Proposed rules don't give states enough time to establish health information exchanges and limit their flexibility and control over operating them, said roughly 30 organizations, including state governments, business groups, lobbyists, and special interest groups, in public comments.
The framework for HIX was established in the Patient Protection and Affordable Care Act of 2010 and is scheduled to take effect in 2014. According to HHS, more than 25 states have launched efforts to create exchanges.
Here's a sampling of the comments posted in response to the proposed rules on regulations.gov:
America's Health Insurance Plans, the health plan industry's trade organization, filed 30 pages of comments. It's no surprise that AHIP supports putting insurers and insurance experts on HIX governance boards. The group recommends the Centers for Medicare & Medicaid Services, which will oversee the program, develop a common definition of quality improvement standards for all exchanges but with the flexibility to meet the needs of the local enrolled population. To balance affordability and provider access, AHIP warned CMS against taking additional steps to define network adequacy and sufficient essential community providers and instead adopt existing state law requirements pertaining to network adequacy.
The Association for Community Affiliated Plans, which represents safety net health plans with more than eight million enrollees in 28 states, recommended that states "be required to assess income on an annual basis to avoid situations where an individual is inappropriately determined ineligible for both Medicaid and HIX coverage." It also wants CMS to reduce any barriers that would limit the ability of safety net health plans to participate in HIX. ACAP said CMS should allow for a five-year transitional period for the health plans to build required reserves, a three-year transitional period to allow unaccredited plans to obtain the required accreditation, and two years to allow Medicaid-focused health plans to gain licensure.
Americans for Prosperity, a conservative think tank and grass roots organization, voiced its concern that states will not have enough control over HIX to meet local market needs. It said CMS created significant changes that would limit a state's ability to alter or control its own HIX without CMS approval. According to the comments, those changes include certification procedures and enrollment processes as well as IT systems. The group echoed a common concern that CMS has not given states enough time to establish exchanges.
Several states, including Louisiana, Ohio, and Oklahoma, submitted comments. Ohio officials asked for more flexibility in the federal-state partnership model. "States are more than capable and should have the ability to customize their state-based exchange by choosing additional options that the state is able to mange, while leveraging federal coordination of functions that make more sense handled nationally." Oklahoma officials questioned whether CMS should limit how and when to charge user fees. "Federal policy should not dictate how user fees can be handled at the state level and further restrictions on how the state may assess user fees are unnecessary. Additionally, the exchange may wish to collect assessments on a more regular basis, such as monthly."
Louisiana officials noted that the rule requires an exchange to verify annual household income information and current household income information. But since few data sources provide such real time information, it asked CMS to define what an exchange can accept as "current household income."
TheNational Association of Medicaid Directors asked federal agencies to make reporting and business process as easy as possible for states and consumers. "States believe they should not be asked to collect or report data that does not result in any substantial difference in the determination of coverage."
The Urban Institute, a bipartisan research organization, suggested more people would enroll in exchanges if open enrollment was early in the year so consumers' could use their most current tax forms to establish eligibility. This could reduce administrative expenses spent to analyze and validate other income documentation, the Institute said.
Rep. Renee Elmers (R-NC), who serves on the House Committee on Small Business, said the proposed rule "does not address the fundamental issues of determining the essential benefits package or the standards for individual eligibility in the exchange. These yet-to-be-determined issues will be vital to insurers in setting rates and employers making insurance purchasing decisions."
The Patients' Access to Responsible Care Alliance is a Northern California group that advocates for the mentally disabled. The group said proposed rules about regional or subsidiary exchanges are too vague and could hinder access to medical care. It recommended that state laws regarding provider scope of practice terms apply to the regional and subsidiary exchanges.
The National Business Group on Health, which represents 330 large employers, suggested states "insulate the exchanges from politics" and "set up non-profit entities to administer exchanges rather than base them at new or existing state agencies." It said CMS should require states to "share eligibility and enrollment information from their individual and small business health options exchanges to allow both the exchanges and employers to better identify individuals transitioning from different coverage."
When the rules were first proposed in July, HHS said it expected to have the final rules in place before the end of the year. However, the comment period was extended by 30 days to Oct. 31, which could delay the final rules. Efforts to confirm a timeline for the final rules were unsuccessful.
