Recent concerns of two members of congress have upped the ante in the war against a key provision of the ACA: the development of an independent payment advisory board^[1] for the purpose of overseeing payments made by Medicare in the event of rapid spending growth in the healthcare delivery sector. It’s just the latest argument in the ongoing saga to balance the major deficit facing the federal government in the wake of world crises, skyrocketing fuel prices, and the controversial Ryan plan.

[This board differs from the current Medicare Payment Advisory Commission (MedPAC), in which recommendations to Congress do not have to be acted upon. If fact they can be ignored.]

Essentially, the panel would have total control over the direction of Medicare spending once it hits the regulatory criterion in comparison to overall government spending. Championed by Kathleen Sebelius and Sen. Jay Rockefeller, the provision for board oversight would “ensure that health costs are reduced” at the discretion of “experts, using evidence, not by the undue influence of special interests”.

The GOP are fearing regulation under the guise of a presumptive non-partisan body (appointed by the president) and don’t like it one bit. Cries of the potential for “rationing boards” and interference in market forces by third parties that contract with Medicare to provide payments to healthcare providers at the hands of non-vetted “bureaucrats” are representative of that party’s concerns.

Perhaps what is a little surprising is the lukewarm reaction by many advocacy lobbies — from the AARP to the American Health Care Association — to Obama’s provisions. The focus on setting Medicare spending policy by unelected officials and the strong potential for policy decisions to be made by unaccountable and seemingly dispassionate arbiters of oversight and governance is of grave concern to these and other groups whose core constituencies (mainly those in long term care and chronic healthcare delivery to seniors) are directly affected by such decisions. The lobby groups allege the legislation of healthcare benefits to seniors by bypassing lawmakers’ authority would result in adverse consequences to coverage and access.

Appointees to the commission are chosen by President Obama and would require Senate confirmation. Currently, Democrats have slim control of the balance of power in that body.

1. Under the PPACA provision, the board cannot make recommendations to ration healthcare delivery, raise revenues or increase beneficiaries’ premiums, deductibles or co-payments. Recommendations of the board will become law unless the House and the Senate each adopt, by a 3/5 majority, a resolution to block them.

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A GOP congressman accepting almost $100K in healthcare industry-related donations in the run-up to the GOP control of the House in the ’10 midterms is the latest targeted in a study commissioned by the Center for Responsive Politics. The study looks at the ongoing flow of campaign finance in the form of donations to both the Repubs and the Dems during this period, and it shows that the mere passage of the reform bill into law was not the end to a hard fought means for the Obama administration to win a top domestic priority last year — but only just the beginning. Political influence by physician advocacy organizations, patient advocacy organizations, and ancillary professional groups constitute just three of the most common originations for heavy donations, many in the form of PACs, to lawmakers. Perhaps a spokesman for such a group sums it up best,

“What does it mean to be a $1 million PAC? It means we have a real seat at the table. It opens even more doors for us and makes our voice louder,” Gary M. Kirsh, a urologist and the group’s PAC chairman, said in a winter 2011 newsletter to members.

Groups which continue to funnel finances to a sharply divided Congress on the issue of health reform law do so to get results, a move often enabled by lawmakers’ fiery rhetoric on either side. With the battle to shape the provisions of the reform law ahead as far from being assured on legislative and even judicial terms (SCOTUS inevitability) it’s not naive to think that finality on the provisions of the ACA will be heavily financed, as well as argued. | LINK

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MedPAC, the Medicare Payment Advisory Commission, is advising Congress to consider imposing a new charge — or copay — for seniors who receive home healthcare-based services. Until this point, home visits for a variety of conditions from nursing and other providers was free of charge. A payment of at least $150 would constitute the amount the commission is advising Congress to implement. It’s all a part of the effort to continue to streamline Medicare and attack waste.^[1] So-called dually eligible patients (those on Medicaid, as well) would obviously not be affected.

More than 3M beneficiaries utilize home healthcare services, and, as expected, some lobbies (including the AARP) pushed hard against the imposition of such additional fees required of many patients with low-to-modest incomes. The charge would be collected for each home health agency admission, not for every visit by a nurse or provider. All of this news comes on the heels of a recommendation by MedPAC to increase the levels of Medicare reimbursement to providers by 1 percent in 2012.

