03.31.08
Posted in Uncategorized at 11:42 pm by Last
Washington -- The push to prevent impending Medicare physician pay cuts is being advanced by a new bill that would block such reductions for 18 months.
The legislation, called the Save Medicare Act of 2008, would continue a 0.5% physician pay update for the last six months of 2008 and would institute a 1.8% update for 2009. Physicians are slated to receive a 10.6% cut starting July 1 and an additional cut of about 5% in 2009.
The bill, introduced by Sen. Debbie Stabenow (D, Mich.) on March 13, has been endorsed by the American Medical Association and other physician organizations.
"The year-and-a-half time frame will inject some stability into the system for seniors and physicians forced to make difficult practice decisions because of planned payment cuts," said AMA President-elect Nancy H. Nielsen, MD, PhD. "The time frame will also give Congress time to begin working on a long-term solution to the broken payment system without having to take action to stop the cuts twice in one year."
The AMA supports replacing the current formula with a system in which payment updates reflect increases in the cost of practicing medicine.
Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, has his own legislative package to address pay cuts and other issues in Medicare. A Baucus aide said the Stabenow bill is "an important contribution to the dialogue we must have about physician payment this spring."
However, the aide said, any discussion that addresses physician payment also should focus on Medicare's deteriorating long-term fiscal condition, should help beneficiaries afford program premiums and out-of-pocket costs, and should be written in a fiscally responsible manner.
Medicare spending is still growing faster than the economy, according to the Medicare trustees 2008 report. One of the biggest problems is that Part A -- which covers hospital, home health, skilled nursing and other facilities -- has enough dedicated funding to cover only 94% of its costs this year. If this trend continues, the $326 billion trust fund supporting Part A will be wiped out by 2019, the trustees said, repeating a warning from last year's report.
Part B, which pays for physician services, is funded adequately every year through general revenues and beneficiary premiums. But as spending continues to grow, Part B will consume an ever-larger portion of general revenues, the report states. The trustees noted that their expenditure projections are likely unrealistically low, because Congress probably will not allow the cuts in physician payment projected for the next decade.
Since 2003, Congress has adopted legislation to prevent physician pay cuts mandated by the formula. However, in more recent years, largely due to the financing mechanisms employed in legislative interventions, the mandated cuts have grown larger and more difficult to avoid under the formula.
Stabenow's bill includes nonbinding language calling generally for Medicare reforms to be handled in a fiscally responsible manner, although it doesn't offer a funding source to prevent the physician pay cuts.
The top Republican on the Senate Finance panel, Sen. Charles Grassley of Iowa, also is concerned about the looming 10.6% physician payment cut. "I'm an advocate for not making it more difficult to recruit doctors in rural America," he said in a radio interview last month. "So I'm going to keep those cuts from happening."
The American Academy of Family Physicians and American College of Physicians support Stabenow's bill. AAFP President Jim King, MD, said his organization's main goal is to replace the payment system with one that makes more sense.
It's difficult to tell how much momentum there is in Congress to prevent the cuts, said Robert Doherty, ACP senior vice president for governmental affairs and public policy.
The Stabenow measure would extend the Physician Quality Reporting Initiative through 2010. Doherty said he would be watching whether lawmakers maintain a separate fund for PQRI bonus payments and other quality programs or if they use funds that would have boosted general Medicare physician reimbursement.
Dr. King was concerned that Baucus' legislation would grow into something too complicated and unwieldy.
Cuts worry Americans
Physicians fear that looming Medicare pay cuts could force them to limit the number of Medicare patients they see or to stop seeing them altogether. They aren't alone in their worries, says an AMA telephone survey of 1,006 adults conducted Feb. 22-25.
Sixty-five percent of Americans are not aware of the scheduled reductions, the poll found. But when told about the cuts, eight out of 10 respondents said they are concerned that access to Medicare would suffer.
Seventy-three percent said Congress should prevent the reductions. The poll has a 3% margin of error.
Stabenow's bill also would continue through 2009 other doctor-supported measures set to expire July 1.
Rural physicians would benefit from a provision continuing Medicare's work geographic practice cost index floor of 1.0. The floor aims to ensure that they are not paid significantly less than urban doctors.
The bill also would maintain a 5% Medicare bonus payment for doctors practicing in underserved areas and would allow physicians ordered into active military duty to engage in substitute billing for more than 60 days.
