Final regulations on "meaningful use" of electronic health records were released today by HHS. The 863 pages specifies the initial criteria that hospitals and physicians hoping to obtain incentive support payments under the ARRA for their use of EHRs must meet. The regulations will be published in the Federal Register on July 28, 2010.
There is a brand new resource for navigating health care reform - a website managed by HHS called HealthCare.gov. According to the website, it is "designed to help you take control over your health care and make the choices that are right for you." Currently, the content is focused on four primary areas: finding health insurance options, learning about preventative health care, comparing hospital quality, and learning more about the Affordable Care Act. Admittedly a work in progress, HHS welcomes user comments to improve the site and make it more useful for the public. This coming October, look for the website to include private health insurance pricing information.
Last week the United States Departments of Treasury, Labor and Health and Human Services issued Interim Final Rules providing guidance on “grandfathered health plans” under health care reform. The Patient Protection and Affordable Care Act (“PPACA”) set different standards for grandfathered health plans than for those plans not grandfathered. According to these regulations, health plans that existed on March 23, 2010 will be significantly restricted in the changes they can make to copayments, deductibles and benefits covered if the plans want to maintain grandfathered status and avoid the new requirements of PPACA.
Most plans will fail to qualify for grandfathered status over the next three years, according to the Departments’ analysis in the Interim Final Rules. The greatest impact will be on small employers with between 3 and 99 employees. The Departments estimate that between 49% and 80% of small employer plans will relinquish their grandfathered status by 2013. In addition, the Departments estimate that between 34% and 64% of large employer plans will relinquish their grandfathered status by 2013.
Continue Reading...I recently led a class on the new health care reform law, the Patient Protection and Affordable Care Act (PPACA), and have attched the powerpoint presentation from that class. I hope this provides a good start on understanding the scope of the this legislation. A good overall detailed summary of the statute, which incorporates the Reconciliation changes into the PPACA provisions, is here. The whole law, including the Reconciliation Act changes, is here.
PPACA is the start of a decades long process of remaking the health care system in the United States.The law calls for many new state or federal agencies, commissions, and other institutions, as well as scores of new federal rules and regulations, and will most likely require changes to other existing federal and state laws if it is to be fully implemented. Congress has already begun talking about amending some of the provisions in PPACA due to "unintended consequences."
Cost estimates for the reformation are continually changing as well, and it now appears the purported $1 Trillion cap on cost will be significantly surpassed.
For a timeline on when the various changes become effective, the Kaiser Family Foundation's is a good reference.
The Internal Revenue Service has begun issuing regulations implementing the Patient Protection and Affordable Care Act (PPACA), the federal health reform law. You can expect to see new regulations under the law coming out monthly for the remainder of the year. At a recent speech to the American Health Lawyers Association, a spokesperson for CMS said that HHS is presently drafting 18 sets of new regulations that have to be in effect duri ng 2010, compared to its normal output of 2 - 3 sets.
The IRS's first rules relate to extending dependent coverage under a parent's health insurance to include children up to age 26.
Continue Reading...Colorado Governor Bill Ritter has begun implementing health care reform in Colorado. By executive order, he has created a new task force called the Interagency Health Reform Implementing Board to oversee this process and has appointed his health care policy expert, Lorez Meinhold, to the newly created position of Director of Health Reform Implementation. On a roll, he also has signed four bills into law that his press release states are designed to "enhance the state's nationally recognized health reform initiatives."
Here is one timeline for the many actions needed to implement the new health care reform law.
No one would contend that the new law provides a "turnkey" solution to changes in the health care system. There will be scores of new government commissions and panels that will be set up, major new regulations promulgated, and systems developed for coordination with state regulatory bodies and legislative action. It is likely that every step along this path will be a contested battle, as it seems clear that this law is a incubator for unintended consequences, and there is a strong public opposition to the centralized regulation of health care in Washington. It would be premature to start hanging any "Mission Accomplished" banners on health care reform.
Every time I hear a politician in Washington praise this law for "cutting" the deficit by $130 Billion over ten years and saving money on Medicare, I wonder if that politician will be voting against the "physician fix" that takes back over $250 Billion in the hoped for savings under the new law and thereby results in a net increase in the deficit over that ten year period.
Update: Another timeline here.
