November 5, 2007

IN THIS ISSUE

Editor's Column: An Enemy At The Gates
Governor Signs Medicaid Budget With No Physician Payment Cuts
CMS Finalizes Rule To Slash Physician Medicare Payments 10 Percent
Senators Want To Hear From You About Medicare
WSUSOM Dean Mentzer Makes Case For Community Commitment
Congress Continues SCHIP Negotiations
HHS Project Experiments With Patient Health Records

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Editor's Column: An Enemy At The Gates

By JOSEPH WEISS, MD
On Oct. 5 Bill Gates announced that he is coming to save the American people. I refer to a three-quarter page editorial in the Oct. 5 Wall Street Journal in which Gates let the public know that he had initiated a health care revolution called Microsoft Health Vault. Each American would have his or her own Health Vault account on the Internet - www.healthvault.com. - of course, best accessed via Internet Explorer.

According to Gates, each individual’s personal health information would be stored in a secure database watched over by Microsoft. Microsoft would set up systems that would guarantee that the individual, with Microsoft at the controls, would make that personal information available only to whomever the individual designated.

Gates goes on to extol the virtues of Health Vault as the way that Microsoft, with its experience and technology, will end fragmentation of medical data, bring the store of medical information on each person into one place, and allow physicians and researchers to share information seamlessly.

The WSJ article and related columns in the New York Times runs to nearly 2,000 words. Gates uses his space to explain the good that will come from his Microsoft Health Vault. The New York Times column quotes a number of famous medical people who say Gates has a great idea.

No one writing and no one praising Microsoft raises the question of who is to put this information into the safety deposit vault in the sky. Nor is any query made as to how any doctor is going to work through this city dump of zeros and ones to find what at that moment he or she needs to know.

The assumption is that somehow, with no human effort or cash outlay, physicians will send that information to Microsoft’s Vault. In turn, when we want to retrieve a fact, we will sit in front of our Microsoft PCs and look through the contents of Gate’s safety deposit box until we find what we seek.

When Gates fails, we will see a new set of articles from the Wall Street Journal and New York Times blaming us. We were not willing to change, we were too technologically inept to respond, and we were unwilling to let go of the information we possess.

We need to watch Health Vault. As its true identity as Health Fault becomes clear, we should make its inadequacy known to the readers of the Wall Street Journal and the New York Times.   

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Governor Signs Medicaid Budget With No Physician Payment Cuts

Gov. Jennifer Granholm signed a budget Oct. 31 for the Michigan Department of Community Health that does not include cuts to Medicaid physician payments. In addition, eligibility was left intact for 19- and 20-year-olds and caretaker relatives. Graduate medical education funding also was left intact.

The Healthy Michigan Fund largely was left intact as well; however,it saw a net cut of $900,000 to programs such as pregnancy prevention, family planning, early hearing detection and screening in infants, and informed consent materials reimbursement.

MSMS reports that physicians, Alliance members, and medical group managers who were active at the grassroots level, sent messages through the MSMS Action Center, or visited with lawmakers played key roles in keeping the programs intact.

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CMS Finalizes Rule To Slash Medicare Physician Payments 10 Percent

CMS last week announced final rules for Medicare outpatient hospital care and physician reimbursements. Summaries appear below.

• Outpatient hospital care: CMS late last week announced a final rule that will increase Medicare outpatient hospital care reimbursements by 3.8 percent in 2008, CQ HealthBeat reports. However, overall Medicare expenditures for outpatient hospital care will increase by 10 percent in 2008, to $36 billion from $32.7 billion, because of the increased volume and complexity of services, CMS said. Under the rule, hospitals will have to report data on the seven outpatient care quality measures or have their reimbursements for such services reduced by 2 percent in 2009. The rule also will combine multiple outpatient services under a single reimbursement rate through "packaging" or "bundling" to prompt hospitals to provide such care more efficiently (Reichard [1], CQ HealthBeat, 11/2).

• Physicians: CMS late Thursday announced a final rule that will reduce Medicare physician reimbursements by 10.1 percent on Jan. 1, 2008, unless Congress acts to reverse the reductions, CQ HealthBeat reports. Under the rule, Medicare will pay $58.9 billion to about 900,000 physicians in 2008. CMS officials said that the agency "has no choice but to implement" the rule under current law (Reichard [2], CQ HealthBeat, 11/2).