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Posted in Uncategorized at 11:42 pm by Last
The Florida Supreme Court ignored decades of peer review protections when it ruled March 6 to allow patients to examine records on past adverse medical incidents, physicians and hospital organizations say.
The 4-3 high court decision says a state constitutional amendment giving patients access to records related to adverse medical incidents applies retroactively and opens up related peer review documents created before the amendment passed via ballot measure in November 2004.
Amendment 7 -- dubbed the "Patients' Right to Know About Adverse Medical Incidents" -- also overrides certain legislative provisions passed in June 2005 to implement the measure and preserve the confidentiality of peer review records created before its adoption, the majority concluded. Justices ruled part of the 2005 statute unconstitutional because it restricted the amendment's purpose in making an "immediate change" in the law governing access to medical incident records.
The high court decision was prompted by a conflict that arose in the lower courts in 2006. Two appeals courts agreed that Amendment 7 preempted earlier statutes shielding peer review records but split over whether the measure affected only future peer review documents.
The Supreme Court said no.
The language in the amendment and the ballot measure "make it abundantly clear that the chief purpose of Amendment 7 was to do away with the legislative restrictions on a Florida patient's access to a medical provider's 'history of acts, neglects or defaults' because such history 'may be important to a patient,' " the majority opinion states. "Medical providers have never been granted a substantive vested right in the secrecy of information contained in the limited medical records in question."
The hospital industry, which filed a friend-of-the-court brief through the Florida Hospital Assn., is asking the Supreme Court to reconsider its decision.
Meanwhile, physicians and hospitals say the ruling undoes 20 years of peer review protections promised under the law before the amendment came along.
Jeffery M. Scott, director of legal and governmental affairs for the Florida Medical Assn., said doctors "had the expectation that these documents would remain confidential, and the court said that wasn't a legitimate expectation." The medical society was not involved in the case but supported the 2005 legislation. He said the decision could change the way peer review is handled and "make it much harder to accomplish."
For example, peer review committees may use less documentation in an effort to avoid possible disclosure of their discussions. Doctors also may be reluctant to participate in peer review, knowing that such records are open to public inspection, whether for patients' personal use or in court, Scott said. Ultimately, patient safety will suffer, he said.
Trial lawyers disagree and praised the high court for protecting patients.
"This will lift the veil of secrecy ... and make sure the health care community works together to make sure when we find a problem, we get at the root of it and make sure it doesn't happen again," said Frank M. Petosa, president of the Florida Justice Assn., a trade group for trial lawyers. The organization also filed a friend-of-the-court brief in the case.
Petosa said the amendment -- which voters passed by 81% -- was meant to open records to which patients did not previously have access so they could make better health care choices.
"When we have to make decisions that affect our health and safety, we have to have the information to make sure we are educated consumers. That's what the amendment did and the Supreme Court reaffirmed," he said.
Dissent: Privilege promise broken
But three dissenting judges said the amendment was not intended to apply retroactively and erase past legal protections on old peer review records.
"The straightforward fact is that the state made a promise by statute that if health care providers were open and frank about problems in care and treatment, their openness and frankness would be protected from disclosure," Justice Charles T. Wells wrote.
While that statutory right can change prospectively, doctors still have a right to rely on the prior confidentiality protections granted them under the law, the dissenting opinion states. But "by this [majority] decision, the state's promise is broken," Wells stated. Privileged peer review communications "will have a whole new character," he noted.
The FMA's Scott recommended that doctors work with their medical staff counsel to determine how best to proceed with peer review under the court decision.
William A. Bell, general counsel to the FHA, said the hospital industry is still evaluating the ruling's potential impact, but he agreed that peer review committees are likely to be more cautious. The decision does not limit a judge's authority to decide what information may be used in court, he added.
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Posted in Uncategorized at 11:42 pm by Last
An integral part of some state and local health system reform efforts has hit a major stumbling block. The business community has taken employer mandates to court.
These state and local laws require businesses to spend a certain amount on workers' health care coverage or put that money into a fund to provide access for the uninsured. U.S. courts in Maryland, New York and California have sided with the business community and ruled that the federal Employee Retirement Income Security Act trumps these efforts.
They found that the measures interfere with the act's core purpose of allowing employers to provide and maintain benefits uniformly without having to deal with a maze of different state or local laws.
But the 9th U.S. Circuit Court of Appeals recently turned that reasoning on its head when it temporarily allowed San Francisco's employer mandate to stand. Judges suggested that as long as businesses have a choice, without specific restrictions on how they provide the benefits, ERISA isn't an obstacle.
