September 24, 2007

IN THIS ISSUE

Editor's Column: Claims Data And Making Claims
Tell Lawmakers To Fund Medicaid!
US Senate Needs To Stop Medicare Cuts Now!
Aetna Ushers In Overhaul With Name Change
Vote On SCHIP Compromise Likely This Week
Health Care Leaders Provide Ethical Reform Framework
WSU Makes Push For 'Translational' Initiatives

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Editor's Column: Claims Data And Making Claims

By JOSEPH WEISS, MD
The messages may remain in the back sections of the newspapers, but their meanings will not stay obscure for long.

I refer to the Aug. 25 announcement in the Wall Street Journal that the Washington DC Federal Appeals Court has ordered CMS (Centers for Medicare and Medicaid Services) to release Medicare physician claims data to the non-profit organization: Center for the Study of Service. The article noted that the federal court stated in its opinion that: “the public interest outweighs the need for individual privacy. Release of claims data (which includes diagnosis and treatment information, among other items) would help the public make more informed (medical) decisions:"

On the same day, the Government Accounting Office (GAO), in a report to CMS, recommended that CMS use Medicare claims data to identify "efficient and inefficient" physicians.[1] The GAO noted that while Medicare currently uses claims data to uncover improper billing practices, a different analysis of the same data can show which physicians provide efficient delivery of care.

The GAO report urged going further with such identification than physician education. Profiling "should lead to financial and other incentives^- to encourage efficiency.”

The public listing of performance data, formerly limited to hospitals, now claims us. The health  insurance companies are free to portray or caricature us to the extent their computer software turns data to graffiti. We have lost the battle on profiling.

These decisions by the courts and administrators will cost us the freedom to develop our clinical practice as we see fit. Attempting to create medical care transparency by making it more public will reveal both too little and too much. The new data will not illuminate the personalities involved in care, and, the additional information will further inundate a public already overwhelmed with data.

What you will see is medical care becoming bland and blind.

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Tell Lawmakers To Fund Medicaid

If state government shuts down Oct. 1 or if the Legislature fails to adequately fund Medicaid in next year's budget, more Michigan children, elderly and disabled persons will have to look harder to find a doctor and more residents will lose their health care, the Partnership for Michigan's Health (MSMS, the Michigan Health & Hospital Association and Michigan Osteopathic Association) said today.

"No state-funded service is more critical to human beings, our fellow Michigan citizens, than health care," said MSMS President AppaRao Mukkamala, MD, a Genesee County radiologist. "Nearly 1.6 million Michigan children, elderly and disabled people rely on Medicaid for health care. They are our state's most vulnerable residents and the Legislature must do the right thing, which is to adequately fund the program before the October 1 deadline." 

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US Senate Needs To Stop Medicare Cuts Now!

The US Senate recently separated the two issues connected under the former "Children's Health & Medicare Protection (CHAMP) Act." This means that MSMS and the AMA must increase and intensify their efforts to push for legislation to boost Medicare funding. The Medicare bill essentially aims to replace projected Medicare cuts (10 percent in 2008 and five percent in 2009) with positive payment updates of 0.5 percent in both years. IMPACT ON MICHIGAN: Visit www.msms.org/medicare to find out how the projected Medicare cuts would affect Michigan physicians.

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Aetna Ushers In Overhaul With Name Change

Aetna has created a new business unit called Cofinity that will focus on providing health related services and products to other insurance companies, third-party administrators (TPAs) and other health plans. With the official formation of Cofinity, effective immediately, the historic names and logos will begin to be phased out for the following businesses:

--HMS Healthcare
--PPOM
--Sloans Lake Preferred Health Networks
--Flora Health Network

The new Cofinity brand will be used immediately. Initially, the most notable change being made is the use of the Cofinity name in place of the names listed above. As of September 5, the phones are being answered using the new Cofinity name, and the email addresses for current contacts may reflect the new name. However, all emails sent to the old addresses will still be delivered despite the name changes.

By the end of the year, you will begin to see the Cofinity name on new member ID cards, explanation of benefits statements, and other printed materials. Your staff should still accept old ID cards until further notice. This change will not affect your contract.

In addition, the operations processes will change over time. Combining these businesses under a single structure is an opportunity for us to review our processes and service. An important goal in making changes is to minimize any service disruption. Any operation process changes will be communicated to you well in advance of implementation.

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Vote On SCHIP Compromise Likely This Week

Senate and House negotiators on Friday announced that they have reached an agreement on compromise legislation that would reauthorize SCHIP and expand enrollment from 6.6 million children to about 10 million children, CQ Today reports.