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Senators Want To Hear From You About Medicare

U.S. Sens. Carl Levin (D-Detroit) and Debbie Stabenow (D-Lansing) are telling the AMA that they are not hearing from Michigan physicians about the looming Medicare physician payment cuts. So MSMS urges you to send a message: now is the time to include positive Medicare physician payment updates in the Medicare bill that is being put together!

The AMA and multiple national specialty medical societies are orchestrating a nationwide physician call-in campaign to the Senate. MSMS urges you and your staff to call Sens. Levin and Stabenow on Nov. 6, 7, or 8. Use the AMA Grassroots Hotline (toll-free) at (800) 833-6354 to connect to our Senators.

Members of the Senate Finance Committee are meeting to discuss ways to avert the pending Medicare physician payment cuts. However, they have yet to reach a consensus regarding how to proceed.

The Finance Committee is gridlocked because certain rules require that any new spending increases be offset by corresponding spending decreases or increases in revenue. To date, members of the Committee have been unable to agree upon offsets. Reducing over-payments to Medicare Advantage plans is viewed as a possible offset for spending to avert physician payment cuts.

“Next year’s 10.1 percent physician payment cut is bad news for America’s seniors as 60 percent of physicians say the cut will force them to limit the number of new Medicare patients they can treat. Congress must step in to replace the cut with payment increases that keeps up with medical practice costs,” said AMA Board Chairman Edward Langston, MD.

“The U.S. House has already acted, and now Medicare patients and the physicians who care for them are asking the Senate to take similar action. By eliminating $54 billion in excess payments to insurance companies, Congress can preserve seniors’ access to health care by funding payment increases for physicians and limiting patient premium increases.”

The Senate needs to hear directly from physicians now—as the Medicare package is being crafted—how important it is that the Senate takes action to stop the pending Medicare physician payment cuts. AMA decries 10 percent Medicare physician payment cut

Ask Sen. Levin and Sen. Stabenow to speak with Sen. Max Baucus (D-MT), chair, Senate Finance Committee, and Sen. Charles Grassley (R-IA), ranking member, Senate Finance Committee, and urge them to include positive Medicare physician payment updates for the next two years in the Medicare bill that they are drafting. Use the MSMS Action Center (www.msms.org/action) or the AMA Grassroots Hotline (800-833-6354), and tell them Congress must dedicate new funding to the update and not use the same old funding gimmicks.

For more information, contact MSMS Executive Director Kevin A. Kelly at (517) 336-5742 or kkelly@msms.org

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WSUSOM Dean Mentzer Makes Case For Community Commitment

Editor’s note: The following opinion piece appears on the Wayne State University School of Medicine and also appeared in a recent edition of the Detroit Free Press.

Recently questions have been raised in the media about the Wayne State University School of Medicine’s commitment to the city of Detroit. Generally such conjecture has been attached to particulars of the university’s relationship with the Detroit Medical Center (DMC), always a popular subject for public debate. Whatever its nature, any speculation about the School of Medicine’s commitment to the city is entirely unfounded and obscures the many essential services the school and its clinical partners provide to the citizens of Detroit.

The university’s loyalty to Detroit is profound and immutable. After the civil unrest of 1967, virtually every institution that previously represented racial integration and cultural diversity left the city; Wayne State University was an important exception. It stayed and continued to play an active role in the city’s life. Since the Detroit Medical College was founded in 1868 as the first unit in what was to become Wayne State University, the city has been able to count on this resident center of scholarship and public service.

The School of Medicine’s specific commitment to the city and its partnership with the DMC are central to the school’s charge to train proficient and compassionate physicians and conduct life-saving research. Although the unexpected elimination of significant training opportunities in the DMC has forced the School of Medicine to establish clinical partnerships with other institutions in Southeastern Michigan, our education, research and clinical care programs are inextricably linked to Detroit.

