The Disruptive Women in Health Care blog continually aims to encourage discussion and debate among readers about emerging issues and topics in the health care world. Historically, one of the ways that we have done that is through our weekly round-ups – that is, posts containing summaries and links to some of the big stories in health care news for the given week, with some original commentary and content sprinkled in as well. The way we see it, there is just too much happening in this burgeoning industry; it’s hard to keep up, especially when you’re busy disrupting and making headlines in the health care world yourselves. We know the weekly round-ups have been on hiatus for a while, but are happy to report that they’re finally making a comeback. Each week, we’ll be gathering some of the biggest health care news you can use from at home and abroad for posting on Wednesdays. Feel free to comment on what’s included and send us some links to articles to be considered for next week!

Has your week been too disruptive for you to keep up with the news?  Disruptive Women are on the case!  Here is this week’s round up of some of the most pressing issues here in America and around the world.

Here at Home:

Thanks to a provision of the Affordable Care Act (ACA), women are now able to receive free birth control, but only if it’s prescribed.  The New York Times explains how Catholic Colleges are using this loophole to combat contraception.

And, speaking of the Catholic Church and the ACA, USA Today says that Obama’s decision on Friday not to expand the conscience exemption to include religious institutions has been met with outrage from Church leaders and parishioners.

Remember that moment of panic you had when the swine flu epidemic came to the United States?  CBS News reports that swine flu numbers are rising again in Mexico. Will the US be next?

Susan G. Komen for the Cure, the nation’s leading breast cancer charity, announced Tuesday that it is halting its partnership with Planned Parenthood (per NPR) – a controversial decision that ignited a backlash from some of its supporters.

Here’s one perspective on Komen’s decision. What do you think? Will this impact your decision in giving donating to Komen, or another breast cancer non-profit in the future?

Sick? Took a sick day?  Is that enough of a reason for you to wind up unemployed?  HuffPo explains how an issue as simple as recovery from the flu has reached the Supreme Court.

With nearly two million women lacking health insurance and a quarter of a million unplanned pregnancies per year, Florida has a lot of challenges in terms of women’s healthcare.  Here’s what the state is doing to try and move ahead.

Around the World:

Brazil is calling for a registration of all pregnant women.  What does this mean for a woman’s right to choose within Brazil?

Japan’s population is shrinking. As more women choose a career over family, Japan faces declining birth rates. Could the United States be next?  ABC News takes a look.

Check back each week for the latest health care news!

There is, however, one area we don’t touch (in fact, we avoid it at all costs): partisan support for a candidate. While certainly all of our individual bloggers have opinions and perspectives, points of view and inherent biases, we will never run posts that are blatantly promoting one candidate for elected office over another.

I say this as a caveat to this post, the purpose of which is to announce a new series we’ll be running this year on the Disruptive Women in Health Care blog in which we explore the presidential candidates’ positions on health care and health policy, where they stand on particular aspect or aspects, what they envision to be an ideal health care system for this country and what role they envision the federal government playing in it.

This series is about more than just the Sustainable Growth Rate (SGR), the Affordable Care Act (ACA) or Medicare and Medicaid; it is about delving into each candidate’s philosophies, beliefs and stances towards health care and health policy, and trying to determine what specific policies and reforms each might undertake.

Image courtesy of the Mobile Press-Register.

The editorial team and I are very excited to be launching this series, as we feel it will provide us the opportunity to address important issues during a significant year from a much different perspective and in much greater detail than the mainstream media is likely to discuss.

You can expect to see a lot of substantive political and policy analysis being put forth via the series in the coming weeks and months, but like I said earlier — one thing you definitely won’t see is bias towards one particular candidate (though our posts will certainly contain links to articles from other outlets that may or may not be biased, because we feel it is important to provide a survey of what others are saying on the topic). Help us make the series even better by letting us know what topics or specific policy areas you would like to see explored – we’ll do our best to incorporate your feedback into upcoming installments.

We’ll be back with our first full installment of the series in the next few weeks, but in the meantime, we’ve rounded up some related articles we think are worth reading:

• CNN takes a look at claims of Medicare fraud being made against Mitt Romney by a pro-Newt Gingrich super PAC
• NPR explores “Romney’s unlikely and persuasive defense of the ‘Individual Mandate’”
• WaPo discusses Rick Santorum’s position on abortion in the context of his personal experiences

CMS Administrator Marilyn Tavenner addressing Care Innovations Summit attendees. Image courtesy of Kaiser Health News.

“I think we would all agree that these are not ordinary times, that this is not an ordinary conference, nor is it an ordinary time in health care,” commented Centers for Medicare & Medicaid Services (CMS) Administrator Marilyn Tavenner, in her address at the first ever Care Innovations Summit Thursday. In saying so, Tavenner captured not only the essence of the problems facing our nation’s health care system and the reason that over a thousand national thought leaders, senior government officials and industry experts had gathered, but also inspiring attendees with the idea that, by being there, they had the opportunity to be a part of the solution.

Driving the day at the Care Innovations Summit, which was hosted by the Center for Medicare and Medicaid Innovation (CMMI), Health Affairs and the West Wireless Health Institute, was the notion that American innovation could solve any problem, and the thousand-plus attendees were the innovators to solve this one. Emphasizing CMMI’s founding mission of better health, better care and lower costs, speakers across sectors, industries and areas of expertise continued to echo each other’s cries that it was all possible, if people began collaborating and innovating across fields.

