By Robin Strongin. Republicans on Capitol Hill are still steaming over President Obama’s decision to install Dr. Donald Berwick as administrator of the Centers for Medicare and Medicaid Services via a recess appointment (http://www.politico.com/news/stories/0710/39759.html), bypassing the normal confirmation process which would have included a hearing before the Senate Finance Committee.

Now, GOP members of the Finance Committee are insisting, in a letter to committee chairman Max Baucus (D-MT), that a hearing should take place anyway.  In their letter, they argue that the lack of such a forum “casts a shadow over (Berwick’s) legitimacy and authority to serve as administrator during a critical time for CMS.”

That rhetoric may be overhyped.  After all, Berwick is hardly the first nominee, Democratic or Republican, to take office by virtue of a recess appointment.

Nonetheless, there is a legitimate point here that a hearing needs to take place.  But, while Senate Republicans want to grill Berwick on his now-infamous speech that some interpret as extolling the virtues of Britain’s National Health Service, I believe there is a far more compelling reason for him to face congressional inquisitors.

By 2014, approximately 30 million now-uninsured Americans are going to be joining the ranks of those with health coverage and, in so doing, significantly increasing the utilization of health services.  As many analysts have pointed out, if this utilization escalation happens within our current health care system, it’s reasonable to expect health costs to shoot skyward without a commensurate increase in quality and cost-effectiveness. (more…)

By Rozalynn Goodwin. Yes, I said “cooties.”  You remember that childhood imaginary disease believed to spread through contact with those infected or worse, those of the opposite sex.  The cooties epidemic has spread to Washington, DC, and has politicians frightened to work across the aisles for the greater good.  I heard that the lesson: “They Have the Cooties” takes up most of the first day of orientation for newly elected congressmen and senators.  This class perfects neophytes’ skills in murdering any attempts for bipartisanship.

Cooties can be deadly for a politician.  Just look at SC’s latest casualty, outgoing Congressman Bob Inglis.  His independent thinking and willingness to sometimes side with the other party were clear symptoms that he had been infected, and now he’s being sent home to be quarantined.  Senator Lindsey Graham’s case of the cooties is thought by some to be in the advanced stages.

Cooties are not only taking out politicians who think for themselves and for the good of America.  Cooties are also killing good policy.  The six-month extension of the FMAP (Federal Medical Assistance Percentage) increase appears to be the latest victim.  This temporary fiscal relief for states was first provided through the American Recovery and Reinvestment Act (ARRA) back in February 2009 to prevent the decimation of state Medicaid programs at a time of rising unemployment and increasing Medicaid rolls.  This relief runs out the end of 2010 (right in the middle of most states’ fiscal years), and therefore produces a significant fiscal problem for state budgets.  Just last week, several governors from across the nation gathered in DC to lobby for this extension.  Guess whose governor was not there…

Earlier this year, it was widely assumed that this extension was a done deal, but Congress has been punked into inaction by some primary election results across the country that some believe reflect voters’ frustration with government spending.

Now don’t get me wrong.  I understand the need to be conservative in tough economic times, but I also understand the need to stimulate the economy and give our most economically vulnerable a helping hand.  It’s funny how we can bail out financial institutions and their wealthy executives, and turn a deaf ear to those truly suffering.

If FMAP is not extended, not only will SC’s disabled, very poor and senior citizens lose access to health care services, our state’s struggling economy will lose as well.  SC stands to lose over $200 million in federal dollars that could help patch our frail Medicaid budget and stimulate our economy with high-paying healthcare jobs and the accompanying exchange of goods and services.  (more…)

Donald M. Berwick, MD, MPP, is President and Chief Executive Officer of the Institute for Healthcare Improvement (IHI). The Institute for Healthcare Improvement (IHI) is a not-for-profit organization leading the improvement of health care throughout the world.

On July 7, 2010, Dr. Berwick was appointed to serve as the Administrator of the Centers for Medicare & Medicaid Services.

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By Glenna Crooks. Full disclosure – I’ve practiced yoga fairly consistently for decades. It’s been good for me.

In grad school it helped me stay focused – and calmer – through killer statistics classes. Later, it was a way to unwind at the end of a workday. Still later, it saved me from surgery to correct fairly severe scoliosis. It’s not cured the deformity but I’m virtually pain free most of the time – no small feat for one who spends 18-24 hours on flights and 8 hours standing to facilitate meetings.

More disclosure – I am certified to teach, though I don’t. The same erratic travel schedule that prevents attending classes on a regular basis precludes committing to teaching them. I trained to be able to practice on the road. It was a good investment of my time and funds.

Yes, my time and funds. Anyone familiar with yoga knows that for the most part, students pay a small amount for a class – or series of classes – out of their own pockets. Sometimes, yoga is offered in schools, hospitals, churches, workplaces and prisons and the cost partially or fully paid by some third party. Sometimes teachers donate their services as part of the ‘selfless service’ that embodies the lifestyle.

