The Senate passed unanimously the Physician Payment and Therapy Relief Act of 2010 (summary here [PDF]), which will extend the period forgoing cuts to Medicare physician reimbursements for another month.^[1] The 23 percent reductions in those reimbursements was to go into effect on 12/1. Although the vote was expected in this lame duck session of Congress, the move marks a step in the right direction as lawmakers — particularly those on the powerful Senate Finance Cmte. — see the value in maintaining Medicare solvency over the next decade.

The so-called successive “doc fixes”, as these iterations have been called, appear to be setting the stage for modifying the SGR formula upon which such reimbursements are based. Several lobbies, among them the AMA, have been vociferous in their attempts to get Congress to act on legislation which would, at the very least, guarantee adequate reimbursements until the end of 2012.

1. The one-month postponement will cost $1 billion, financed by savings from planned cuts in Medicare reimbursement for therapy services. The plan still must be passed by the House of Representatives.

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Dr Berwick’s appearance before the Senate was an essentially anticlimactic affair, serving only a ninety minute sample of what the GOP wished were an actual confirmation of the now-recessed appointed CMS chief. Many thorny issues carried like an albatross around Berwick’s neck, pre-appointment,^[1] were either given cursory treatment or not visited at all.

According to Orrin Hatch (R-UT), Max Baucus’s heir-apparent when the next Congress convenes in January, the meetup was “pathetic”, as he decried what turned out to be more of a show-and-tell — instead of purposeful vetting. Berwick, whose Medicare and Medicaid quality assurance intentions of reform are quickly becoming his locution, did address upcoming Medicare cuts in provider reimbursements on December 1 — stating he would approve of yet another monthly reprieve as the lame duck session tries to produce a solution to the SGR crisis. | LINK

1. Healthcare rationing, adopting the British model of socialized-driven care delivery, the recess appointment itself, among other issues.

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It’s on. New CMS chief Don Berwick is scheduled to appear before Congress next week. You may recall that his appointment was of the recess variety, bypassing the traditional confirmation process before the Senate. This fact alone has raised the ire of Republicans opposed to the reform law and has given the party one more reason to favor repeal of at least parts of it.

As a result of the so-called GOP wave that was the result of the midterms this year, Sen. Orrin Hatch (R-UT) will most likely head the Finance Committee, a position now held by Blue Dog Max Baucus (D-MT). Currently, CMS manages a budget of about $960B.

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It’s official. The FDA will convene this Tuesday (13) to discuss and come to a decision on the fate of GSK’s Avandia. I guess you could literally call this agent a wonder drug — as its continued availability in the Pharma marketplace in spite of hundreds of class action lawsuits, multiple studies stretching back to at least 2005 documenting a clear association with an increase in heart attack risk, and copious physician calls for its withdrawal — continues to amaze healthcare policy watchers.

For the first time it appears that the handwringing on both sides of this hotly debated drug (Pharma/GSK vs. medical critics) appears to be taking on an overtly political tone, as even within the government agency itself, there is a deep devision over just how this entire case should be handled. The hoopla surrounding the removal of Vioxx and Bextra (anti-inflammatories with similarly documented cardiac risks) was never this contentious. Even U.S. senators have weighed in on the issue.^[1] What will the fate of this drug be? Tighter restrictions on its use, or complete removal from the pharma marketplace? Perhaps the answer says as much about the FDA as it does about GSK. | LINK

1. Sens. Baucus and Grassley published a report questioning the FDA’s rationale for keeping the drug available while GSK knew about the drug’s risks.

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If anyone needs any proof of how irrelevant the American Medical Association has become in its advocacy of the physicians the organization is supposed to represent, one needs look no further than in the last minute unexpected rejection of the postponing of cuts (21%) to Medicare reimbursement schedules. So much for being in the physicians’ corner on this issue. Senate Republicans essentially killed the measure via a vote along party lines. Initially, there was hope for a compromise fashioned at the eleventh hour by Max Baucus (D-MT) — one of the key figures in the establishment of many of the provisions set forth in the reform bill’s passage earlier this year.

The Senate had rejected a Finance Committee compromise^[1] that would have delayed the cut in Medicare payments to physicians until 2012, along with measures to extend unemployment benefits and provide $24 billion to states to cope with their Medicaid programs. Senate Republicans have apparently had enough — as CMS now has the greenlight to move forward on the cuts which were to have initially been implemented on June 1. This entire episode is a reminder of how serious matters are for primary care to sustain itself in a slowly recovering economy and increasingly prudent healthcare marketplace — which now, in a new reform-minded environment, has to manage to do more with less. The calling for innovation for the recruitment of primary care physicians has never been greater this century than as a result of this moment.

