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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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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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

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The SCOTUS has begun a new term, and the most august judicial body is hearing a case involving potential for healthcare consumers (patients), hospitals, or even doctors to sue a state government for what they may see as unjust — or even, unethical — cuts to the state’s Medicaid program. The Obama administration is asking that cuts by proposed to Medi-Cal (of California) in the wake of already massive declines in reimbursements in that state due to its well-know budgetary woes be implemented and shielded from such lawsuits.

The court did not consider the legality of California’s reductions, only whether private citizens could sue to challenge them. No clear majority emerged at Monday’s one-hour hearing.  A lawyer for doctors and patients told the court the reductions would be both illegal and cruel.

Barred lawsuits would mean total involment by the federal goverment in policing an already massively bureaucratic Medicaid program — as HHS would have authority over proposing further reductions. A ruling on this case is expected next June — one of many rulings in what appears to be a very interesting pending SCOTUS term. | LINK

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Alzheimer dementia continues to be among the most heavily researched and funded chronic diseases in medical science today. The increased awareness, brought into the spotlight and “modernized” more than 20 years ago following the high profile revelations of celebrites and politicians afflicted with the disorder, has led to increased patient education, public policy initiatives, and, of course, greater research monies in the effort to not only treat symptoms, but also to find a cure.

An international advocacy group is now asking municipalities to take awareness a notch higher with the commitment to even greater awareness of the disorder — addressing what it calls a “treatment gap”, hampering any gains on detection of the disorder at its earlier stages. Here in the U.S., the Obama admin is apparently hard at work in developing the country’s first-ever national anti-Alzheimer strategy aimed at sharply cutting the enormous healthcare costs associated with ancillary treatment .

The National Alzheimer’s Project: From Act to Action is an effort to support a committed and effective implementation of the National Alzheimer’s Project Act (NAPA). Information collected from individuals living with the disease, caregivers, providers and other stakeholders will be shared with the U.S. Department of Health and Human Services, which is responsible for creating a national strategy to address the crisis and coordinate across government agencies. This project is facilitated and supported by the Alzheimer’s Association.

Consider this effort an amalgam of citizen awareness and discussion (townhalls) and legislation (congressional passage of the National Alzheimer Project Act) garnering bipartisan^[1] support to fight a scourge that can leave heavy financial tolls on caregivers, families, and the healthcare delivery system itself.^[2] A daunting task, to be sure — but one that is sorely needed. Here’s looking forward to December — the date when the president makes his plans for these initiatives very public. | LINK

1. Just how bipartisan? In 2007, Newt Gingrich co-authored an article in Alzheimer’s and Dementia: The Journal of the Alzheimer’s Association, making the case for the creation of a federal Alzheimer strategy.
2. Alzheimer’s Association advocates sent more than 15,000 email messages to the White House asking the President to sign the National Alzheimer’s Project Act into law; on 1/4/11, he did — making this action the most significant legislative action with respect to Alzheimer funding intiatives up to this point.

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The initial spin on the recently squared away budget deal preventing a national default relates a necessary evil that not only carries the partisan rift seen in advance of the legislation, but also becomes a harbinger for a financial outlook that, in some ways, looks as bleak as the presumptive default did. Still retaining its triple-A rating, the credit outlook for the United States will be reflected in a “negative” forecast — likely resulting in a downgraded credit status within the next couple of years. Of course, all of this big-picture wrangling really doesn’t mean much to the millions of people whose salaries are paid — in part — by the federal government. A harsh reality at the forefront of this thinking, given the current jobless rate and achingly persistent unemployment levels is the specter of the loss of unemployment insurance for those currently receiving benefits. Minnesota is just one of many states bracing for such an apocalypse which appears to be sparing future cuts in another enormous federal subsidy — Medicaid.

Department of Human Services Commissioner Lucinda Jesson said she was relieved that Medicaid, known as Medical Assistance in Minnesota, is exempted from the initial cut. That doesn’t mean the new bipartisan commission charged with driving down the deficit won’t come after it once the panel breaks out the budget knife. “We are going to track it very closely,” Jesson said Tuesday. She said her department will also keep a close watch on child protection, food support and other assistance for seniors.

What about cuts to the service side of the equation? Since Social Security and Medicaid are specifically exempted from the ravages of the debt ceiling bill, physicians could see an additional 2 percent pay cut on top of double-digit Medicare reductions already slated for 2012 under the debt ceiling deal. Perhaps more concerning is the strong likelihood for major Medicare cuts and overhauls in long term care payments as a by product of a commission^[1] created as part of the deal agreed to on Sunday. Nursing homes would be hit extremely hard in this scenario — potentially affecting care delivery to the most medically complex beneficiaries in the LTC sector. Understandably, the deal reached by a less than jubilant Hill on Sunday has many folks extremely wary about the nation’s prospects on an already shaky economy. Its effects on federally subsidized healthcare delivery ups the ante for lobbyists, providers, and most importantly — patients. | LINK

1. The deal to raise the debt ceiling would task a 12-member bipartisan committee to come up with $1.5 trillion in deficit reduction and would require a significant swath of cuts starting in 2013 if those efforts at reducing the deficit should fail.

