A federal judge in Pensacola, FL on Monday threw out as unconstitutional the entire Patient Protection and Affordable Care Act because of the inseverable individual mandate provision that requires people to carry health insurance or else pay a penalty.
"This case is not about whether the Act is wise or unwise legislation. It is about the Constitutional role of the federal government," Senior U.S. District Judge Roger Vinson wrote in a 78-page ruling. "Because the individual mandate is unconstitutional and not severable, the entire Act must be declared void."
The ruling will likely be appealed by the federal government at the U.S. Court of Appeals in Atlanta, and the case is expected to be heard eventually by the U.S. Supreme Court.
The suit was filed last March minutes after President Obama signed the reforms into law. The 26 states' attorneys general – almost all of them Republicans – who joined the suit complained that the federal government had overstepped its authority by mandating insurance coverage in the healthcare reforms.
Vinson agreed.
"I must reluctantly conclude that Congress exceeded the bounds of its authority in passing the Act with the individual mandate," wrote Vinson, who was appointed to the court by President Ronald Reagan. "That is not to say, of course, that Congress is without power to address the problems and inequities in our healthcare system. The healthcare market is more than one-sixth of the national economy, and without doubt Congress has the power to reform and regulate this market. That has not been disputed in this case. The principal dispute has been about how Congress chose to exercise that power here."
Vinson's ruling is the fourth by a federal judge on the constitutionality of the healthcare reform law. A Republican-appointed federal judge in Virginia struck down the individual mandate provision of the law, while two Democratic-appointed federal judges have upheld it.
The White House and the Department of Justice did not immediately respond to the ruling.
Republicans in Florida, however, applauded the decision. Attorney General Pam Bondi, who took office in January, called the ruling "an important victory for every person who believes in the freedoms granted to us by our Constitution."
"This proves that the federal government requiring Americans to purchase health insurance is in fact unconstitutional," Bondi said. "In addition, the bipartisan effort from Attorneys General across the country shows the federal government that we will not back down from protecting the constitutional rights of our citizens."
Florida Gov. Rick Scott, who also took office in January, said Vinson has "confirmed what many of us knew from the start; ObamaCare is an unprecedented and unconstitutional infringement on the liberty of the American people."
Online job ads for healthcare practitioners and technical workers surged in January by 78,500 listings, and ads for healthcare support jobs also grew by 16,600 listings, as healthcare jobs led a strong first month of 2011 that saw 438,000 new job listings in the overall economy, The Conference Board reports.
June Shelp, vice president at The Conference Board, called the January surge "welcome news" after relatively flat job growth during the second half of 2010, but she cautioned that it's too early to call it a trend. "Last year, after a promising start (up about 350,000 in January 2010), labor demand fizzled, and the last half of 2010 was actually flat with no appreciable gains in job demand," Shelp said. "Hopefully the January 2011 increase suggests that employers are seeing a pickup in their businesses and labor demand will continue to improve throughout this year."
The board's Help Wanted Online Data Series tracks more than 1,000 online job boards across the United States. Forty-nine states posted gains in online job listings. Rhode Island reported a decline of 200 job postings.
The surge in skilled healthcare practitioner job listings was fueled by a demand for registered nurses, and family and general practitioners. There were three job listings for every healthcare practitioner job seeker, with the average salary of $33.51.
Healthcare support saw an increase in many areas including home health aides, nursing aides, orderlies,and attendants. However, there are still 2.4 workers seeking positions in healthcare support for every advertised vacancy, with pay averaging $12.84 an hour.
Hospitals created 50,100 jobs in 2010, nearly double the rate of job creation from 2009, and the entire healthcare sector - everything from allergists to X-ray technicians -- created 265,800 jobs for the year, Bureau of Labor Statistics preliminary data shows.
Overall, the healthcare sector employed 13.9 million people at the end of 2010, including 4.7 million jobs at hospitals, 6 million jobs in outpatient ambulatory services, and 2.3 million jobs in physicians' offices, BLS preliminary data show.
For December, the healthcare sector recorded 35,700 payroll additions, including 8,000 hospital jobs. However, ambulatory healthcare services continues to be the major driver of healthcare job creation, with 20,600 payroll additions in December, and 160,200 payroll additions recorded in 2010, BLS preliminary data show.