1. The compromise would have decreased the total cost to $118 billion and the overall deficit impact by some $20B;  it would have delayed the planned Medicare cuts and provided a 2% raise for physicians through November 30, rather than for the 19 months as part of the original bill. Essentially, the compromise would have amounted to a short term “fix” of the SGR — the method by which the cuts are computed in the face of increasing healthcare expenses by the government.

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Add yet another blow to GSK’s once-blockbuster diabetes drug, Avandia (rosiglitazone). The ongoing soap opera that is this drug’s manufacture and continued presence begins another chapter in its struggle to retain some semblance of competition in the pharma marketplace. Avandia’s troubles and brushes with near-market revocation are greater amidst news of the FDA considering axing its inclusion in a safety study involving itself and its much safer congener, Actos (pioglitazone).

The concerns over Avandia’s possible involvement in increasing death due to cardiovascular problems are legion and stretch back at least nine years, with its most recent actions coming this past February — as Senators Max Baucus (D-MT) and Charles Grassley (R- IA) released a report on the drug in February as well as a 2008 memorandum from two FDA drug safety reviewers who recommended pulling the drug from the U.S. market. | LINK

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The health reform debate has had its share of key players. Many of them have been elevated to star status (Snowe, Baucus, Stupak), although the meaning of “star” would depend on whom you asked. Perhaps a more apt term would be a “highly influential” player, or a “significant game changer”. All of these monikers could also apply to a collection of individuals who, over the course of the debate’s more interesting and contentious moments (think House debate), seem to be setting the fiscal parameters on which the key Senate debate is being issued — the Congressional Budget Office.

The CBO’s cost-setting results have been fodder for many media outlets, as they have seized on the big number — the lofty amount usually expressed in the hundreds of billions that’s sure to grab headlines and is ripe for the spinning from both sides in the debate. HHS Secretary Kathleen Sebelius puts her spin on the CBO’s influential numbers by showing how they support the Obama administration’s argument that cost controls from its vision of health reform will benefit the small business owner. How? By using the proposed healthcare exchanges to lower administrative overhead by increasing competition with other private and government run plans (public option provision).

I suppose that, magically, this can happen. However, Sebelius’s fact sheet explaining these reform benefits for business doesn’t really take into account how the government subsidized players in the exchanges will behave. Depending upon how much subsidy is piped into the public plan, how can the quality of what private plans offer avoid oversimplifation of their services in order to compete with the public plan? Will employers get fewer choices and be forced to spend more on coverage outside of the healthcare exchange, rendering Sebelius’s claim of lowered administrative costs irrelevant? Will even more potential patients migrate to government plans as a result?

Sebelius:

CBO attributes savings to “providing a centralized marketplace in which consumers could compare the premiums of relatively standardized insurance products.” This includes competitive pressure from a public health insurance option.

How much “pressure” will the public option place on the ability for plans to rein in costs? The CBO estimates by the year 2019, 30 million people will be insured through insurance exchanges, while about 20% of that number will go the route of the public option — a substantial number. Insurance exchanges may be hard pressed to keep plans’ premiums from being, essentially, regulated by the effect of government subsidies within that healthcare marketplace.

Congressional Budget Office data, cherrypicked by lawmakers on both the Left and Right, is no stranger to (mis)interpretation; the final version of the merged reform bill will rely more on the spin surrounding it than the reality upon which it is based.

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Less than a couple hours after Senate Majority Leader Harry Reid (D-NV) publicly made the current definition of the health reform bill on the senate side an official one, the WH has issued a perfunctory measure of support for its language, which includes an “opt out” mechanism for states.

The President congratulates Senator Reid and Chairmen Baucus and Dodd for their hard work on health insurance reform. Thanks to their efforts, we’re closer than we’ve ever been to solving this decades-old problem. [...] the President is pleased that at the progress that Congress has made. He’s also pleased that the Senate has decided to include a public option for health coverage, in this case with an allowance for states to opt out. [...] he supports the public option because it has the potential to play an essential role in holding insurance companies accountable through choice and competition…

Perhaps even more unexpected is the level of apparent support Max Baucus [D-MT] (long a vehement PO detractor) has for the majority leader’s version of the merged product.