Last week's Medical Group Management Association conference in Las Vegas featured four days of workshops, networking, and almost 100 sessions devoted to the challenges facing physician groups as they attempt to navigate the business of healthcare reform.
Here is my analysis of the big ideas discussed at MGMA:
The healthcare reform train has left the station.
If you’re sitting around waiting for the final court decision on healthcare reform before investing in electronic health records or exploring different payment models, then your practice is so far behind that it may never catch up. The feds have been pumping some serious dollars into demonstration projects and other initiatives to help physicians and hospitals develop the infrastructure to compete in the new world of healthcare.
Even providers that don’t participate in these projects are aligning themselves with other providers and payers to develop healthcare delivery systems and payment models that move patient care from volume to value and focus on higher quality and lower cost care. Through these partnerships, providers and payers are putting processes in place to collaborate, develop clinical engagement, and manage transitions of care. Healthcare has changed and it will not return to the old way of doing business.
The physician-patient relationship is in flux.
Physicians tend to make many treatment decisions for their patients, but implementing new healthcare delivery systems that emphasize collaboration will require patients to be more engaged in the decisions that affect their medical care. Studies show that, all things being equal, patients tend to select less invasive and less expensive procedures when they have the tools and information to assess the trade-offs of different treatment options. That means the physician or the staff must take time to provide the resources a patient needs to make informed healthcare decisions.
I predict physician practices will adopt a common practice of pushing decisions and jobs to the lowest level possible. A physician’s time will be reserved for patients who need more intensive care and physician assistants will handle more of the everyday medical cases. E-mail, once health plans agree to reimbursement terms, will play a larger role in patient-physician engagement.
Physicians have a role in incentivizing patient behavior.
My insurer tells me that I can earn $50 just by completing an online health risk assessment. I still haven’t taken the time. But what if my insurer put some real money on the table and got my doctor involved in the process? One insurer offered $1,000 for family members to complete an HRA, review it with their primary care physician, and then develop and follow a medical care plan. Its HRA completion rate jumped to a whopping 80%. By engaging physicians and adding a medical plan, this insurer added real value to the HRA.
Healthcare will be important to economic development.
Employers will send their jobs to cities and states that support a robust healthcare industry with sufficient providers. Some companies are already taking healthcare services into consideration when they look at facility locations. Employers are becoming more aware of how healthcare price competition and availability of medical services can affect their workforce and their bottom line.
Making a list and checking it twice isn’t just for Santa Claus.
Physician offices can benefit from developing checklists for even routine activities. A checklist clarifies a process so the same steps are taken each time. It establishes priorities, makes sure everything that needs to get done gets done, reduces errors, and can help the physician office staff function better as a team. It’s a relatively simple effort that can save a practice time and money.
These hot topics will change the practice of medicine for years to come. If you were at MGMA, or even if you weren’t, what’s your take on these big ideas?
It's back to square one for states' efforts to recoup an estimated $4.3 billion they erroneously paid for Medicaid services for almost 280,000 beneficiaries who should instead have been enrolled in the Medicare program.
At issue is a Social Security Administration error that classified some disabled enrollees as eligible for Supplemental Security Income when actually they were eligible for Social Security Disability Insurance. That means states used their own Medicaid funds to cover the care that Medicare should have provided. The mistake was first discovered in 1999 and dates back to cases in the 1970s. The SSA created the special disability workload project to work through the errors.
In June 2011, the National Association of Medicaid Directors (NAMD) sent a letter to the Department of Health and Human Services asking Secretary Kathleen Sebelius to use the department's Medicare and Medicaid demonstration program authority to resolve the longstanding issue.
Sebelius responded in an October 27th letter that she lacked "the statutory authority to use my demonstration authorities to this end." She added that she would "work with affected states to explore possible legislative solutions."
The funds are particularly important as states face mounting Medicaid expenses. States' spending for the Medicaid program is expected to increase by a record 29% in fiscal year 2012, according to a survey from the Kaiser Family Foundation's Commission on Medicaid and the Uninsured. The individual state shares of the misallocated funds are estimated to range from $3.5 million for Wyoming to $821.2 million for California, according to data from the University of Massachusetts Medical Schools Center for Health Care Financing.
