Any momentum gained by President Obama when the issue of exorbitant insurance premium hikes was the healthcare topic du jour last month seems to be all but forgotten as Insurance continues to conduct business as usual. In Mass., the Blues in that state face fighting caps on their rates as its governor, Duval Patrick, reviews requests for increases of anywhere from 8 to 32 percent.

In California, the apparent epicenter of the firestorm over rate hikes, insurance companies seem loathe to change as well, citing the “increasing costs of healthcare” as  a reason for those hikes. All of this movement by Insurance is forcing Obama to take his message to the public to get support for reform. He’ll begin his week by doing so today in Philadelphia.

Wise move? It’s perhaps his only move. With the GOP urging going back to the drawingboard, moderate Dems uneasy over the pricetag of reform ($1T), and House liberal Dems suspicious of Senate motives once the bill is passed; it appears that Obama is turning to the only group left to fully convince the utility of a healthcare overhaul — the American people. | LINK

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 [↩]

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

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.

It’s often said that the beleaguered emergency department (ED) is the initial point of care for many patients. In this current broken healthcare delivery system, that means an umbrella which “covers” the uninsured as well as those who are underinsured. The total cost for these points of acute care notwithstanding, how is the best way to explain new numbers out of the CDC this week?

The CDC’s National Center for Health Statistics reported the numbers in its annual summary of U.S. data on disease conditions, health behaviors and use of medical services. The scan figures are based on visits to roughly 500 hospitals and 3,000 doctor’s offices and outpatient clinics.

According to this survey data, the CDC says that the use of imaging modalities in the ED has quadrupled since the mid-1990s. Besides being just another point of confirmation of the origin of skyrocketing healthcare costs in this country, the heavy emphasis placed on tech will not abate anytime soon. Issues pertaining to defensive medicine, integration of such tech into ingrained training of new physicians, and the cost of using such technology within the medical device market are all good reasons to try to begin attacking this startling — yet, unsurprising — statistic. | LINK

Twenty-ten is the year for mergers and acquisitions in the healthcare delivery marketplace? A year ago, with President Obama’s massive push for government-enabled reform, a scenario such as this would have been unthinkable in polite (poltical) company. But recent developments in the drive toward reform are really anything but.

Although reform is on shaky ground, major health plans and other third parties are not exactly rushing toward consolidation. A wait-and-see attitude is the gameplan for now. But don’t be surprised to see the market for Medicaid managed care benefit from the weakened stance on reform in Washington. | LINK

You just have to hand it to Minnesota and its spirit of rugged self-determination. Its citizen individualism and desire to pioneer are just a couple of the qualities that are part of the state’s storied history as innovator and trendsetter. The concept of managed care as a healthcare delivery ideal had some of its roots in Minnesota, a concept going back over 35 years. Designed as a way to create a balance between providers and payments for services rendered, it has evolved — for better or worse — into a system upon which today’s healthcare marketplace has codified current business practices. That is, the very dynamic which has given the current President of the United States such a strong (though somewhat misguided) desire to overhaul the way healthcare is delivered in this country.

Pharma, Insurance, and the physician are the core triptych at which so much in the debate to reform healthcare is directed. Many primary care physicians feel as though they are at the epicenter of this reform morass, and many are left feeling dismayed over why they chose medicine as a profession at all. For many family docs, for example, navigating the complexities of day-to-day practice; feeling the pressure of seeing enough patients to justify employment in many manage care systems; and dealing with Insurance and public payers in order to simply get paid are essentially too much for them to deal with. Attrition from the profession usually results.

Imagine the self-determination of one Minnesota family physician — an employee of a primary care group in the Twin Cities for decades — when he simply could not “take it any more”. With actions that can at once be described as both narcissistic and noble, this doc decided to go it alone and get Insurance out of the mix altogether. Armed with $80 000 and a desire to accept only cash, he’s jumping into uncharted territory in 21st century healthcare delivery and going back to the pre-managed care days of Dr. Marcus Welby — and he’s doing it in one of the most heavily-penetrated managed care states in the country. The spirit of Minnesota innovation shines again, at least for one physician. | LINK

You know about the movie Avatar? Of course you do. It’s the new James Cameron movie which recently beat out that other Cameron flick Titanic to become the biggest worldwide and, shortly, domestic grossing film of all time — taking in a whopping $1.8B to date (almost $600M in the U.S.).

Now imagine the next Cameron vehicle surpassing Avatar by 33X. That’s the amount of public and private healthcare spending lost to fraud each year, according to remarks made by Atty. Gen. Eric Holder. Obama’s top lawyer was at the NIH yesterday pushing for a cabinet level commission designed to administer enforcements against healthcare fraud in both public and private sectors.