The Conference Board reports that in the overall economy, online advertised vacancies grew by 438,000 in January, to 4.2 million listings, following a decline of 9,400 listings in December. With the January increase, labor demand has risen 1.44 million job postings since the series low point in April 2009. This increase now offsets approximately 80% of the 1.76 million drop in ad volume during the two-year downturn period from April 2007 through April 2009.
Even with the uptick, however, the nation's supply/demand rate stood at 3.78 unemployed people for every advertised vacancy in December (the last available unemployment data), down from a peak of 4.73 in October 2009. Nationally, there are 10.6 million more unemployed than advertised vacancies, The Conference Board reports.
The American Hospital Association issued a report this month on the status of wellness programs at the nation’s hospitals. It’s worth reading, even though the findings are less than encouraging.
As my HealthLeaders Media colleague Cheryl Clark notes, the AHA’s report, A Call to Action: Creating a Culture of Health, finds that most healthcare systems in the U.S. offer wellness programs of varying intensity and enthusiasm to their employees. Few, however, measure outcomes and fewer still have engrained healthy behaviors as part of their employees’ culture.
That sounds discouraging, but it shouldn’t be. The wellness movement in the workplace is a relatively new but simple concept: Improving employee health will reduce the growth of healthcare costs, and other ancillary costs, like absenteeism. The problem is not the wellness concept. That’s easy. Tens of millions of people who’ve tried to lose weight, or take up exercise, or quit smoking to improve their health understand the importance and desirability of wellness.
The problem is changing people’s less-than-healthy habits, like poor diet or sedentary lifestyle, learned over decades, and reinforced in everyday life – mostly during the two-thirds of the day that they’re away from work. (That’s why they’re called "habits," after all.) These habits took years to develop and it’s unrealistic to think that people will change their lives in the span of a few weeks or months with a "biggest loser" diet contest or discount rates at the local gym.
John Bluford, CEO of Truman Medical Center which has 4,000 employees in Kansas City, wrote the AHA report, and he was spot on when he told HealthLeaders Media: "This is not the program of the month. It’s a culture," and "You can’t do this for a year and think it’s a done deal."
In addition to the many suggestions that Bluford lists in his report – which you can read in Cheryl’s account -- I would also suggest that a little empathy goes a long way. If you are a hospital executive, not everyone on staff will have the same ability to embrace wellness.
Imagine how a low-wage, manual worker in environmental services at your hospital might view the idea. Maybe that worker has to get up at 4 a.m. every day to take a bus to work, where he’s on his feet all day wrestling with heavy objects. Maybe that worker has a second job to make ends meet, or he’s a single parent with two kids at home. That worker is probably not going to take advantage of your lunchtime Jazzercise class, or spend a couple hours after work running a treadmill.
Bluford talks about how important it is to have top leadership on board, leading your wellness program by example. He is right. However, I would suggest that while any wellness program should be led from the top, it should be designed from the ground up to be accessible for the lowest-paid employees.
Low-wage workers are often the ones who have the most to gain from wellness programs, because studies have shown that health issues like obesity – and all the ancillary problems overweight create -- disproportionately affect lower-wage workers. If you’re going to offer financial incentives for employees to get eat better, or exercise more, it’s unfair not to design programs readily available to everyone on your staff in a practical way.
You want staff to eat better, but do all of your workers have ready access to fresh fruits and vegetables, or even a decent supermarket? You’re offering a rebate to cover a partial cost of a health club, but what good is a rebate if you don’t live near a health club, or if you don’t make enough money to sign up for a health club in the first place?
That $60 a month for a gym membership might not seem like a lot to a hospital executive or clinician, but it can be out of reach for some folks on support staff. Exercise more? It’s hard to take a walk around the block if you live in a crummy neighborhood, or you don’t have sidewalks, or the streets aren’t lighted when you get home from work at night.
None of these problems is insurmountable, of course, and anybody who wants to improve his health has to take most of the initiative on exercise and diet. However, bad habits can be more easily overcome when everyone on staff feels a sense of ownership with the wellness movement.
If you want employees to embrace wellness, talk to them, all of them, including the environmental staff folks working the graveyard shift. Explain what you want to achieve with your wellness program, find out what is important to them, how they’d like to improve their lives, what they’d like to see in the program, and what limitations their lifestyle may impose. You probably won’t resolve all of their problems, but you’ve at least listened to their concerns, and made it clear to them what you’re doing. That’s a good start.
People want to be healthy. How many people enjoy being overweight, or enjoy smoking? If you want your wellness program to work for everyone, design it with everyone in mind.
