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.
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
The good news: the media have done a reasonably good job of getting the word out to consumers of healthcare with respect to the prevention of medical and surgical mistakes in acute care settings. The bad news? Here in Minnesota, the numbers of “wrong surgeries”, a collective term meaning never-events in this care realm, topped 2010′s tally by five cases — creating a surge in such cases last year.
The figure is the highest in eight years of self-reporting by Minnesota hospitals. Officials cited many reasons for the mistakes — from doctors filling out incorrect orders to sloppy inventories that make it easy to grab the wrong joint implants for orthopedic procedures.
While the surge appears to be from the absolute numbers of incorrect procedures performed, the rate of adverse events has globally decreased, bringing into question the efforts of many healthcare systems in the processes involved in preventing completely avoidable lapses in care delivery. | LINK
After a two-year investigation into disclosure issues surrounding a top University of Minnesota physician faculty member, the case is now closed — accompanied by a stern “cautionary letter” which
instructed him to take corrective measures to prevent further problems, but decided against further disciplinary action. A review committee found no evidence of fraud or misrepresentation. However, the committee found that Polly failed to sufficiently disclose the Medtronic relationship in connection with two medical journal publications and a conference presentation.
He no longer does work which requires scrutiny for disclosure since the investigation’s launch in November 2009. | LINK
When she was diagnosed with multiple sclerosis, a Minnesota woman thought that her carefully chosen neurologist had her best interests in mind when prescribing initial treatments to modify the disease. That was before a little detective work uncovered the real motivation for her physician’s patterns of prescribing that left her even more debilitated than when she was initially showing symptoms.
It worried me that none of them ever suggested that I discontinue treatment—or switch to another treatment—even after I reported that my injection site reactions were affecting my quality of life. Despite the fact that my neurologist insisted that I begin disease-modifying therapy, I was never contacted by him, his nurse, or anyone else in the neurology clinic with questions about how my Copaxone injections were going.
The patient, a U of M philosophy graduate student, puts into her own words the ethical issue she gradually uncovered while under the specialist’s care. Just how influential are pharma companies’ financial compensations for physicians who choose to prescribe their products? Just how willing are they to prescribe knowingly untested medications without concern as to their problematic and potentially lethal adverse effects? Her answer came at her next appointment, after enduring months of increasingly debilitating pain and enfeebling function from the trial with the first drug.
[M]y neurologist informed me that I’d begun to develop lesions inside my brain stem. He explained that this was a very bad place to have lesions, occupied as it is with regulating some of the body’s basic functions, such as breathing. He strongly recommended that I go back on MS treatment, suggesting this time a drug called Tysabri (natalizumab), which had worked wonders for some of his patients but also carried some amount of risk. Worried about the new lesions, but knowing little about the drug he was advising, I told him I’d think about it. I needed to be convinced through my own investigations that this drug would be worth taking.
Her investigations were not only telling, but they are also indicative of an all-to-familiar refrain for patients of (mostly specialist) physicians who pocket major coin from pharma companies to get these ridiculously expensive agents to the marketplace, at the risk of patient harm. In Minnesota, the patient was assisted by a database which lists pharmaceutical third parties with which a prescribing physician has a financial interest. She makes little doubt of her eagerness for this requirement to spread nationally as the result of the reform law. | PDF LINK
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
As a follow-up to a DP post on the unusual strategy pharma company Pfizer is implementing in trying to protect market share for the formerly solely branded drug Lipitor, here’s another take on the issue. According to one analyst profiled, Pfizer faces an uphill battle in trying to convince the pharma marketplace that its branded agent is more clinically efficacious than generic atorvastatin.
Pfizer is doing a so-so job of convincing health plans and [pharma benefit managers] that Lipitor is somehow better than a generic. On a scale of 1 to 10, Pfizer received a 4. Nonetheless, 54.8 percent say they will offer the authorized generic, which is being sold by Watson Pharmaceuticals. Meanwhile, only 30.4 percent report they will receive added rebates or discounts from Pfizer.
Of course, the pharma company stands to lose a ton during its loss of exclusivity over the next 6 months, but it will remain tenacious — as many analysts do not believe future antitrust issues will occur. Perhaps even more interesting is the new ground being broken here: can healthcare consumers be weaned off of generics and stay loyal to branded medications — if insurers and key third parties allow them to gain incentives by continuing to utilize them? | LINK
Okay, here’s what we do know about the current state of solvency of Medicaid post-stimulus funding: states are grappling with a larger share of Medicaid liabilities than before, and they are immediately reacting with a combination of cuts to providers/hospitals and pulling in the reins on certain services.