Recent weeks presented an interesting confluence of events in my life as a yoga-practicing health policy analyst: health reform passed and Yoga Journal published a major article on methods, issues, controversies and implications of yoga research.

I started a yoga research literature review a few years ago. It was to be the opening chapter of an adaptation of my grantseeking guide (see www.strategichealthpolicy.com for a free download), revised and updated for yoga teachers intending to seek and secure third-party – including health insurance – financing support for classes.

I abandoned the project for many of the issues raised in the Yoga Journal article: research methods were relatively undeveloped, uncontestable positive results were scant and within the yoga community both were controversial. That’s right, even the need for research to demonstrate the value of yoga is controversial. Many thought there was proof enough.

Proof enough for an individual to pay? Yes, that’s been well-demonstrated. Thousands of times each day, people around the world pay out-of-pocket to attend classes. Proof enough for a third-party to pay? Far from it, at least as we have defined proof within the American health care sector.

Now, the health reform era is upon us, some people will press for yoga services as a covered benefit and if a serious discussion takes hold – and succeeds – in adding yoga to American health care armamentarium, yoga teachers will face issues common to other product and service providers. Clearly, not all yoga teachers will want to participate and none will be forced, but those who choose to do so will need to address – at a bare minimum – questions commonplace to physicians, hospitals and drug companies:

First, is yoga effective? Any prevention or treatment modality used in health care is expected to be safe and effective, demonstrating that it performs as advertised, promoted and hoped.

That means prospective research, such as trials comparing yoga against a non-intervention, a placebo or a standard therapy treatment, or a study of a sufficiently large population through ‘natural observation’ to gather similar evidence over many years.

Research such as this will raise questions about whether the ‘style’ of yoga matters, how many sessions might be required to achieve results and whether results last after classes are stopped. People in the study will be carefully selected and ‘assigned’ to each intervention group. They’ll be asked about other aspects of their lifestyle to assure that they’re not confounding the results with other possibly-effective therapies.

Side effects will be monitored. Injuries in class or suicidal thoughts outside of class (if any occur) will be noted so that cautionary warnings and contraindications can be addressed in coverage and reimbursement decisions. Other unintended consequences – weight loss comes to mind – will be documented but can’t be claimed a benefit unless the study was specifically designed to test for it.

Research might also need to tease out yoga’s “mechanism of action” as is the case for medications; for example, by what mechanism does yoga breathing techniques reduce hypertension?

Researchers will be required to seek approval from Institutional Review Boards protecting patients, may be required to vet research methods with regulators or payers, will likely be required to disclose financial interests in yoga and if any are found might be precluded from doing research and/or might be restricted from committees that address yoga policy and financing issues – all to assure research subjects are protected and conflicts-of-interest are prevented. (more…)

Every January, new billing rules and rates go into place for physicians’ services as part of the annual update to Medicare’s Physician Fee Schedule. Dominating DC health policy concerns in this arena are the medical community’s efforts with Congress to address Medicare’s cost-of-living adjuster, known as the “sustainable growth rate” (SGR), which would have lowered 2010 fees across-the-board by 21 percent, if not for a last-minute temporary stay through the end of February. Negotiations with Congress are on-going to provide a long term or multi-year solution—a costly “fix” that I believe is well worth the price to keep physicians in the Medicare program, and seems to have widespread support.

Getting much less attention is a unilateral policy pronouncement made by the Centers for Medicare and Medicaid (CMS) that Medicare will no longer pay specialists a higher rate for consultations—services often provided by specialists like cardiologists and neurologists. Instead, all physician visit services, whether defined as “evaluation and management” (E&M) services or consultations, will be reimbursed at the same E&M rates. (more…)

In the midst of furious showdowns on health care reform at town hall meetings, a moment of peace surfaced in Montana when President Obama drew bipartisan applause after calling a mother heroic.  This mother of two had voiced her concern about the Medicaid program she relied on for her child who has multiple chronic conditions.  The president reassured her and went on to discuss how our disease-care system does not proactively manage chronic conditions.

Children and young adults with chronic medical conditions and disabilities (CMCD) need proactive management now and for their entire lives.  Our health care system fails to serve the young people who need it the most.

Children with CMCD are completely dependent on adults for their health care.  Poor health management negatively affects their growth and development, education, and socialization – and drags the entire family down.  As the mother of a young adult with CMCD and the founder of a non-profit created because of our experiences with poor quality health care, I cannot understand why this population is not a major focus of health care reform.

One path to start on is to build on successful programs to create a comprehensive system of care.  Take a look at the 35% of children with CMCD covered by SCHIP/Medicaid. Medicaid provides a specialized set of comprehensive services known as EPSDT, Early Periodic Screening, Diagnosis, and Treatment Program. The current model of care in favor for chronic conditions is the medical home. First conceptualized by the American Academy of Pediatrics for children with CMCD in the 1960s, the medical home has yet to become the standard of care for children with CMCD in Medicaid.  Pairing EPSDT with the medical home would be a step forward in developing a system of care for children covered by Medicaid.    Another step is to expand EPSDT and medical homes to cover the remaining publicly covered children with CMCD enrolled in SCHIP.