Even before HHS Chief Technology Officer Todd Park compared data to rocket fuel, the Summit was beginning to sound like President Kennedy’s speech to Congress announcing the Space Race. In fact, the addresses and panels were broken up by “Ignite Talks” — wherein private-sector stakeholders presented problems and issued challenges to attendees and to entrepreneurs across the country, offering not only prizes, but implementation funding for the best solutions (you can see a list with links to descriptions of the various challenges issued here).

Park best captured the sentiment of the Summit, saying, “There is no problem that Americans can’t invent themselves out of…Transformation driven by a tide of grassroots innovation mojo has already begun.”

While this sentiment and attitude towards repairing and revitalizing our nation’s health care system certainly drove the day, it is not new, nor is it exclusive to CMMI. In fact, it echoes many of the themes that motivated us to launch the Health in Place™ (HIP) initiative last month. The concept of HIP is built around the idea that, thanks to wireless communications and emerging technologies, our homes are more than ju

st houses, our offices are more than just workplaces, our schools are more than just places of learning and our cars are more than just modes of transportation — and that, for this facet of 21st century health care to achieve its full potential, a number of public policy issues are involved, cutting across multiple disciplines from health care regulations and benefit structures to tax policy and technology incentives. HIP aims to connect the dots between industries, inspire innovation and drive policy changes that accomplish CMMI’s goals of better health, better care and lower costs while simplifying things in the process.

With all of this collaboration and innovative thinking, there is no doubt that this is an exciting time in health care, but as Don Casey expressed in his closing remarks at the Summit, there are some significant obstacles to overcome to get the rockets to the moon. “I think a lot of people are skeptical about two things,” Casey said, “the American economy and do we have the ingenuity to get this stuff done, and can we actually engineer a jailbreak for health care.”

Are you planning to take part in any of the innovation challenges issued? Do you think cross-industry collaboration is really possible? And, what do you think we need to do in order to break down the barriers Casey and others at the Summit alluded to?

If you chose to partake in what HuffPo referred to yesterday as “ your country’s empty displays of patriotic kitsch” — aka a State of the Union Drinking Game — last night, I certainly hope health care wasn’t one of your buzzwords.

President Obama delivered his 4^th State of the Union (SOTU) address to Congress last night, outlining his goals and his priorities for the nation in the coming year, and – as Sarah Kliff from the Washington Post’s WonkBlog put it  – “For health policy wonks, Tuesday night’s State of the Union speech wasn’t a thriller.”

In fact, in his nearly 70-minute, 7,000 word address, “President Obama mentioned Medicare and Medicaid… once. ‘Health care’ got two shout-outs. The Affordable Care Act? Not even a name-check,” (per Kliff).

To think of it another way, consider how Daily Briefing editor Dan Diamond broke it down — the president spent 44 words on health reform, accounting for 0.6% of the total speech.

As Politico pointed out, “Obama spent so little time on the [health reform] law that he didn’t even acknowledge an audience member the White House had brought to the speech — a cancer survivor who could have been an example of someone with a pre-existing condition who was helped by the law.”

The White House had announced earlier Tuesday that this young man, Adam Rapp, would be sitting in the first lady’s box. Rapp was diagnosed with testicular cancer on his 23^rd birthday, the same day that he would have lost health insurance coverage were it not for the Affordable Care Act (per CBS) – a potentially powerful testament touting the impact of ACA, and yet one that went unmentioned.

All of this is more staggering when you consider what a departure it represents from years past.

Medscape Medical News reports that, “Obama mentioned either “healthcare” or “health insurance” only 3 times, compared to 6 references in 2011 and 10 in 2010.”

The California Healthline blog lays it out a bit differently, explaining that, “Two years ago, the president spoke for several minutes — a total of 570 words — in urging Congress to pass the Affordable Care Act. Last night, Obama devoted just 44 words to his health reforms — never once touting the law’s actual impact, like 2.5 million young Americans gaining coverage through the ACA. In comparison, the president spent more than 130 words on his renewed cause of streamlining the government.”

And for you visual learners and/or infographics enthusiasts like myself out there, Dan Diamond tweeted this graphic a few hours ago, which I think best serves to drive the point home.

Wondering what Obama spent 70 commercial-free minutes talking about, then? According to the Washington Post, the economy mostly. Check out WaPo’s interactive infographic breaking down the speech by time spent/mentions per subject, and how this year’s spread compares to his previous SOTUs, here.

Meanwhile, the GOP rebuttal, delivered by Indiana Gov. Mitch Daniels, was only marginally better to us health wonks – at least for our interest’s sake. While it steered clear of “repeal and replace,” it did echo Rep. Paul Ryan’s pitch for an overhaul of entitlement programs.

“Medicare and Social Security have served us well, and that must continue. But after half and three-quarters of a century respectively, it’s not surprising that they need some repairs,” Daniels said. “We can preserve them unchanged and untouched for those now in or near retirement, but we must fashion a new, affordable safety net so future Americans are protected, too.”

No one would deny that the SOTU, above all, is an act of political theater. But were there even more theatrics occurring last night than usual? Many Beltway insiders have seemed to indicate this, saying that the SOTU was not only a list of goals for the year, but also, as Kliff put it, “an opening campaign gambit.”

If that is the case, it raises some interesting questions about what we can expect to hear in the fall. After all, as The Hill’s Healthwatch blog pointed out, “Although Democrats insist that Obama will be able to campaign on the healthcare law, it was almost entirely absent from a speech that helped establish the themes and frames of his reelection campaign.”

Just because the president seems to be steering the narrative away from health care so far doesn’t mean it won’t be issue in the upcoming presidential election. Odds are that the Republican nominee – whoever it turns out he (or she… hey, you never know!) may be – will want to discuss health reform, as it has certainly been a hot topic on the campaign trail.