Matt Salo, executive director of the NAMD, told HealthLeaders Media that the waiver proposal was the ideal solution because "it didn't require the federal government to write a huge check." Instead HHS would have issued credits to reimburse states for their share of the erroneous Medicaid payments. The credits could have been used to meet a state's share of its current Medicaid expenditures.
Salo says he's unsure what will happen next, adding, "We've been working to resolve this issue for a long time."
The SSA has long contended that the only remedy available to states is to recoup from providers the mistaken Medicaid payments and then to have those providers file Medicare claims for the medical services. Salo said the effort to chase down decades-old medical records for patients and providers would be fruitless. "Providers could be dead, retired, relocated and their practices closed. They aren't going to want to go through this process," he says.
In her letter, Secretary Sebelius referred to court cases brought by New York and Massachusetts, which stand to gain $414.4 million and $158.3 million, respectively. "The courts concluded that nothing in either the federal Medicare or Medicaid acts authorizes the Medicare program to directly reimburse states for these expenditures," she wrote.
NAMD has tried unsuccessfully to get federal legislation passed to provide for the repayment, Salo says. "The current political climate just doesn't allow for this kind of expenditure."
Continuing economic woes at the state and federal levels, increased Medicaid enrollment, and the end of the federal stimulus program will contribute to a projected 29% increase in states’ spending for the Medicaid program in fiscal year 2012, according to a survey of Medicaid officials in all 50 states, released Thursday from the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured. That would be the largest increase in Medicaid history.
The American Recovery and Reinvestment Act was a double-edged sword for the Medicaid program. While it pumped more than $100 billion into state coffers to help hold down program costs, it was short-lived, lasting only three years, and it restricted states from cutting Medicaid beneficiaries. The program ended in June 2011, leaving states with fewer dollars to cover more enrollees.
"Unemployment remains high with increasing numbers of poor and uninsured keeping pressure on state budgets and Medicaid programs to meet growing needs," said Diane Rowland, executive vice president of the Kaiser Family Foundation, in a statement. “The cumulative effect of two recessions since 2001 and a decade of constrained spending has left no cushion and many of the latest cuts will hit at the core of the Medicaid program."
The joint state-federal Medicaid program provides healthcare coverage for 59 million beneficiaries and accounts for 16% of national health spending. Almost 75% of the enrollees are adults and children; the elderly and disabled account for the remaining beneficiaries.
States are taking multiple steps to tighten their Medicaid belts. The most common strategy has been to reduce provider payments. Some 39 states already take that step and seven more report plans to implement payment reductions in 2012. Other steps include:
New and increased copayments. Six states have already made copayment changes and 14 more expect to follow suit in 2012. Pharmacy benefits and emergency rooms account for most of the copayment changes.
Reduced or limited benefits. States are trimming benefits and imposing utilization limits on optional benefits such as dental services, therapies, medical supplies, durable medical equipment, and personal care services. Almost all states have added preferred drugs lists to their pharmacy benefit package and many are looking at implementing cost controls on specialty drugs, as well as introducing competitive bidding for pharmacy contracts.
States are also trying to make their Medicaid programs more efficient by making changes in how qualifying services are delivered. According to the Kaiser Foundation survey, these efforts are focused in three areas:
Managed care. An estimated 66% of Medicaid beneficiaries are enrolled in some form of managed care. At least 17 states expanded their Medicaid managed care programs in FY 2011 by adding geographic areas and expanding the eligible populations. Another 24 states are poised for expansion in FY 2012.
Disease and care management. States are expanding their disease and care management programs to help coordinate care for dual Medicare-Medicaid eligibles and beneficiaries with chronic conditions. According to the survey, 37 states have submitted letters of intent to expand their efforts to coordinate care for “dual eligibles”—people qualifying for both programs.
Long-term care. More than 33 states are shifting Medicaid long-term care away from institutions and into community-based settings.
Despite these efforts, Medicaid officials in more than half the states said in the survey that there is a 50-50 chance that they will see a budget shortfall in FY 2012 as Medicaid enrollment continues to grow. But there is also some good news for Medicaid in the survey—the rate of enrollment growth has steadily declined since 2009. States project a 4.1% enrollment increase in 2012. That’s down from a 7.8% increase in 2009.