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On the New Health Dialogue blog, Paul Testa analyzed the ongoing public debate about comparative effectiveness research:

The New York Times‘ Robert Pear examines the content and contentiousness of the comparative effectiveness provisions of the $787 billion stimulus package. HR 1 provides $1.1 billion (pdf starting on page 156) to AHRQ, NIH and the HHS to evaluate the relative effectiveness of different health care services and treatment options. The goal is to create a process of funding and disseminating comparative effectiveness research that is transparent, professional and free from conflicts of interests. As the Dartmouth Atlas’ Elliott S. Fisher, MD, tells Pear, the funding would be used to try to answer questions such as:

… What is the best combination of “talk therapy” and prescription drugs to treat mild depression?
…
Is it better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient’s blood pressure and weight?

In health care, though, simple questions rarely have simple answers. Nor will answers be static; biomedical science changes at a pretty astonishing clip. We wrote about this topic twice last week, and we expect to hear more about it as the health reform debate intensifies. Last week Kyle Noonan wrote about some of the alarmist rhetoric surrounding the issue, and Joanne Kenen wrote a longer piece about how comparative effectiveness fits into “health” as well as health care reform. We also want to point out Bob Laszewski’s posts at the Health Care Policy and Market Place Review, which has provided interesting coverage on this topic.
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Beginning to measure what works best for what patients or populations under what circumstances can provide a baseline. Providers and patients will have access to information that will help them better understand their choices and the likely consequences. Providing that information in a manner that is transparent, credible, and easily understood will go a long way to ensuring that all Americans receive the most effective care whether they live in Florida or Nebraska or California.

At Science-Based Medicine, Peter Lipson shared his perspective on comparative effectiveness research: (more…)

One of the best things about blogging is the opportunity it provides to “meet” some incredible people. I’d like to introduce you to one of them, Carrie Ostrea, Hannah’s mom. Hannah was born with Gaucher’s Disease—a rare disease. Carrie is on a mission—she shared the following with me and asked if I would help “get the word out” about her efforts, her Hannah, and her hope to make change. A Disruptive Woman in every sense of the word.

To learn more, read on:

It is so important to me that awareness be created regarding the Ryan Dant bill as well as rare diseases such as Gaucher’s Disease. That is why I’ve dedicated my blog not only to sharing updates with family and friends, but to create awareness for rare diseases, legislation, and other life experiences raising a child and family with unique special needs.

Here are some details regarding the Ryan Dant bill. I have actually been emailing with Mark Dant, Ryan’s Dad, about getting Hannah very much involved.

Basically, the bill will remove the income requirement for Medicaid if the applicant’s medical treatment would cost more than $250,000 a year (Hannah’s medication will cost about $250,000 to $300,000 a year as an adult, and that doesn’t include doctor’s fees, other procedures, therapies, and surgeries). If Hannah was a young adult, she would have to get a low-paying job (poverty level) in order to get Medicaid for her treatments because there are very few insurance companies that would accept an adult with that kind of insurance cost.

Here is a copy of my letter.

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The holidays are upon us, and we all know what that means for health issues — besides higher sugar and alcohol intake. That’s right, healthcare reform house parties! Check out the message from HHS Secretary nominee Tom Daschle below, and learn more about hosting or attending a healthcare community discussion over the holidays.

Meanwhile, four issues dominating discussions around the web this week are the future of the FDA, the new Nursing Home Compare rating system and web site, physicians and health IT, and of course, healthcare reform issues.

At the Center for Medicine in the Public Interest DrugWonks blog, Peter Pitts shared his recommendations for reforming the Food and Drug Administration:

I was honored when the Obama FDA transition team called and asked for my advice on how the incoming administration could make the agency a more robust and forward-looking regulatory instrument.
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My suggested areas of focus are

1. A strong, science-based FDA
2. The Reagan/Udall Foundation — a Partnership of Unequals
3. Clarity vs. Ambiguity
4. Information Management
5. Food Safety and Security
6. Risk Communications
7. The Drug Label and the “Safe Use” of Drugs

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There are, obviously, many, many other important issues … and I look forward to working with the transition team to ensure that the new commissioner can hit the ground running… And kudos to the Obama transition team for reaching out to a wide variety of groups.

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Given the historic opportunity to lead the nation as it transforms to a nation that is about to become a majority of current minority populations, President Elect Obama and his Transition Team, announced this week, should consider identifying a diverse leadership among the political appointees in the health related positions–not just HHS, VA, DOD, but at the White House-–to develop a realistic transformation in the health care reform policy making process. There is a critical need to consider health care reform that allows the health system to become more responsive to the new America with cultural competence and literacy as well as including issues based on the social determinants of health. The President-Elect plan for access to care and quality health care that addresses health disparities is a vision needed sooner than later in order to prepare for the changing population. And of course, the health of minority women and their families needs to become a priority item as the policy making starts after January with the attention to helping them through SCHIP, Medicaid and Medicare.