We’re inching closer to the multi-day arguments set to happen before the SCOTUS regarding the constitutionality of the ACA, specifically, the individual mandate provision. A Kaiser Foundation tracking poll indicates that a third of all voters (respondents) think that the entire law will be revoked if the high court finds the plaintiffs’ assertions has cause. Perhaps what is more important is the fact that Americans remain divided over the issue of the existence of the law.

As the anniversary of the Affordable Care Act approaches on March 23, Americans remain as divided on the law as ever, with 37 percent in January saying they have a favorable view of it, and 44 percent having an unfavorable view. At the same time, the share of the public that favors expanding the law (31%) or keeping it in its current form (19%) remains larger than the share who would like to see the law repealed outright (22%) or repealed and replaced with a Republican-backed alternative (18%).

Mitt Romney, the probable GOP nominee for president, will have to exploit the differences between presiding over the initiation of the reform law’s progenitor in his home state of Mass. and Obama’s finished product — backed by the full faith and support of Big Insurance. | LINK to study PDF

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The good news: the media have done a reasonably good job of getting the word out to consumers of healthcare with respect to the prevention of medical and surgical mistakes in acute care settings. The bad news? Here in Minnesota, the numbers of “wrong surgeries”, a collective term meaning never-events in this care realm, topped 2010′s tally by five cases — creating a surge in such cases last year.

The figure is the highest in eight years of self-reporting by Minnesota hospitals. Officials cited many reasons for the mistakes — from doctors filling out incorrect orders to sloppy inventories that make it easy to grab the wrong joint implants for orthopedic procedures.

While the surge appears to be from the absolute numbers of incorrect procedures performed, the rate of adverse events has globally decreased, bringing into question the efforts of many healthcare systems in the processes involved in preventing completely avoidable lapses in care delivery. | LINK

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The long term care marketplace is one of those sectors in healthcare delivery on the cusp of markedly innovative practices in this young century, buoyed by the sudden proliferation of the senior Boomer demographic. Sky’s the limit on the impact of care services and offerings a market-based approach can muster on the eve of reform. Unfortunately, certain models are ripe for abuse.

The DOJ said today it joined a whistleblower case against AseraCare in federal court in Birmingham, Alabama, accusing the closely held company of seeking to cheat Medicare for the hospice care of patients who weren’t terminally ill. The U.S. is seeking three times the damages and a penalty of $5,500 to $11,000 per claim.

The hospice company is owned by a national company that provides services within LTC. Whistleblowers prompted the government action when the hospice operation recruited Medicare beneficiaries and continued to fraudulently collect payments by inappropriately cycling those patients under the hospice benefit. The process would continue upon initial termination of Medicare payments for those services once the initial LTC services ceased. Multiple referrals for covered services later, the LTC contractor would continue to collect those payments, based upon allegedly fraudulent qualifying practices by the LTC contractor/company.

The case is an interesting one which will, hopefully, provide Medicare reform in yet another overlooked care sector that will only increase in prevalence as the rate of patients diagnosed with chronic disease and disability skyrockets. More here

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The cost of the delivery of healthcare in this country always seems to be independent of traditional models of demand in practically any other market-based, for-profit operation. That is, instead of relying on the parameters of patient (consumer) satisfaction or dissatisfaction; further innovation fuels the development of costlier, more advanced technology seemingly designed to break the bank (in one way or another) the very entity it is supposed to benefit: the patient.

An editorial reprint in today’s Minneapolis-St. Paul paper of record, the Star Tribune, makes the case for the unintended costly consequences this very innovation has on the big picture with respect to healthcare delivery in the 2010s. It focuses on the use of nuclear diagnostics developed by the Mayo Clinic as a superfluous and disruptive innovation which does the patient-as-consumer no favors…while benefiting the institution at the hands of government abetting.

Proton beam therapy is a kind of radiation used to treat cancers. The particles are made of atomic nuclei rather than the usual X-rays, and theoretically can be focused more precisely on cancerous tissue, minimizing the danger to healthy tissue surrounding it. [...]

To generate sufficient revenue, proton beam facilities need to treat patients with other types of cancer. Consequently, they have been promoted for patients with lung, esophageal, breast, head and neck cancers.

But the biggest target by far has been prostate cancer, diagnosed in nearly a quarter of a million men each year. [...]

With Medicare reimbursement so generous, and patients and doctors eager for the latest technology, building new machines is sane, profitable business for hospitals like Mayo.

But it is crazy medicine and unsustainable public policy.

Maybe so, but the practice of medicine depends upon the richness of technologies in which parties not only compete toward developing paths of effective treatments for chronic diseases (like cancer, in this case), but also race to spur further research on the nature and behavior of disease. It is within this self-fulfilling prophecy of the cycle of medical education that knowledge moves forward — something the creators of publications like this one thrived upon. And, that’s a good thing. | LINK

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The cornerstone of the ACA is the provision for a coverage mandate — whether that coverage includes complete subsidized services (Medicaid or another fed subsidized program) or via private insurer. In order that individual states comply with this most essential of the reform law’s benefits, HHS has announced that states have the option to create “essential benefits packages” as a method of increasing compliance within the ACA.

“Flexebility” is the key, according to Secretary Kathleen Sebelius.

The national health law lists 10 categories of health care that all insurance policies must cover: hospitalization, emergency care, out-patient services, maternity and newborn care, mental health and substance abuse services, prescription drugs, laboratory testing, preventive and wellness care, pediatric services (including dental and vision examinations), rehabilitative care and habilitative care such as services for children with developmental disabilities. But within those categories, the federal government is allowing each state to determine its own basket of essential benefits by choosing a “benchmark” package offered by any of a variety of insurers.

