It had all the trappings of a political football; a blue state’s extremely unpopular Republican governor — looking toward a possible presidential run a year after his term ends — used his partisan hardline to threaten veto of one of the most well-funded social programs for healthcare delivery to the state’s working impoverished, all the while setting the stage for a political attack on his character for all of the nation to see at the hands of the opposing party. The apparent newfound conciliatory stance taken by Minnesota governor and 2012 prez hopeful Tim Pawlenty concerning the threatened veto of GAMC headed this scenario at the pass, however, as the healthcare delivery safety net for thousands of the state’s working poor got a last-minute reprieve to continue being funded, albeit scaled back. Of course the negative PR surrounding a pending lawsuit by three beneficiaries of the program didn’t make eating crow any easier for the chief executive.

Though funding for the program was supposed to end on April Fools Day, the brokered change in funding commitment means that service providers will see less in reimbursements. Also,

[u]nder the agreement, hospitals will receive $71 million from the state’s general fund for the year starting July 1 and $131 million the following year. About 12 to 15 hospitals likely can start serving patients in the new program on June 1. For others not yet ready, $20 million will be set aside to pay for uncompensated care for six months.

The key is in acute care — often the first and only mode by which this underserved patient population will continue to receive care. With a decrease in monies to provide it — even with a grace period of sorts for charity care — the level of participation of acute hospitals is emblematic of both ongoing problems with funding (providing care) and simply surviving as they continue to operate in a program whose demand will only increase until reform is achieved on the national stage. | LINK

Physicians — especially those of the primary care type — are spared the potential problems that come with cuts in Medicare payments. At least for another month. President Obama has delayed the anticipated 21% cut in reimbursements while Congress has to take the matter up yet again.

Sen. Jim Bunning (R-KY) created a legislative frenzy last week when he placed a procedural hold on the bill that would have extended health care benefits to the unemployed for an additional length of time. That measure would have also allowed taxpayer subsidies to be used for premiums. Bunning relinquished his standoff yesterday, allowing this extension on cuts in payments to be avoided for another 30 days.

Polling, as a result, shows just how far cuts in Medicare payments to providers and provider organizations will go in threatening care delivery to a huge segment of the chronic care patient population — the same demographic responsible for the heaviest utilization of pharma, primary care, and acute care. Approximately two-thirds of primary care physicians polled by Medscape said they would cease to care for Medicare beneficiaries as a result of the cut.

An extension only holds off the inevitable, and although Senate Democrats are looking for ways to delay cuts further, there has to be a day of reckoning. That could come October 1, if senate legislators work to pass another bill [PDF] and try to reverse the SGR formula [PDF], which is responsible to establishing pay cut schedules in Medicare provider reimbursements.

With reform, the current band-aid strategy the Obama administration is using continues on its sloppy course.

Does the higher cost of providing care actually mean better care? In more fiscally flush times, the knee-jerk among patients and providers would probably be a nod toward the affirmative. Today, in the wake of a reform fight which has placed front and center the once-mundane issue of healthcare delivery previously reserved for ivory tower wonkish types; this issue is as bread-and-butter essential to the American public as, say, enormous property tax increases.

Researchers, studying over 3000 hospitals over a two year period (2004-2006), put this question to the test when they compared Medicare beneficiaries who were treated for pneumonia and heart failure. Those treated for the latter condition at “lower-cost” hospitals fared better^[1] chronically with this diagnosis than those treated for the former — essentially calling into question the hypothesis that low-cost hospitals discharge patients earlier but have higher readmission rates (for certain diagnoses) and greater subsequent inpatient care costs. The implications of this trial — no major differences in outcomes between hospitals with longer patient stays and shorter ones — could be far-reaching when setting policy on Medicare reimbursements for acute patient care. | LINK (Study abstract only)

1. using 30-day mortality rates, readmission and six-month costs of inpatient care among two of the most common Medicare-covered inpatient diagnoses [↩]

House Speaker Pelosi says she is confident that healthcare reform will pass. This, apparently, is the major mode of thought coming from the Democrats as a result of the flurry of activity and speculation filling the Sunday morning talkfests yesterday. Relying on the sheer numbers of votes in her party, the pronouncement comes a few days ahead of President Obama’s announcement later this week of how he’ll proceed on reform.

Votes are one thing, but how those votes will be cast is quite another — and in the Beltway, perception is everything. The GOP is ready to counter any move by the Dems with criticism they hope to ride all the way to November. If it’s getting the bill through reconciliation (to avoid a filibuster)^[1] or starting over from “scratch” — the GOP’s version of a legislative “gotcha” directed toward Obama — the Democrats seem to be playing a risky game with the nation closely divided on the reform bill as it stands today.