Although states are bearing a bigger share of the Medicaid burden this year than they have in the recent past, overall Medicaid spending (state and federal dollars) is projected to grow by only 2.2 percent, the lowest amount since 2006, [a] Kaiser report [shows]. That is because the stimulus funding ended, and program costs are stabilizing as the national economy shows tentative signs of recovery and enrollment growth slows.
The article is a lengthy one, but worth a read. The Kaiser-funded survey trial of states with respect to this question suggests many states are implementing myriad Medicaid spending stopgaps in the short term. All this is on the table as the bipartisan so-called congressional supercommittee gets ready to release its report on trimming the current budgetary deficit.
One axiom is certain in medicine: there is always room for controversy. And that’s good, because it spurs further scholarly thought and research — both qualities can only help patients and providers in the long run. With the current discussion in the media regarding the utilization of the PSA in determining the course of action in prostate cancer screening, so many fundamental issues surrounding patient informed consent, unnecessary treatments, and the potential harms from treatments — can serve as valuable teaching points for patients and current and future physicians alike. The discussion — highlighted in the current NEJM — really brings this point home.
Watchful waiting and active surveillance may help prevent the conversion of overdiagnosis to overtreatment, mitigating the harms of screening that are so accurately portrayed by the task force. … we primary care clinicians must ensure there is no more routine, indiscriminate PSA screening — and no washing our hands of responsibility once the patient is referred to a specialist for prostate-cancer treatment. We owe it to our patients to provide them with the kind of guidance about this screening test that they need and deserve…
A physician advocacy group has released a report detailing the costs to Massachusetts in the wake of its healthcare reform. The goal is to shed light on the potential costs to the country as a whole once reform begins in earnest. The single-payer advocacy group mainly cites that cost shifting of taxpayer subsidies to fund the private insurance marketplace is creating an access burden for the state’s impoverished and lower middle class by pricing them out.
Most of the gains in coverage have come from expansions in publicly subsidized insurance. This largely represented a shift of patients from the state’s former Free Care Pool, which compensated hospitals and community health centers directly for care of the uninsured, to private insurance plans, which is a more costly way to provide care.
Read the PDF of the entire report. The report appears to yearn for a less-than-market-based approach to solving this financial crisis as a way in which access to care can remain intact amid long-term reform sustainability. This report was released jointly among this group and via the state chapter of Physicians For a National Health Program.
With the continued destigmatization of some forms of mental illness in the community (namely, the diagnoses of depression and anxiety), it comes as no surprise that we are more willing than ever to discuss treatment and prevention more openly. Oh, and it also doesn’t hurt that — within the general population at any given time — 10 percent of Americans are taking an antidepressant.
According to the Centers for Disease Control, the rate of antidepressant use has skyrocketed by a factor of 4X over the past 25 years. Females lead the pack in all age demos save for the youngest — ages 12-17. Interestingly, income status was not a predictor of use, the agency cites; although, slightly more than 1 in 12 persons taking the drugs is Caucasian. Most disturbingly, though, is the apparent lack of care access or followup once these drugs are prescribed: just under a third of patients have seen a mental health professional (or primary care physician — assuming the drugs are possibly given for off-label uses) within the previous 12 months. Excellent survey data here.
The reining in of costs associated with spiraling Medicare coverage amidst the proposed so-called “doc-fixes” addressing incessant threats of congressionally mandated cuts has many on the Hill wondering what will the Super Committee do to remedy the situation? FYI, the Super Committee is the bipartisan congressional panel made up of 6 Dems and 6 GOPers tasked with putting the brakes on deficit spending to the tune of $1.5T over the next ten years. Issues of Medicaid and Medicare spending are high on the panel’s agenda.
Specifically, futher tightening of Medicare eligibility rules and block-grant funding of Medicaid are mong the most rancorous of discussions — so much so, that at least one Republican moderate senator has chosen to distance herself from the Super Committee recommendations forthcoming. Sen Olympia Snowe (R-ME) also cites her support of branded pharma rebates (something her GOP colleagues really aren’t enthusiastic about) as another mechanism to trim costs.
The ramped-up schedule endorsed by the panel has states, insurance companies, and policywatchers of reform on the edge of their collective seats as issues of funding of the Medicare hospice benefit funding and possible elimination of the SGR formula for determining Medicare reimbursements to phsyicians and hospitals are discussed along with Medicaid funding. | LINK
Originating from Saint Paul, Minnesota, [doctorpundit.com] is a weblog about the policy of healthcare and where it intersects with politics and public opinion; it is edited by Michael Douglas, MD, MBA. Welcome, and please consider my take on what is Healthcare 2.0, complemented by a few of my thoughts on my personal avocations and guilty pleasures: music, prose, and writing. Follow Doctor Pundit via RSS above.
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DOCTOR PUNDIT @ ONE YEAR | An occasional DP series from 2010 highlighting healthcare policy trends over the period from 2009-2010 in a compare/contrast format.
