Janaury 8, 2010
By Clinton Mikel*
Senate Approves Healthcare Bill
The Senate approved healthcare overhaul legislation on Christmas Eve with a sixty-to-thirty-nine vote. The bill would require most Americans to have health insurance, add fifteen million people to the Medicaid rolls, and subsidize private coverage for low- and middle-income people at a cost of $871 billion over ten years to the government, according to the Congressional Budget Office. While the bill will cover thirty-one million otherwise uninsured people by 2019, another twenty-three million uninsured will remain.
The bill was approved by the narrowest of partisan margins. The vote split directly along partisan lines, underscoring not only the great divide between Democrats and Republicans but also the deftness with which Majority Leader Harry Reid (D-NV) at long last united his fractious caucus by offering key compromises to centrists but keeping liberals in the fold. The Senate capped off a nearly month-long floor debate with its near-record twenty-fifth consecutive day in session by holding a vote on Christmas Eve for the first time since debating the Vietnam War in 1963.
The Senate's version of the bill will need to be reconciled with a House version passed earlier, and a compromise is not expected until January at the earliest. In Republicans' view, the bill would impose massive regulatory and financial burdens on taxpayers and businesses, and would dig even deeper debt for the government.
While many parts of the bill would not take effect for several years, many provisions would kick in six months after the bill takes effect. Those provisions would: (1) prevent insurers from limiting the amount of money they spend on a single individual over their lifetime; (2) similar, annual caps would also be limited; and (3) preventive care would be fully covered without co-pays.
In a short statement at the White House before leaving for a holiday vacation in Hawaii, President Barack Obama praised the Senate vote, calling the provisions "big reforms."
Kaiser Daily Health Policy Report, Senate Approves Healthcare Bill, Henry J. Kaiser Fam. Fdn. (Dec. 24, 2009).
C-SPAN Asks Democrats to Open Healthcare Reform Conference Negotiations
C-SPAN has asked congressional Democrats to open to the public the conference negotiations on reconciling the two healthcare reform bills.
C-SPAN Chief Executive Brian Lamb requested opening up all important negotiations, including any conference committee meetings, to electronic media coverage. He told lawmakers in a letter dated December 30, 2009, that they have spoken of transparency in discussions in the past and that they should allow it now. House Minority Leader John Boehner (R-OH) has used the letter to call out Democrats for breaking their campaign promises to bring more transparency to Congress.
A spokesman for Senate Majority Leader Harry Reid (D-NV) said that Reid has not yet responded to C-SPAN. President Obama pledged repeatedly during the 2008 presidential campaign to specifically broadcast healthcare negotiations on C-SPAN so that the American people could participate in a transparent process.
Kaiser Daily Health Policy Report, C-SPAN Asks Democrats to Open Health Reform Conference Negotiations, Henry J. Kaiser Fam. Fdn. (Jan. 5, 2010).
CMS Makes Adjustments to Reflect Pay-Cut Delay
The Centers for Medicare & Medicaid Services (CMS) announced that it would be making adjustments to Medicare's physician fee schedule to reflect the temporary stay on physician payment cuts through February 2010. President Barack Obama recently signed a spending bill that prevented a scheduled 21.2% cut to physician payments from taking effect on January 1, 2010. Instead, the measure provides for a 0% update to the 2010 Medicare physician fee schedule for a two-month period, beginning January 1, 2010, through February 28, 2010. The measure was signed to give Congress extra time to come up with a permanent solution to Medicare's sustainable growth rate formula, which has been threatening cuts to physician payments since 2003.
This temporary reprieve, however, means adjustments had to be made to ensure that the 0% update was accurately reflected in 2010 payments. In a memorandum, the agency clarified that it would be instructing its Medicare contractors to hold claims for services paid under the fee schedule for the first ten business days of January. This will allow Medicare contractors time "to receive the new, updated payment files and perform necessary testing before paying claims at the new rates," CMS explained in its memo. In the meantime, all claims for services delivered on or before December 31, 2009, will be processed and paid under normal procedures, the agency stated.
