The new phrase being heard in the House this week is "deem and pass"—a process that would let the Senate healthcare reform bill go through the House—without members actually voting on the measure itself.

The "deem and pass" process instead would let the House vote on a package of changes to the Senate bill, which would approve the provisions in the bill without officially passing the bill.

Whether House Speaker Nancy Pelosi (D-CA) will proceed with "deem and pass" remains to be seen, but the GOP has spoken out against the option.

House Minority Leader John Boehner (R-OH) called it a "controversial trick" that would prevent members from voting on the bill. "There is no way to hide from this vote. It will be the biggest vote that most members ever cast," he said. "You can run but you can't hide."

Senate Minority Leader Mitch McConnell (R-KY) said "deem and pass" is a move for House Democrat to "to keep their fingerprints off a bill." In addition, he said: "Anybody who thinks this is a good strategy isn't thinking clearly. They're too close to the situation. They don't realize that this strategy is the only thing that they or this Congress will be remembered for."

Pelosi, following a meeting with senior advocate representatives on Tuesday afternoon, said she has not made a decision on which way the House may opt to vote on reform legislation. "[We] have several options available to us. And we've asked the Parliamentarian and the Rules Committee to tell us what our options are and they've given us some."

Pelosi added that she is waiting to hear the Congressional Budget Office's reform bill estimates before deciding when to vote, which could be by the end of the week at the earliest.

"I didn't hear any of that ferocity when hundreds of times, the Republicans used these methods when they were in power. This is part [of] maybe 25% what they did," she said, commenting on the GOP reaction.

The wheels began turning this week toward completing a final healthcare reform measure.

On Monday afternoon, one of those wheels was the House Budget Committee, which voted 21-16 to approve a draft bill that will be used to make changes to the Senate-approved healthcare reform bill.

Budget Committee Chairman John Spratt Jr. (D-SC) said at the beginning of the hearing that the reconciliation process had been used 22 times throughout the past three decades—oftentimes to create or alter social insurance programs. In 20 of those instances, the GOP was either the majority party in Congress and/or in the White House, he said, in response to GOP arguments that reconciliation should "not be used for this purpose."

The bill passed out of the committee on Monday contains no specific language related to healthcare: It instead will act as a "shell" for the provisions that will be added by the House Rules Committee later this week. The bill is being used to create a type of legislative framework that will modify the Senate healthcare reform bill.

The Budget Committee's ranking minority member, Paul Ryan (R-WI), called the particular process a "blind markup" and said that the panel was creating a "legislative Trojan horse" in which "a handful of people hidden from public view will shape how Americans receive and pay for healthcare."

As the next step, the House Rules Committee, chaired by Rep. Louise Slaughter (D-NY), will determine how long House can debate the legislation and who will be allowed to introduce amendments. The House could vote as early as the end of the week on the Senate bill and add-on bill.

In response to whether the votes are there, House Speaker Nancy Pelosi (D-CA), surrounded by more than a dozen babies and mothers at a news conference Monday, said that if healthcare reform is finally brought to the House floor, possibly by the end of the week, "we will have the votes."

In the meantime, Pelosi has been indicating that no time is left for long negotiations over controversial issues, such as abortion and permitting illegal immigrants to purchase insurance through a health exchange. "It's a bill about healthcare, health insurance reform," she said on Monday. "It's not about abortion. It's not about immigration."

And another wheel on the healthcare reform debate turned as well with President Obama paying a visit to a recreation and senior center in Strongsville, OH. Citing a new Urban Institute report, he talked about how premiums could more than double up to $25,000 for individuals and families over the next decade.

"We have debated this issue now for more than a year. Every proposal has been put on the table. Every argument has been made," he said. "I know a lot of people view this as a partisan issue, but the fact is both parties have a lot of areas where we agree it's just politics are getting in the way of actually getting it done."

While hospital care accounts for one-third of dollars spent in healthcare, overall spending for hospital care has shown the slowest growth among healthcare services, according to a new American Hospital Association report that examines spending growth on patient care.

From 2007 to 2008, spending for hospital care rose by 4.5%, which was less than health insurance premiums, the report said. During this time, the rising costs to hospitals for goods and services purchased to provide care accounted for 64% of overall growth in spending on hospital care; the remainder was related to changes in the number of services provided (34%) and intensity and other factors (2%).

The single most important factor driving up costs was labor, accounting for about 35% of overall growth. Labor was also responsible for more than half of the growth in the costs of purchased goods and services, according to the data in the report that was obtained from the Centers for Medicare & Medicaid Services and the AHA annual survey data for community hospitals.

These increases are occurring while hospitals are facing shortages of registered nurses, pharmacists, medical technicians, and other clinical workers, AHA said. The high vacancy rates for registered and licensed practical nurses are largely related to a declining number of students seeking careers in nursing and competition with non hospital employers, the report added.

