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By Paul Campbell, on March 28th, 2009  Print This PostThe House Budget Committee’s budget resolution for Fiscal Year 2010 includes a reserve fund for reforming the Medicare payment system for physicians. Included in the Reserve Fund for Medicare Improvements is more than $87 billion of additional Medicare spending for a five-year period starting in 2010. The additional spending over a ten-year period is almost $285 billion. The budget resolution anticipates that Medicare physician payment reform will require additional funding to:
· encourage efficiency and higher quality care;
· improve payment accuracy to ensure that primary care is compensated appropriately;
· coordinate care across all appropriate settings; and
· hold providers accountable for their utilization patterns and quality of care.
While the Reserve Fund for Medicare Improvements represents a significant amount of additional spending, it is 40 percent less than the amount included in the President’s budget for the same five year period and it is about half of the Congressional Budget Office (CBO) five-year estimate of the cost of replacing the Sustainable Growth Rate (SGR) system. CBO estimated that, over a ten-year period, an additional $556 billion would be needed to update Medicare physician rates based on the Medicare Economic Index (MEI).
The five-year amount of reserve funds in the House budget resolution is similar to the CBO’s five-year estimate for a proposal which would use the MEI to update rates for evaluation and management (E&M) services, while maintaining the SGR for the other four categories of services, including those related to major and minor procedures, anesthesia, and imaging and testing. CBO estimates that this approach would result in a reduction in payments for minor procedures and imaging and testing procedures.
The budget resolution language makes it clear that the Medicare physician “fix” is likely to be linked to payment reforms which are designed to change how healthcare services are delivered and will, by necessity, encourage the formation and diffusion of new organizations such as patient-centered medical homes, bonus eligible organizations and accountable care organizations or systems.
By Maura Farrell, on March 28th, 2009 Print This PostThings are heating up for those of us following, participating in, and blogging on the process to enact comprehensive health reform. Hearings over the past few days, including those in the Senate Finance and HELP Committees, and the House Energy and Commerce Committee, focused on topics critical to any reform package: improving access to care, reforming the insurance market, and long term care issues. However, it was the House Budget Committee’s passage of its annual budget resolution that really lit up the debate.
As the FY 2010 budget process continues to unfold, a parliamentary argument involving the use of budget reconciliation instructions has imploded in both bodies of Congress. While President Obama met with Senate leaders to defend his top budget priorities, comprehensive health reform being chief among these, Democrats on the other side of Capitol Hill were laying their own set of rules for passage of health reform legislation.
Both the House and Senate budgets contain a deficit neutral reserve fund, or placeholder, to enact health reform. However, only the House budget blueprint, which passed out of the House Budget Committee on Wednesday night, contains reconciliation instructions. The use of this parliamentary procedure would enable passage of health reform in the Senate with only a majority of votes (as opposed to the 60 votes needed to invoke cloture). Chairman Conrad’s mark did not contain reconciliation instructions on health reform, but Majority Leader Reid has not ruled out employing reconciliation to enact reform.
Also, with the introduction of the new coalition of 15 moderates in the Senate led by Senator Evan Bayh of Indiana and created to “work with the Senate leadership and the new administration to craft common-sense solutions to urgent national problems,” it appears that enactment of meaningful health reform is increasingly dependent on the Democratic leadership’s ability to heed the concerns of those in their own party, not just those of their Republican colleagues on the other side. In fact, Senator Ben Nelson, a member of the moderate coalition, called the use of reconciliation to enact health reform “a deal-breaker.”
The stakes are high and the need for reform is very real. But as the political maneuvering continues, we are left asking what the prospects for true reform – reform which includes consensus building on polarizing key issues such as an individual mandate, the availability of a public plan, paths to expanded coverage, and the all-important sources of revenue and savings– really are.
By Ted Mannen, on March 24th, 2009 Print This PostHowever one views the controversial bonuses paid AIG executives, we can perhaps all agree that rarely has a single legislative clause so inflamed the nation’s political discourse. For it took only 48 words, tucked into page 404 of a 407-page economic stimulus bill, to make possible TARP bonuses if “paid pursuant to a written employment contract executed on or before February 11, 2009.”