How important of an issue do you think health reform will be in the upcoming election? Will a candidate’s position on health reform and the Affordable Care Act impact your decision to support him or her? Tell us your thoughts in the Comments section below!

By Randi Kahn.

I have been unable to get these strong, Disruptive Women out of my mind, and could not help thinking about both Evelyn and Cynthia while listening to the National Journal’s “Living Well at the End of Life” event on Tuesday, wondering what their conversations about end of life care were like with their clinicians, and if there was a difference between them as a result of their insurance and financial statuses. Did Cynthia choose to live her final days in the hospital?  Did her medical situation necessitate it? Was she given proper information about her hospice and palliative options?

Although we’ll never know the answers to those questions, it is interesting to take a look at barriers that exist for clinicians in end of life care that are likely impacting potential disparities.

First, there are Medicare and Medicaid reimbursement issues. Although both programs currently provide some coverage for hospice and palliative care, there is not reimbursement for the tough conversations doctors should have with their patients about their care options at the end of life. Former Obama advisor on health reform and now chair of the National Institute for Health’s Department on Bioethics, Ezekiel Emanuel, MD, PhD, said at the National Journal event, that those consultations can take anywhere from a few minutes to several hours and that without reimbursement for them, some clinicians don’t take the time to conduct them. His statements align with a survey of 500 board certified physicians conducted by the National Journal and the Regence Foundation where 82 percent of respondents identified inadequate reimbursement from Medicare, Medicaid and private insurers for end of life consultations as a significant barrier for palliative care.

There is also the issue that some clinicians put off the conversations because they do not know enough about end of life care options, or about how to talk to a patient about the decisions that need to be made as they near death’s door. The poll data found 73 percent of physicians 39 or younger reported “a great deal or some exposure to palliative care during medical school” compared to 36 percent of those 40-49, 23 percent of those 50-59, and only 6 percent of those age 60 or older, highlighting the need for continuing medical education courses on palliative care, hospice care, and the development of an advanced care directive. The poll didn’t inquire about communications training that, according to Dr. Emanuel, would help clinicians overcome their own psychological barriers to having these discussions and enable them to better address the patient’s psychological needs to make the conversations more effective.

With entitlement reform almost inevitable, and much of continued medical education focused more on health care reform related topics like coordinating care and utilizing health IT, what will the end of life look like for women like Cynthia and Evelyn in the future?

The newspaper listed five ways to “squeeze” Medicare spending and then discussed the political arguments for and against each.  Some, such as gradually raising the Medicare eligibility age from 65 to 67 and requiring higher-income beneficiaries to pay full premiums for their Medicare Part B (physician services) and Part D (prescription drug) coverage are recommendations that the Healthcare Leadership Council has made to the congressional deficit reduction “super committee.”

But, in a number of ways, the USA Today article missed the mark:

In discussing cutbacks to Medicare providers, including physicians, hospitals and pharmaceutical companies, the newspaper expanded on the likelihood that those health sectors would strenuously argue against any cuts, but there was no reporting on the impact those reductions would have upon beneficiaries.

This is a pet peeve of mine, as I’ve noted previously.  Too often, both politicians and commentators speak of the value of cutting providers instead of patients, obscuring the fact that reduced payments to providers has an impact on both the accessibility and quality of healthcare.  If, as the Obama Administration has proposed, pharmaceutical companies are required to send over $100 billion in rebates back to the government, can there be any other outcome besides higher prices for consumers and less money available for research and development of new innovative medicines?

Relating to another sector, there was an interesting discussion on the KevinMD blog yesterday that raised legitimate questions over whether cutting physicians’ incomes will make a dent in overall healthcare spending.

• Aside from a quick reference to the controversy over Congressman Paul Ryan’s (R-WI), USA Today quickly dismissed the idea of giving Medicare beneficiaries greater consumer choice among competing health plans, citing one study that showed it would increase out-of-pocket costs.

The concept deserves more consideration than that.  If, as the Healthcare Leadership Council and experts like former Clinton budget director Alice Rivlin has proposed, you give beneficiaries the choice of staying in conventional fee-for-service Medicare or moving into a new competitive Medicare Exchange, both health plans and providers would be compelled to find innovative ways to reduce costs while maintaining high quality and value.  This is a pro-consumer direction that deserved more than a couple of sentences in a major story on Medicare costs.

• Where was any reference in the USA Today story to medical liability reform?  Fixing our nation’s broken medical malpractice system won’t, by itself, fix Medicare’s long-term fiscal problems, but reducing the practice of defensive medicine to protect against exposure to litigation will certainly generate meaningful savings.Or

Originally posted on Prognosis Blog on October 4th.

Caregiver supports are defined by the Scorecard to include:

• Percent of caregivers getting needed support
• Legal and system supports for caregivers
• Health tasks able to be delegated to aides.

The Scorecard showed that 77% of family caregivers who were surveyed a few years ago reported that they get emotional and social support when they need it.   Legal and system supports scores were much lower, averaging a “3″ on a 12-point scale. These supports  were defined as:  state family medical leave laws;  mandatory paid family and sick leave; protection of  caregivers from employment discrimination; the  extent of financial protection for the spouses of  Medicaid beneficiaries who receive nursing home or  long term community support services; and  assessments of the caregiver’s health, quality of  life, etc.    The researchers also proposed that family caregivers would benefit if state nursing license laws permitted aides to perform a list of key “health maintenance” activities, such as administering medications, and diabetes testing and injections.

You can view your state’s score on the Scorecard’s  interactive website at: http://www.longtermscorecard.org/

We live in Virginia, so I looked up my state’s ranking  among the 50 states and D.C.