CMS estimates the holding of claims should have minimum impact on provider cash flow "because, by law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt," the agency stated. The agency also announced it would be extending its enrollment period for physicians to participate in Medicare through March 17, 2010.
Jennifer Lubell, CMS Makes Adjustments to Reflect Pay-Cut Delay, Modern Healthcare's Daily Dose (Dec. 30, 2009) (note: registration is required to view this content).
Nelson's Medicaid Deal Comes Under Attack
A deal reached to secure a final vote for healthcare reform by Senate Democratic leaders and Senator Ben Nelson (D-NE), regarding funding for his state in the context of healthcare reform's proposed Medicaid expansion, is drawing increasing criticism.
Thirteen Republican attorneys general were joined last week by Drew Edmondson (D-OK), the sole Democrat of the group, in threatening to sue if the provision wasn't removed. Two top state prosecutors are asking attorneys general across the country to let Washington know if they oppose the healthcare reform bill that they say includes a political deal for Nebraska. Attorneys general from South Carolina and Oklahoma urged their colleagues to call on U.S. House Speaker Nancy Pelosi (D-CA) and Senate Majority Leader Harry Reid (D-NV) to remove the provision.
Senate Democrats, too, are blasting the deal. Senator Sherrod Brown
(D-OH) was the latest to criticize the provision that forever exempts Nebraska from picking up its share of the Medicaid expansion. Other Democratic senators, including Senators Blanche Lincoln (AK) and Michael Bennet (CO), have also been critical of the deal.
California Governor Arnold Schwarzenegger (R) said the healthcare bill is full of "'bribes, deals and loopholes. . . . California's congressional delegation should either vote against this bill that is a disaster for California or get in there and fight for the same sweetheart deal Senator Nelson of Nebraska got for the Cornhusker State. He got the corn; we got the husk,'" Schwarzenegger said.
Kaiser Daily Health Policy Report, Nelson's Medicaid Deal Comes Under Attack, Henry J. Kaiser Fam. Fdn. (Jan. 7, 2010).
Groups Sue Over Impending Reimbursement Cut
The American College of Cardiology (ACC) and several other professional medical associations have filed a lawsuit against U.S. Department of Health and Human Services Secretary (HHS Secretary) Kathleen Sebelius in an attempt to block a Medicare reimbursement rate reduction scheduled to take effect January 1, 2010.
The complaint, filed in U.S. District Court in Fort Lauderdale, FL, charges that the Secretary used a flawed Physician Practice Information Survey, which gathers information about practice expenses, to help determine the rate reduction. Those flaws include using information from a sample of only fifty-five cardiologists, which the plaintiffs allege is too small and unrepresentative of the 37,000 cardiologists now practicing throughout the country.
"The process by which Medicare determined reimbursement rates was deeply flawed," said ACC Chief Executive Officer Jack Lewin in a news release. "As a result, the 2010 rule will levy cuts to cardiologist services by up to 40% and will deny critical cardiovascular care for millions of heart patients" by forcing doctors to shutter practices, he added.
Joining the ACC in the lawsuit are the Association of Black Cardiologists, the ACC Florida Chapter, American Society of Nuclear Cardiology, and the Cardiology Advocacy Alliance. They are seeking a hearing prior to January 15, 2010, when the first set of Medicare payments for 2010 are scheduled to be issued.
Shawn Rea, Groups Sue Over Impending Reimbursement Cut, Modern Healthcare's Daily Dose (Dec. 29, 2009) (note: registration is required to view this content).
"Meaningful Use" Criteria Released
The U.S. Department of Health and Human Services (HHS) issued two sets of much-anticipated federal regulations that significantly further the government's healthcare information technology (IT) adoption agenda. The first set of regulations lists the "meaningful use" criteria that healthcare providers must meet to qualify for federal IT subsidies based on how they use their electronic health records (EHRs). The second set of regulations lays out the standards and certification criteria that those EHRs must meet for their users to collect the money.