Dave Gans thinks every physician group needs to be an HRO—a high-reliability organization. HROs handle emergencies well because they recognize danger signals and respond in such a way that their systems continue to function and catastrophic outcomes are avoided.
Gans, the vice president for innovation and research for the Medical Group Management Association, talked about HROs at the MGMA annual conference in Las Vegas. He had a lot of hard questions for the physician audience, including:
Have you thought honestly about the high likelihood of a life-threatening occurrence at your office?
Who will lead the response?
Does your staff know what to do?
HROs are transparent, Gans says. “They are always looking for the unexpected. They have a system in place and everyone knows their job.” He adds that too many physician practices operate on a need-to-know basis, which can leave staff out in the cold when an emergency arises or something out of the ordinary occurs in the practice.
The HRO concept comes from studies of risky operations, including aircraft carriers, the U.S. air traffic control system, and nuclear power plants, that avoid catastrophe because they prepare for it. HROs are found in a lot of industries, and they’ve usually earned their HRO stripes the hard way: through tragedy or crisis. Gans says physician practices don’t need to go through those trials—they can learn from the experiences of other organizations. HROs like NASA and the commercial aviation industry involve complex activities with many people involved. A space launch, for instance, requires the coordination of millions of pieces of information and hundreds of people who know exactly what they need to be doing at any instant.
What does a physician practice have to gain by being an HRO? There’s not a plaque or a framed certificate that identifies an HRO. Gans says that for a medical group, operating as a highly reliable organization means it’s ready to deal with the unexpected. Staff roles and responsibilities are clearly defined, decision-making is deferred to the most knowledgeable person on the team regardless of their position in the hierarchy, and a high degree of accountability develops among the office and professional staff. “It becomes everyone’s job to look at the big picture and identify potential problem areas in a physician practice. Everyone is involved in identifying small problems that need to be resolved before they become worst-case scenarios,” Gans says.
One common stumbling block for physician groups developing an HRO—and for many organizations—is accepting the inevitability of human error. “We don’t always like to hear about mistakes, but successful HROs are preoccupied with failure. They want to know what went wrong and what steps can be taken to avoid that situation in the future,” Gans says.
Physician practices building toward HRO status can encourage error reporting and even develop reward programs around reporting errors as a way to enhance reliability.
The bottom line for physician group HROs is that they often see improved financial results, Gans says. “They are able to work faster, smarter, and see more patients”—with the confidence that when the crisis comes, they will be ready.
Physician groups looking to make their practices more efficient and increase their bottom lines should develop patient safety lists that address emergent events and routine activities. That's the advice of Elizabeth Wertz Evans, RN, the executive director of professional practice for the Oncology Nursing Society in Pittsburgh.
Speaking in Las Vegas during a session at the annual conference of the Medical Group Management Association, Wertz admonished the audience members who didn't think that they had time for checklists to consider that The Johns Hopkins Hospital has saved $2 million with a five-item checklist that reminds hospital personnel to first wash their hands.
"Every physician office is trying to be more efficient. Checklists can be a simple effort that can save a practice time and money," said Wertz.
She noted that checklists have been developed across many industries -- most notably aviation. "What we know from other industries is that developing a checklist clarifies processes so the same steps are taken each time. It establishes priorities, makes sure everything that needs to get done gets done, and it reduces errors." She added that it can also prompt the physician office staff to function better as a team.
During the session, and perhaps unsurprisingly, Wertz provided a checklist of her own, which describes four steps a physician group should take as it develops checklists for an office practice.
1.Develop the best checklist for the task
Wertz explained that some checklists are "do-confirm" while others are "read-do." Do-confirm is a memorized list that is often used to address an emergency where staff needs to jump into a task—a patient faints in the waiting room, for example.
A nurse would follow the steps from memory, but stop at a certain point to review the checklist to confirm that everything that needs to happen is happening. Read-do is a typical checklist. The order the items are completed may not matter. What matters is that they are completed.
2.Keep it short, precise, practical
Wertz suggests between five and nine easy-to-remember items. "Checklists should only include the most critical and important steps in a complex process and assign responsibility for those steps. The steps need to be clearly written and in simple language." So, a checklist for an office emergency would state: Office manager calls 911 not just "call emergency personnel."