• Overall, Virginia somehow ranked a 12 out of 51.  Minnesota was #1, the best in the country. Mississippi was #51, the worst.     I think Virginia’s high overall rank was skewed  by the high ranking for “affordability,” which in  itself is a little misleading. Nursing home annual  costs were “only” 196% or about 2 times annual  median income in the state, and annual home health  costs “only” 70% or about 3/4ths of annual median  income.
• Virginia ranked 16th for our State Medicaid  program giving choice of setting and provider; and  25th for quality of life and  quality of care.
• Virginia did not do so well in its “Support for Family Caregivers,” ranking 44th in legal and system supports–a dreadful 1.6 on a scale of 0-12.  I guess we’re a friendly state (our motto is  “Virginia is for Lovers”), because 81% of  caregivers said they usually get needed emotional  support.

AARP and the other Scorecard developers hope that consumers will use this data to push their state governments to do more to provide long term services and supports in the community, mostly funded by the federal-state Medicaid program.

Meanwhile, Medicaid program funds have been targeted as a potential source of cut-backs by the House-Senate special deficit reduction super-panel.   AARP and 70 other volunteer groups supporting people with disabilities will be holding a rally, “My Medicaid Matters,” at noon on Capitol Hill in  Washington, DC, on Wednesday, September 21.  Details at: http://www.adapt.org/main/medicaid_rally

I plan to send the link to this Scorecard report to my elected officials and ask them to help improve community services.

But there was another line in the blockbuster movie that moved me even more. I heard it and the heavens seemed to open. The light bulb came on.

Hilly Holbrook’s new maid is $75 short on one of the college tuitions for her twin sons and asks Hilly and her husband for a loan so she doesn’t have to choose which son should go to college. Doing the ‘Christian thing,’ Hilly refuses, “God does not give charity to those who are well and able.”

Twelve simple words from a fictional 1960’s character summed up our nation’s current political will regarding the poor. And allow me to condense this into just one word: selfishness.

We movie-goers were quick to see the bigotry in Hilly’s statement. The maid and her husband had been saving money from their meager wages for a long time and she wasn’t seeking a hand-out, but a loan she would pay off with her thankless labor. But I was also quick to see the hipocracy in those of us who identify ourselves as Christians regarding the poor–many like this maid are in temporarily tight spots by no fault of their own. I was convicted by the thought that a selfish Christian is just as much of an oxymoron as a Christian murderer.

We use the word Christian so loosely nowadays, especially in politics. Calling ourselves Christians is not just the politically sexy thing to do. It is bearing the responsibility to personify the totality of God’s word and value every stage of every life, even the poor. Perhaps our selfishness is rooted in fear, more specifically, fear of shortage. We are so afraid that assistance to the poor robs us, but the Bible is clear that it is better to give than to receive (Acts 20:35) and we will never lack giving to the poor (Proverbs 28:27). Now I’m not suggesting that Christians are obligated to give to any and everybody. We must be good stewards over what we’ve been blessed with and use wisdom, but we must never forget we have been blessed with what we are stewards over. None of it truly belongs to us.

What makes giving complicated is when the poor is undeserving for reasons we determine in our own minds. With the issue of Medicaid, for example, we are quick to point to the rare cases of system defrauders. But for every story of fraud, there are at least nine stories of genuine need.

The Institute of Medicine, the trusted, non-political council advising the nation on ways to improve health, recently released “The Healthcare Imperative Report” on how to lower health care costs and improve outcomes. The Institute thoroughly studied excess costs in our health care system and identified six domains of excess spending: unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities and fraud. Want to guess how much waste is due to fraud? Less than you think. Only 10 percent. And that figure includes fraud at the hands of payers, clinicians and patients, so patient fraud represents only a fraction of health care waste.

I got ticked off… Oh, pardon me… I was greatly disturbed this week while speaking with a cousin who attends one of Columbia, SC’s most prominent churches. After the August 5-6, SC Mission 2011: Midlands event that served more than 2,000 uninsured from around and outside the state, a water cooler conversation at the church included appalling accounts of some people in line for services using iPhones. The nerve of those beggars!

Thankfully, my cousin was quick and correct to point out that many of those in line were among the working poor. SC Mission 2010 in Greenville, SC, for example, drew 1,200 of the state’s underserved to the Carolina First Center. Forty-four percent were employed, tax-paying citizens. My co-worker even received a call from an area city councilman inquiring if his uninsured family of four (wife, two teenagers and himself) could come for services at the Midlands event at the Carolina Coliseum.

These are realities, but we citizens have made it too easy for our elected officials to turn a blind eye and deaf ear. In an attempt to heighten awareness of these realities to policy-makers, the South Carolina Hospital Association sent personal invitations to Mission 2011 to more than 400 elected officials in federal, state and local government. Guess how many showed up? Two. Republican SC House Representative Todd Atwater who also serves as President of the South Carolina Medical Association and volunteered at Mission, and Democratic SC House Representative Leon Howard. Two, I said! One Republican. One Democrat. Zero from the Tea Party. Zero Independents. Zero from local government. Zero from the federal government. Raise your index finger, then your middle finger. Two. They could have at least followed the lead of Columbia, SC Mayor Steve Benjamin who knew he’d be out of town. Mayor Benjamin marketed the event through e-mail and social media.

Maybe if more of our officials had seen the lines of men, women and children forming as early as 10 am the day before the Midlands event began, those camping on the concrete outside the Carolina Coliseum, and the countless people who were turned away due to maxed capacity, these and other social ills would not plague our community as much because policy-makers would be more prone to do the true ‘Christian thing’ and care.