Will Congress listen? Just earlier this week, during his first SOTU address, Obama pledged a government spending freeze for three years — asking the legislature to pass a “pay as you go law” — requiring lawmakers to offset the cost incurred by the current tax cuts or incurred expenses due to programs like Medicare (which would be exempt from this law) with the increase in taxes. In essence, Obama would be keeping a ledger of the average budgetary effects of all legislation affecting mandatory spending.

According to Holder, public and private healthcare sectors need to embrace this new reality and the spending it will take to make it happen.

[O]ur ability to protect taxpayer dollars, to ensure the viability of our government health care programs, and to strengthen our national health care system depends on our ability to expand the discussion beyond the federal government…

LINK

Higher copays mean a higher incidence of unnecessary acute care visits, thereby placing elderly patients at higher risk for significant medical problems if not caught earlier. This, according to a study just published in the NEJM. This trial sheds light on a phenomenon not adequately studied until now because of numerically inadequate elderly subjects for study and the absence of reliable Medicare claims data.

Patients affected were principally enrolled in Medicare Advantage (MA) plans whose premium copays increased.  They were compared to patient cohorts whose plans did not increase copay amounts for a 5 year period (2001-2006). The shifting of the cost of care burden to the patient resulted in the findings of almost 20 fewer annual outpatient visits per 100 enrollees in the year after the rise in copayments and 13 more annual inpatient days per 100 enrollees of MA.

Although study limitations were quite notable for the lack of randomization among specific medical diagnoses (non-randomized controlled mechanism); the use of primary care versus specialty care measurements; and the lack of the inclusion of the measurements of cost-shifting on future hospital visits — the basic take-home message is the same: increased out-of-pocket healthcare costs for ambulatory (office) visits for elderly patients mean decreased secondary prevention of adverse medical consequences and higher healthcare costs overall, owing to increased use of hospital services. | LINK

Times are tough in all service industries, as well as in healthcare delivery. In many health systems, the acute hospital is not only a prime revenue-generator, it also is a service aggregate which can provide a multitude of care environments, within which specialty care and primary care can thrive.

So, imagine the public despondency among one financially troubled parochial hospital in NYC in response to a large city system’s plans to buy a revenue-hemorrhaging Catholic hospital in the city’s fabled Greenwich Village and turn it into an ambulatory care center. St. Vincent’s Hospital, home to the treatment of many of the city’s HIV positive and mentally ill indigent, has struggled to remain fiscally viable after emerging from bankruptcy only a few years ago.

One-hundred sixty years of charity care and national prominence the hospital earned in the months and years after 9/11 could be just a memory for New York’s last Catholic acute hospital if its buy-out is realized. | LINK

[The following editorial is crossposted at HealthcareWealthcare.com]

I’ve written much on my health policy blog … of the microscope under which the state of Massachusetts is operating its own brand of healthcare delivery in the wake of universal healthcare coverage. The ambitious undertaking by the state’s lawmakers to introduce the concept of universal coverage to its citizens over two years ago attempts to answer the question — can healthcare delivery costs be reined in while mandating care for everyone? The answer is, to the surprise of no one, a resounding “no”. As a matter of fact, the cost of covering an additional 430,000 people has thrown the state’s healthcare economy into a tailspin.

Read the rest of this entry »

The Twin Cities’ first new acute hospital in 10 years will be opening its doors next week, ushering not only a new year but also a new decade in staking its claim in Minnesota’s local healthcare economy. When the project was proposed many years ago, it was unclear which systems would be involved. That number will be two — North Memorial and Fairview. The latter has has its share of expansion plans within latter part of the ’00s, and this latest venture definitely has a forward-thinking energy about it.

Construction in a rapidly growing and prosperous Twin Cities suburb, built-in plans for expansion within the facility, and the potential for a fresh start in healthcare labor in the local economy are factors which could make this project succeed. For a such a labor intensive industry as healthcare, it appears as though the deliberate approach toward expansion at this new facility will not only sustain the local healthcare economy, but it will also create the potential for development within each healthcare system from within — which bodes well for quality care and efficiency.

Now that the House has unveiled its consolidated health reform bill, it will head to the Congressional Budget Office for a cost estimate. Although the Democrats’ proposals for a public option were tempered somewhat, there is still some concern over the future funding for their version of a less robust public option.

Even if reform with respect to a public option is viable, it has to be financed appropriately. Provisions such as insurance exchanges championed by the Senate, for example, may make short term cost estimates difficult to calculate. And speaking of the Senate, CBO analysis takes time — possibly hampering the amount of time vigorous debate can occur on the Senate floor before Thanksgiving. | LINK