3.Focus on "killer items"
Medication and dosages immediately come to mind here, but Wertz said this can also mean something as basic as making sure the physician or the physician assistant has the correct patient records in the examining room. "Checklists can help avoid situations that could not only harm a patient but that could embarrass a doctor.
If a physician starts going through the wrong patient records that could make a patient question the physician's competence." Wertz said a checklist that makes sure every patient is identified as they move through the office will help.
That could be something as simple as referring to the patient by name as the staff goes through the process of taking blood pressure, doing lab work, putting the patient in an examining room, confirming prescriptions and taking payment.
4.Practice the checklist
Wertz said this step means more than setting aside office time to review the checklist with the staff. "You need everyone to actually perform the checklists tasks." She explained that practice will identify tasks that may not be properly performed as well as out-dated tasks that are no longer necessary.
Wertz stressed that a key to developing effective checklists is to empower any member of the team to stop the process if one item on the checklist isn't followed. "We need to encourage everyone to be an advocate for quality patient care. That's what checklists are all about."
The Department of Health and Human Services is making Medicare accountable care organizations look more like commercial ACOs in effort to gain the interest of providers. A sweeping set of revisions to the final rules governing Medicare ACOs was announced by the Centers for Medicare & Medicaid Services Thursday.
Prospective assignment, advanced payment, and accelerated shared savings are among the commercial ACO features that will now be available in Medicare ACOs, explains Michael Nugent, managing director of managed care practice for Navigant Consulting. Nugent said he had already fielded calls on Thursday from providers who want to take a second look at ACOs.
Retrospective assignment as presented in April in the proposed ACO rules was a stumbling block for provider participation. Providers said they couldn't manage risk if they didn't know who their patients were. The final rules use prospective assignment, which will allow hospitals and physicians to know upfront the Medicare beneficiaries assigned to their ACO. This is the approach commercial plans have always taken.
Advanced payment will be used to help the Medicare ACOs cover capital reserves, short-term losses, and other expenses. Blue Shield of California recently provided about $20 million to 18 California hospitals, health systems, clinics and physician groups to help the health information systems that ACOs need to share clinical information.
Commercial payers use accelerated shared savings to help offset the reduced utilization experienced by providers in ACOs. Initially the Medicare program was expected retain the early savings; under the final rules Medicare ACOs will have quicker access to their shared savings dollars.
The final regulations also reaffirm certain features of Medicare ACOs, says Sharon Siler, director of healthcare networks for Washington, D.C.-based Avalere Health.
The added good news for health plans is that the features align with many of the operational functions, and management tools and processes that health plans already have in place, such as:
Quality assessment. The final rule reduces the proposed measures to assess quality. Instead of meeting 65 measures in five domains, the ACOs will need to meet 33 measures in four domains. Most health plans already have robust quality reporting programs in place to support the collection, aggregation and reporting of data on a real time basis.
Health and disease management. Commercial health plans have been promoting disease management for years and already have in place successful programs that providers can use to improvement outcomes for chronic illnesses such as diabetes and heart disease.
Data analytics. Siler termed managing financial risk as the "bread and butter" of health plans. "They have the numbers to help providers understand what is happening to their finances and why."
On the flip side, Siler says health plans need to be concerned that the new rules may weaken antitrust protections. She explains that the proposed rules issued in April 2011 required all ACOs to participate in an antitrust review as one way to ensure that an ACO wouldn't limit competition by dominating a market and having an adverse affect on reimbursement rates.
The final rules make the antitrust review voluntary. Siler says that means there will not be a way to stop providers from being so large that they shift the balance of financial power completely to their side. "Payers and employers are very worried that this will create a situation where they have no control over costs," she said.
In a statement, Karen Ignagni, president of America's Health Insurance Plans, said that the program takes important steps towards achieving greater accountability and better quality care." She added, however, that the organization remains "concerned about the trend of provider consolidation that drives up medical prices and results in additional cost-shifting to families and employers with private coverage."
"The initial regulation," Ignagni said, "created an antitrust screening mechanism that would have protected consumers with a mandatory up-front antitrust review and exclusion from the program for those ACOs facing a legal challenge. Doing away with the mandatory review process raises concerns that provider market power may not be scrutinized sufficiently, potentially increasing health care costs for consumers and employers.