Spring break in Congress occurs on 3/26. Will things be wrapped up by them? Will the long road to reform end with votes to secure a bill, any bill? Or will it come down to reconciliation as the line in the sand: for the Dems, it means passing a bill to expand Medicaid, require employer-sponsored coverage, and require people to have coverage; for the GOP, it means fighting against reconciliation and turning Obama’s push for reform into a protracted referendum on the balance of power in Congress come November. | LINK

1. The House would pass the health bill approved in December by the Senate, and both chambers would approve changes, separately. [↩]

What could possibly be worse for patients as the current state of reform (tune in tomorrow) is more uncertain than ever? According to a JAMA study [PDF], the fact that more physicians are cutting hours — not just primary care docs, but most physician demos across most specialties. Reasons are myriad, but the one essential kernel remains: the increasing layer of oversight (administrative and managed care constraints) has slowly but steadily gained a prominent foothold into how much time a physician can actually devote to seeing patients. According to one family physician

“It added five or six years onto my practice life – and I love what I do,” [Virginia family physician] Dr. Ellington said. “I couldn’t have continued to do what I was doing. I couldn’t do it physically, emotionally and financially. It had become overwhelming.”

And it will only get worse — at the very least for the primary care physician who is already burdened with heavier admin and paperwork hassles, lower pay, increasing patient loads, and lower Medicare reimbursement schedules. | LINK

Pennsylvania and Hawaii are the only two states in the country that do not have a mechanism in place for the regulation of premium rates set forth by insurers as it applies to their small businesses — a demographic courted heavily by both Republicans and Democrats as players in the final direction of pivotal health reform. The Pandora’s Box cast wide open by the recent Anthem BC scandal is adding a new critical layer of scrutiny not only to Barack Obama’s reform trajectory, but also to the ways in which Insurance market fluctuations influence the overall cost of healthcare delivery and access.

Implications for the these two states are obvious, as government regulatory oversight could go a long way in keeping the relationship between small business and the insurance they purchase an open, transparent, and freely accessible system for consumers of healthcare (patients), giving states’ insurance commissioners added muscle. Alternatively, control of regulatory processes by the federal government could add just another layer of bureaucracy (read: increased administrative healthcare costs to the taxpayer and shifting rising costs to other entities — like Pharma) to an already overburdened HHS Dept. Over the next few days, the unfolding issue of federal gov’t Insurance regulation over state’s private insurance markets will become a hot-button one, adding some eleventh-hour drama to the health reform debate. | LINK

President Obama’s version of the reform bill (the one he is personally proposing and defending, come later this week) is getting a shot in the arm. Hoping to stoke public animus against the recent massively outrageous insurance premium hikes by Blue Cross in California and in other states, Obama will once again renew the call for a bill mostly on his terms.

Coming nearly a year after he put the push toward reform into overdrive, Obama will include the new provision that will allow the government (HHS) and states the power to bar or limit such increases — even demanding rebates for consumers of healthcare in such an environment. All of this is in anticipation for the bipartisan summit with senate Republican and Democratic leaders at which Obama will add previous provisions which include barring claims denials for pre-existing conditions, and a tax on HDHP (Cadillac plans).

Republicans are standing fast on their admonition to force Obama essentially to start from scratch, with a nod toward a more tepid bill with less obvious government funding. The showdown takes place later this week and will be televised. | LINK

UPDATE: The WH has posted Obama’s proposal summary. | LINK | At initial look, the president’s plan does not appear to repeal the antitrust exemption. | LINK [PDF] | Also, without public option language in the proposed bill (as expected), what’s next for each side? The heavily hyped bipartisan summit awaits this week. But what about afterwards? Assuming the Republicans stick to their guns, obliterating the WH’s strategy of forcing them to defend their antipathy toward the bill on fiscal grounds, will the party extend the drive for nay votes toward mditerms? Since the Dems are down by at least three votes, this could be likely. Perhaps, a protracted fight among both sides will be good for the bill’s ultimate passage on (mostly) Obama’s terms —  then, and only then, will the true transparency of the proposed bill’s language come to light as Americans may use November as a referendum on health reform.

Last Februrary, Medicare fraud once again took center stage; a Tampa, FL-based managed care outfit was outed by the federal government for intentionally hiding Medicare payments in a specially created private entity called Harmony Behavioral Health. Citing administrative costs as the reason for diversion, WellCare Health kept for itself state funds meant for mental health services and delivery. If there were any reason in the heat of Obama’s reform rhetoric in 2009 to rail against the government’s mishandling of its own Medicare reimbursement policies (as part of shoddily run MA plans) as being part and parcel of the overall increase in the cost of healthcare delivery — it was quite apparent with this case.

