Here’s a convenient talking point for the Obama campaign as it begins to coalesce its message surrounding healthcare reform spending under the ACA: enrollment in Medicare Advantage is up since the beginning of the current decade, while premiums have been on the decline. HHS Sec’y Sebelius attributes this to the core provisions within the ACA allowing stipulations of bonus payments based upon quality, changes to enrollment periods, new medical loss ratio requirements and penalties, and the power for CMS to reject plan bids.

According to Humana’s last quarterly report, it bought two Medicare Advantage contractors in the third quarter of last year and enrollment increased over the past 12 months. Wellpoint also acquired an Advantage contractor in 2011 and saw increased enrollment.

While it may be a little premature to trumpet reform to this sector of Medicare spending by the government as being a permanent fixture of ACA implementation, it does highlight the need to revisit the drama surrounding payments to providers in FFS plans. Will the doc-fix ever be truly fixed? Bipartisan Senate and House members tasked with establishing a permanent end to reimbursement cuts to physicians will have their work cut out for them starting today — apparently considering everything from repeal of the SGR in its current form for Medicare spending to the use of war funds to finance such a permanent patch. Should be interesting.

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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the law (31%) or keeping it in its current form (19%) remains larger than the share who would like to see the law repealed outright (22%) or repealed and replaced with a Republican-backed alternative (18%).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 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 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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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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Honestly, these “clock-ticking countdowns” are getting a little irksome. The eleventh hour negotiations surrounding the legislative extensions of the payroll tax cuts for the middle class just hit another roadblock, outlets have reported. Cue the Senate showdown between the GOP and Dems. Closely tied into the GOP plan for the extension of the tax cut is the inclusion of the Keystone XL oil pipeline — a controversial project which President Obama had originally hoped to decide upon by 2013 its potential for environmental sustainability.

The Keystone pipeline pawn would force Obama to make a decision on its contruction by the end of this year.

With respect to healthcare, the inclusion of provisions to forestall cuts to Medicare payments for 2 years, preventing incremental threats to physician reimbursements (no permanent overhaul), would be the political gambit. It’s a political mixed bag for some healthcare entities. Hospitals would be better served by more long-term solutions to the so-called doc-fix problem. Providers would be spared more frequently intermittent threats to reimbursement. If passed, this payroll tax cut extension would eliminate the possibility of approximately 27 percent in cuts to Medicare payments.  | LINK

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He’s leaving his much embattled post, and he is not mincing words. Don Berwick will be stepping down as CMS head in lieu of what was sure to be a highly contentious Senate confirmation procedure next year. Calling much of what Medicare “does” as wasteful, the departing CMS chief sounded more like he was delivering a eulogy than offering up hopeful solutions to be implemented in his absence.

Dr. Donald M. Berwick, listed five reasons for what he described as the “extremely high level of waste.” They are overtreatment of patients, the failure to coordinate care, the administrative complexity of the health care system, burdensome rules and fraud. “Much is done that does not help patients at all,” Berwick said, “and many physicians know it.”

Berwick’s ascension came at a time in which President Obama was looking for a CMS chief who shared the same sense of analytical urgency in efforts to fix the nation’s ailing healthcare delivery system. Berwick sounded the clarion call for reform, but received very little cooperation from the GOP side of the ideological aisle, with those members of congress (and some Dems) essentially putting up a wall between him and any actionable improvements. Perhaps his own words project why he was essentially doomed from the start.

Berwick said he had not sought the job. Indeed, he said, “I did not even know if I was fit for it.” He took the post, he said, because he sensed that immense “tectonic shifts” were occurring in the health care delivery system.“I came with an agenda,” Berwick said. “I wanted to try to change the agency to be a force for improvement, covering one out of three Americans.”

Restating the obvious really does physicians he laments no good unless positive change, outside of obvious hyperbole, does occur. According to many pundits — including this one — his replacement offers more of the same, with true change occuring only if legislative control swings back to the Dems in 2012. | LINK

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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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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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