By Mary Grealy. I wonder how long it will take before people who should know better stop implying, or even saying outright, that payment cuts to Medicare providers don’t affect beneficiaries.

This weekend, I was among those following the cable news shows to see if Congress would finally reach agreement on a debt ceiling package.  It appears now that, even though it may be a “sugar-coated Satan sandwich” to some, a legislative approach has been crafted that will raise the debt ceiling and establish a process for achieving approximately $2.5 trillion in budget cuts over 10 years. 

In this process, a congressional super-committee will be charged with identifying $1.5 trillion in deficit reductions by Thanksgiving.  If they fail to do so, automatic cuts will occur and fall most heavily on the defense budget and Medicare.

As I was watching the news analysis, though, I saw a continued misunderstanding of what it means to cut Medicare provider payments.  One commentator praised the deal for protecting the most vulnerable in society, pointing out that Social Security and Medicaid were exempt from cuts, and Medicare cuts “would only affect providers.’  We’ve seen the same type of analysis several times today in print reports.

This kind of verbage creates the impression that an acceptable way to reduce Medicare spending, in a way that doesn’t do harm to patients, is to ratchet down payments for physicians, hospitals, medical devices, pharmaceuticals and medical supplies. (more…)

Many of the debt-reduction plans being considered by Congress and the Administration include proposals that would achieve substantial savings from the Medicare program over time. A  side-by-side summary of the proposals allows users to easily compare the key Medicare provisions found in five major debt-reduction plans put forward by the White House, Congress and independent, bipartisan commissions. The five plans are: the President’s Framework for Shared Prosperity and Shared Fiscal Responsibility; the House Concurrent Budget Resolution; the Senate “Gang of Six” Proposal; the National Commission on Fiscal Responsibility and Reform (Bowles-Simpson); and the Bipartisan Policy Center Debt Reduction Task Force (Domenici-Rivlin).

The summary also includes brief descriptions of Medicare proposals in other deficit reduction proposals from American Enterprise Institute; Cato Institute; Center for American Progress, Sen. Tom Coburn; Congressional Progressive Caucus; Dr. Bill Galston and Ms. Maya MacGuineas; Heritage Foundation; Institute for America’s Future; Sen. Joseph Lieberman and Sen. Coburn; Our Fiscal Security; Dr. Alice Rivlin and Chairman Paul Ryan; Republican Study Committee; Roosevelt Institute Campus Network; and Chairman Ryan.

The side-by-side summary is part of the Foundation’s Project on Medicare’s Future, which focuses on producing timely analysis of leading Medicare reforms affecting people on Medicare.  .The Kaiser Family Foundation is a non-profit private operating foundation dedicated to producing and communicating the best possible analysis and information on health issues.

By Hope Ditto. Most of the country is sweltering its way through this week’s heat wave, but there is one thing here in DC rising faster than the mercury in our thermometers – tensions on the Hill as the debt ceiling stalemate continues. Whispers [well, tweeted whispers] of default “what ifs” abound here in the nation’s capital as lawmakers continue to play a high-stakes game of chicken through day after day of floor debates, committee hearings and negotiating sessions. With interest rates, Social Security payments and America’s credit score dangling in the balance, and the clock ticking towards the Aug. 2 deadline, the air is even thicker with panic than it is with humidity (though my frizzy hair would say otherwise). (more…)

By Mary Grealy. It wasn’t a head-to-head battle, as such, but Congresswoman Allyson Schwartz (D-PA) squared off against the USA Today editorial board yesterday on the subject of the Independent Payment Advisory Board (IPAB), and I believe the lawmaker clearly made the better arguments.

USA Today’s editorial made the point that the IPAB, created as part of the Affordable Care Act to curb Medicare costs, is essential to do the job that Congress won’t in cutting program spending.  The newspaper compared the new board to the base closing commission that successfully shuttered unneeded military installations.

That’s a dubious argument, though, at best.  The base closing commission carefully studied the value and usefulness of military bases before choosing which ones could be closed without undermining national security.

IPAB will function in a completely different way.  If Medicare spending goes above arbitrary levels, then the board will bring the ax down on program budgets without regard to quality, value or seniors’ access to healthcare.   We’re facing a near future in which the senior population will be rising in number while physicians will be in shorter supply.  Simply cutting provider payments is the wrong answer.