Any suggestion that the School of Medicine’s commitment to the city may have ebbed simply cannot stand scrutiny. For example, about 40 percent of the nearly 700 primary care physicians in the city of Detroit are Wayne State/DMC resident physicians-in-training. At Children’s Hospital of Michigan, Wayne State pediatric faculty care for almost 50 percent of hospitalized Wayne County children. And at the Karmanos Cancer Institute, Wayne State physicians treat 40 percent of all cancer patients in Detroit – 96,000 outpatient visits each year. Perhaps most important of all, Wayne State physicians deliver 80 percent of all uncompensated care given to metropolitan Detroit’s uninsured and underinsured citizens, to a value of more than $40 million annually; every year, one of 10 Detroit residents receives free care from a Wayne State faculty physician.

The Wayne State University School of Medicine is the nation’s largest single-campus medical school. And we are growing rather than diminishing our presence here. In the past two years, there has been a capital investment of $70 million in renovations of Scott Hall and the Mott Center, and in the imminent building of the Richard J. Mazurek, MD Medical Education Commons. Wayne State also is exploring the feasibility of an additional $200 million capital investment over the next five years for construction of a multidisciplinary research building that will house the university's evolving Center for Clinical and Translational Science.

We also have added both faculty and students to the school, further emphasizing a commitment to grow and serve.  Our strategic plan already is consistent with recommendations made in September 2007 by the Panel on Medical Education and Research. This Panel was formed by the Detroit Regional Chamber and Detroit Renaissance in cooperation with Gov. Jennifer Granholm to evaluate medical education and research capabilities and indigent care needs in the metro-Detroit area.

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Congress Continues SCHIP Negotiations

Senate and House negotiators this week will continue discussions to craft an SCHIP bill that would receive enough support in the House to override a presidential veto, CQ Today reports. However, language proposed by House Republican leadership "reveals just how daunting" reaching compromise might be, according to CQ Today (Armstrong, CQ Today, 11/2).

The Senate last week voted 64-30 to approve revised SCHIP legislation (HR 3963) that would expand the program to cover 10 million children and increase spending on the program to $35 billion over five years, funded with a 61-cent-per-pack increase in the federal cigarette tax. The measure is similar to the bill vetoed by President Bush last month, but it would limit coverage to children in families with annual incomes below 300 percent of the federal poverty level. The House last month approved the bill but failed to pass it with a veto-proof majority (Kaiser Daily Health Policy Report, 11/2).

The language proposed by House Republican leadership would require that all states enroll 90 percent of children in families with annual incomes less than 200 percent of the poverty level before enrolling higher-income children. In addition, the Republican language would require stricter guidelines for proving citizenship by requiring the adoption of current Medicaid regulations. According to a GOP aide, the language was a starting point for negotiations and lawmakers have moved forward since it was delivered. Both Senate negotiators and House Republicans "seem eager to reach a deal and avoid the likely alternative"" passing a temporary extension of the program that will expire directly prior to the 2008 elections, CQ Today reports (CQ Today, 11/2).

National Agenda
The SCHIP debate "symbolizes the inability of Mr. Bush and the new Democratic leaders of Congress to work together, but it also highlights the rift between Mr. Bush and members of his own party," the New York Times reports. According to the Times, "misconceptions and frustrations on both sides" led to the veto of the bill (Pear, New York Times, 11/5). However, Democrats are "expressing increasing confidence" that their emphasis on SCHIP "has succeeded in putting health care on the national agenda," the Boston Globe reports.

Democratic pollster Geoffrey Garin, president of Peter D. Hart Research Associates, said, "Everything I'm seeing in terms of public opinion is that voters feel good that Democrats are taking on this fight. It's the president who is perceived as being mule-headed and stubborn." Robert Blendon, a professor of health policy and political analysis at Harvard School of Public Health, said that "what has happened with the Democrats fighting for [SCHIP], and the president attacking it, is that it's become a poster child for the broader debate on whether government should guarantee coverage for people" (Donnelly, Boston Globe, 11/5).

Tax Increase Implications
Bush's refusal to sign any legislation that calls for a tax increase "could lead to the awkward scene of a large number of congressional Republicans voting to override his veto of a high-profile bid to expand" SCHIP, the AP/San Jose Mercury News reports. Many House Republicans "have agreed to swallow" the tax increase, and the issue "is so settled that it isn't even discussed by House-Senate negotiators" trying to craft a new bipartisan bill, the AP/Mercury News reports. According to the AP/Mercury News, Bush's stand on SCHIP puts House Republican leaders "in a tough spot" because changes to the bill could attract enough support from House members to override a veto. If lawmakers can negotiate a veto-proof bill, "it would mark a rare legislative defeat for Bush on a major issue," the AP/Mercury News reports (Babington, AP/Mercury News, 11/5).