The compromise bill, which resembles the Senate version of SCHIP legislation, would provide an additional $35 billion in funding over the next five years and bring total spending on the program to $60 billion. The additional funding would be paid for by a 61-cent-per-pack increase in the tobacco tax, as proposed in the Senate version (Wayne [1], CQ Today, 9/21). The compromise legislation does not include revisions to Medicare (Lengell, Washington Times, 9/22).

In addition, the bill would:

• Change the name of the program from SCHIP to the Children's Health Insurance Program;
• Require dental benefits for all children enrolled in the program, as well as "mental health services on par with medical and surgical benefits" covered under SCHIP, according to a summary released by the Senate Finance Committee;
• Reinforce coverage of early periodic screening diagnosis and treatment benefits;
• Allow states to enroll pregnant women in SCHIP or cover them through other approaches;
• Phase out coverage of childless adults after one year. The government would provide temporary Medicaid funding to cover those adults enrolled in SCHIP, and states would be able to ask the government for a waiver to cover the adults through Medicaid;
• Revise CMS enrollment restrictions announced in August, including the provision that mandates states cover the lowest-income children prior to enrolling children in families with annual incomes above 250% of the federal poverty level. The SCHIP bill "gives states time and assistance in developing and implementing best practices" to prevent substitution of private coverage for public assistance, according to the Senate Finance Committee summary;
• Provide enrollment incentives to states that include "additional up-front funding for states planning improvements to their" SCHIP programs; adjustment payments to states that "face a funding shortfall and meet enrollment goals" to ensure that "no child who is eligible for Medicaid or [S]CHIP is denied coverage or placed on a waiting list;" and provide $100 million in grants to states, local governments, schools, community organizations and others to enroll eligible children in the program, according to the summary;
• Expand premium assistance programs; and
• Set overall spending caps on the federal funding to ensure that program costs do not exceed the amounts authorized (Reichard, CQ HealthBeat, 9/21).

Final language is expected on Monday (Stout, New York Times, 9/21). Sen. Jay Rockefeller (D-W.Va.) on Friday said that the delay in the final language is due to concerns about the wording of the provision that revises the CMS rule. Rockefeller said that the rule could not be rescinded completely because supporters of the bill did not want to "hand [President Bush] a reason to veto" the compromise bill.

While some House Democrats expressed concern over the size of the cigarette tax increase, House leadership said that they expect the bill to be approved (Johnson/Bourge, CongressDaily, 9/21). The House is scheduled to vote on the measure on Tuesday (Chicago Tribune, 9/22). The Senate is expected to vote on the bill by Thursday (Lee, Washington Post, 9/22).

Comments
Senate Finance Committee ranking member Chuck Grassley (R-Iowa) said, "This legislation will get [SCHIP] back on track and reclaim precious resources for low-income kids," adding, "It breaks the legislative impasse and should have strong support from both Democrats and Republicans" (Swanson, The Hill, 9/22). Sen. Orrin Hatch (R-Utah) said on Friday that the negotiated bill is "an honest compromise that improves a program that works for America's low-income children" (New York Times, 9/21). House Speaker Nancy Pelosi (D-Calif.) said, "We are hopeful that the president will reconsider his veto threat and sign this bill into law on behalf of our nation's children" (Washington Post, 9/22).

Bush Radio Address
Bush in his weekly radio address on Saturday called the compromise legislation "irresponsible," the AP/Washington Post reports. "Democrats in Congress have decided to pass a bill they know will be vetoed," Bush said, adding, "Members of Congress are risking health coverage for poor children purely to make a political point." He continued, "Our goal should be to move children who have no health insurance to private coverage -- not to move children who already have private health insurance to government coverage" (Loven, AP/Washington Post, 9/23).

White House spokesperson Dana Perino on Friday said, "Once the Democrats finish their political posturing, the president looks forward to working with Congress to pass SCHIP reauthorization he can sign" (Washington Post, 9/22). HHS Secretary Mike Leavitt said that the debate over SCHIP "is a crossroads" and Bush sees the SCHIP deadlock as the "moment" to have a "larger debate" about health care (Wolf, USA Today, 9/23).

Democrats on Saturday responded to Bush's statements, saying that if Bush vetoes the bill, 15 states will run out of funding by the end of September and thousands of children will lose coverage, according to the AP/Post. Pennsylvania Gov. Ed Rendell (D) said, "The administration has tried to turn this into a partisan issue and has threatened to veto. The health of our children is far too important for partisan politics as usual." Rendell added, "If the administration is serious about solving our health care crisis, it should be expanding, not cutting back, this program, which has made private health insurance affordable for millions of children" (AP/Washington Post, 9/23).