Here's the text of the 153 page House Bill called the Heath Care Education and Affordability Reconciliation Act of 2010. We'll be reading it too and posting our thoughts on how it affects you and your business.
No longer a question of will it pass, here are links to a variety of articles discussing this issue:
Regardless of what happens to the current health care reform legislation, it appears that the government's push for more research into the comparative effectiveness of treatments will get continued emphasis in 2011. In the recently proposed 2011 budget, the Administration has requested almost $300 Million for the Agency for Healthcare Research and Quality (AHRQ) to conduct comparative effectiveness studies. This would be on top of a little over $300 Million authorized in the current year.
I don't think many people would disagree that innovations and new treatment options are occurring very rapidly in the medical field and that it is difficult for physicians to keep on top of these developments and make informed recommendations to their patients as to the best alternatives for them. Understanding and then following "best evidence" medicine is not easy for the busy practitioner. Better research on comparative effectiveness will certainly help this situation.
But as we saw in 2009, a change in recommended treatment based on comparative effectiveness studies is not an easy pill to swallow. The proposed revision in the use of screening mammography exams caused an uproar, as it was seen as a possible justification for third party payors to deny payment for routine screening exams for younger women with no history or indications of problems.
The bad press and angry reactions surrounding that relatively simple proposed modification in recommended treatment highlight the difficulty of gaining general acceptance to "best evidence" medicine in the United States. We are accustom to being entitled to get whatever we want in medical care, without consideration of comparative effectiveness. While physicians overwhelmingly may want to recommend what they think to be the best treatment for the specific patient, there is not a good support system in place for a doctor who wants to follow "best evidence" medicine if payors will permit anything the patient or doctor want to try and if the doctor has to worry about liability for his or her recommended course of care. Managed care in the 1990's tried to control expensive treatments that had no proven degree of effectiveness, and were shut down in those efforts by media and political uproar based primarily on the isolated anecdotal story of the effects of a denial of coverage.
We can spend $300 Million each year on comparative effectiveness research, which undoubtedly will benefit practicing physicians as they consider treatment options, but until we as a society start to discuss and come to a consensus on what it means for an individual to have access to appropriate health care, expect more outrage every time some panel suggests that the benefit of a test or treatment is not effective enough to justify its use.
For those interested in learning more about the final version of the Bill passed by the Senate on December 24, this offers a guide for getting through the 2074 pages. Scroll down the page and click the link offers help on understanding the Bill, and it has summaries and a full PDF copy of the Bill to review and search online.
A recent Wall Street Journal article discusses a new contract between Blue Cross Blue Shield of Massachusetts and the Caritas Christi Health Sytem based on a new approach to payments. Under Massachusetts near-universal coverage, there has been a significant escalation of health care costs, and BCBS is making an effort to rein in that cost spiral. It has begun entering in "alternative quality contracts" with networks of hospitals and physicians in Massachusetts to replace the traditional fee-for-service payment system.
Under the new arrangements, Caritas, a system of hospitals and over 1000 employed or affiliated physicians, will be paid a fixed amount to provide all the care for 60,000 patients. This is reminiscent of the 1990's capitation payments, a flat monthly payment per patient (known as a per member per month, or "PMPM", payment) assigned to the providers. Under a capitation contract, providers could have higher revenues if less care was rendered, as the PMPM amount didn't vary with actual services provided. Health care plans and providers were widely criticized for capitation payments, as it was perceived that this would result in withholding needed care or cherry picking only healthy patients. By the end of the decade, most plans had eliminated capitation contracts and returned to fee-for-service arrangements.
In order to avoid the seeds of criticism, the BCBS methodology pays a monthly fee per patient, but also rewards providers with bonuses if they meet certain quality targets. The goal is to refocus profit-potential from capitation's less care being provided to having better patient outcomes. These new contracts are for hospital-physician networks, to encourage coordinated efforts.
The WSJ article suggests that today's information technology might make this goal of cost-saving and outcome improvement reachable. To make this incentive system work, though, it will require that hospitals, primary care doctors and specialists collaborate to determine appropriateness of care and a fair division of the payments. This has been an unresolved problem for prior efforts to reform health care delivery and payment. It may be easier in a unified system of hospitals and employed physicians, but it has proven to be a real dilemma in most networks of independent physicians. I guess if it were easy, we would have health care reform twenty years ago.