Proof-of-Citizenship Requirements
Proof-of-citizenship requirements for SCHIP have "become a major hang-up delaying renewal" of the program, the Omaha World-Herald reports. Republicans claim that the bill as written would allow undocumented immigrants to receive SCHIP benefits, but bill supporters say that is untrue and accuse Republicans "of using the immigration issue as political cover," according to the World-Herald. Under the bill, states could verify citizenship of applicants by checking the applicant's Social Security number against Social Security Administration records.

Sen. Chuck Grassley (R-Iowa) said, "There's absolutely nothing in this bill that would make coverage more easily available for illegal immigrants," adding, "Those who say otherwise believe what they want to believe, not the facts." Rep. Lee Terry (R-Neb.) said, "Social Security numbers are a dime a dozen on the streets, fraudulent Social Security ID's," adding, "So, the fact that there's no verification allows illegals to obtain the benefit" (Thompson, Omaha World-Herald, 11/5).

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HHS Project Experiments With Patient Health Records

In a move that will improve health care for millions of Americans, HHS Secretary Mike Leavitt Oct. 30 announced a five-year demonstration project that will encourage small to medium-sized physician practices to adopt electronic health records (EHRs).

“This demonstration is designed to show that streamlining health care management with electronic health records will reduce medical errors and improve quality of care for 3.6 million Americans. By linking higher payment to use of EHRs to meet quality measures, we will encourage adoption of health information technology at the community level, where 60 percent of patients receive care,” Secretary Leavitt said.

“We also anticipate that EHRs will produce significant savings for Medicare over time by improving quality of care. This is another step in our ongoing effort to become a smart purchaser of health care - paying for better, rather than simply paying for more.”

Conducted by the Centers for Medicare & Medicaid Services (CMS), the demonstration would be open to participation by up to 1,200 physician practices beginning in the spring. Over a five-year period, the program will provide financial incentives to physician groups using certified EHRs to meet certain clinical quality measures. A bonus will be provided each year based on a physician group’s score on a standardized survey that assesses the specific EHR functions a group employs to support the delivery of care.

The CMS demonstration also will help advance Secretary Leavitt’s efforts to shift health care in the United States toward a system based on value.

The Department is working to effect change through its Value-Driven Health Care initiative, which is based on Four Cornerstones: interoperable electronic health records, public reporting of provider quality information, public reporting of cost information, and incentives for value comparison. 

“Broad adoption of electronic health records has the potential not only to improve the quality of care provided, but also to transform the way medicine is practiced and delivered,” said Secretary Leavitt.

“We are looking for 1,200 physician practice pioneers who will help us move health care toward a system that delivers better quality at lower cost for more Americans.”

Under the CMS demonstration, all participating practices will be required to use a certified EHR system to perform specific functions that can positively affect patient care processes, such as clinical documentation and ordering prescriptions. The system, which must be in place by the end of the second year, must also be approved by a certification body officially recognized by HHS. The core incentive payment to practices will be based on performance on the quality measures, with an enhanced bonus based on the how well integrated the EHR is in helping manage patient care.

“We want to revolutionize the way vital health data is managed and maintained, so we are taking steps to change from a paper-based medical record to an electronic health record,” said CMS Acting Administrator Kerry Weems. “This project will appropriately align incentives to reward doctors in small physician practices who use certified EHRs as tools to deliver higher quality care. This reward structure will bring the benefits of electronic health records to Americans at their most frequent point of contact with health care - their family doctor.”

During the five-year project, it is estimated that 3.6 million consumers will be directly affected as their primary care physicians adopt certified EHRs in their practices. In order to amplify the effect of this demonstration project, CMS is encouraging private insurers to offer similar incentives for EHR adoption.

“We believe that encouraging higher quality care through the use of EHRs benefits every health care stakeholder. That is why we are asking private insurers to help accelerate certified EHR adoption by offering incentives similar to those in this demonstration,” Acting Administrator Weems said.

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