Congresswoman Schwartz, in her response, acknowledged that Medicare costs must be contained, but she wrote that the solution is to reduce costs through innovations in health delivery to “reduce errors, eliminate duplication and waste, use technology to safely share information, and coordinate care between practitioners and settings.” 

She said it best when she wrote, “The threat of reduced payments is the least imaginative option.”  She’s absolutely right, and Washington can and should address the Medicare cost issue more creatively and effectively without diminishing healthcare for those who need it most.

Originally posted on the Prognosis Blog on May 24th.

“What Does Health Reform Do for People on Medicare?” 

The new health reform law benefits people on Medicare in a number of ways. This video explains some of the ways, such as ending out-of-pocket expenses for recommended screenings, checkups and other preventive services, and reducing prescription drug prices in the “doughnut hole.” Featuring John Rother, executive vice president of policy and strategy for AARP.

“Will Health Reform Reduce the Federal Deficit?” 

 The Congressional Budget Office estimates that the health reform law will reduce the federal deficit by $124 billion by 2020. Respected analysts disagree, however. In this video, economist Joe Antos of the American Enterprise Institute explains why he believes health reform will cost much more than expected, primarily because he doubts that future Congresses will go along with the Medicare savings in the Affordable Care Act.

The completely updated 200-page Alliance sourcebook, “Covering Health Issues, 6th Edition,” is now available.

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
• Acronyms and Glossary
• Experts
• Websites

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.

By Mary Grealy. At this moment, there appear to be few issues that have elicited as much partisan rhetoric as Medicare reform.  Ever since Congressman Paul Ryan (R-WI) released the House Republicans’ 2012 budget proposal – a proposal that includes a transition of Medicare to a “premium support” model, in which the federal government will provide a financial contribution to assist beneficiaries in choosing from a list of private health coverage plans – there has been a pitched battle in the media between Democrats and Republicans over whether such a change would mean essentially an end to Medicare and be harmful to beneficiaries.

But the Washington Post reminded us this weekend that the premium support concept has its roots in bipartisanship.  The idea was, in fact, endorsed by the Bipartisan Commission on the Future of Medicare, which did its work in the late 1990s.  One of the co-chairs of that commission, then-U.S. Senator John Breaux (D-LA) championed the approach, saying “Medicare as we know it is going to end by itself if we don’t make some changes.” 

More recently, Alice Rivlin, President Clinton’s budget director, worked with Congressman Ryan on a bipartisan premium support proposal when they were both members of President Obama’s bipartisan deficit reduction commission (although she makes it clear that she does not support the current Ryan plan).

Senator Breaux and I have served together as co-chairs of the Medicare Today coalition, a group that helps provide information to seniors about the Medicare Part D prescription drug benefit.  Senator Breaux has told me that his work on the Part D issue has convinced him that seniors value the ability to make their own healthcare decisions, including a choice of coverage plan, and that supporting this freedom of choice really should be a bipartisan objective.

It isn’t bipartisan today, but we can only hope that as work continues on making Medicare sustainable for future generations, we’ll rediscover the bipartisanship that existed on Senator Breaux’s Medicare commission and see Democrats and Republicans working together to make changes the program needs to live on for future generations.

Originally posted on Prognosis on May 2nd.

This post was co-authored by Disruptive Woman Archelle Georgiou and Emma Dougherty, Senior Analyst at TripleTree and originally published on the firms blog site, Uncommon Clarity. It was also posted on Archelle on Health.

9 million. That’s how many web hits are returned during a Google search for “Accountable Care Organization,” and reflects the countless articles, white papers and opinions that have been published regarding the potential successes and more likely pitfalls of the proposed ACO mandate. As highlighted in TripleTree’s recent post, our team is continuously evaluating the business development opportunities being fueled by the demands and requirements of these new provider organizations.  Last week, the members of our Healthcare Executive Roundtable recently discussed and debated an element of the ACO equation that is not typically highlighted but is clearly a critical component of ACO success (or failure)…Trust.