The ambient conditions – huge bill, little time, immense complexity, even more controversy – are the very ones likely to obtain if Senate and House leaders make good on their pledge to move comprehensive health care reform legislation to within sight of enactment by August. If the scenario holds, what policy essence awaits us once the President has signed the bill, the bloggers have touted the moment, the law firms have written the summaries, and the CMS officials have drafted the regulations?
A lesson of AIG is that it’s the words on the legislative page that ultimately matter. Hearings, white papers, reports, Twitter blasts, TV ads, etc., are all indispensible for refining discussion and building consensus. But as with any major national issue, the concept of “comprehensive health reform” must ultimately be reduced to legislative words – not just any legislative words, but the ones that exert the precise policy effects intended. Such is no mean feat, no mere Tweet.
The lawyer’s adage – “know your opponent’s best argument” – should perhaps be flipped to say: “Know how your opponent will interpret your legislative provision.” For CMS and stakeholders will be squinting hard, looking for that little slip that spoils your clause on risk pools, bundled payments, sustainable growth rates, P4P, prior authorization, or whatever other issue you’re trying to push or defend.
As a former (and sometimes still) drafter of legislation, I’ve observed the unfolding of the AIG episode with no small amount of interest. The other AIG lesson: Watch those effective dates; they’ll get you every time.
By Robert Hudock, on March 19th, 2009 Print This PostOver the last year Employer-Employee “Global” Privacy Policies are becoming more common place (in-part) due to recent legislation in Connecticut and Michigan. Until this recent legislation, within the United States there were few situations where an employee had an independent right to access, inspect, or challenge information collected or held by the employer (unlike his/or her counterpart within the European Union). Within the European Union employers have
been bound by EU Directive 95/46/EC entitled the “European Data Protection Directive”. This directive applies to employment or employee data collected by an employer within the European Union or the European Economic Area regardless of where processed or stored. Employers when creating an employer-employee privacy policy should carefully consider the implications of implementing an overly broad privacy policy. Data security breaches, e-Discovery obligations, and the ability to investigate criminal or other non-productive activity may be hindered by an unnecessarily broad workplace privacy [...]
By Emily Bajcsi, on March 14th, 2009 Print This PostIn yesterday’s post on The Health Care Blog, Bill Kramer remarks upon a key difference in the health reform discourse this go-round. Simply put, “the Obama Administration is changing the debate in a fundamental way.” As President Obama stated in his opening remarks to last week’s White House Forum on Health Reform, “[h]ealthcare reform is no longer just a moral imperative, it is a fiscal imperative.”
Kramer explains that past attempts at reform suffered from political sticker shock over concerns that health reform would dramatically enlarge the federal deficit. However, this time, the Obama Administration is emphasizing that reform will not pose an additional burden to the already laden deficit. Indeed, health reform is a necessary tool to “tame” the deficit over the long term.
And framing health reform as an economic necessity is already having an effect. As Nancy-Ann DeParle, director of the White House Office for Health Reform, pointed out in her Wednesday op-ed in The Boston Globe: there are no defenders of the status quo. Two happenings from yesterday, both involving key stakeholders, echo this sentiment:
Regional White House Forum on Health Reform – Dearborn Michigan
Underscoring the link between long-term economic prosperity and health reform, the White House chose Michigan, the state with the highest unemployment rate in the nation, as the site for the first of five Regional White House Forum on Health Reform. In his announcement of the Regional White House Forum series, President Obama called on participants of these forums to “put forward their best ideas about how we bring down costs and expand coverage for American families."
Among the 250 attendees were doctors, patients, insurers, policy experts and health care advocates. The forum was hosted by Governors Jennifer Granholm of Michigan and Jim Doyle of Wisconsin. Notable politicos in attendance included Congressmen John Dingell and John Conyers, Jr., as well as White House Domestic Policy Director Melody Barnes, who helped to moderate the event. Reports of the town hall-style event indicate that “guests in the room uniformly supported broad and sweeping reform focused on expanding access to the uninsured, improving medical records and emphasizing preventative care.”
