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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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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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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With the SCOTUS set to take up the ACA and its constitutionality this term, more fuel to the fire has just been added to an otherwise white hot election ’12.

Although recent polls seem to dignify the usually staid Newt Gingrich with the flavor-of-the-campaign tiara at the moment, the sure bet is on the “electable” former governor of Massachusetts and originator of all things Universal Healthcare, Mitt Romney. For President Obama, it presents an interesting “problem” which will require appropriate strategies for the White House in keeping the president on message, as they say, over the next twelve months.

No matter how the SCOTUS rules on the matter before it, Obama has got the winds of the ACA behind him. The wheels have been in motion for the past year-and-a-half to the get the first provisions of the reform law into place. Issues such as coverage extensions  for adult children of policy beneficiaries and increased employer-based protections for workers practically guarantees and confirms widening of likes versus dislikes ratio with respect to the law. All of this cannot be ignored by the court as it hears arguments early next year.

Conversely, Mitt Romney could benefit from a negative ruling by the court. After signing into law an individual mandate provision in Mass’s. law as governor, Romney initially praised the action, calling it the “ultimate conservative idea”. Known as much for his flip-flops on this issue (because he is running for president, after all) as he is for his corporatist, milquetoast demeanor — a negative decision of the courts would give him immediate justification for blasting it.

Perhaps that’s why he is mum on the issue now. Further, Romney can make the repeal of the law a central campaign mantra, if the SCOTUS upholds it — “realizing” that individual states can have mandates if they so desire, but not at the direct imposition of the feds.

Regardless, the rhetoric on the constitutionality of the ACA will ramp into high gear next summer; and the ride will be a tumultuous one for both candidates. | LINK

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Is it too early for this sort of news, or is a political agenda afoot? According to a new Gallup survey, the nascent reform law is still leaving a significant amount of uninsured without adequate coverage from employers. Ditto for the elderly and the government.

Some of the main components of the Affordable Care Act, such as tax credits for small businesses that provide health insurance to their employees, and the establishment of a pre-existing condition insurance plan, have done little to boost Americans’ health coverage, the survey found.

This report comes on the heels of a recent appeals court decision reaffirming the constitutionality of the law and its coverage mandates. It’s no secret, however, that the ACA is still struggling to get in the good graces of the majority of stalwart congressional Republicans and some Dems. Still a little early to say if the report will gain traction ahead of the first GOP primaries in less than two months; but, it represents another PR hurdle the law’s proponents must overcome on the road to reclaiming the White House in ’12. | LINK

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Could retail be the solution to comprehensive healthcare delivery? Well, if big-box retailer Walmart has anything to say about it — then, bring it on! Stretching the idea of retail minute clinics to extremely absurd heights, the retailer wants to partner with other entities to increase care access ahead of the tsunami of increased coverage sure to occur once reform kicks in a couple of years from now. It lays out its plans in a 14-page Request for Information [PDF].

In-store medical clinics, such as those offered by Walmart and other retailers, could also be players in another effort in the health law: encouraging collaborations of doctors and hospitals who want to win financial rewards for streamlining care and lowering costs. Such collaborations, known as “accountable care organizations,” might contract with in-store medical clinics, says Paul Howard, a senior fellow with the Manhattan Institute for Policy Research.

The other entities, sometimes labeled as “vendors” in Walmart’s RFI, appear to be (healthcare) organizations which have the potential to collaborate on best practices for many chronic conditions — enabling the partner vendor to benefit in terms of quality, accountability, delivery of healthcare services in order to maximize their bottom lines.

This mode of healthcare delivery raises concerns, to be sure. Could we be seeing an entirely new way of the delivery of healthcare as a pure commodity to be negotiated and priced like any other product? Will it encourage other major national retailers to follow suit? What will this do to the traditional model of healthcare organizational delivery of primary care? Will it enhance it? Will it make it more accountable to third parties? How will this model benefit insurance companies’ approach to premiums in an altered delivery marketplace? Quite an interesting development in the ongoing saga of the cost of healthcare in this country. | LINK

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News comes today from a largely conservative appeals court, no less. (Does the ruling in support of the law by a solid conservative justice on the appeals panel nix the idea that ideology is controlling the judges’ votes on this very politically-charged and polarizing issue?)

The Obama administration prevailed Wednesday in the first appellate review of the 2010 health care law as a three-judge panel from the United States Court of Appeals for the Sixth Circuit held that it was constitutional for Congress to require that Americans buy health insurance.

All of this — as the SCOTUS prepares to consider this week whether to resolve conflicting rulings over the law’s requirement that all Americans buy health care insurance.

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The reining in of costs associated with spiraling Medicare coverage amidst the proposed so-called “doc-fixes” addressing incessant threats of congressionally mandated cuts has many on the Hill wondering what will the Super Committee do to remedy the situation? FYI, the Super Committee is the bipartisan congressional panel made up of 6 Dems and 6 GOPers tasked with putting the brakes on deficit spending to the tune of $1.5T over the next ten years. Issues of Medicaid and Medicare spending are high on the panel’s agenda.

Specifically, futher tightening of Medicare eligibility rules and block-grant funding of Medicaid are mong the most rancorous of discussions — so much so, that at least one Republican moderate senator has chosen to distance herself from the Super Committee recommendations forthcoming. Sen Olympia Snowe (R-ME) also cites her support of branded pharma rebates (something her GOP colleagues really aren’t enthusiastic about) as another mechanism to trim costs.

The ramped-up schedule endorsed by the panel has states, insurance companies, and policywatchers of reform on the edge of their collective seats as issues of funding of the Medicare hospice benefit funding and possible elimination of the SGR formula for determining Medicare reimbursements to phsyicians and hospitals are discussed along with Medicaid funding. | LINK

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Now that the GOP field fighting for the ’12 nod has been essentially set, political pundits and junkies alike will now settle in for the real race and issues to emerge. In the case of the media-anointed frontrunner, former Mass. Gov. Mitt Romney, it is his tenure with what has become the nation’s incubator for universal care coverage on a global scale — colloquially known as Commonwealth Care — that will either haunt him … or define him in the all-important run up to January^[1].

Not only does Romney have to meet issues of his faith and politics (Mormonism) and social conservatism (regarded as a moderate, esp. by Tea Party activists) head on, he now has to prove that his stance on healthcare delivery is actually a conservative one — in spite of the fact that the law guaranteeing care to all of Massachusetts’ citizens was signed on his watch. The bar on how Romney will position himself just became a little more precarious, with news breaking that the WH’s blueprint for the reform law, pejoratively known as Obamacare, was based upon Romney’s Mass. law more closely as a model than was previously thought.

“The White House wanted to lean a lot on what we’d done in Massachusetts,” said Jon Gruber, an MIT economist who advised the Romney administration on health care and who attended five meetings at the Obama White House in 2009, including the meeting with the president. “They really wanted to know how we can take that same approach we used in Massachusetts and turn that into a national model.”

The president even presided over one of those meetings himself in mid-2009. In an effort to diffuse the impact of this revelation, aides to Romney suggest that Gruber’s role was not central to the ultimate tone of the reform law. Good luck with that strategy.

Gruber was personally recognized by Romney for his role when he signed the health-care bill into law and was later appointed by Romney as a board member to the Connector Authority. (He also was given a photograph of the signing ceremony personally signed by Romney that read: “Jonathan, with deep appreciation and congratulations. A Triumph! Mitt Romney.”)

It will be interesting (and fun) to see how Romney can continue to make distinctions between the ACA and his personal stamp on Massachusetts’ model of universal coverage. | LINK

1. IA caucuses and FL primary will occur on the 3rd and 31st, respectively

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