In boardrooms around the country, health care executives are focusing on the technical requirements for their future ACO’s clinical and administrative systems. They are pouring over spreadsheets and attempting to understand the data and analytical tools that will be necessary for adequate financial and quality of care reporting. Getting these operational elements “right” is important; however, these business leaders should also focus on designing a culture – and the corresponding behaviors, communication, and incentives that will fuel strong and collaborative relationships between the ACO and its community of providers.

As Ed Brown, CEO of Iowa Clinic puts it, “People are unclear about what the value-based world looks like, and they’re unsettled on what clini­cal integration really means. And nobody has really made it work.”  This lack of clarity around the value-based model will make it challenging for providers to leave the financial security blanket of the traditional fee-for-service payment engine.  Moreover, influencing them to modify their approach to patient care for the benefit of the system and the promise of shared savings is a monumental effort. Success by any measure will largely depend on the trust established between providers and the ACO organization itself. ACO’s should prioritize establishing trust with providers in three key areas:

• ACO Operations and Management:  Providers need to trust that the ACO is well run. Understanding the organizational governance, expertise of the management team and core capabilities (strategic assets) will help generate confidence that the ACO is well-positioned to generate enough shared savings to make participation worthwhile. In addition, it is critical that the ACO measure and report management performance metrics that demonstrate its accountability to the providers. (more…)

By Mary Grealy. An interesting comment was made today at the annual national health research forum sponsored by the non-profit organization Research! America, and it drove home the conflict lawmakers face in trying to balance deficit reduction against the need for quality healthcare and better preventive care.

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.

By Diana J. Mason, PhD, RN. I was quite distressed to read in this morning’s news that the Obama Administration had reversed the new Medicare regulation that would pay for periodic conversations between physicians and patients about preferences for end-of-life care.  According to today’s New York Times, Speaker John Boehner said that  “the provision could be a step ‘down a treacherous path toward government-encouraged euthanasia.’”

Sara Palin started this rhetorical myth when she declared efforts to incorporate paying for such conversations under Medicare in the House health care reform bill (not included in the final law) as creating “death panels”. This lie is undermining advances that advocates for better end-of-life care have worked on over the past decades. While the Times article quotes an unnamed White House official as saying that this reversal will not preclude these conversations happening anyway, the reality is that conversations about the treatments one wants and doesn’t want at the end of life take time. If this time isn’t paid for, the conversations will not take place or will not be as thoughtful as they ought to be.

In 2010, the American Academy of Nursing convened a task force to develop a policy brief on end-of-life conversations (PDF) to counter the distortions of the “death panel” rhetoric. One of the recommendations is paying for these conversations — not just for physicians, but for nurses and social workers who may be the providers who patients and family members seek out to discuss these difficult issues.

Palin’s political rhetoric has co-opted reasoned discussions of policies to support better end of life care. I have talked with leaders of national consumer organizations, health-related organizations (including insurers), and foundations that are reluctant to engage in public discussions of end-of-life decision making because of how politicized the issue has become. Now the Administration runs in fear, too.  Those of us who know the evidence supporting better and more frequent conversations about end-of-life preferences, those of us who have seen people die a horrible death that is prolonged from unnecessary and agonizing medical interventions that are assaultive, those of us who have been part of someone’s experience of dying according to their own values and preferences and who know that dying can be as journalist Robert Lipsyte once described as “the richest of experiences” in his book In the Country of Illness — all who know how difficult, yet crucial end-of-life conversations are must not fear publicly challenging the myth of death panels. We need to point out that the real “death panels” are what occurs now when health care providers make the end-of-life decisions for someone who has not had the opportunity to explore and write down their preferences. Silence means that the death panels win.

By Lynn Shapiro Snyder. I have been a managed care, Medicare and Medicaid attorney for over 30 years. Although this focus includes compliance and enforcement work, I also do a lot of work helping entrepreneurs bring new ideas to the health care marketplace. Providing strategic, legal and regulatory assistance for some of these innovations has been some of the most rewarding work for me.

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. (more…)

Do you find yourself a little confused about what happens when with the health care reform law? To help clear up the confusion the Kaiser Family Foundation wrote and produced a short animated video that explains the problems with the current health care system, the changes that are happening now, and the big changes coming in 2014. The video is narrated by Cokie Roberts, a news commentator for ABC News and NPR and a member of Kaiser’s Board of Trustees. View the video.

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.

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…)

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…)