If you're looking for some clarification on what the House and the Senate are bringing to the table in terms of health care reform, the New York Times provides an informative, click-through guide that will provide some insight. With a bulleted, issue-by-issue comparison, the guide highlights some of the key differences between the House and Senate health care proposals, including insurance mandates, employee contributions and total coverage and cost.
In case you are looking for a little light reading, the Senate Committee on Finance has released the full text of their proposed bill for healthcare reform - all 1504 pages - as well as its Committee Report.
A story in today's Wall Street Journal talks about the hospital and insurance sectors preparing to fight the latest Congressional efforts to reduce or eliminate penalties for individuals who do not purchase health insurance, on the grounds that it will mean millions of individuals, many of whom will be healthier young adults (the "invincibles"), going without coverage. Hospitals contend that their industry's agreement to accept lower reimbursement from the government in order provide funding to cover the uninsured was conditioned upon insurance mandates to assure that all patients would have insurance coverage. The insurance companies' willingness to support guaranteed issue for all applicants was based on having universal required coverage as well, so people cannot put off buying insurance until they became sick, an insurer's nightmare about guaranteed issue.
We have been hearing recently about the union opposition to taxes on "Cadillac" insurance plans, too, as the realization sinks in that these high-benefit plans are more prevalent in collective bargaining agreements than in most businesses. In short, the more the details of proposed legislation become known (and it is still rare to find anyone who has been struggling through the various versions of the draft bills, all of which are in the 1000-page range), the more the special interests are surfacing to defend their turf and fight anything that will negatively change their worlds.
Health care reform sounds good to everyone in the abstract. There are even some pieces of the puzzle that most everyone seems to agree would be good, mostly things that require little additional funding and little federal regulatory control. Trying to fund hundreds of billions of dollars in new commitments in a budget neutral way means somebody is going to have to pay more, and adding scores of new government commissions and regulatory bodies to control the insurance industry and the delivery of health care services means some people's livelihood and careers are going to be disrupted or marginalized. An open debate over these issues would mean a fight in Washington like we haven't seen in some years, as there is more at stake when you are making radical changes to 16% of our economy. Is there any wonder that Congress prefers to deal only with vague 200-page "plain English" summaries of the massive changes they are considering? I don't think we have even seen the start of the battle. It will be an interesting Fall.
On September 16, Senator Baucus released a 230 page summary of his version of a health care reform bill. [See: www.opencongress.org/articles/view/1225-Max-%20%20%20%20%20%20%20%20Baucus-America-s-Healthy-Future-Act with a PDF link] The actual 1000 page draft of the legislation will be released today. While the Finance Committee had hoped to have a bi-partison bill from its subcommittee of 6 Senators, that group had been unable to reach an agreement and Senator baucus submitted his own draft for full Committee review starting next week.
Criticism of Baucus's draft bill has already begun, with Senators from both parties expressing concerns over its various provisions. It appears he has found a way to anger every special interest group. Maybe that will motivate all the factions in this debate to find a middle ground that can actually pass both Houses.
On July 14, House Democrats unveiled a comprehensive health care reform bill, referred to as America's Affordable Health Choices Act of 2009, a 1000+ page document that radically changes the way Americans obtain health insurance and the current approaches for reimbursement to providers, as well as adding new taxes to help fund the program. The 10-year cost to implement this bill has been estimated at over $1Trillion. The draft bill will now go to three House Committees for review and mark-ups. A summary and discussion of the draft bill's major provisions has been posted. The Energy and Commerce Committee, chaired by Rep. Waxman, is also posting regular updates on its mark-up activities.
On the 15th, the Senate Health, Education, Labor and Pensions (HELP) Committee released its version of the Affordable Health Choices Act, only 650 pages, with its summary of the key provisions. While somewhat shorter than the House draft, it also is a comprehensive overhaul of all aspects of the present health care payment and delivery system. The Senate Finance Committee, chaired by Senator Baucus, is expected to release its proposed bill within a few days.
Opposition to the various bills began to be expressed immediately from all across the political spectrum, and from members of both parties. The most widespread concerns focus on the costs of the reforms and the government control over all aspects of health care. It looks doubtful for any serious developments occurring by the August recess of Congress as had been sought by the President.
It's going to be an interesting Summer.
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