These continued workforce shortages—during a period of rising service demand—likely will put additional cost pressures on hospitals, the report said.

The rising demand for care accounted for about 34% of the overall growth in spending on hospital care between 2004 and 2008. That demand is related to rising population growth and an increase in use per person of hospital services.

The aging population is driving part of this increase: as people age, they generally use more health services. Between 2000 and 2050, the population aged 65 and older is expected to grow from 12% to 21%, as the baby boomer generation ages and life expectancy rises. As the population ages, many individuals may also encounter multiple chronic conditions.

The remainder of the growth—about 2%—is related to the  increased intensity of hospital care, such as hospitals using more resources to care for patients. Increased intensity can be related to a variety of factors, including sicker, more complex patients as well as the high costs of advances in technology.

One of the steps toward achieving quality care is getting patients more engaged in their health by working with their providers to better understand the treatment they are receiving.

Not surprisingly, some patients are far more motivated and engaged—asking questions or searching for more detailed information. Others, not so much. But all patients can—and should—have the ability to be more involved in their care, according to one healthcare expert.

Judith Hibbard, a professor of health policy at the University of Oregon, noted patients usually encounter a one-size-fits-all provider approach when it comes to finding ways for them to manage their chronic conditions. However, if providers had more information on their patients' abilities to engage and self manage their conditions, they might be better able to target and support a patient's healthcare needs, she said.

"We've found that tailoring support to the patient's level of [engagement] is an important way to help [patients] become more activated and to be able to do all the behaviors we're asking them to do," she said.

Hibbard and her colleagues developed a measure to assess skill, confidence, and knowledge among patients about managing their conditions. With the measurement, they've been able to find new ways "to actually do a better job of engaging people," she said last week at a forum on "Exploring the Promise of Patient Engagement" sponsored by the Alliance for Healthcare Reform in Washington, DC.

"One of our very first insights was how much variation there is in any population group. If you take a Medicaid population, a Medicare population, or a sicker population, you will see people who are at the high end of [the measure's] dimension and people who are at the low end of this dimension, and everywhere in between," she said.

"No one seems surprised to hear that," she said. "But what is surprising is that we treat [all patients] the same—as if they actually did have the skill and knowledge they the need to do the job. And, we know that many do not."

One of the insights gained through early measurements is that this is a "developmental process" that people go through on "their way to becoming effective self-managers," she said.

In interviews with individuals, they found that people at the lower end of the measure are "very disengaged and not activated," she said. "They've had a lot of experience with failure, they are overwhelmed, they are discouraged . . . they don't feel they can have a positive impact. They may not have the understanding that this is their job."

"Think about this low-activated person and what their experience is with healthcare—especially if it's chronic illness, they probably go in and see their doctor and they're told to do 17 different things about how they are to live their lives," she said. For someone who is overwhelmed and discouraged, "the usual response to that is to do nothing."

"So by not understanding where people are, we may be further discouraging them," she said. "By not knowing what their skill set is for doing the job, we're . . . essentially throwing non-swimmers into the deep end of the pool and hoping for the best."

Engagement or activation by the patient is important because "activation is related to every type of health behavior: those who are more activated are more likely to engage in all of these types of [productive] health behaviors," she said.

But this doesn't mean individuals who are less engaged—and have less confidence—should be left behind. "And how do people get confidence? They experience success," she said. "We saw that there are some behaviors that are realistic for people who are less engaged to start with."

These strategies can involve peer support or learning problem-solving skills. "Provider support makes a very big difference with giving people strategic help in how to learning how to manage conditions and monitoring set goals," she said.

Later on, the patient can becomes more persistent in asking questions when they don't understand something in the medical encounter. "Turns out only the most activated [patients] do that, and sadly it's only the most activated who know where to get quality information and actually use it," she said.

"Many of the things that we are asking consumers to do are actually well beyond many of them," she said. "So, thinking about what is realistic—and helping people break them down into smaller steps—is going to help people to feel that they can actually [become more engaged]."

Activation and engagement are important because they are related to better outcomes, she said. She cited earlier studies where more engaged patients are found to be less likely to be readmitted to hospitals within 30 days of discharge. Patients who are engaged also have been found less likely use emergency rooms for care.

In one Kaiser Permanente study, measuring the activation level among diabetic patients was found to correlate with hospital readmission rates within a two-year period: Higher rates of engagement were related to less hospitalization.

"What we've learned overall is that we can do a better job," she said. "We know that we can help people gain in their confidence and their skills and ability to self-manage, but we have to move away from a one-size-fit-all approach. In doing so we can do a better job."

"And, we don't have to throw people into the deep end of the pool."