The remaining four regional forums will take place in Burlington, VT (March 17th), Des Moines, IA (March 23rd), Greensboro, NC (March 31st), and Los Angeles, CA (April 6th).
Business Roundtable urges lawmakers to act quickly on health reform
Yesterday heard from another key stakeholder group, Business Roundtable. The association released a study showing that American companies were losing out to other countries with cheaper healthcare and healthier workers. As reported by Reuters, Business Roundtable “wants changes that would reduce costs through greater use of technology and other efficiencies and require everyone to obtain health coverage. The group also supports plans to provide government aid to help those who cannot afford insurance, but said they do not want to see a government insurance plan that dominates the market.”
Members of the Business Roundtable also heard from President Obama yesterday on the critical need for health reform. A transcript of the President’s speech is posted on the Wall Street Journal’s Washington Wire blog.
If yesterdays goings-on are any indication, Kramer and DeParle are right: the landscape has changed and the health form battle will be fought on different grounds. Everyone is in favor of change. The devil, of course, will be in the details.
By Robert Hudock, on March 10th, 2009 Print This PostInformation not originally thought to be relevant may become a vital resource in laying the groundwork for your case. However some materials absent specific notice may be purged pursuant to a written document retention policy thereby providing opposing counsel and his/her client safe harbor protection under Rule 37(f) of the Federal Rules of Civil Procedure. On the other hand if you can provide notice as to potentially relevant information, and opposing counsel fails to preserve this information opposing counsel and his/her client will potentially be subject to serious sanctions.1 The universe of responsive documents can be further expanded using interrogatories designed to ascertain relevant electronic information systems that may contain information relevant to your litigation. (This process will also facilitate understanding of opposing counsel’s technological infrastructure, information that will be useful in the event opposing counsel claims data are [...]
By Mark Lutes, on March 6th, 2009 Print This PostFor health care facilities, and those who invest in them or lend to them, the President’s budget underscored the emerging “shape of things to come” in the delivery system. In short, the Administration intends to compel delivery system modifications through aggressive payment policy changes.
What industry segments are immediately concerned? — home health agencies, skilled nursing facilities, IRFs, LTCHs, and rehab facilities. In the name of “efficiency and accountability” the President proposes to bleed (Bleeding Edge redux?) $950M over 5 years and $17.8B over ten years from payments that would otherwise have gone to these facilities. We know this because the budget is echoing Director Orszag’s work at the CBO, finding savings from putting into the hands of hospitals financial responsibility, on an MS-DRG by MS-DRG basis, for the care Medicare otherwise would have paid these facilities for within 30 days after inpatient discharge.
In the CBO formulation, bundled payments would have been applied to 1/3 of discharges by 2013 and all discharges by 2015. The budget scores this proposal somewhat higher than CBO did so one might speculate that more rapid application is now on the Director’s mind. Somewhat comforting to investors in the affected facilities is that savings begin in 2013 and that over half of the ten year savings are not realized until 2018 and 2019.
Does this “reform” propel acquisitions of post-acute facilities by acute facilities? Alternatively, will acute facilities have the market power to negotiate favorable terms in purchasing post-acute services from such facilities? Does this require additional hospital and physician integration to produce the admission patterns that will allow hospitals not to lose their shirts in paying for the new care?
Will any state insurance departments want to see hospitals establish reserves against the possibility of the cost of their post-acute care payment responsibilities exceeding their financial wherewithal? The CBO write-up of this program also included take backs so that hospitals would only realize 20% of the savings that Medicare expects that they would produce. Of course there could be a big negative for acute care hospitals if Medicare’s take backs make the margins small and expected savings do not materialize because of case mix, physician ordering patterns, or a dozen other variables. What upheaval do you predict?
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