A bit of Hollywood silly escapism?  No doubt.  But, you can say this for President Dave and his fictional cabinet.  At least they approached the budget process with a constructive purpose and vision.

We can only hope that the same holds true for the supercommittee, the panel of 12 Senators and Representatives created as part of the cobbled-together solution to the debt ceiling debacle.  By Thanksgiving, the supercommittee must come up with $1.5 trillion in deficit reduction that must then be ratified by the full Congress no later than December 23.

There’s no question that health care will play a key role in those calculations.  When it comes to finding ways to reduce federal deficits, health spending is the rapidly growing elephant in the room. 

And that leads to genuine concerns about this process.  Already, policymakers are bouncing around ideas to extract more money from the healthcare system and tighten belts further.  Medicare provider payment cuts.  New home health care co-pays and budget reductions.  Mandated Medicare Part D prescription drug rebates.  The upshot of each of these steps will be a health care system that’s more expensive, less accessible, but not necessarily better.

It’s important to note, though, that the supercommittee isn’t limited to only using the subtract key on the calculator.  The panel has essentially been given carte blanche to recommend any steps it deems necessary to reach that $1.5 trillion target.  That means that, in addition to budget cuts, the committee can venture into areas like entitlement reform, tax reform and a host of wide-ranging policy changes.

Thus, a supercommittee born out of political necessity and the fear of financial default could also present a rare opportunity.  In the weeks between now and Thanksgiving, these 12 lawmakers have a window of time in which to gather input and develop concepts to improve health care quality and cost-effectiveness.  The Affordable Care Act started a process to implement health system delivery and payment reforms.  It could be said that this supercommittee has an opportunity and even a mandate to accelerate that evolution.

There are important choices to be made this fall.  This new legislative entity could very easily take steps that will prompt more doctors to turn away Medicare patients, make prescription drugs more expensive for consumers and make home health care less accessible for seniors and the disabled.  Or, they can go a step beyond and generate savings through better, more innovative care.

Perhaps the supercommittee should begin its work with a screening of Dave.

As with April’s narrowly-avoided government shutdown, pundits are all atwitter (figuratively and literally, as many seem to get special joy in posting their doomsday provocations in 140 characters or less) posting increasingly ugly “what if” scenarios and rumors. No doubt one day, a researcher will be reading the tweets of July 2011 (since all tweets are part of the official public record and documented in the Library of Congress) and come to the not-completely-unsubstantiated conclusion that mankind only narrowly averted total annihilation at the hands of some sort of Armageddon-like natural disaster (only to be corrected by a wiser researcher that there was a far greater threat to mankind in 2011 than natural disasters and that was Congress).

All joking aside, all the chatter led me to wonder – how would the various outcomes of the debt ceiling debate (yes, including defaulting) impact health care? Amongst all the speculating and posturing, despite the usual inclination of political reporters to relate everything back to the Affordable Care Act, I could find nary a mention of how a debt ceiling deal or even defaulting might impact health care [and the yet-to-be-implemented ACA provisions]. Until yesterday, that is, when Kaiser Health News first reported a document summarizing areas discussed by House and Senate negotiators at a debt ceiling meeting with Vice President Biden Monday had been leaked. As it turned out, this document was a spreadsheet identifying potential Medicare and Medicaid savings that could be included in a debt ceiling deal. In total, the list adds up to between $334 billion and $353 billion in savings over the next decade – including $100 billion in Medicaid cuts.

Want all the details? A PDF of the leaked spreadsheet can be viewed here: http://capsules.kaiserhealthnews.org/index.php/2011/07/list-of-potential-medicare-and-medicaid-cuts-stirs-washington/

The situation is no different in my state of South Carolina. Last week, one of our state senators referred to South Carolina’s Medicaid program as a “Mercedes health plan.”  Our Department of Health and Human Services responded by saying, “It’s a little bit of a stretch to call it a Mercedes.”

This morning, that same senator posted a guest editorial on FITSNews, “A Hand Up, Not a Hand-Out.”  In this piece, the independent pharmacy manager claims that Medicaid’s benefits are better than those of hundreds of insurance plans he works with.

“Hard working South Carolina taxpayers are forced to pay for premium coverage for others. These same hard working taxpayers could never afford these benefits themselves. Where’s the fairness in that? Welfare programs should be a “hand up” instead of a “handout.” Government assistance should be a temporary benefit instead of a lifestyle.”

The Senator says he and his colleagues in the Senate should focus on those unable to help themselves like the low-income elderly and mentally disabled. He then goes on to give two examples about welfare recipients who would rather get a check than work.

It’s disturbing that one of only six legislators in the entire South Carolina General Assembly with any type of health care experience would intermingle Medicaid and welfare as if the programs are the same. Some confuse the typical Medicaid recipient with the infamous Reagan-era “welfare queen.”  What an outrageous comparison.  Medicaid recipients don’t receive checks.  They receive access to health care services like primary care, prescription drugs, screenings, and hospitalizations.  High-paying-job-producing, tax-paying businesses get the checks and pump billions of dollars into the state economy both directly and indirectly. South Carolina hospitals, for example, employ more than 80,000 citizens, and contribute greatly to our state’s well-being and prosperity. Not to mention all the physician practices, nursing homes, health centers and other providers that do the same.

Let’s set the record straight on these Medicaid recipients seeking a hand-out in South Carolina:

• Two-thirds of Medicaid recipients live in working families, but their incomes are too low to afford insurance,
• Eligible families stay on Medicaid an average of only two years,
• A single parent making just more than $7,000 a year is too rich to qualify for Medicaid in South Carolina,
• And adults without children, regardless of their income, cannot qualify for Medicaid because they are categorically ineligible.