Read the rest of this entry »

Minnesota Governor Tim Pawlenty is making good on his executive powers to slash the state’s budgetary expenditures the only way he knows how — via veto. Almost on cue, the state’s chief executive promised to do so in a letter [PDF], explaining that Minnesota simply cannot afford the almost $300M pricetag for a stopgap program designed to be a healthcare safety net to its working poor, the chemically dependent, the mentally ill, and homeless.^[1]

Amid dwindling hopes of a Medicaid expansion of funds, Democratic legislators passed the measure by large margins in both House and Senate to extend the state’s GAMC payer program for another 16 weeks. The governor’s veto underscores his support for the alternative — enrollment of GAMC beneficiaries into another finitely-funded state program, MinnesotaCare. This program has come under fire by Pawlenty’s critics as being a worse choice for public healthcare financing of this patient population, because costs to cover this high-risk demo will essentially cost the state more (since funds are not from the state’s general fund but from the more restrictive Health Care Access Fund).

GAMC beneficiaries who transition to MinnesotaCare under the governor’s proposal will have to renew membership with the new payer when the transition period ends, increasing the possibility of the loss of coverage — only postponing the pending crisis to access to care, according to Democrats. An interesting time for a bill whose language stirs passions equally among ideological camps in Minnesota, and one that appears achievable — at least for another 16 weeks. | LINK

1. In spite of a veto, the MN Senate has enough votes on the Dem side to override, creating a cushion. [↩]

What’s the healthiest county in the state in which you live? A new survey just published by the RWF finds what is essentially common knowledge in the healthcare policy blogosphere —  that persons in more rural counties fare worse than their urban counterparts with respect to decreases in healthcare access, increases in premature death, increases in hospital admissions for the treatment of highly preventable conditions, among other findings.

These findings should come as no surprise, because all (healthcare) politics is local, right? Here in Minnesota, research findings such as these take on an entirely prescient meaning — as our Governor is proposing enormous cuts in spending within the budget this cycle in order to balance it. The vast majority of those cuts are occurring in within the Dept. of Human Services, particularly its wholly funded General Assistance Medical Care public payer program. | LINK

• The Wellpoint saga continues…as well as the blame game for significant premium hikes.
• Study: alcohol + energy drinks (like Red Bull) = recipe for disaster.
• Has the H1N1 pandemic peaked?
• The first study of the anti-CSF prototypes for treatment/reversal of Alzheimer dementia is underway.

The trial will measure in the cerebrospinal fluid (CSF) and blood plasma of amnestic mild cognitively impaired (MCI) patients the biochemical changes that are associated with AD and correlate them with the pharmacokinetics of the drug and its metabolites.

• For California, the bleeding never ends. Today, Gov. Schwarzenegger releases his spending plan for 2010-11 which details even deeper cuts to its Dept. of Human Services.

In the Massachusetts healthcare economy, the balance between employer, employee (policyholder, beneficiary), and health plan (insurer) is getting new scrutiny. Its chief executive, Gov. Patrick, filed a bill calling for the broadening of powers of the state’s insurance commissioner in capping rates for care delivery services by hospitals, doctor groups, imaging centers, and insurers. He cites the crippling effect of higher rates on employers and employees of small businesses.

Of course, in a state rocked by lowered reimbursement schedules, a diaspora of primary care physicians to other practice locales with a secondary shortage in those primary care services — the news of capped payments to docs is not generating a lot of support in that camp for Patrick’s plan. And what do the small businesses think? Cautious optimism rules the day. Smaller acute hospitals (who already are at the mercy of government whims with respect to Medicare and Medicaid payments) fear for their bottom lines amid the potential for layoffs and cuts in healthcare delivery services.

Insurance companies have no problem supporting the governor’s proposal, just as long as negotiations of rates with the other parties don’t cut into their bottom lines. | LINK

A year ago, this blog cited a study which detailed the difficulties cancer patients faced when navigating the byzantine nature of health plans which essentially made it difficult, if not impossible, to receive life-saving treatments. The paper [PDF] went on to describe the problems these patients would still face even when eligibility requirements for government assistance via Medicare or Medicaid were at least partially met.

Either through ignorance of policyholders’ plans limitations or via the inability for their out-of-pocket costs to cover the difference, cancer patients have continued to face significant challenges in accessing crucial care. The verdict may still be out on the finer points of President Obama’s goals for reform, but Insurance does not really seem to be waiting for his signature on legislation to react.

With respect to one insurer, news comes of a cancer patient’s current fight to obtain treatment oncologists thought could save his life. Relapsing neuroblastoma has sidelined a five year-old’s life right now; his insurer has refused a new treatment option it deems as expiremental — in spite of covering a cheaper treatment in 2007 that was also called such, resulting in a full remission. The child’s parents are suing the carrier.

Advocates for insurance reform have taken a backseat in the reform debate, which is not surprising. Although, Obama has described his reform plans are not a referendum on reform of Insurance in a strict sense, it is apparent that sound arguments based upon solutions in the way coverage is paid and delivered need to transcend the rather simple promise of non-discrimination based upon claims denials.