E-DMN - December 17, 2007

December 10, 2007

Editor's Column: BCBS: Friend Or Foe
Medicare Cuts: Keep Heat On Congress
Senate Says Medicare Bill Must Pass Unanimously
Blues Bills Draw More Fire
New UHC Policy Puts Quality Over Cost
HFHS Brain Cancer Study Shows Promise
WSUSOM Student Researches Lung Cancer Susceptibility

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Editor's Column: BCBS: Friend Or Foe

By JOSEPH WEISS, MD
BCBS is back in the halls of the Michigan State Legislature. This time the Blues seek legislative approval of their proposal HB 5282.

This legislation would give BCBS exclusive right to write premiums for that group of patients who are both high risk , not covered by Medicare, Medicaid, or through employer sponsored health insurance, and have been rejected by the state’s other commercial health insurance companies.

In return for being responsible for the health costs these high risk patients engender, BCBS wants the legislature to mandate 1) that BCBS can develop four tiers of premiums depending on whether the individual is a less or greater risk than others in this patient pool and 2) that the law place a $10 million cap on the losses BCBS could sustain if reimbursements exceed premium payments. The law would mandate that beyond $10 million would be apportioned among all health insurance carriers selling policies in the state.

This BCBS initiative raises questions. One is uneasiness in giving BCBS an even greater share of the health insurance market. Is obtaining this mandate now a strategy for BCBS to position itself favorably if the election 2008 brings a surge for universal coverage? A second concern is the $10 million cap on BCBS losses. Is this a generous offer by BCBS or is $10 million a pittance, a gesture when considering the total cost of the risk group?

Keep in mind that 37 states use risk pools rather then a single carrier monopoly in providing for high-risk individuals. Shouldn’t Michigan consider that approach?

Furthermore, the medical community has the right to feel exasperated by yet another maneuver that further fragments American health care.

For now, the Medical Society should withhold its endorsement of the HB 5282. The long term consequences of the legislation giving BCBS this mandate are unknown, and the alternatives for care of the high risk individual in Michigan remain unexplored.

It isn’t clear how much HB 5282 poses a risk to us, for as BCBS gains more market we receive less.

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Medicare Cuts: Keep Heat On Congress

Time is running out to stop the 10 percent Medicare physician payment cut that goes into effect January 1, 2008. Soon the US House and Senate will attempt to craft legislation to avert the pending cuts.

Congress needs to hear from you and your colleagues, patients, office staff and everyone affected—as this legislation is being drafted—about how important it is that they stop the pending Medicare physician payment cuts before they go home for the holidays.

RAMP UP THE PRESSURE ON CONGRESS NOW – Use the MSMS Action Center (www.msms.org/action (http://www.msms.org/action) ) to send an electronic message to your Senators and Representative. Also, call them directly using the AMA Grassroots Hotline (toll-free) at (800) 833-6354.

Ask them to speak with their respective leaders and urge them pass legislation that (1) stops the cuts, (2) provides positive Medicare physician payment updates, and (3) does not increase the cost of future MD payment interventions.

IMPACT OF MEDICARE CUTS ON MICHIGAN – Click here to find documents outlining the impact of cuts on Michigan (and other states), statistics on costs versus payments, and more: www.msms.org/medicare

(http://www.msms.org/medicare) .

For more information, contact MSMS Executive Director Kevin A. Kelly at

(517) 336-5742 or kkelly@msms.org.

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Senate Says Medicare Bill Must Pass Unanimously

Senate Minority Leader Mitch McConnell (R-Ky.) last week said that any Medicare bill coming to the chamber floor this week must pass by unanimous consent, CongressDaily reports. Lawmakers are crafting legislation that aims to reverse a 10 percent physician fee cut, scheduled to go into effect Jan. 1, 2008 (Johnson, CongressDaily, 12/14). Lead Senate negotiators say that a bill should be completed before the end of this legislative session, but the measure likely will contain only the bare essentials, CQ HealthBeat reports (CQ HealthBeat, 12/14). Senate Finance Committee ranking member Chuck Grassley (R-Iowa) on Thursday said that Republicans would only accept a package that alters current policy and will oppose any measure creating new policy.

A one-year patch of the physician fee cuts could be paid for by cutting about $8 billion in Medicare Advantage payments for medical education, according to CongressDaily. In addition, Finance Committee Chair Max Baucus (D-Mont.) has indicated that lawmakers also could offset the measure by cutting about $1.5 billion from a "stabilization fund" created under the Medicare prescription drug benefit to attract preferred provider organization plans to underserved areas. Republicans have said that a bare-bones package funded by those cuts would provide enough money to delay the physician fee cut but not to increase physician fees or expand rural and low-income subsidy programs (CongressDaily, 12/14).

Baucus on Friday said that Congress "will definitely have a Medicare bill this year," adding, "What it is, I don't know. Bare bones" (CQ HealthBeat, 12/14). According to Baucus, the package "is looking more and more minimalist all the time" (CongressDaily, 12/14). Grassley said, "We are still working on it. We don't know what can get through the Senate because at this point we're told by leadership that we better have something that's gonna get unanimous consent" (CQ HealthBeat, 12/14).