The very people the Senator says are unable to help themselves are the very people Medicaid benefits the most. Though women and children make up 75% of Medicaid recipients, they only consume 33% of the costs. The low-income elderly and disabled make up 25% of recipients, but consume 66% of the costs. Simply put: cut Medicaid, cut your Granny.

There’s this ludicrous idea out there that Medicaid recipients are gaming the system. NEWSFLASH: Ain’t nobody getting rich off Medicaid (improper English intended)! The only Medicaid fraud I’ve heard of has been at the hands of a provider. How would a recipient fraud the Medicaid system anyway? By being so desperate for health care access that they don’t disclose their full income? There are standard documentation requirements and yearly reviews in place at our state Medicaid agency to thwart that. By getting one or two unnecessary colonoscopies? I say that if those extra colonoscopies ‘tickle their fancy,’ more power to them! I kid…

Though I understand that overuse of unnecessary services drains our fragile health care system, I’ve been on the other side of health care enough to know that it’s easy to discuss rationing until it’s your loved one who is in medical distress.  

Our state’s budget debate this year has been laced with several misconceptions about the Medicaid program and its beneficiaries.  The three-to-one federal Medicaid match our state receives was even compared to crack-cocaine. Intended or unintended, that characterization also feeds into the erroneous stereotypes for some of our state’s most vulnerable citizens. 

It is incumbent upon us in health care to take the time to share the facts with decision makers and our communities. We cannot allow persons blinded by political ambition to make these important policy decisions that will impact our communities without our expertise and without hearing the perspectives of those without a voice.

Written with reporters in mind, “Covering Health Issues” is useful for anyone looking for concise information on health policy issues, and experts from across the political spectrum. Chapters contain fast facts, background, tips for reporters, story ideas and experts with contact information. The book also includes an extensive glossary, ideas and examples for TV and radio reporters, and links to polls on health issues. Supported by a grant from the Robert Wood Johnson Foundation.

To see a video demonstration of the book by Julie Rovner of NPR, click here. To see individual chapters, click on any of the chapter titles below. To download the entire sourcebook as a PDF, click here.

For all chapters, links are available to local news stories on the chapter topic. For many chapters, there is also a short video featuring one of the nation’s top health policy experts.

Table on contents:

• Introduction and Acknowledgments
• Health Reform
• Cost of Health Care
• Quality of Care
• Employer-Sponsored Health Coverage
• Individual Health Coverage
• Children’s Health Coverage
• Medicare
• Medicaid
• Long-Term Care
• Disparities
• Mental Health and Substance Abuse
• Public Health
• Polls on Health Care Issues
• Covering Health Issues for TV and Radio
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The Alliance for Health Reform is a nonpartisan, not-for-profit health policy education group. We are committed to helping journalists, elected officials and other shapers of public opinion understand the roots of the nation’s health care problems and the trade-offs posed by various proposals for change. Our aim is quality, affordable health coverage for all in the U.S., although we do not lobby or take positions on legislation. Sen. Jay Rockefeller (D-W.Va.) is our founder and honorary chairman; Robert Graham, MD, of the University of Cincinnati is our board chairman.

Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, said that the ideal American, from a budget standpoint, “is one who dies at age 65 on the drive home from his retirement party.”  His comment gets to the heart of the budget conundrum.  If our healthcare system takes steps to help people live longer in their retirement years, then they consume more Social Security and Medicare resources.

Yet, as Frieden also said, we should all be able to agree to the societal goal that “Americans are better off not dead.”

There are some important points here.  First, that there is not necessarily a perfect alignment between budgetary goals and the imperative to have a healthy population, that funding for medical research and the effort to prevent and cure disease should not be viewed in the same vein as other areas of discretionary spending.  And, second, as Frieden also pointed out, investments in disease prevention do not always fit into the neat, tidy 10-year window that Congress and federal budgeters like to use to score spending, that health prevention measures can sometimes take 20 or 30 years to fully assess their return on investment.

At the same Research! America event, former Congressman Mike Castle said that the need to contain Medicare and Medicaid costs will be one of the major campaign issues in the 2012 elections.  No doubt he’s correct, but let’s hope we hear office holders and candidates provide some creative solutions on how to curb cost growth while still achieving the greater objective of keeping Americans alive and healthy.

First posted on the Prognosis Blog on March 15th.

It used to be the case that when an innovator wanted to launch a new drug or device in the United States, the key regulatory tollgate was the federal Food and Drug Administration (FDA). That standard focuses on safety and efficacy. Once that tollgate was satisfied, the company could promote its product, and the product would enjoy general distribution in the marketplace. Those days are over.

Two new additional tollgates include access to identifier codes – especially for certain medical devices and coverage for the innovation. The focus of this blog is on the new coverage challenges to innovation.

In the United States, we have a wide variety of payers of health benefits. There are publicly funded payers such as Medicare and Medicaid. There are privately funded payers such as self-funded employers and private health insurance plans. Traditionally, the scope of covered benefits focused more on illnesses. The new benefits focus on prevention and population health management. There are enumerated benefits, enumerated exclusions and general coverage phrases like covering what is “reasonable and necessary.”

More and more payers will be offering similar benefits as Title I of federal health reform is implemented. This is because a proposed federal regulation will be issued soon by Department of Health and Human Services to define the “Essential Health Benefits Package” for individual and small group health plans. This benefits package is supposed to be comparable to coverage by existing employer plans.