Total compensation costs – wages, salaries, and benefits – for hospital employees rose 2.1% in 2010, just above the 2% rise in total compensation costs for all workers in the larger economy, the Bureau of Labor Statistics' Employment Cost Index shows.
Wages and salaries for the hospital sector—which generally make up about 70% of total compensation costs—increased 1.6% in 2010. The ECI does not provide a separate estimate on hospital benefits costs. In 2009, hospital total compensation costs rose 2%, including a 2.1% increase in wages and salaries costs. In 2008, hospital total compensation rose 3.2%, and wages and salaries rose 3.6%, ECI shows.
Over the last decade, the growth in total compensation in the hospital sector has slowed each year, from 6.3% in 2001, to 2.1% in 2010. In that time, hospital wages and salary growth has steadily declined from 5.9% in 2001, to 1.6% in 2010, ECI data show.
In the larger economy, compensation costs for all civilian workers increased 2% in 2010, as compared with a 1.4% increase in 2009. Wages and salaries increased 1.6% in 2010 and 1.5% in 2009, while benefit costs grew by 2.9% in 2010, compared with 1.5% increase in 2009. BLS attributed the near doubling of the rate of increase to retirement costs.
A further breakdown of the civilian workforce showed that private sector overall compensation grew by 2.1% in 2010, compared with 1.2% in 2009. Private sector wages and salaries grew 1.8%, up from a 1.3% increase in 2009, while benefits costs grew 2.9% in 2010, compared with a 0.9% increase in 2009. Employer costs for health benefits grew 5% in 2010, compared with 4.3% in 2009, ECI shows.
Compensation costs for state and local government workers fell from 2.3% in 2009, to 1.8% in 2010, owing largely to salary and wage reductions. Benefits costs increased 2.9% for the year, ECI shows.
Despite the trend of slowing growth in total compensation, hospitals continue to be job creation machines. Hospitals created 50,100 jobs in 2010, nearly double the rate of job creation from 2009, and the entire healthcare sector - everything from allergists to X-ray technicians -- created 265,800 jobs in 2010, Bureau of Labor Statistics preliminary data shows.
ECI data for the December report were collected from 63,000 occupational observations selected from 12,900 private sector businesses, and 11,500 occupations from 1,800 establishments in state and local governments. The full report may be viewed here.
Financial challenges ranked No. 1 on the list of hospital CEOs' top concerns, as it has for the last six years, according to the American College of Healthcare Executives' annual survey of top issues confronting hospital leaders.
Healthcare reform and its implications ranked No. 2 on the 2010 survey released this week, similar to last year's No. 2 issue "healthcare reform implications." Concerns about governmental mandates moved to No. 3 on the list, up from No. 5 in 2009.
"Because health reform became a reality last year, it is not surprising that the importance of implementing reform has not only remained the No. 2 issue on CEOs' minds but has also elevated the area of governmental mandates to CEOs' No. 3 concern," said Thomas C. Dolan, president/CEO of ACHE.
ACHE asked 542 hospital CEOs who responded to the survey to rank 13 issues affecting their hospitals in order of importance, and to identify specific areas of concern within their top three issues. After financial challenges (77%), and healthcare reform (53%), other top issues included government mandates (32%), patient safety and quality (31%), physician relations (30%), providing care for the uninsured (28%), patient satisfaction (16%), personnel shortages (11%), technology (10%), capacity (6%), governance (3%), not-for-profit status (2%), and disaster preparedness (1%).
CEOs who expressed concerns about finances said they were most concerned with Medicaid reimbursements (88%), followed by Medicare reimbursements (78%), bad debt (70%), overhead costs (63%), inadequate funding for capital improvement (63%), managed care payments (51%), other commercial insurance reimbursements (42%), revenue cycle management (37%), emergency department (30%), and competition from specialty hospitals (20%).
The nation's hospitals reported 137 mass layoffs of 50 or more employees in 2010, down 9.8% from the record 152 mass layoffs in 2009, but still significantly higher than any other year in the last decade, Bureau of Labor Statistics preliminary data shows.
Hospital mass layoffs appeared to be on a pace to match the 2009 record but layoffs tapered off in the fourth quarter of 2010, with six mass layoffs recorded in November, and three in December, BLS preliminary data shows.
In 2010, hospital layoffs resulted in 10,490 initial claims for unemployment benefits. In all of 2009, there were 11,787 initial claims for unemployment linked to hospital layoffs, BLS data shows.