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Blues Bills Draw More Fire

By PAUL NATINSKY
After hearings before the state Senate Health Policy Committee last week, it has become clear that objections to the Blue Cross and Blue Shield bills (HBs 5282 and 5283) are coming from an increasing number of directions, setting the stage for a contentious set of hearings in January when the legislature returns from its holiday break. The bills passed by the Michigan House of Representatives Oct. 24, six days after being introduced at the behest of the state’s largest insurer.

Among other things, the bills would allow the Blues to base rates on age and other factors, a practice which they are currently unable to do by statute; end the state’s statutory ability to review BCBS’ rates; and permit the Blues to set up a “guaranteed access plan,” under which the Blues would set up a plan that would provide coverage for, presumably, high-risk, hard-to-insure people. BCBS would then charge a surcharge based on market share to other insurers and absorb the plans losses for the first two years.

Criticism of the guaranteed access plan comes from the interest group that represents HMOs (Michigan Association of Health Plans) and Health Alliance Plan, a managed care plan associated with Henry Ford Health System.

“We would be subsidizing the losses of Blue Cross and Blue Shield,” MAHP Executive Director Richard Murdock told Crain’s Detroit Business last week. The Blues countered that their competitors are insuring mostly healthy customers and leaving the Blues to cover the sickest patients, which the Blues is statutorily required to do as the state’s “insurer of last resort.” The practice is know as “cherry picking.”

However, the Blues receive substantial tax breaks in exchange for their unique status.

“The legislation “was crafted by a single carrier, perhaps disguised as a solution for the issue of the uninsured and the cost of individual health care in our market,” HAP Vice President Jim Clement told Crain’s Dec. 9. “After simple analysis, it’s more a solution for the Blues,” he said.

The cries of foul from the managed care community join those of Michigan Attorney General Michael Cox, AARP Michigan, The Consumers Union, the UAW, Aetna and the Michigan Osteopathic Association, all of whom denounced the bills as dangerously limiting consumer choice and potentially creating an overall increase in rates for individual insurance policies.

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New UHC Policy Puts Quality Ahead Of Cost

Editor’s Note: The following letter was sent to WCMSSM among other parties by UHC Medical Director Richard Frank, MD.

As you may know, UnitedHealthcare has entered into an agreement with the New York Attorney General’s Office regarding core transparency and disclosure principles in physician performance measurement and reporting programs. This agreement embodies key elements in our current UnitedHealth Premium^® designation program. For example, the UnitedHealth Premium program evaluates physicians for cost efficiency only if they receive the necessary quality designation.

Consistent with the principles of the UnitedHealth Premium program, we voluntarily commit to the following across all markets where the UnitedHealth Premium program is available:

The purpose of the UnitedHealth Premium program will continue to be consistent with our goals of advancing safe, timely, effective, efficient, equitable and patient-centered care.
Physicians will continue to be reviewed against quality criteria first and will not be evaluated for cost efficiency unless quality criteria are met.
The UnitedHealth Premium program will use measures endorsed by the National Quality Forum, where available. We will also use measures, where available, endorsed by the AQA and national accreditors. When these measures are not available, or data to calculate the measures are not available, other bona fide nationally-recognized guidelines, expert-based physician consensus quality standards, or leading objective clinical evidence and scholarship measures will be utilized. In addition, we will continue to support the development and use of standardized quality and cost efficiency measures.
UnitedHealthcare will continue its commitment to core accuracy and transparency principles. We will fully disclose the methodology we use, including statistical sample size and rules for attribution. In addition, we will disclose the basis for the number of patients for each disease state or specialty used in the evaluation, as well as the data used and its relative weight or relevance to the overall rating.
UnitedHealthcare will continue to use appropriate and comprehensive episode of care software, such as those provided by Symmetry, to ensure that appropriate risk adjustment occurs for characteristics such as patient population, case mix, severity, co-morbidities, outlier episodes and other factors.
In measuring physician cost efficiency, UnitedHealthcare will continue its policy of comparing physicians within the same specialty and within the appropriate geographic market.
UnitedHealthcare will also continue its policy to provide reasonable prior notice to physicians regarding any material changes to its methodology and assessment process.
UnitedHealthcare will continue to provide full, fair and understandable consumer disclosures regarding the UnitedHealth Premium program, its methodology and vehicles for registering complaints.
Physicians will receive advanced notice regarding their assessments, along with an opportunity to request review and/or reconsideration of their designation via an appeals process.

Additionally, UnitedHealthcare has already applied for review of the UnitedHealth Premium designation program by NCQA through the Physician Hospital Quality Standards and Guidelines ("PHQ Standards") process, and that review is ongoing. We are committed to working with the Wayne County Medical Society, and other appropriate stakeholders in Michigan, regarding the mechanism for external program review, oversight and continuous process improvement.

