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.

Related posts:

1. CDC: The Use of Imaging Studies in Emergency Medicine Up 4X in Fifteen Years It’s often said that the beleaguered emergency department (ED) is...
2. Minnesota’s Largest Acute Care Safety Net Announces Cuts in Care Delivery So much of what happens to safety-net healthcare delivery really...
3. Amid Budget Shortfall, Minnesota Hospitals Defend Spending on Economic Terms The current economic crisis that is afflicting many states, including...

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.

Related posts:

1. NYT Editorial: Congress Needs to Eliminate ‘Unjustified Subsidies’ for Private Medicare Advantage Plans Barack Obama hasn’t officially taken office yet, and the “shift...
2. CMS Targets Medicare Advantage Provider in High Profile Compliance Case What’s a patient to do if the Medicare Advantage plan...
3. Insurers’ Desire to Increase Payments under Medicare Advantage Draws Warning from Sebelius HHS Secretary Sebelius is warning insurers’ Medicare Advantage contracts not...

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

Related posts:

1. Funding Long Term Care — An Issue Missing from the Current Healthcare Reform Debate The relationship between Medicare funding/reimbursement patterns and nursing home operational...
2. Managed Care Insurer Convicted of Medicare Fraud Comes Clean Last Februrary, Medicare fraud once again took center stage; a...
3. Mental Health Services Chain Perpetuated Medicare Fraud Medicare reform as it relates to expenses for mental healthcare...

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.

Related posts:

1. White House Budget Director’s Plan to Overhaul Medicare Spending Policy Irks Lawmakers An independent panel of sorts meant to develop payment, spending,...
2. Happy New Year from Doctor Pundit, Minor Predictions on 2011 As one year changes into another and Doctor Pundit steps...
3. As Health Reform Develops, GOP Strategies to Cut Spending Evolve The legislative conundrum Wisconsin finds itself in is having repercussions...

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

Related posts:

1. Medicare Payment Cuts Threaten the Practices of Some Medical Subspecialists Proposed Medicare cuts looming as part of the health reform...
2. Obama Signs Bill Delaying Medicare Payment Cuts to Physicians until April 1 Physicians — especially those of the primary care type —...
3. Obama Appears Intolerant of Waiting for Definitive Legislation to Curb Medicare Payment Cuts to Physicians A year ago, Doctor Pundit highlighted the perennially contentious matter...

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

Related posts:

1. Obama Signs Bill Delaying Medicare Payment Cuts to Physicians until April 1 Physicians — especially those of the primary care type —...
2. Senate Republicans Reject Last-Minute Democrat-Led Effort for Compromise, CMS to Enforce Medicare Reimbursement Cuts If anyone needs any proof of how irrelevant the American...
3. Senate Reverses Course on Inaction in Preventing Steep Cuts to Medicare Physician Payments No sooner had the Senate’s stonewalling led to the expectation...

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

Related posts:

1. Hospitals to Face HAI Reporting Requirements Hospitals that accept Medicare funding will eventually have to report...
2. MN Health Plan Set to Release Crucial Quality Data on Its Physicians The planned rollout for quality scores and transparent data from...
3. Study: Comparative Data on Pharma Products Lacking from Previous Decade Comparative effectiveness research — the direct comparison of care interventions to determine...

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

Related posts:

1. Obama’s Pick to Head CMS Goes Back to Senate President Obama’s recess appointment for CMS chief, Donald Berwick, made...
2. Berwick to Meet US Senate Next Week It’s on. New CMS chief Don Berwick is scheduled to...
3. Berwick Finally Meets Legislators Dr Berwick’s appearance before the Senate was an essentially anticlimactic...

Medicare will now expand its breadth of covered preventive services to include obesity treatment and management. In what could be a sign of the increasing population of beneficiaries who were weaned in the Boomer mentality, treatment coverage for such a hot-button topic among politicians, lobbyists, healthcare advocates, and physicians themselves — will remain, indeed, controversial. According to CMS, obese Medicare beneficiaries (defined as those with a body mass index of 30 or higher) may see their primary care physician for one face-to-face visit every week for the first month. Then, Medicare will pay for one face-to-face visit every other week for the next five months. If the patient loses at least 3 kg (6.6 lbs.) over the first six months, Medicare will pay for an additional six months of once-a-month face-to-face visits with the doctor.

Insurance remains above the fray here. While the feds may explain away this coverage as putting a dent in future healthcare costs associated with the obese patient, the fact remains, that outside of a universally defined pragmatic treatment regimen (ie, dedicated drugs = dedicated reimbursements/payments) — provider acceptance of this latest move by CMS will continue to advance at a trickle. It’s hard to get on board with yet another taxpayer funded government initiative whose intentions really haven’t been proven to lower across-the-board healthcare costs, lower all-cause mortality, and assume that all physicians are competent weight-loss counselors. Also: about 30 percent of beneficiaries are projected to qualify for this latest Medicare preventive care benefit. | LINK

Related posts:

1. Innovation in Minnesota Chain of Nursing Homes Offers Critical Look at Dementia Symptom Treatment and Care Delivery Since the late 20th century, innovation in long term care...
2. Medicare to Reimburse Voluntary Physician Counseling of End-of-Life Care Remember the “death panels” the GOP and other right-wing pundits...
3. One Month in, Multiple Parties Already Reporting Problems with Medicare Bidding Program Just over a month into the Medicare competitive bidding program,...

For Don Berwick, MD, the path to greatness as head of the Centers for Medicaid and Medicare Svcs was essentially doomed from the start. President Obama’s choice to head the federal agency was one made via his executive powers, bypassing congressional confirmation and giving Berwick a scarlet letter on the forehead ever since. Sure, there were the efforts at priming the PR pump in the first year since the reform bill was signed into law — his efforts to eliminate the quality chasm in hospitals and other care settings, bringing new light and interest into so-called comparative effectiveness research to improve healthcare, and most recently, his support of a citizen-led innovation care advisory panel, of sorts, to create models of reform in cutting Medicare spending on the run-up to reform. But it was all for naught. Senate Republicans, miffed at the recess appointment at the outset, never were willing to give the new CMS head a chance. Rather than face an uphill battle with pending confirmation hearings amid a hellish re-election campaign, Obama decided to drop him in favor of a less controversial pick:

President Obama said on Wednesday he plans to nominate Marilyn Tavenner as administrator of the Centers for Medicare & Medicaid Services to replace Dr. Donald Berwick, who has never won the support of Congress. [...] Tavenner, Berwick’s principal deputy, was the Virginia secretary of health and human resources. She has served as a board member of the American Hospital Association and as president of the Virginia Hospital Association.  Ms. Tavenner holds a B.S. in nursing and an M.A. in health administration, both from the Virginia Commonwealth University.

You can bet that this nominee will be a safer one — an administrator who can hold steady on policies of Medicare spending without being seen as a “rationer” of healthcare delivery whose ideas on cutting federal costs of healthcare will not be perceived as coming from a wealth redistribution model.

Related posts:

1. Obama Set to Announce Nominee for FDA Head President Obama is set to name his pick for FDA...
2. Obama Has Yet to Consider Nominee to Head CMS The run up to passage of the health reform bill...
3. Obama Appoints New CMS Head The fact that President Obama is naming Don Berwick, MD,...