The conflict may set the stage for a U.S. Supreme Court battle. Meanwhile, the legal tangle raises the question of whether such mandates are a viable component of larger health reform efforts.
Despite the ERISA hurdle, lawmakers -- frustrated with the strain of rising costs associated with the uninsured -- continue to explore employer mandate legislation. According to the National Conference of State Legislatures, at least nine states are currently exploring employer responsibility proposals.
Three states already have reform laws that include employer mandates on the books. The statutes in Massachusetts and Vermont have not been challenged. However, Hawaii is the only state to require employer-sponsored health insurance without fear of preemption. Congress granted Hawaii a waiver because its law pre-dates ERISA, passed in 1974.
"It's clear that what the framers of ERISA intended is that states should not be in the business of telling employers they have to have a [benefit] plan and what the plan should look like," said Phyllis Borzi, a research professor in Health Policy at George Washington University's School of Public Health and Health Services. "The question is whether requiring employers to spend money [on health coverage], in or out of a plan, or pay into a government pool, is the same thing as telling them they have to provide benefits."
Split views
Employers say it is and that ERISA gives them the protection and incentive they need to be able to offer health coverage.
"ERISA allows employers to provide the same benefits to employees [everywhere] and have only one set of costs," said Helen Darling, president of the National Business Group on Health, an organization of large employers that studies health care issues. The group supports expanded access, but contends mandating coverage through various state and local rules would increase expenses without adding value.
At least 9 states are exploring employer health insurance mandates.
Echoing concerns from the 4th U.S. Circuit Court of Appeals, Darling said allowing such laws to stand would set a dangerous precedent that could disrupt existing benefit plans.
In January 2006, the 4th Circuit struck down Maryland's Fair Share Health Care Fund Act. The law required companies with more than 10,000 employees to spend at least 8% of payroll costs on health benefits or to pay into a pool to boost Medicaid programs. Judges said the law violated ERISA by forcing businesses to restructure their health plans.
In New York, a federal trial court in July 2007 also cited ERISA concerns when it ruled against a similar measure targeting large grocery retailers in Suffolk County.
But some consumer advocates say employer responsibility is crucial to health reform and suggest that there are ways to make it work.
"This is not off the table," said Kathleen Stoll, director of health policy for Families USA, a nonprofit consumer health advocacy group that supports employer mandates. "The notion of shared responsibility is important from the perspective of what is fair."
As courts continue to weigh in, they offer states a road map on how to draft employer mandates that withstand legal scrutiny, Stoll said. For example, states can structure laws to act as a tax to fund public programs, while exempting businesses that provide coverage.
San Francisco's ordinance is the latest test. In January, the 9th Circuit issued an emergency order allowing the employer mandate to remain in effect while the city appeals a December 2007 trial court ruling that rejected the provision. Oral arguments are scheduled to begin April 17. A full decision in favor of the reform law could propel the issue to the U.S. Supreme Court.
The city measure requires employers with 20 or more workers to spend $1.17 per hour per employee on health coverage. Companies with more than 100 employees must spend $1.76 per hour per worker. Businesses that don't meet this requirement must pay the equivalent to a universal access fund for a primary and preventive care program called Healthy San Francisco. The 9th Circuit found an ERISA preemption unlikely because employers have options and can comply without a significant impact on their benefit structures.
Physician opinion varies
Just like the courts, physicians appear to be split on the issue. AMA policy does not address employer mandates, and state medical societies typically have not taken a position on them. The AMA advocates for expanding access to health coverage through tax credits, insurance reforms and individual responsibility.
Although employer mandates generally are not considered a stand-alone solution to covering the uninsured, some experts say such proposals can play an important part, especially since most consumers receive health coverage through work. Some doctors support state and local efforts to experiment with the mandates, in conjunction with other approaches, to find out what works.
Employer responsibility "is a necessary part of the solution ... until we get a better one," said Gordon Fung, MD, immediate past president of the San Francisco Medical Society, speaking on his own behalf. The society did not take a position.
Dr. Fung served independently on the mayor-appointed council to develop Healthy San Francisco, which is funded by city and some state dollars, as well as individual and employer contributions. Many businesses already offered coverage, but not to part-time workers, he said. That was one area that the panel found employers could pitch in.
"It was an approach that basically said the health care program needs whatever help we can give it," Dr. Fung said. "But we never said everything we are doing is locked in stone."