AHIP , which filed in June a 20-page comment letter on the proposed ACO regulations, declined to comment on how the final regulations address the specific concerns expressed in that letter. "We are still going through the regulations and will have additional comments in the future," explained Robert Zirkelbach, press secretary for AHIP.
While the final regulations hold promise for health plans, Siler said that as stakeholders have a chance to completely review the 626-pages of regulations they may discover that "CMS has made this an easier pill to swallow, but it's still difficult to digest."
An Anthem Blue Cross and Blue Shield pilot program under way in three states aims to determine whether cash incentives offered by employers can move healthcare consumers to select low-cost facilities for medical care.
Smart Shopper is being piloted by self-insured employers in Connecticut, Indiana, and New Hampshire by Anthem Blue Cross and Blue Shield. The on-line program is offered as part of health insurance benefit packages and is voluntary for employees.
Chris Ulbrich's family-owned stainless steel and special metals manufacturing business in North Haven, CT has about 300 employees participating in the Smart Shopper pilot. The company pays about $7 million annually for health insurance benefits. "We've cost-shifted about 25% to our employees but we were looking for other ways to trim our expenses when this program came along."
Based on 2010 utilization Ulbrich's company expects to save about $160,000 on medical services during the one-year pilot. That includes any incentive payments and the administrative costs of the program. "At that rate in six years we'll save almost $1 million. That's money we can invest in the business and our employees," said Ulbrich.
The program targets more than 35 high volume procedures and tests, including: ACL repair by arthroscopy, cataract removal, colonoscopy, computerized tomography or CT scans, hysterectomy, knee arthroscopy, mammogram, MRIs, sinus surgery, and upper GI endoscopy.
Smart Shopper works a bit like the Priceline service for booking hotels and airlines. When a physician recommends a medical service or diagnostic test, the patient logs onto the Smart Shopper site and enters information about the prescribed services and the zip code where the service will be supplied.
A list of facilities—as many as 10—is displayed, but the provider names are withheld. Charges are represented by dollar signs with one dollar sign the lowest cost and five individual dollar signs representing the highest cost. The price differential between the lowest and highest costs is about 200%. All facilities are part of the Anthem network.
Employers set the incentives, which typically are $100 to $250 depending on the procedure, and are responsible for making the incentive payments to the employees. Anthem is testing payments up to $1,000 for price comparing on some more expensive procedures such as MRIs.
An Anthem spokesperson offered this example based on colonoscopy costs at locations less than four miles apart from one another in Hartford: Provider A charges $3,280, provider B charges $2,821 and provider C charges $1,718. The patient receives a $100 incentive for selecting provider C and the employer saves between $1,103 and $1,562 on the cost of the procedure.
Savings are captured and reported to the employer each month. Self-funded employers save money by paying less for medical services.
Ulbrich sees more potential savings by improving the health of his employees. "Over the long-term, wellness is the way to hold down the cost of our health benefits. Our employees are getting the medical care they need and through this program they'll have a better idea of how much healthcare really costs and how much can be saved by shopping around," he explained.
Ulbrich admitted that he has heard some physicians complain that the Smart Shopper program is more about saving money than improving the quality of care. "I see this as beginning to help our people understand why their premiums increase and what they can do to help us hold down costs. All of the facilities are in the Anthem network so they're already available to our employees."
House and Senate committees submitted on Friday their recommended budget cuts and reforms for the Joint Select Committee on Deficit Reduction, which has until November 23 to develop legislation to cut a mere $1.2 trillion from the federal budget over the next 10 years.
I thought it might be useful to take a close look at the Democratic and Republican proposals for healthcare spending reform. This task contains an assumption that the parties’ positions would be clearly stated. My bad. What I found instead is a big mishmash of policy statements wrapped in political dogma.
The biggest surprise is how the Democrats make their case to the “super committee.” Republicans are all about the dollars—Medicare spending increased from $37 billion in 1980 to $514 billion in 2010, for example. The Democrats take a more touchy-feely approach, citing the potential loss of Medicare benefits to people who depend on the coverage. There’s nothing wrong with that argument, but let’s face it, the debt committee needs to find a lot of money fast to cut from the budget. The Republicans seem more than happy to help.
Here’s a brief look at how the two political parties would address cuts to some specific healthcare programs. Let’s start with an easy one—the Patient Protection and Affordable Care Act (ACA).