1. There have always been allegations among lawmakers — the GOP in particular — of waste in this sector of Medicare delivery.

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The three gubernatorial candidates have engaged in multiple debates and will continue to do so here in Minnesota until election day. The GOP, Democratic, and Independent party nominees for the state’s highest office are in a race which is anyone’s to lose. Although Minnesota’s healthcare fortunes have withered in the past 4 years as have other economic sectors in the state, its general coffers and the general state of its economic health amid a looming budget deficit of approximately $6B are the main focus of the race in which all three candidates are jockeying for differentiation.

In a race that is being touted as the most important for the state in years, appearance is everything. The Democrat, former U.S. Senator Mark Dayton; Repub Tom Emmer, current MN congressman; and businessman IP candidate Tom Horner are in a contest that may find an even three-way split among likely voters in the coming couple of weeks. The latter candidate has been coming up strong in recent polls and represents an apparent break from the perceived hyperpartisanism that plagues the other two parties and their base of stalwart likely voters.

On the issue of healthcare — expressed in the form of delivery of care to senior citizens in Minnesota — the three candidates offered soundbites that will eventually set the stage for their overall approach to healthcare legislation in a state that recently was not guaranteed fed matching funds for its Medicaid program until its current Republican governor grudgingly accepted them, ending months of speculation over the possibility of an indigent care crisis in Minnesota.

The Republican nominee for governor, Tom Emmer, is staying close to his party ethos, saying he would not agree to expanding Medicaid in the coming budget biennium. He cites the use of tax breaks to spur increased job growth in the healthcare delivery sector to control costs and highten innovation — along with creating a voucher system to increase patient access to providers. IP candidate Horner would favor expansion but not a single payer scheme for increased care access, as Dayton would have done. He is also the first candidate in the race to address the increasingly important issue of chronic disease care coordination as a cost-savings measure. Additionally, Dem candidate Dayton would further subsidize the current Minnesota Care [PDF] model to ensure its solvency well into the next budget cycle — although he was not clear on where those subsidies would come from.

Minnesota’s commitment to healthcare makes up roughly 33 percent of its budget. In 20 years, the numbers of people over 65 years of age in the state will make up more than 20 percent of its population, according to the AARP. In Minnesota, longevity of its citizenry is the rule, and, in 2010, the need to address this issue of healthcare delivery is not only at a crucial crossroads — it is also the starting point from which sound leadership of the next governor will chart the course for healthcare delivery in the state for years to come. This is a race to watch. | LINK

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The AARP today released a watchdog analysis (using Medicare claims data) depicting the general increase in the price of the most popular prescription medications relative to prevailing inflationary trends. And, surprise! The lobbying group notes an almost 10 percent increase in the price of branded preparations straight from the manufacturer for 2009. Apparently, all but 6 of the over 200 brands studied showed any increase over the rates of inflation for that period. Pharma is quick to dispute the group’s findings as they do not include more precise reporting of actual point of purchase data to the consumer, forgoing mentions of rebates and plan discounts. | PDF LINK of AARP’s report

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The initial impact of the new healthcare reform law won’t begin until late September/early October. But how much do Americans really know about the legislation’s benefits and changes? President Obama has embarked on some PR jaunts to remind the public of the virtues of reform, but is the White House’s awareness campaign really enough to get the word out that reform is actually imminent? Apparently not.

Many key parts of the new law, signed by President Obama in March, take effect in several stages beginning next month and continuing through 2015. Because it’s so complex, consumer advocates worry that people won’t take advantage of its benefits, so they have embarked on a nationwide education campaign. [..]

