Against the backdrop of the so-called safety net hospital (those with heavy Medicare, Medicaid claims utilization) as a healthcare-related industry and campaign ’12 meme, there is interesting data out in JAMA this week that either supports Mitt Romney’s assertion that the “very poor” are taken care of in this country quite adequately, or there is reason to believe that P4P measures (or, at least the idea, anyway) are superficially quite similar in non-safety net acute care centers in terms of ultimate patient dispositions.

Researchers studied whether patients were admitted to the acute hospital within eight hours ED admission or if they were to be discharged, transferred or moved to observation within four hours of coming to the ED. They found that

compliance with proposed ER length-of-stay measures for admitted, discharged, transferred, and observed patients to not differ between safety-net and non-safety-net hospitals

Although length-of-stay (LOS) data is interesting, it is not compelling — quite limited in its implications, actually. Currently there is no “accepted” ED LOS strict guideline in the U.S. Digging deeper into this study (abstract-only text cited above available without a JAMA susbscription), one can infer more from the upper decile of data — in which LOS significantly increased among both types of institutions (10-15 h in length), the authors citing mostly acute patient decompensations in mental illness as the reason for protracted admission LOS.

Still, the trial provides renewed attention over a surrogate care parameter just a few years ago was hailed as an agreeable target upon which to base healthcare reform on spending within the government sector. These days, the study may only serve as yet another reason why P4P as a quality measure is so derided by many as the ACA is just beginning to take hold.

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Probable GOP nominee for president, former Mass. Gov. Mitt Romney, came under attack over the past couple of days for comments on discounting the “very poor” as this demographic benefits from the existence of a societal “safety net” for the delivery of essential services — presumably basic healthcare among them. Terming the gaffe as simply a “misspoken” choice of words, the GOP frontrunner initially found it difficult to run from those words and their implications from members of his own party and the Democrats.

Chief rival Newt Gingrich jumped on the metaphorical bandwagon early.

Gingrich said both Romney and Democratic President Barack Obama think poverty can be solved with a safety net.”What the poor need is a trampoline so they can spring up,” he said. “So I want to replace a safety net with a trampoline.” Romney spokeswoman Amanda Henneberg responded that Gingrich was joining Democrats in “distorting Mitt Romney’s comments.”

South Carolina Gov. Jim Demint, a prominent force of social conservatism within the party, was a little more sanguine.

“He needs to address it,” DeMint told Roll Call. “Because I know he does care about the poor. But I think he was trying to make a case that they’re taken care of. But, in fact, I would say I’m worried about the poor because many are trapped in dependency, they need a good job; they don’t need to be on social welfare programs. I think he needs to turn that around because — the middle class is key, and we have to focus on that. And, really, the problem with the middle class is not successful people, it’s politicians — but the key to making our country successful it to get everyone on that economic ladder.

Typical “bootstrap” rhetoric, to be sure, but a teachable point for Romney; because, as it applies to healthcare — let’s take Medicaid, for example — his disavowal of basic healthcare delivery to the poor (and elderly) runs in stark contrast to his pledge to “fix it” — meaning the “safety net”. What does Mitt Romney want to fix, exactly? Continued taxpayer subsidied care for the indigent without further acknowledgement, or does he want to weaken an already painfully inadequate payor of healthcare in chronically cash-strapped states — threatening any stake they have as the reform law takes hold? In his efforts in trying to explain away his current campaign gaffe, Romney has made his stance on healthcare reform much murkier in this young election season. | LINK

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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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Embattled WI governor, Scott Walker (R), issued a statement yesterday opposing the implementation of a state exchange as provisioned by the ACA — opting to defer action on the measure until the case is heard by the SCOTUS in March. In doing so, he will be returning almost $40 M in federal funding earmarked for the healthcare exchange. Whether this is earnest on his part or merely a symbolic gesture to Wisconsin GOP faithful in the wake of a pending certified recall vote on his office remains to be seen. Walker has always been against the passage of the reform law, instead focusing on efforts to deny federal assistance in doing so (states which choose this path will have to demonstrate fiscal independence on healthcare exchange creation by 1/1/13 or will be mandated a program by the feds).

Is this entire episode a game of chicken by Walker in light of his sudden vulnerability? It is, if one listens to the rhetoric from the state’s Democrats on the issue. Advocacy groups are also weighing their own disapproval of the governor’s intentions. The SOCTUS will hear testimony on the constitutionality of the reform law (notably, the mandate for coverage) over a two day period by the end of March. By the end of Februrary numerous amicus briefs will be filed by both Obama admin (DOJ) and plaintiffs (states) in the case. In spite of all the rancor surrounding this issue, it will difficult to envision striking of the mandate provision, much less the entire reform law as two lower courts have offered split decisions on the matter — prompting the SCOTUS to act quickly on a decision on the entirety of the ACA well before the election. | PDF brief from UCB Labor Center in support of the ACA’s constitutionality

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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 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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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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The federal government finally announces that it will open up its Medicare claims database to allow third party access (advocacy groups, insurers, hospitals, etc). This follows a few years of speculation on the part of pundits and legislators alike on what such a move could entail and how it would impact heatlhcare reform — in particular, enhancing quality parameters. The benefits of availability of such information gleaned from billing, requisitions, and payments will vary among groups seeking such data.

Though the data aggregate is invaluable for constructing tools for everything from clinical trials to arranging care delivery based upon demographics, there is always the specter of misrepresentation of that data. For years, many clinicians (including professional associations like the AMA) have lobbied against the release of such info on the gounds that internal reviews should be made before that info is released to the general public. End data may not always be reflected by the healthcare delivery means for many difficult-to-treat patients, for example.

Still, the move is a win for groups wanting to move beyond the formerly impenetrable wall imposed and maintained by physicians and physician groups in order to access that gold mine of clinical, financial, and parametric information. | LINK

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Are the citizens of Minnesota ready to take a look at prototype models for healthcare exchanges? The marketplace stimuli as part of reform are being unveiled today. Although it may seem early for such exposure, MN must demonstrate that it can operate an exchange as part of reform much sooner — just over a year from now, in fact. Four companies have placed demo modules up for public review. Playing around with a couple of them, I get the feel of sites that are actually consumer portals into products that resemble reservation services, only instead of purchasing a flight or hotel accomodations, I am choosing a provider which can treat certain chronic conditions more cheaply, for instance, in one organization in comparison another based upon my personal situation.

States participating in this exercise which are not able to fully integrate these virtual exchanges at the outset of reform will get fed assists. Minnesota seems ahead of the curve here, as the governor has taken a seemingly personal role in getting this state’s offerings public and implementing diligent task-force support to the process early.

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