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Much has been written of late regarding the initial media presentations of the virus that causes AIDS and the de rigueur comparisons to how far awareness, activism, and innovation have propelled its discussion to every corner of the planet in 2011. Its chilling descriptions more than thirty years ago cannot belie the fact that, in spite of advances, there is still much to be done on the road to eradication and cure. Within this paradigm is the notion that an entire generation or two have witnessed how the existence of HIV/AIDS has shaped healthcare policy in this country and worldwide.

Here in the U.S., the specter of the aging patient with this now “manageable chronic disease”, the numbers of patients this will represent, and the availability of physicians knowledgeable enough to not only treat chronic HIV disease but also its unknown effects in the increasingly “geriatric” patient — are gaining consideration and acknowledgement in policy circles. Discussion almost always leads to the role of the primary care physician in not only screening but also becoming an active treatment provider.

In 2009, a record 82.9 million American adults were tested for HIV. [...] By 2015, the IOM estimates that half of Americans living with HIV/AIDS will be older than 50. For primary care doctors, this means a growing number of their patients will need care for chronic diseases as well as HIV.

Today’s generation of physicians has inhereted the mantle of providing care for a disease whose spurred innovations ranks as one of the greatest medical achievements of the last century. It is time to consider the primary care approach to chronic HIV disease as another fundamental skill set as reform redefines healthcare delivery in the 21st century. | LINK

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How does obtaining health coverage (insurance) compare to not getting it at all? According to a trial published via the National Bureau of Economic Research (Harvard/MIT), beneficiaries’ quality of life was enhanced and made a “big difference” in those patients’ self-health perceptions and their daily outlook — according to the study’s lead author. A quick glance at the results confirms that all encompassing statement, especially since the study employed the diagnostic “gold standard” in trial research by utilizing a randomized, controlled design.

Taking a look at approximately the first year of coverage for Medicaid beneficiaries in the state of Orgeon, the study showed that healthcare expenditures for those who got coverage increased by almost $800/year. Those who received Medicaid were around 60 percent more likely to get mammograms. Medicaid recipients were over 50 percent more likely to have a regular primary-care doctor. They were also in better shape financially and less likely to have unpaid medical bills. Those who got Medicaid were also far more likely to report themselves in good or excellent health. ED admissions did not decrease; however, the increase in ED utilization by beneficiaries was not statistically significant.

It is clear from the results that coverage, in and of itself, has a positive effect on patients’ perceptions of health and wellness. What is not documented as much at this time is how this translates into outcomes with respect to various chronic problems such as obesity, diabetes, and risk factors (such as serum cholesterol, blood pressure, etc.) for heart disease. Also, it is unclear how these results translate into real numbers once reform increases Medicaid rolls substantially by 2014. Researchers plan on following the participants for at least another year. | LINK

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For the first time, a major private coporation is partnering with a local hospital in assisting Medicaid beneficiaries in obtaining legal assistance in squabbles with the entitlement over public health care delivery, housing, medical equipment, and other basic needs guaranteed by Medicaid. It’s not just any partnership. The corporate entity is Wal-Mart, and it insists it will not be an adversarial force to the feds. The retailer’s involvement with a local Arkansas hospital is being piloted and could become a model for future national rollout. These medical-legal partnerships, as they are called, are designed to promote changes in the healthcare public-private policy sphere by becoming part of the beneficiaries’ heatlhcare team — alongside providers and hospitals.

Onsite, legal professionals become a part of the healthcare team.  Doctors will refer patients to lawyers for legal assistance when appropriate.  Just as a pediatrician refers a patient to a radiologist for a broken bone, a healthcare provider may refer a patient to an onsite attorney when an underlying social circumstance impairing a patient’s health is detected. 

Lest one believes that this is some conservative vs. progressive battle implemented by activists to inflame further the current drive toward reform in this administration — think again. These MLPs have the backing of the traditionally liberal-leaning American Bar Association. It is the hope of the parties involved that providing this type of legal assistance to Medicaid beneficiaries will usher in a new area of accountability by building broad public-private networks with a common goal enriching Medicaid care delivery as reform begins to take shape. | LINK

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Many physicians, including myself, who see a majority of elderly patients are always interested in ways we can educate patients and concerned family members of the wide spectrum of clinical presentations of cognitive decline. For many Boomers who are now just turning 65 (as the first and oldest cohort does this very year) the specter of that “senior moment” possibly belying something more ominous and progressive is a little more than just an afterthought that can be dismissed. When the moment came for a discussion with the patient and the family over the concern of cognitive impairment, it was always a delicate balance with respect to validating patient concerns with the real world possibility of subclinical disease.

New diagnostic indicators and guidelines for primary care providers and their patients as recommended and formulated by the National Institute on Aging are out to demystify the process, while making research more goal focused, tangible, and accessible with respect to discovering therapies that can actually reverse progressive dementia.

While laudable in these efforts, the three-stage set of guidelines for diagnosis and treatment insertion offered by the NIA and Alzheimer Association is just the beginning. It certainly complements what we geriatricians have been doing quite adeptly for a couple of decades now — informing and educating patients and their families while squelching myths that could delay or, worse, prevent treatment from ever occurring. Of course, the ability for researchers to recruit the most appropriate patients for targeted clinical trials doesn’t hurt, either.

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