Even with the layoffs, the nation's hospitals continue to be job creation machines, reporting 8,000 payroll additions in December, and 50,100 payroll additions in 2010. Those numbers, however, are well off the pace of hospital job growth for most of the decade. After erratic hospital job growth in the first seven months of this year, hospitals saw five straight months of growing employment, and have added 31,900 jobs since August. Overall, BLS data shows, hospitals employed more than 4.7 million people in 2010.
In the overall economy, BLS reports that employers imposed 1,483 mass layoffs involving 137,992 workers in December, 96 fewer mass layoffs than recorded in November. This figure reflects a 6% decrease and is the lowest reported level of mass layoffs since April 2008.
There were 19,564 mass layoffs in 2010 and the 1.8 million initial unemployment claims were lower than in 2009 when both events and claims reached their highest annual levels since layoffs among the 19 major industrial sectors began to be tracked in 1996, BLS reported.
President Obama's State of the Union address got a calculated review from major players in the healthcare sector, with most groups praising the overall message, but vowing to work with both political parties to improve their own standing in the coming months as Congress moves to amend the sweeping reforms under the Accountable Care Act.
The strongest support came from the AMA. "President Obama outlined a vision for our nation's future that includes key AMA priorities, such as lowering healthcare costs through medical liability reform, improvements to the new health reform law, and investments in biomedical research," said AMA President Cecil B. Wilson, MD.
"The AMA applauds the president's willingness to consider medical liability reform to rein in frivolous lawsuits and help reduce healthcare costs. Medical liability reform is critical as every American pays the price for high medical liability costs," Wilson said.
Wilson said the AMA was gratified to learn that the president will consider eliminating the 1099 reporting requirement for physician practices and other small businesses. "We will continue to work with members of Congress from both sides of the aisle and the administration during the implementation phase of this new law to ensure the best outcomes for patients and physicians," Wilson said.
Pharmaceutical Research and Manufacturers of America President/CEO John J. Castellani praised the president for focusing on economic development. "We believe that medical innovation specifically will continue to play a crucial role in advancing patient health and spurring economic growth in the U.S. The President recognized this crucial point tonight, as he stressed the need for investments in biomedical research," Castellani said.
The pharmaceutical industry invested more than $65 billion in research and development in 2009 alone, Castellani said, adding that drug makers should be considered "a national health and economic asset. Our global leadership in medical progress, and the domestic jobs and economic output that goes along with it is ours to lose if our nation's leaders don't support policies that help preserve and nurture future medical innovation," he said.
The trial lawyers' lobby, normally a strong supporter of Democrats, rejected Obama's support for tort reform. "As many as 98,000 people die every year from preventable medical errors, with countless more injured," said AAJ President Gibson Vance. "President Obama should direct his focus towards tackling this startling figure, not promoting efforts that could eliminate the legal rights of patients."
With an eye towards the nation’s growing physician shortage, the American Medical Association is calling for a streamlined and standardized reentry process for physicians who want to return to medicine after an extended absence.
“About 10,000 physicians could re-enter clinical practice in the U.S. each year,” said AMA President Cecil B. Wilson, MD. “Easing the reentry process can help increase the physician workforce and improve access to care for patients. These new recommendations are aimed at helping ease a range of challenges physicians can face as they pursue re-entry.”
The recommendations are designed for physicians who want to return to clinical practice in the same capacity they have been trained and certified following an extended period of time away, not resulting from discipline or impairment issues. Physicians take voluntary leaves of absence from clinical practice for many reasons, such as child rearing, personal or family health issues, and academic leave, AMA said.
Every state has different requirements for reentry, and barriers include high costs and limited information and resources. Reentry programs lack standardized curricula and an officially recognized accreditation process. The AMA said its recommendations are designed to help state medical licensing boards, the Federation of State Medical Boards, state and specialty societies, and medical education programs develop and implement reentry programs.
AMA said it wants national reentry policy guidelines that are consistent and evidence-based. Guidelines should specify the length of time away from practice that requires participation in a reentry process and how much clinical care constitutes active practice. Physicians participating in reentry programs should be allowed to engage in supervised clinical practice, the group says.
The AMA collaborated with the Federation of State Medical Boards, the American Academy of Pediatrics, and other stakeholders—including leaders in licensure, board certification and medical education, and directors of reentry programs—to develop the guidelines.