The Massachusetts and Vermont medical societies backed their states' multipronged approaches but took no position on the employer mandates. The AMA praised the Massachusetts plan as a positive step.
But the state's health reform effort remains a work in progress, said Massachusetts Medical Society President B. Dale Magee, MD. "Any time we make changes to this delicate system, we have the obligation to measure its success and unintended consequences so we can back up and adjust to make improvements."
Some legal and policy experts suggest that the Massachusetts and Vermont statutes -- which require roughly a $300 annual contribution per worker for certain-sized firms not offering coverage -- are not so burdensome as to warrant a challenge. The laws also combine individual and employer responsibility, which may buffer an ERISA preemption, experts say.
Other physicians agree that businesses must step in but worry that employer mandates will stifle efforts to find innovative ways to cover the uninsured.
"We don't have all the answers ... but it can't evolve when things are rigid," said Robert F. Hamilton, MD, a director and founding member of Consumers for Health Care Choices, a nonprofit consumer health care advocacy group. He said health benefit choices are best left to employers and consumers, whether in the form of traditional insurance, health savings accounts or reimbursement programs.
"But employer mandates take away options," he said. They can strain businesses financially, especially smaller ones. Not only could workers be left uninsured, they also could wind up unemployed, he said.
Some San Francisco businesses already are feeling the administrative burden of the new rules, said Kevin Westlye, executive director of the Golden Gate Restaurant Assn., which challenged the ordinance.
For example, employers have to track hours worked in and outside of the city, calculate benefit expenditures, have employees verify those numbers, train workers on the benefit contributions, and document the reports to the city. Existing insurance plans also could be disrupted, Westlye said.
"Everybody wants to improve health care delivery, but I don't think this ordinance is a step in the right direction," he said.
The 9th Circuit, however, suggested the rule imposed little added burden, since much of the record-keeping involved already is required.
Headed to the Supreme Court?
Experts say the U.S. Supreme Court has not directly addressed ERISA in relationship to the trend of employer responsibility statutes. Other high court precedents have interpreted the federal act strictly in different types of cases.
Public policy concerns may play a role when it comes to employer mandates. George Washington University professor Borzi noted that the high court has upheld states' authority to legislate areas of public concern, even in the face of ERISA, as long as the measures do not interfere with benefit administration.
She added that the 4th Circuit may have looked at Maryland's law differently if it hadn't singled out Wal-Mart as the only company that did not meet the requirements. That aspect of the measure factored largely into the 4th Circuit's decision, Borzi said.
Meanwhile, the absence of a final say from the Supreme Court could prompt congressional action, said Robert L. Schwartz, a health law professor at the University of New Mexico School of Law.
For example, some lawmakers have proposed doing away with ERISA preemption to "let the laboratory of states operate," Schwartz said. But attempts to give states the power to enact employer mandates -- similar to Hawaii's waiver -- thus far have proved unsuccessful.
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Posted in Uncategorized at 11:42 pm by Last
Washington -- The jumble of terms in health information technology soon could be simplified. The National Alliance for Health Information Technology announced March 24 that it finished proposed definitions for five key HIT terms and will seek public comment on them until April 9.
The alliance, a nonprofit organization serving as a forum for companies and officials to debate emerging HIT issues, started its work in November 2007 for the Office of the National Coordinator for Health Information Technology. The terms are electronic medical record, electronic health record, personal health record, health information exchange and regional health information organization.
The ONC chose the terms because they are the most often confused. Lawmakers have proposed bills that use the terms in different ways, said Karen M. Bell, MD, director of the ONC's Office of HIT Adoption.
After the definitions are finalized, the ONC will officially adopt them and use them in its contract language, said alliance Vice President and Chief Marketing Officer Jane Horowitz, who leads the project. Organizations and companies should follow and operationalize the definitions throughout health care, she said.
One of the most significant developments would be distinguishing EMRs from EHRs. The two are frequently used interchangeably. The alliance proposed identifying an EMR as medical information on an individual patient from a single organization, including affiliated settings. EHRs would be data on a patient aggregated from multiple organizations.
The EMR definition is built upon the notion that a person's medical history is recorded to help a physician address an immediate health condition at a single care setting. EHRs, by contrast, intend to boost health care quality by organizing and enabling the sharing of information across care settings to allow a broad spectrum of clinicians to coordinate care for individual patients. An EMR would be a distinct building block of an individual's EHR, the alliance said.