We are committed to working with you collaboratively to better achieve the goal of increasing transparency and disclosures to consumers, as well as performance issues generally. We want to work with you to help ensure that your members are fully aware of the UnitedHealth Premium program and understand its methodology and tools to support performance improvement. To facilitate this, we ask that you post the attached notice for your members on your website.

We take these commitments seriously and look forward to working with the Wayne County Medical Society and the physicians of Michigan to support enhanced quality of care and most appropriate consumer health related decision making.

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HFHS Brain Cancer Study Shows Promise

A clinical study conducted at Henry Ford Hospital on the use of a drug to extend the survival of patients with the most common and aggressive type of brain cancer, has yielded results that were significantly better than expected.

The randomized Phase II study focused on patients with glioblastoma multiforme (GBM), whose cancer had recurred after first- or second-line therapy. The study revealed that more than a third who were treated with Avastin (bevacizumab) alone, as well as more than half of those treated with Avastin in combination with the chemotherapy drug irinotecan, lived without further progression of the disease for a period of six months.

In addition, no new or unexpected adverse effects from the use of Avastin were observed during the study.

“This is very encouraging news,” says Tom Mikkelsen, MD, a neuro-oncologist who is the study’s principal investigator at Henry Ford and co-director of the Hermelin Brain Tumor Center. "Historical estimates suggest that only 15 percent of patients with this aggressive type of brain cancer live without their cancer progressing within six months. Although gliomas [fast-growing malignant brain tumors] are nearly always incurable, use of a drug like Avastin may help to buy precious time for patients, as well as to preserve their physical and mental functions longer than was previously possible.”

Avastin is a therapeutic antibody designed to inhibit Vascular Endothelial Growth Factor (VEGF), a protein that stimulates development of new blood vessels in a process known as angiogenesis, while maintaining existing tumor vessels. By binding to VEGF, Avastin acts as an anti-angiogenesis agent that chokes off the blood supply to tumors, which in turn inhibits their growth and metastasis.

The national study is sponsored by Genentech and Henry Ford Hospital is one of the large study sites.

“The same process that makes gliomas so deadly may turn out to be exactly the same thing that makes it possible to slow down their progression,” Dr. Mikkelsen says. "This is a very significant advance in the battle to control these aggressive tumors because it could lead to treatment options where none existed previously for patients with recurrent disease.”

Previously Avastin had been used in combination with chemotherapy as a first-line treatment for metastatic colorectal cancer and lung cancer.

Because of its demonstrated success rate with these cancers, Avastin currently is being studied worldwide in more than 300 clinical trials for 20 different tumor types.

“With currently approved therapies, the chances of suppressing GBM are poor at less than 10 percent,” says Dr. Mikkelsen. “This type of targeted therapy using Avastin may prove to be the best new hope we have for helping patients with recurrent disease who previously had few options available to them.”

According to the American Cancer Society (ACS), the five-year survival rate for patients with GBM is 3 percent, a figure that has not changed in more than 25 years. The ACS estimates there will be 20,500 new cases of brain cancer and 12,740 brain cancer deaths in 2007.

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WSUSOM Student Researches Lung Cancer Susceptibilities

Alison Van Dyke believes that her work as an MD/PhD candidate studying in the Cancer Biology program may one day lead to much earlier diagnosis of those at high risk for lung cancer.

Studying with Ann Schwartz, MPH, PhD, Ms. Van Dyke’s work focuses on inflammation in non-small cell lung cancer (NSCL), including chemoprevention methods, and the association between biomarkers and survival among NSCL patients. Future projects include exploring the relationship between cytotokine single nucleotide polymorphisms and the risk of NSCL and survival among those patients.

The research, she said, may lead to the development of screening tools that could be used to identify people at high risk for developing lung cancer. Those identified as high risk for development of the disease could then be clinically monitored more closely, resulting in earlier diagnosis and improved prognosis.

“I’m attracted to helping make highly unpredictable diseases more predictable in their course, thus enabling patients to lead lives that are not dictated by variability in their disease manifestations,” she explained.

Ms. Van Dyke decided to enter a medical career while studying behavioral neuroscience as an undergraduate.

“I took a course on the psychobiology of stress,” she explained. “It focused on how chronic elicitation of the stress response can lead to cardiovascular disease, peptic ulcers and other conditions. It was through that course that I was intellectually drawn to medicine as an applied science. I like the idea that something being researched could directly translate into the care of a human being.”

Originally from Memphis, Tenn., Ms. Van Dyke, 33, selected Wayne State University School of Medicine for her education because the school presents a “unique combination of intensive clinical training unparalleled elsewhere and competitive interdisciplinary research” in her interests.

The second-year graduate student, who has completed two years of medical school, said the new formalized MD/PhD program administrators have been flexible in allowing her to tailor her course of study to current research and her future interests.

Ms. Van Dyke’s goals include a career in academic medicine. “I’ve discovered that I really enjoy making complex subjects more digestible and like giving talks,” she said. “Deciphering genetic associations with disease risk, presentation, and outcome and adverse reactions to pharmacological interventions while focusing on inflammatory pathways in autoimmune diseases remain my future focus.”

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