The Republicans on the Senate Finance Committee would like the super committee to strongly consider repealing “this flawed and partisan health law as an essential step in improving our nation’s future economic and fiscal outlook.” In making its point, the group cites a Senate Budget Committee report that pegs the full implementation cost of the ACA at $2.6 trillion over 10 years.
House Democrats on the Energy and Commerce Committee, which includes healthcare, think it would be premature for the committee to eliminate the ACA. They don’t assign dollar amounts to the bill, but they do tug at the heart strings, noting that “many of the proposals to reduce spending would undermine programs essential to the health and financial security of lower-income and middle-class families.”
Medicare
Republicans want the eligibility age addressed. They note that in 1965, average life expectancy was 70 years and there were five workers paying the benefits for each retiree. Today life expectancy is 79 years, Medicare spending has increased 13-fold, and only three workers pay the benefits for each retiree. Republicans want more cost-sharing, especially for high-income seniors.
Democrats contend that raising the Medicare eligibility age will lead to higher overall health spending. They see the prescription drugs and uncoordinated care as cost drivers for Medicare and have asked the super committee to focus on those areas. They also want the government to reinstitute the rebate that drug manufacturers used to pay in return for the large volume of patients they access through Medicare. They note that cost-sharing does nothing to control healthcare costs.
Medicaid
For Republicans, Medicaid is a significant cost driver that currently consumes 22% of state budgets. They want the super committee to revamp Medicaid by giving states more leeway to change the benefits offered and the program’s financing. Democrats want no part of blended rates or anything that threatens the federal dollars that flow to the states in support of Medicaid.
Reading the policy recommendations provides insight on why 535 members of Congress have happily put this budget debacle onto the backs of just 12 of their members: It’s hard, thankless work. The odds are that no one will be happy with the outcome.
I have no particular insight on how the super committee is approaching its work. But I do suspect that, once the 12 have made their proposals, the rest of Congress will be happy to let the automatic trigger do the dirty work. The automatic trigger, built into the super committee’s creation, will cut every program except Medicaid and reduce Medicare provider payments by 2%.
But as the saying goes, nothing is ever final in politics. AsJosh Barro, a Manhattan Institute fellow, pointed out in the New York Times, pulling the trigger on healthcare still leaves the option of unpulling the trigger. Many of the automatic cuts wouldn’t even go into effect until 2013. That’s a lifetime in politics with plenty of time to gauge electoral opinion and make changes.
The Centers for Medicare & Medicaid Services announced Monday that it is accepting applications for a program designed to help healthcare professionals drive improvements to patient care and reduce healthcare costs.
CMS administrator Don Berwick, M.D., was on hand to kick-off the $6 million program, which will recruit up to 200 innovation advisors "with the knowledge and the vision to find innovative ways to improve care and reduce costs for beneficiaries in Medicare, Medicaid, and the Children's Health Insurance Program." The CMS Innovation Center will manage the program.
Innovation advisors, who will be selected on a local and regional level, will include what Berwick calls "healthcare system insiders capable of managing change." That includes clinicians, allied health professionals, health administrators, physicians and nurses. Skill sets will include healthcare economics and finance; population health, systems analysis, and operations research.
The deadline for applications is Nov. 15; participants will be selected by Dec. 15. An initial group of 50 innovation advisors will be selected to gather in Washington, D.C in January 2012 to begin six months of orientation and training. A second group of 150 advisors will begin orientation by mid-2012. Training will include in-person national and regional meetings, virtual training sessions, seminars and presentations by healthcare experts.
One of the goals is for each participant to take what they learn during training and apply it to their home organizations and areas, explained Joe McCannon, senior advisor to Dr. Berwick. Innovation advisors will be expected to develop and implement a hands-on systems improvement project.
Each innovation advisor will receive a stipend of about $20,000 to help cover the cost of transportation, lodging and other expenses. During the six-month training program each participant will be expected to set aside 10 hours per week to study the curriculum and to implement their individual systems improvement project. The entire program will last about one year.
A CMS spokesperson explained that the program's success will be measured in a couple of ways—successful completion of individual improvement projects by each innovation advisor and the level of support for testing new models of healthcare care delivery.