Who decides whether an innovation fits within an existing covered benefit or whether a new coverage decision is needed so that patients can get access to the innovation? And, what is the criteria for confirmation of coverage? Is it enough that the innovation is comparable to existing options? Does it have to be breakthrough? While there is a whole body of literature about randomized control trials and other data points needed to establish FDA approval, what should be the study protocol to establish a positive coverage determination by the payer? Finally, should the new cost of the innovation even play a role in the coverage decision-making process?  These are the key questions across payers.

Centers for Medicare & Medicaid Services (CMS) uses the MEDCAC – the Medicare Evidence Development & Coverage Advisory Committee- to provide independent guidance and expert advice on specific clinical topics.  In its deliberations, the MEDCAC reviews and evaluates available evidence, including medical literature and technology assessments, and listens to public testimony.  The Committee then makes coverage recommendations to CMS based on its review.  Private payers usually have some type of technology assessment processes.

In recent years, to facilitate access to some innovative products, CMS also has adopted some conditional coverage strategies. For example, see CMS’s website about conditional coverage with evidence development.  The idea is to allow the product to obtain coverage so that it can enter the market and then capture data to earn the right to stay in the market.  Otherwise, it can be a Catch-22 – without access to the market, it is difficult for the innovator to demonstrate its value proposition to a payer.

There also are some new and some not so new regulatory players in this space. CMS is still a major player in the area of coverage – with its National Coverage Determinations and local coverage determinations at the claims administrator levels. However, the most important regulatory player in this space is the Agency for Healthcare Quality and Research (AHRQ), which “supports health services research that will improve the quality of health care and promote evidence-based decisionmaking.”  AHRQ addresses key coverage issues using comparative effectiveness research conducted through its Effective Health Care program.  AHRQ also was a key recipient of funds under the federal Stimulus legislation.  

Health reform also heralded a new institute, the Patient-Centered Outcomes Research Institute (PCORI), charged with establishing national clinical comparative effectiveness research (CER) priorities as well as providing federal funding to conduct CER.   Health care innovations need to focus on these types of coverage and outcomes tollgates as we move from a fee for service model to an evidence-based bundled payment model.

Finally, not all widgets of health care innovation require a specific coverage determination by a payer. Innovations may be subsumed inside already existing bundled payments such as innovations that minimize the likelihood of “never events” happening in the inpatient setting. These are desired innovations, and they likely are subsumed either in the DRG or in avoiding reductions in payments. Coverage is subsumed inside the existing bundled payment for the episode of care.  Other innovations may be more process oriented, such as innovative techniques to avoid unnecessary re-admissions to hospitals.

While implementation of health reform continues to roll out, one of the key themes for public comment should be the need to maintain a flexible process for adopting health care innovations, especially within the context of coverage for health benefits.  Without such flexibility, certain innovations with great value propositions may never get to market.

* This post is part of the Disruptive Women series on innovation.

In addition to this video, the Kaiser Family Foundation has great resources/basic information to help you understand the new law. To access this information, click here.

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.

The new health reform law establishes a framework for developing health care delivery and payment reforms, but it’s just that – a framework.  CMS, the Centers for Medicare and Medicaid Services, is charged with evaluating and selecting demonstration projects that have the potential for nationwide implementation – a process that former CMS administrator Dr. Mark McClellan has said could take a decade.

I want to see Dr. Berwick before the Senate Finance Committee so we can learn more about how he, a strong advocate of delivery reform, plans to accelerate this process.  Our health care system can ill afford to have coverage expansions and essential system improvements be years out of synch.

I mean, let’s be honest here.  Congress isn’t going to allow Don Berwick to transform the U.S. health care system into the British NHS, assuming he really wants to do so.  But the executive and legislative branches do need to work together on making health system improvements a reality sooner rather than later.  That needs to be the subject of the confirmation hearings Dr. Berwick never had.

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.  These enhanced FMAP dollars would also help fund prescription drug coverage for low-income citizens and those with HIV and AIDS.  But who cares about folks with HIV and AIDs?  They are just a bunch of minorities and homosexuals whose choices have caught up with them, right?  And who cares about the poor?  Heck, we have had candidates build political campaigns on picking fights with those lazy, shiftless stray animals, and Medicaid is just another one of those welfare programs perpetuating our “culture of dependence,” right?

NEWSFLASH: Ain’t nobody getting rich off Medicaid (improper English intended)!

Right now, SC’s Medicaid program only covers the very poor in our state.  A single parent making a little over $7,000 a year is too rich to qualify for Medicaid in SC, and if an adult without children makes just $5 a year, they cannot qualify for Medicaid because they are categorically ineligible.  Some confuse the typical Medicaid recipient with the infamous Reagan-era “welfare queen.”  What a ridiculous comparison.  Medicaid recipients don’t receive checks.  They receive access to vital health care services like primary care, prescription drugs, screenings, and hospitalizations.

If Congress fails to extend temporary relief through FMAP, states across the nation will see drastic Medicaid cuts, as their budgets are already strained in this economy.  These cuts will include reductions in benefits, increases in out-of-pocket health costs for Medicaid enrollees, and lower payments to health providers—which will only decrease health care access and delay care for the most vulnerable, costing all of us more in the long run.

Let’s inform Congress that cooties are only imaginary, and encourage them to work across the aisles to garner the votes to pass this important, temporary extension.  The FMAP extension is good for South Carolina and good for America.

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

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.