“People are still afraid that there are death panels . . . or that Medicare is going to go away,” says Cheryl Matheis of AARP, the nation’s largest seniors organization. “We have an obligation to get the information out there…”

It’s the new reality. Focus groups, polls, lobbies. To bad reform won’t cover the cost of these mechanisms of information dissemination. | LINK

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Perhaps the most salient aspect to the hubbub surrounding the reform bill (politics aside) is the tremendous amount of myth surrounding its individual provisions. Of course, no single lobby or advocacy group (mainstream media included) has the desire to read the entire thing — only the portions that benefit their needs, for whatever reason.^[1] However, groups under the radar, such as those which lobby for the needs of the Alzheimer patient population, stand to benefit from the recently passed legislation. According to the VP of the Alzheimer’s Association’s Public Policy and Advocacy Division, Obama’s reform legislation would

[Establish] a Medicare pilot program to provide transitional care to seniors at a high risk, including those with cognitive impairment, of re-entering a hospital. Cognitive impairment due to Alzheimer’s and other causes increases the complexity of care transitions and post-acute care, resulting in increased risk for medication errors and hospital readmissions. Alzheimer families need assistance with planning and managing discharge and post-acute care, including arranging and monitoring in-home medical treatment and supportive services.

It is easy to see the mixture of hope, advocacy, and idealism in this organization’s comments on the possibilities inherent in the reform bill. It’s also apparent how difficult it will be to apply them in the face of other lobbies desirous of the same possibilities and resources Obama’s reform will bring. | LINK

1. The AMA and AARP are perhaps the most well-known examples of lobbies taking public postures on reform.

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Sen. John McCain’s move to include an amendment in the health reform bill was overturned by a 58-42 vote. Recall that his provision would have thrown out the possibility for women’s preventive services (chiefly, screening mammograms) and also would have eliminated cuts in Medicare spending. Joining in the Democrats’ fight against McCain’s proposals is the (new) political lobby, the AARP.

The leading seniors’ group, AARP, said in a statement that the McCain amendment would “do nothing to improve Medicare benefits and essentially stop health reform in its tracks.”

That’s probably a little grandiose; after all, the Republicans want to save Medicare, right? As for the Senate Democrats, their caucus is still hanging on, albeit somewhat precariously. | LINK

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As the Senate mulls a timetable on initiating debate on the reform bill, the AARP is holding firm on its political backing of the Democrats’ House formulations. The GOP, ironically the party that is telling its constituents that it wants to “save Medicare”, is warning that providers will essentially stop seeing Medicare patients. This is all based upon a CMS report that forecasts cuts to the program based upon President Obama’s plan to use some of those monies to fund a public option provision — threatening public-private partnerships (Medicare Advantage plans). What amounts to posturing by the Republicans in advance of Senate debate is summed up in a letter [PDF] addressed to the influential seniors’ lobby.

HR 4038, otherwise known as the “Republican alternative” to the House reform bill recently passed, argues against a public option. It soundly went to defeat earlier this month as the Democrats’ historic version passed. The GOP appears to be making a public posture to put the pressure on Senate Republicans to vote against any version with a public option provision. The controversial Stupak amendment just may give them that “out”.

Yesterday, Bart Stupak, a Democratic congressman from Michigan, warned that if the Senate version was stripped of his abortion restrictions (his amendment which got the bill passed in the House), there would be no reform bill with a sound public option. Potentially, women with employer-based insurance plans which cover the range of women’s health and reproductive services will be at risk.

Are progressives throwing the pro-choice movement under the bus to get Obamacare passed? Or, will a woman’s civil liberties essentially be up for debate in the Senate, as some Republicans suggest? AARP support or not, it should be interesting to see what really motivates Republicans (and more importantly, moderate Democrats) in the Senate to modify the breadth of what ultimately passes as a public option. | LINK

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Rep. Michelle Bachmann and her cadre of “tea-baggers“, AARP, the AMA. What do these three disparate groups have in common? They have all made appearances in one way or another on the Hill to make their feelings known on pending healthcare legislation — which is now set to begin debate this weekend on the House side.

• Bachmann held a “freedom” rally of sorts today to “kill the bill” — a nod to Democratic lawmakers she thinks will be “scared” into voting against a reform bill.
• The AARP has taken a political stand — uniting with the Democrats in support of the bill, for seemingly obvious reasons.
• The AMA “supports” the bill but really hates congressional provisions within which will tie facility reimbursements with Medicare, diluting payment reform issues with CMS even further so than they are now.

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