A Maryland state appeals court this week upheld a state law prohibiting physicians from referring patients for MRI, CT, and radiation therapy services to providers in their own group practice.
The Maryland Court of Appeals, in Potomac Valley Orthopaedic Associates, et al. v. Maryland State Board of Physicians, et al. ruled that the board was entitled to interpret and apply the self-referral statute to its administers. The court also clarified that the law's "direct supervision" exception -- which is limited to referrals to "outside entities" -- requires that the referring physician be "personally present within the treatment area when the service is being performed" and must personally provide that service or directly supervise it.
A receptionist at Potomac Valley Orthopedic Associates said the physicians' group had no statement about the ruling, and would not say whether or not it would appeal.
However, the American College of Radiology cheered the court's decision, which it called a major victory for quality patient care and patient choice.
"Studies have shown that there is very little, if any, patient benefit to self-referral of advanced imaging and radiation therapy," said John A. Patti, MD, chair of the American College of Radiology board of chancellors. "Instead, the practice often results in significant unnecessary utilization of imaging, unwarranted radiation exposure, lower quality of care and increased cost that is ultimately passed on to patients.
Patti called the Maryland law "a model to which other states should look to," and he noted it has been under attack since it was enacted in 1993.
The court ruled that the Maryland General Assembly clearly intended to exclude MRIs and CTs from the "in-office ancillary services exception," and that lawmakers rejected four attempts since 2007 to weaken the statute.
Last year, the ACR unsuccessfully led an effort to put language in the federal Accountable Care Act that would eliminate the in-office ancillary services exception for advanced imaging and radiation therapy. However, ACA requires self-referring physicians to disclose their financial interest to patients and tell them about other facilities near them.
"The College continues to push for further legislative action that would discourage financially motivated self-referral and to educate lawmakers at all levels of government regarding sound imaging and radiation therapy policy," Patti said.
Potomac Valley Orthopaedic Associates, et al. v. Maryland State Board of Physicians, et al may be viewed here.
As Republicans in Congress prepare to dissect the Affordable Care Act, the Obama administration is stepping up its public relations campaign to point out the program's benefits for Medicare beneficiaries.
Health and Human Services Secretary Kathleen Sebelius said three million Medicare beneficiaries who fell into the "donut hole" prescription drug coverage gap in 2010 have been mailed a one-time, tax-free $250 rebate check.
"For too long, many seniors and people with disabilities have been forced to make impossible choices between paying for needed prescription medication and necessities like food and rent," Sebelius said in an HHS announcement. "The Affordable Care Act offers long overdue relief by lowering prescription drug costs each year until the donut hole is closed."
Eligible beneficiaries who fell into the donut hole in 2010 are continuing to receive rebate checks and HHS said ACA will reduce prescription drug costs for beneficiaries in the donut hole each year until it is closed in 2020. Starting in 2011, HHS said beneficiaries in the donut hole will receive a 50% discount on covered brand name medications while in the donut hole. Medicare will also begin paying 7% of the price for generic drugs during the coverage gap.
HHS is also promoting the ACA's financial provisions that it says will extend the life of the Medicare trust by another 12 years. Under the ACA, HHS said the average savings for traditional Medicare enrollees will amount to more than $3,500 over the next 10 years. Savings will be even higher – as much as $12,300 over the next 10 years – for seniors and people with disabilities who have high prescription drug costs. Total savings per beneficiary enrolled in traditional Medicare are estimated to be $86 in 2011, rising to $649 in 2020. For a beneficiary in the donut hole, estimated total savings increase from $553 in 2011 to $2,217 in 2020.
HHS said ACA also provides new Medicare benefits, safeguards, and incentives in 2011:
Original Medicare no longer charges out-of-pocket costs for the "Welcome to Medicare" physical exam and, for the first time since the Medicare program was created in 1965, Original Medicare now covers an annual physician wellness visit, also at no cost.
Most Medicare beneficiaries can now receive critical preventive services, including certain cancer screenings such as mammograms and colonoscopies, for free.
Qualifying doctors and other healthcare professionals providing primary care to people on Medicare a 10% bonus for primary care services.
An innovation center that will research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patient with Medicare, Medicaid or Children's Health Insurance Program coverage.
To prevent fraud, there will be more strenuous screenings for healthcare providers who want to participate in Medicare, Medicaid, or CHIP. In addition, enforcement officials will be able to see healthcare claims data from around the country in a searchable database, and criminal penalties for fraud will be strengthened.