Prospects
According to CQ Today, House Democrats are attempting to win Republican support through "both cajoling and outright pressure." The Democratic Congressional Campaign Committee on Sept. 20 issued press releases to the media in the districts of 50 House Republicans asking whether the lawmakers would "stand with ... children, or with President Bush?" However, "[w]hat distresses some supporters is that there does not appear to be any plan for what to do after" Bush vetoes the compromise bill.

Bruce Lesley, president of First Focus, said, "It's sort of like, 'Don't talk to us about that, we're not there yet'" (Wayne [2], CQ Today, 9/21). Hatch said that Congress would have difficulty overturning a presidential veto and most likely would need to pass a temporary extension of the program, according to the Los Angeles Times (Alonso-Zaldivar, Los Angeles Times, 9/23).

Fiscal Conservative
Bush "is headed into a spending battle with Congressional Democrats" after threatening to veto SCHIP because of its "fiscal irresponsibility," the New York Times reports. According to the Times, Bush's shift toward being fiscally conservative "has undeniable political benefits for a president struggling to reassert his authority when his standing even within his own party is under attack." Democrats say that the administration is hypocritical in accusing them of being fiscally irresponsible, the Times reports.

If Bush "was interested in fiscal discipline, he should have started $3 trillion ago," House Democratic Caucus Chair Rahm Emanuel (D-Ill.) said. The White House defends the veto threats, saying that Republicans when in the majority stayed within fiscal limits, while Democrats have not (Gay Stolberg, New York Times, 9/22).

Editorials

• Richmond Times-Dispatch: "Congressional Democrats claim too many Americans can't afford to buy health insurance in the private market" as a reason for expanding SCHIP coverage, according to a Times-Dispatch editorial. The editorial continues, "Americans certainly have a harder time of it when taxes take more money out of their pockets than food, clothing or shelter. Expanding the current program to cover the upper middle class is a shameless example of trying to buy people's votes with their own money." It concludes that Bush "should carry through on his veto threat, and sink this SCHIP" (Richmond Times-Dispatch, 9/24).
• Seattle Post-Intelligencer: Bush's "bring-'em-on determination to block expansion of American kids' access to health coverage is deeply troubling," according to a Post-Intelligencer editorial. The president's veto threat "is absurd, coming from the same president who earlier wouldn't wait for Senate Republicans to finish work on an excellent expansion compromise before promising a veto," the editorial writes, adding, "Bush is blatantly misrepresenting compassionate expansion as a step toward government takeover of health care" (Seattle Post-Intelligencer, 9/21).
• Wall Street Journal: The administration's SCHIP enrollment standard that limits enrollment of children in families with annual incomes greater than 250% of the federal poverty level "moves the most disadvantaged children to the head of the line, before subsidizing those who need it less" and "checks SCHIP's mission creep," according to a Journal editorial. It concludes, "With his veto pledge, ... Bush is trying to hold SCHIP to something close to its original intent. We hope enough Republicans appreciate the policy stakes to sustain it" (Wall Street Journal, 9/24).

Opinion Pieces

• Jim Wooten, Atlanta Journal-Constitution: "As Democratic leaders have demonstrated repeatedly in grandstanding on Iraq, offering pullout legislation they know has no chance of succeeding, the SCHIP bill that will hit the president's desk in the coming weeks is entirely about politics," and Bush should veto it, Wooten, associate editor of the Journal-Constitution editorial page, writes (Wooten, Atlanta Journal-Constitution, 9/21).
• Judith Graham, Chicago Tribune: "After years of being a third rail of American politics, health care reform is back on the national agenda, raising the issue's political profile," which has turned the debate over SCHIP "into a much larger, more contentious argument," Graham, a health and medicine writer for the Tribune, writes in an opinion piece. Graham writes, "Amid the political jockeying and the inflamed rhetoric, it can be easy to lose sight of the facts -- and the stakes -- of this debate" (Graham, Chicago Tribune, 9/23).
• Newt Gingrich/David Merritt, The Politico: "Fundamental questions over which direction our country takes on health care are at the heart of the discussion over SCHIP," but lawmakers must "not lose sight of what is at stake in their rush to find a quick fix to a long-term problem: the health and well-being of children who are in danger of losing their insurance coverage," Gingrich, former House speaker and founder of the Center for Health Transformation, and Merritt, head of the Insure All Americans project at the center, write in a Politico opinion piece. They write that Congress "can protect kids by passing a clean, temporary 18-month extension of the current program," which would "give members of Congress the time and opportunity to carefully consider the future of SCHIP and how it can play a role in extending health insurance coverage to all Americans" (Gingrich/Merritt, The Politico, 9/22).
• Rep. Jim McCrery (R-La.), Washington Times: Democrats have focused "attention on the authorized cost of [SCHIP] over the next five years, while ignoring the long-term shortfall -- a classic bait and switch," House Ways and Means Committee ranking member McCrery writes in a Times opinion piece. "There is a better way" to reauthorize SCHIP, McCrery writes. A bill by House Energy and Commerce Committee ranking member Joe Barton (R-Texas) would "increase the programs' funding and keep the focus where it belongs, on helping low-income kids, according to McCrery. "The Democrats' bill is a Trojan horse, cynically exploiting our desire to help needy children in a stealthy attempt to create a massively expensive government health system," he concludes (McCrery, Washington Times, 9/24).

