents also become lax about wearing personal protective equipment (PPE) because putting it on and discarding it can be an arduous process that adds several minutes to seeing a patient. "They have a heavy workload … and this just adds another layer of complexity," Polsky says.
Instructing residents on the proper way to wear gloves and gowns is critical, and involving program leadership in the training will make the lesson resonate more with residents. At St. Luke's-Roosevelt, program directors demonstrate how to correctly wear gear, conveying that wearing PPE is important.
In a situation where a resident does not follow hand-hygiene or PPE guidelines, Polsky says the punishment should not be punitive. "We want people to understand it is for their own protection and … this should be a standard part of taking care of patients."
Program directors should focus on remediation and coach the resident on the proper way to perform the technique, says Polsky.
Julie McCoy is associate editor for the Residency Department at HCPro, Inc. For more residency-related news, visit www.residencymanager.com.
On the 11th day of Senate floor debate on healthcare reform, Majority Leader Harry Reid (D-NV) slowed down the pace—reserving the afternoon to address appropriations legislation and cancelling plans to work around the weekend like the week before. Ironically, the most disappointed in this slowdown were the Republicans.
"We were in last weekend presumably because the majority felt it was really important to try to pass this healthcare bill. We agree it's an important subject, and we'd like to vote," said Senate Minority Leader Mitch McConnell (R-KY) at a briefing.
Overall, Thursday failed to bring a clearer picture of the exact plan that the Democrats have in mind—whether the public option is being dropped completely or whether some new proposals are gaining acceptance among most of the senators. Each decision will have supporters and detractors not only within the Senate, but outside the walls of the Capitol, which the legislators will have to take into consideration.
Now under review, a provision making Medicare accessible to the estimated 4.5 million uninsured Americans between the ages of 55 and 64. While not new, the idea (which emerged even before the Clinton era) is seen as gaining acceptance among those who would like to see movement toward a single-payer system.
However, this system has made major providers of care—including hospitals and physicians—uneasy after previously pledging to cut down on care costs during the next decade. At particular issue are the lower reimbursement rates paid under Medicare when compared with private insurers. More details are pending until a cost estimate is issued from the Congressional Budget Office—probably by early next week.
Also under consideration is creation of a plan—such as the Federal Employee Health Benefit (FEHB) plan—which supports health coverage for nearly 8 million government employees and their families.
The Office of Personnel Management operates FEHB as a huge employer sponsored health plan, with the federal government picking up a share of the premiums. Federal employees get the opportunity to work with regional and rate based plans offered through the FEHB.
The OPM could bring its ongoing experience in negotiating contracts with insurers to provide health coverage on a state and regional basis. However, it is unclear whether the office is prepared to take on a huge new program.
Supporters believe the compromise would be enough to inject more competition into the exchanges. Detractors have said that the total costs could be too high for those who could use the services.
Meanwhile, other parts of the bill remain hotly debated, such as the amendment proposed by Sen. Byron Dorgan (D ND), that would permit pharmacies and wholesalers to import less expensive drugs from countries with comparable safety standards.
As a senator, President Obama had supported efforts in the Senate to permit this drug importation. However, the White House is not likely to promote this idea heavily because it could challenge current pharmaceutical industry support for the bill—support Obama does not appear to want to lose.
Industry support is considered a key to passage. That is why the White House negotiated a controversial deal to limit the financial effect of the overhaul on the industry in exchange for its support.
Earlier this week, the Food and Drug Administration announced in a letter that it opposed Dorgan's amendment because it would be "logistically challenging" to implement and raised "significant" concerns about drug safety.