In addition, the organization defined a personal health record as information managed and controlled by an individual, who would act like a librarian by organizing it and deciding who can "check it out." PHRs would exist separately from EHRs, which would be under the control of a health care entity.
The terms health information exchange and regional health information organization have overlapped, the alliance said. It based its definitions on their root meanings. HIE reflects the technological aspects of sharing data, while RHIO reflects the drive for better health care quality and efficiency within a region.
So the alliance defined HIE as the electronic movement of health-related data across nonaffiliated organizations in a way that protects privacy and security.
It defined a RHIO as a multi-stakeholder governing entity responsible for electronic information exchange within a geographic area. A RHIO must involve data sharing between separate entities in a defined area whose collaboration crosses organizational boundaries. It also must be focused on the greater good of a defined population area, instead of specific disease communities, such as a network exchanging information only on diabetics.
"Now is the time to be heard and provide input on the definitions," Horowitz said. "Final definitions will provide an important reference point for policy evaluation and standards development activities, and they will help explain health IT concepts in language that consumers can readily understand."
The definitions are intended to create an HIT culture based on what people should expect from the technology, Dr. Bell said. For example, patients who know that their physician has health IT capabilities should expect it to improve the quality of medical care, she said.
The latest draft of the definitions is available online . The terms are expected to be finalized and sent to the Dept. of Health and Human Services by the end of spring, Dr. Bell said.
Once the definitions are approved, the national HIT coordinator's office will start a campaign to educate the public and physicians, she added.
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Posted in Uncategorized at 11:42 pm by Last
Washington -- Higher-than-expected costs and enrollment in Massachusetts' health reform program are translating into higher premiums and co-payments for enrollees and a concern physicians will face pay cuts.
The Connector Authority, the board overseeing the state's comprehensive health system reform program, unanimously agreed on March 20 to raise monthly premiums by 10% for its subsidized health plans starting July 1, the beginning of the state's 2009 fiscal year.
Residents earning less than 300% of the federal poverty level are eligible for these plans, collectively known as Commonwealth Care. More than 176,000 people were enrolled in these plans as of March 1 -- 40,000 more than expected for fiscal 2008.
The hikes are an improvement over the 14% premium jump initially proposed by the health plans, according to Connector board spokesman Dick Powers.
The 10% increase will apply to enrollees in several income groups. For example, premiums will go up by $4, to reach $39 a month, for enrollees earning between 150% and 200% of the poverty level. Those at the high end of the qualifying income range, between 250% and 300% of the poverty level, will see premiums increase $11, to reach $116 a month.
Enrollees earning less than 150% of the poverty level will continue to pay no premiums. Those earning more than 300% of the poverty level are eligible for unsubsidized Commonwealth Choice plans.
Lawmakers, Connector board members and other reform stakeholders are looking for ways to balance the program's budget. It was initially estimated to be $869 million in fiscal 2009. But at the authority's March 20 meeting, Leslie Kirwan, the state's secretary of administration and finance, said that would not be enough. She did not offer specifics, but said the premium increase wouldn't cover the anticipated shortfall, according to Cindi Roy, spokeswoman for Massachusetts Gov. Deval Patrick.
Patrick and the Legislature face a July 1 deadline for finishing the budget. Options for closing the unspecified remaining funding gap could include requiring larger contributions from hospitals, insurers, businesses or others, or increasing tobacco taxes. Businesses that don't offer health insurance to employees have to pay up to $295 per worker annually, while hospitals and insurers contribute to a fund that supports the program.
Dale Magee, MD, president of the Massachusetts Medical Society, is concerned that the financial pressure on the program could fracture the broad coalition that's been supporting the Connector reforms over the last few years. He said he wouldn't be surprised if physician pay and insurance company administrative costs become part of the discussion on where to trim spending.
The Connector's budget problems are a result of residents making predictable choices, Dr. Magee said. People who needed health coverage and qualified for subsidized Commonwealth Care plans took the state up on their offer. Those who didn't qualify because they had higher incomes weren't as interested in signing up for the unsubsidized Commonwealth Choice plans.
Nearly 75% of Commonwealth Care enrollees earn less than 150% of the poverty level and therefore pay no premiums, Powers said. Meanwhile, enrollment in Commonwealth Choice plans has been about half of what was initially expected.
Dr. Magee is not optimistic that providing health care to the uninsured is going to reduce overall health spending, as some have argued. "The truth is that health care costs money, and that more health care costs more money."
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