Broadcast Coverage
WAMU's "The Diane Rehm Show" on Monday is scheduled to include a discussion about the debate over SCHIP. Scheduled guests include Robert Greenstein, founder and executive director of the Center on Budget and Policy Priorities; Jonathon Weisman, a reporter for the Washington Post; Nina Owcharenko, senior policy analyst at the Heritage Foundation's Center for Health Policy Studies; and Grassley ("The Diane Rehm Show," Web site, 9/24). A broadcast schedule and additional details about the segment are available on the program's Web site. Audio of the segment will be available online about one hour after the broadcast.

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Health Care Leaders Provide Ethical Reform Framework

A new consensus report published last Thursday in the ethics journal The Hastings Center Report outlines a basic ethical framework necessary for health system reform. The report, "Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform," highlights key ethical obligations and recommendations to guide health system reform proposals in order to improve access to care. The report was authored by members of the Ethical Force Program, a multi-stakeholder collaboration led by the American Medical Association's (AMA) Institute for Ethics.

"By all accounts, health care in America faces many ethical challenges - one of the most notable being that 47 million people are without health insurance," said Paul Schyve, MD, chair of the Ethical Force Program Oversight Body and senior vice president at The Joint Commission. "One of the barriers to change has been the lack of consensus on the fundamental principles that should govern reform of the American health care system. This report provides a shared ethical framework for health reform agreed upon by individuals who represent the perspectives of patients, practitioners, employers, politicians, and the public."

In the report, the group outlines four fundamental ethical obligations that are mandatory for successful access to health care in a just society. According to the ethical framework:

• Every member of society must have an adequate array of core health care benefits.
• The contents and limits of health care benefits must be established through an ethical process.
• The health care system must be sustainable.
• The health care system must ensure that its stakeholders have clear responsibilities for which they are accountable.

"The ethical framework is based on shared American values, such as equality of opportunity, justice and compassion for our most vulnerable," said Mark A. Levine, MD, member of the Ethical Force Program Oversight Body and chair of the AMA's Council on Ethical and Judicial Affairs. "These are values that everyone can embrace, yet until now, they haven't been organized and articulated in such as way as to help drive health system reform. That's what this report can do."

"As the number of uninsured continues to increase, we are faced with a forceful reminder that action is desperately needed," said Ardis Hoven, MD, member of the Ethical Force Program Oversight Body and member of the AMA Board of Trustees. "The uninsured live sicker and die younger. Currently, 47 million Americans, including nearly nine million children, are without health insurance coverage. That's not just a statistic, it's a tragedy. As we work together toward reform, we can use this ethical framework to create a system where all Americans have access to the health care they need."

The release of the Ethical Force Program report comes only a few weeks after the launch of the AMA's "Voice for the Uninsured" campaign, a three-year, multi-million dollar campaign to spur action to cover the uninsured. The AMA is reaching out to voters and candidates to talk about the problem and the AMA's solution, and encouraging Americans to vote in 2008 with the issue of the uninsured in mind. For more information about the AMA campaign and the AMA proposal, please visit www.VoiceForTheUninsured.org

The Ethical Force Program report, "Improving Access to Health Care: A Consensus Ethical Framework to Guide Proposals for Reform," is published in the September/October 2007 edition of The Hastings Center Report, a leading bimonthly ethical journal on for issues in health, medicine and the environment. View the complete report.

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WSU Makes Push For 'Translational' Initiatives

In accordance with the strategic initiatives of the National Institutes of Health and Wayne State University Clinical and Translational Sciences initiative, applications are being solicited for seed funds to support multidisciplinary investigations in clinical and translational sciences. Translational research facilitates the integration of research and healthcare by transferring scientific discoveries from laboratory, clinical or population studies into clinical practice. The overall goal is to improve health and patient care by reducing disease incidence, morbidity or mortality. The funding announcement and details for submission are available at www.ctsa.wayne.edu/pilot.php.  Deadline for submission of proposals is November 15th, 2007.   Further information regarding the WSU CTSA initiative is available by visiting www.ctsa.wayne.edu or by e-mail at ctsa_rfa@lists.wayne.edu.

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