It is time to make our system work better for patients and providers, for small business owners and for our economy. It is time for health care reform. [...] Success should be our threshold and I am going to fight hard for the 60 votes we need to meet that goal this year.

Is this a watershed in the entire reform movement (at least by standards on the Hill)? Will progressives warm to the notion of a public option in which many, if not most states, choose to participate? Or will they grow to loathe a position which ultimately favors Insurance and its practically assured regulation of any individual public product placed into the healthcare marketplace? | LINK

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Yesterday, while this blog took some time off, healthcare’s political power players took to the Sunday talk shows. And while they did not explicitly say so, Obama’s push for a public option appears to be turning into something less demonstrative. Top Obama aides are framing his push for a public option provision as an insistence now. This all sounds plausible to some degree — except, he has been doing that all along, hasn’t he?

President Obama isn’t demanding that health care legislation include a government-run insurance option even though he believes it would best meet his reform goals, White House advisers said yesterday.

The White House and lawmakers are trying to blend five House and Senate committee versions of health care legislation into a bill that will pass both houses, where near unanimous GOP opposition was expected.

Senior adviser Valerie Jarrett said Obama believes the public plan is still the “best possible choice,’’ but she said he’s not demanding it.

White House chief of staff Rahm Emanuel, who is deeply involved with Democrats in trying to merge the various committee proposals, also appeared to set aside the public option.

“It’s not the defining piece of health care. It’s whether we achieve both cost control, coverage, as well as the choice,’’ Emanuel said…

Where’s the choice without a public option? This was the platform upon which Obama’s #1 domestic priority was placed. One possible interpretation for Obama’s newfound reticence: a “laying low” strategy. Realizing the House’s version of the bill includes a public option provision and that the Senate’s version is anything but, he could be waiting for subsequent committee placement of it back into the bill if the Senate’s final version passes without the provision; that would require sixty Republican votes.

Democrats who wish to have any semblance of a political future in 2010 should be clamoring for a public option. If CBO estimates are to be believed^[1], when voters realize that they will have to wait a few years for the Max Baucus Senate-backed law to be implemented and show any potential savings for care delivery in general, there could be a backlash for healthcare consumers led to believe that public option alternatives in healthcare marketplace competition would be immediate and healthy (insurance co-ops, for example). | LINK

1. The Congressional Budget Office finds that the country would get the most savings on health-care costs from a public option tied to Medicare rates. This version, found in two of the House bills, would save $110 billion over 10 years.

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By now healthcare policy watchers everywhere know that the Baucus Senate Finance bill passed and that Olympia Snowe’s (R-ME) moderate voice was the lone Republican modicum of support. Next up — no more than two weeks (according to Harry Reid [D-NV] — majority leader) of debate before the final floor bill. Besides keeping busy with the pending debate, possible reconciliation, and floor vote; senate Dems are busying themselves with another cause. The deer in the health reform headlights is none other than Insurance itself.  Whatever the reason, the eleventh hour report the industry’s lead lobby — the AHIP — rapidly rolled out on the eve of the Baucus bill vote has complicated matters for themselves. If the AHIP thought that this move would help their cause by drawing a line in the sand, it’s done nothing but inflame all three (four?) sides of the healthcare debate: the Republicans, Democrats, Obama & the WH, and the healthcare beneficiary.

It’s the latter demo that the other three have to contend with over the next crucial 14 days before the most sweeping changes in 65+ years in healthcare delivery occur. Vitriolic townhalls may be a thing of the recent past, but the public’s ire over what is now seen as insurance reform (as opposed to true grassroots healthcare reform) is sure to grow over the next few days – in part due to the latest stirrings by the AHIP. Obama’s spearheading of the reform debate up to this point has generally been heralded as positive, if not mildly successful. But that victory may be a pyrrhic one if many see this detour on the road toward reform as beholden in some part to Insurance.

As the blending of the House and Senate versions of the reform bill coalesce for a vote on its passage, Democrats (who, let’s not forget, own the majority in both houses) must continue to frame the debate on reform as one of guaranteed access that won’t bankrupt the “system” by skewing risk pools, as the AHIP’s report suggests.^[1] Sound fiscal arguments persuasive enough to woo and keep moderate Republican interests like Sen. Snowe are the Dems’ best shots at melding a bill that will please many at the expense of a dilute public option.

1. The AHIP says that young healthy ‘invinvibles’ will not gravitate toward coverage and spread the risk pool, causing an incentive for the sickest, oldest, and neediest to clamor for it — driving up costs.

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