Between $14.1 billion and $27.3 billion is at stake, which was made available under the Health Information Technology for Economic and Clinical Health Act provisions of the American Recovery and Reinvestment Act of 2009.
The meaningful use regulations are proposed regulations subject to a sixty-day public comment period after which HHS would issue final regulations. The EHR certification regulations are interim final regulations that take effect in thirty days, with a sixty-day public comment period. HHS said final regulations will be published in 2010.
Under the proposed meaningful use regulations, eligible healthcare providers must use their EHRs to: (1) improve the quality, safety, and efficiency of healthcare services; (2) reduce healthcare disparities;
(3) engage patients and their families; (4) improve the coordination of care; (5) improve population and public health; and (6) ensure the privacy and security of personal medical information.
Under the interim final EHR regulations, EHRs must be able to securely exchange information among providers and between providers and patients using standardized data elements and technologies. The regulations outline standardized formats for such things as: (1) clinical summaries; (2) medical descriptions of clinical conditions and test results; and (3) how that information is exchanged over the Internet.
David Burda, "Meaningful Use" Criteria Released, Modern Healthcare's Daily Dose (Dec. 30, 2009) (note: registration is required to view this content).
GOP Assails "Widely Hated Legislation"
Republicans were withering in their criticism of what they deemed a budget-busting government takeover. Senate Minority Leader Mitch McConnell (R-KY) blasted the healthcare bill, saying that it "fails to lower costs." He said that Republicans would continue to battle the legislation. House Minority Leader John Boehner (R-OH) assailed the bill moments after passage. "Not even Ebenezer Scrooge himself could devise a scheme as cruel and greedy as Democrats' government takeover of health care," Boehner said in a statement.
Senator Orrin Hatch (R-UT) contended that it just might wind up being the most widely hated legislation of the decade. Senator Charles Grassley (R-IA) said on the Senate floor that "[f]rom rationing care to infringing on the doctor-patient relationship, this government-run system will guarantee U.S. taxpayers a staggering tax burden for generations to come. . . . [The final bill] doesn't do any of these things that we set out to do at the beginning."
Kaiser Daily Health Policy Report, GOP Assails "Widely Hated Legislation", Henry J. Kaiser Fam. Fdn. (Dec. 24, 2009).
Mortality Impact of Obesity Said to Be Underestimated
Obesity may have an even greater impact on mortality than anticipated, according to a new method of adjusting for confounding. When a son's body mass index (BMI) was linked to a father's cardiovascular disease mortality, risk increased 82% with each higher standard deviation of BMI, according to Finn Rasmussen, MD, MPH, PhD, of the Karolinska Institute in Stockholm, and colleagues.
This association was stronger than the standard approach linking an individual's own BMI and cardiovascular disease mortality (45% increase in risk per BMI standard deviation, P<0.001), they reported online in BMJ. The same was true for all-cause mortality (HR 1.16 for offspring BMI as a proxy, P=0.120, versus HR 1.09 for direct link, P=0.001).
Thus, the results suggested that conventional observational studies may underestimate the link between BMI and all-cause and cardiovascular mortality, Rasmussen's group concluded.
"These conclusions have important implications for public health practice because they suggest that reducing population levels of overweight and obesity (or preventing their rise) will have a considerable benefit to population health," they wrote. "Suggestions to the contrary are probably misguided."
Their analysis of more than one million parent-son pairs in Sweden "avoids problems of reverse causality," they said. Reverse causality has been blamed for the U-shaped curve seen in prior studies, in which mortality is highest for those at the extremes of weight. The bias could come from smoking and other lifestyle factors and, most importantly, from weight loss as a result of disease, rather than BMI itself, the researchers noted.
Crystal Phend, Mortality Impact of Obesity Said to Be Underestimated, MedPage Today (Dec. 28, 2009).
*We would like to thank Clinton R. Mikel, Esquire (Hall Render Killian Heath & Lyman PLLC, Troy, MI), for providing this week's update.