Sebelius: This move protects consumers by respecting states’ role in healthcare delivery under the ACA. Obama administration: This is the only way in which the mandate can be upheld while making essential services affordable in all fifty states. Consumers? Increased standardization among offerings of basic services by states under the ACA raises the possiblity of mandated coverage rather than making things too onerous for the feds in getting the legislation off the ground in just a couple of years. | LINK

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As 2011 fades into 2012 and the inevitable roll of “best of” lists begins to infiltrate the print, online, and broadcast media universe, healthcare policy is sure to be included. One of those bridging year-end/new year issues apprears to be headed in a more assured direction, as the House GOP and Senate Dems have agreed on a 2 month extension of the payroll tax cut — including the Medicare “doc-fix” provision. Here’s hoping GOP Speaker Boehner does the right thing and continues to push for a yearlong extension…

Of course, this saga is the first of many issues sure to keep the health policy flames ablaze in ’12. Concerns by states of rising Medicaid expenses as reform draws closer; more permanent solutions to incremental and programmatic Medicare reimbursements to be sought; continued legal challenges to the ACA (which the SCOTUS will be taking up in an unprecedented 3-day affair); and last — but certainly not least — the 2012 campaign itself. Will an Obama defeat mean the end of reform as we presently are getting to know it, or will a (narrow?) victory for the president bring greater sympathy for cause, establishing the type of legacy for his top domestic issue he so desperately desires after two terms in office? As always, stay tuned. Next year looks to be an exciting one.

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After a two-year investigation into disclosure issues surrounding a top University of Minnesota physician faculty member, the case is now closed — accompanied by a stern “cautionary letter” which

instructed him to take corrective measures to prevent further problems, but decided against further disciplinary action. A review committee found no evidence of fraud or misrepresentation. However, the committee found that Polly failed to sufficiently disclose the Medtronic relationship in connection with two medical journal publications and a conference presentation.

He no longer does work which requires scrutiny for disclosure since the investigation’s launch in November 2009. | LINK

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In an effort to track physician referral patterns, some hospital systems are resorting to detailing to increase revenue. Much like the pharma reps hired by their respective companies back in the day, hospitals are hiring these paid ambassadors — many former pharma reps – to trumpet favorable care data in order to buffer the bottom line. Hospitals say they are doing this to better streamline care — especially among providers who split referrals among hospitals, thereby cutting administrative waste in this regard. Proponents call these detailing visits to primary care offices liaison-like – initiatives allowing providers a voice from beyond the hosptial arena in an affort to enhance patient care quality. They are also quick to point out that hiring former pharma reps displaced by shrinking sales, fewer NDAs, increased generic availability, and general prohibition of access by reps by healthcare orgs only benefits the economic sector in a flailing economy.

Hospitals say their new sales approach is part of a broader strategy to develop closer ties to physicians, who largely determine where patients go for care. Hospitals also are buying doctors’ practices or forming closer partnerships with physicians to improve care and drive admissions.

Like it or not, healthcare delivery is an industry in this country. In one sector in which market share is showing a tremedous decline, there jumps in another opportunity to create new platforms for innovation. As long as no antitrust issues occur, there should be room for the experimentation of new avenues to enhance quality of care delivery. As the components of care delivery (ambulatory versus inpatient, for example) become more specialized in their own right, it will be interesting to observe this effort by hospitals to grow and innovate in an increasingly crowded healthcare marketplace, allowing regulation by government entities only if patient care is truly at risk. | LINK

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The wrangling back and forth in the US legislature concerning the upcoming vote on the payroll tax cut extension (which includes a provision giving providers a two-year break on Medicare payment cuts) continues to raise the ire of acute hospitals, which would shoulder part of the financing for such an action. The amount to be financed, at the literal expense of hospitals, approaches $17 billion. Essentially, the proposed offsets to direct provider payments would come from reduced payments to hospital administrative and evaluatory functions.

House GOP leaders are in the hospitals’ crosshairs, as the hospitals complain that, under the proposal, there is little incentive for them to continue to collect other payments (copays, deductibles) in the face of such financing, compromising care delivery in the process. Republicans are quick to point out, however, hospitals did agree to major cuts in Medicare as part of reform and that overall Medicare spending would fall by less than 1 percent over the next 10 years. | LINK

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As a primary care geriatrician, I am especially fortunate to have the dual experience of meeting the difficulty of treating chronic disease and, at the same time, making a difference in the lives of patients and their families. But, I have also been bitten by the acute care bug. For the past couple of years, I have also done urgent care medicine part time. I really enjoy it. And it seems to be falling into a healthcare delivery niche, as far as reform is concerned.

Across the country, an estimated 3 million patients visit these centers each week, according to the Urgent Care Association of America, a trade group based in Chicago. To meet increased demand, the number of facilities has steadily increased from 8,000 in 2008 to more than 9,200 this year, the association said. About 600 new urgent centers opened this year. Fueling that rise are two longstanding trends — crowded emergency rooms and a lack of primary care doctors. Urgent care operators also say another factor is helping to propel business: the drive to lower costs.

I’m not sure what to make of the supposition that the cost savings derived from urgent care as an emergency department surrogate. In the long run, these presumed cost savings will likely be minimal if patients-as-conumers remain in the mindset that urgent care access is equivalent to primary care access. Yes, the decreasing numbers of primary care physicians may be entering a critical phase, and as this scenario demonstrates, urgent care as a delivery mechanism, will not replace the reality of impaired access to primary care. Paitents desirous of value as recipients of health care will always gravitate toward the path of least resistance. Only by increasing the primary care workforce can that level of access and value actually be realized. | LINK

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