Second, is yoga cost-effective? Having passed the first hurdle regarding effectiveness, yoga would then be subject to a test of relative value against other therapies. This will likely be determined by a combination of cost and patient satisfaction factors. Yoga is less expensive than the spinal surgery I faced and I’m very satisfied not to have suffered the projected month of hospitalization, surgical risks and likely post-surgical pain. In fact, had I not learned yoga, even daily classes – were I to pay for them – would likely cost less than the pain medications that might otherwise be a staple of my day and would be immensely cost-beneficial over the disability others in my family have faced.

Could the same be said for hypertension? Generic medications cost only pennies per day and require only seconds to swallow, at far less cost and time investment than a yoga class or daily practice. In fact, even brand products are likewise less expensive and easier to comply with than a regular yoga practice. No therapy is effective – and is certainly not cost effective – if patients don’t use them. Medication adherence can be as low as 50%; are there data to show how yoga compares? If yoga is judged by payers to require more of patients who will not likely adhere to the regimen, payers may be skeptical and reluctant to cover it.

Third, how will yoga teachers and studios be regulated? It’s not a question of ‘whether,’ but ‘how’ requirements will be framed through regulations and provider contracts, and what group will monitor compliance with those.

Products and services reimbursed by Medicaid and Medicare, purchased with federal or state health funds, distributed through the VA, Community Health Centers, Indian Health Service, and Public Health Departments must comply with certain conditions and those will likely apply to yoga as well. Non-government third party payers set their own, similar standards.

Payers want to know they’re financing the activities of legitimate providers of care capable of assuring access and quality at a good cost, adhering to acceptable practices of promotion and protecting against fraud. This will happen through regulation and contractual agreements with providers that will address.

Quality

• Will yoga teachers, as ‘providers’ of health care, be subject to standards beyond those of their training schools?
• Will they be subject to state licensing (as are other providers and facilities), credentialing, periodic re-licensure and re-certifications, continuing education requirements and personal background checks?
• Will yoga teachers be required to collect and report injuries or adverse events sustained during classes, as do hospitals or pharmaceutical companies in reporting injuries and adverse events? If so, will those be published in increasingly-familiar formats like report cards on providers?

Access

• Will yoga studios, as a ‘setting’ of health care, be subject to requirements for access for special populations such as children, seniors and the disabled?
• Must yoga address non-financial barriers (e.g., language)? Government-funded providers must treat patients in their language – providing translators if needed. Must yoga teachers do likewise?

Cost

• To control for appropriate use, will a prescriber order be required, much like for physical therapy?
• Will the number of reimbursed yoga classes be limited, much as other visits for psychotherapy or physical therapy?
• Will payers require pre-authorization for yoga classes, such that the prescriber or yoga teacher will need to justify a prescribed number of classes, or additional classes for some patients?
• How will the fee for a yoga class be set? Will the rates be negotiated? Or set by the payer?  Will government get the ‘best price’ through rebates, competitive bidding, volume purchasing or price controls?
• If only a portion of the class fee is paid by a third party, may teachers collect the difference from the student/patient, or as in Medicare will they be prevented from doing that?

Marketing and Promotion

• How may yoga be marketed and promoted?
• Can claims be made for health outcomes without clinical evidence to demonstrate its validity? What endpoints are satisfactory to prove the claim? For example, is ‘toning muscle’ or ‘developing balance’ a satisfactory endpoint or must reductions in hip fractures from falls be demonstrated?
• Can one form of yoga claim superiority over another, and if so, under what criteria and circumstances?
• Must all promotional claims also include a list of possible injuries to assure ‘fair balance’ or ‘informed consent’ and clear warnings to patients?
• Will promotion to health care providers be allowed and if so, of what type? Sampling? Reminder items? Continuing medical education?

Fraud Protections

• Will yoga teachers be required to transmit class attendance information and provide progress reports to payers that provide coverage and reimbursement?
• Are payers entitled to know how often – and with what results – patients attend classes?
• Will yoga providers be required to link class attendance to electronic personal health/payment records?
• How will payers audit records to assure that billing matches the actual class attendance by covered patients?

Some payers – as businesses do now – may choose to offer yoga and never address the issues raised here. In my own company, for example, having seen the value for myself, I’d gladly underwrite the cost for my employees. The same might be true for even a very large company.

If yoga ‘goes mainstream’ in health care, however, it is likely that it – and other ‘alternative’ modalities – will be scrutinized. I know both sides and can envision a dozen questions more than the ones posed here.

It’s not my place to say what is best for yoga in America, its students and teachers, or what’s best for health care in America, its patients or payers.

A match made in heaven? It’s too early to tell. Time will. OK everyone, relax, take a deep breath….and another….

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.

CMS explained that this new policy would equalize reimbursement among primary care and specialists. Medicare Fee Schedule rates are based on “relative value units” (RVUs) for each CPT (billing) code, with higher RVUs for consulting codes. By eliminating payment for specific consultation codes, CMS was able to reallocate those RVUs into the E&M rates used by all physicians, and so raise those rates. This action was part of CMS’s determination to attract and retain primary care physicians to serve Medicare beneficiaries.

Given the typical 30 to 60 day lag in billing and reimbursement, specialists will not feel these new Medicare reductions in their consulting fees for a few weeks or more. Also, it is too soon to tell if the increases in the E&M rates will be seen as a sufficient reward for primary care.

I agree that we need more primary care physicians in our health care system to help guide all of us along a pathway of good health and wellness, as well as to treat Medicare patients and other more complicated patients, like those with chronic conditions and/or disabilities. But these generalists also need to have a reliable referral base of specialists who can diagnose, treat, and advise on managing particular concerns. We need all of these physicians and more, so I hope we can find a fair balance between them.

Source: Final Physician Fee Schedule Rules (PDF), p. 33 (via the CMS website)