Baucus Healthcare Plan Pushes Reform, Earns Kudos from AGS
Amid concerns that a narrow focus on the economic crisis could delay needed healthcare reform, Senate Finance Committee Chairman Max Baucus (D-MT) offered a detailed plan for overhauling the nation’s healthcare system last week and urged president-elect Barack Obama to enact substantive health reform in his first six months in office.
“The health-care system is broken for individual Americans and is straining our economy," Sen. Baucus told Reuters Wednesday, the day he released the plan.
The American Geriatrics Society applauds the Senator’s efforts to bring about timely reform aimed at ensuring all Americans, regardless of age, access to high quality, affordable care. AGS also strongly supports many of the recommendations in the 89-page plan.
“We are heartened by Sen. Baucus’ proposal, his dedication to ensuring that healthcare reform is swift and comprehensive and benefits the young and old alike, and his willingness to work in a bipartisan manner to effect needed reforms,” said AGS President John B. Murphy, professor of medicine and family medicine at Brown University's Warren Alpert Medical School and Chief Physician Officer at Rhode Island Hospital. “Sen. Baucus’ call for universal access to affordable, quality health coverage and expansion of care to enhance the prevention and treatment of chronic diseases will improve the quality of life for millions of Americans of all ages, especially our most vulnerable older adults.”
Sen. Baucus emphasized that he plans to work closely with Obama and other lawmakers involved in healthcare reform efforts. "Much of what's here dovetails with the president-elect's own health plan," he told The Washington Post. "And where we differ, I have committed to work with him to find a consensus." President-elect Obama likewise signaled his interest in working closely with the Senator and other legislators “to make quality, affordable health care are a reality for all Americans,” and praised Sen. Baucus’ efforts.
In many ways, Sen. Baucus’ plan parallels the president-elect’s campaign proposals for overhauling healthcare. But there are differences. The Baucus plan calls for mandated healthcare coverage, something the president-elect did not support during the campaign.
Like Mr. Obama, Sen. Baucus has proposed a national health insurance "exchange" or “marketplace” through which individuals and businesses could buy affordable health coverage -- choosing from among both private and public policies. It would create a new public health insurance plan, and expand eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP). Large employers would have to either offer health coverage to employees or contribute to a fund to cover the uninsured. Certain small businesses would be exempt or get tax credits, however, and the plan would also provide subsidies to individuals in need. Sen. Baucus estimates it would take three years to fully implement the provisions in the plan and ensure all Americans access to quality, affordable health coverage. In the interim, the plan would allow adults 55 to 64 to buy into Medicare coverage. Once affordable quality coverage is universally available, all Americans would be required to have health coverage and this requirement “would be enforced, possibly through the tax system,” the Baucus plan notes.
The AGS strongly supports many of Sen. Baucus’ recommendations to provide appropriate and cost-effective care to Americans of all ages, including those to:
- Prohibit insurers from denying coverage to those who are or have been sick, and limit insurers’ ability to charge higher premiums based on age or prior illness.
- Strengthen chronic care coordination. The Senator’s plan calls for efforts to promote coordination among healthcare providers by encouraging those in different care settings to collaborate and provide patient-centered care. For older patients with multiple medical conditions, coordinated care has been shown to both improve quality and save money. The Senator's plan notes that approaches utilizing comprehensive geriatric assessment to identify patients in need of care coordination show promise and merit further examination. The AGS has long supported legislation that would fill a gap in traditional Medicare by covering both comprehensive geriatric assessments and care coordination services for beneficiaries with multiple chronic conditions. AGS also supports certain patient-centered models of care that deliver high quality and coordinated care tailored to the needs and well-being of frail geriatric patients. These include “Medical Home” models; the Program of All Inclusive Care of the Elderly (PACE); and the Care Transitions Model.
- Bring about meaningful reform of the current payment system, and address shortages in the healthcare workforce. The Medicare system currently rewards providers for quantity -- for doing more procedures, for example - - rather than for providing high quality, comprehensive, patient-centered and coordinated care. As a result, the current Medicare payment structure undervalues the work of primary care providers, such as geriatricians. This flaw in the payment system has created a disincentive to pursue or continue careers in geriatrics and other primary care disciplines and is a leading contributor to the growing nationwide shortage of geriatrics healthcare professionals. The Baucus plan also calls for replacing the seriously flawed Medicare “Sustainable Growth Formula,” which creates further financial disincentives and exacerbates geriatrics workforce shortages. AGS looks forward to working with Congress and the new Administration to implement such changes and to boost recruitment and retention in other ways. Among other initiatives with this aim, the AGS supports legislation, proposed by Sen. Barbara Boxer (D-CA), to offer loan forgiveness and create career advancement opportunities for geriatrics healthcare professionals in all disciplines.
- Support long-term care services, particularly services provided in the home and community. With Americans 85 and older the fastest-growing demographic group in the nation, ensuring older adults access to a wider range of high quality and affordable care options, including those that enable them to “age in place” in their own homes and communities, is imperative. For this, we will need to invest in the direct care workforce, new assistive technologies, and secure means for electronic communications between healthcare providers and their patients.
At the same time that Sen. Baucus announced his plan, major advocacy groups representing business, labor and retirees announced the start of a campaign to press president-elect Obama to enact comprehensive healthcare reform without delay. The Business Roundtable, the National Federation of Independent Businesses, AARP and the Service Employees International Union urged the president-elect to tackle healthcare reform in his first 100 days. According to The Los Angeles Times, the groups plan to spend nearly $1 million on newspaper and television advertising urging Washington to pursue reform aggressively. "
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As Congressional Democrats Begin Crafting Healthcare Reform Plan, Obama Team Weighs Whether to Pursue Change on Multiple Fronts Simultaneously -- And if Not, Which to Tackle First
Congressional Democrats have already started drafting a comprehensive plan for overhauling healthcare that would address coverage, cost and quality, but “will follow President-elect Barack Obama’s blueprint for healthcare overhaul,” Congressional staff told Congressional Quarterly last week.
“With the Obama victory, the question is now longer whether we will pursue comprehensive health reform, but when and what form,” said Michael Myers, director of the Senate Health, Education, Labor and Pensions Committee staff.
In the midst of the most threatening financial crisis in decades, president-elect Obama and advisors are still weighing whether to pursue promised economic, healthcare, energy and environmental reforms all at once, or to tackle these separately – and, if so, in what order, and to what extent.
Proponents of simultaneous reform argue that healthcare, energy, environmental and educational policies significantly affect economic outcomes.
Over the weekend, the president-elect suggested that he would move quickly to address the nation’s economic problems. He has also indicated that he plans to make good on promised healthcare, energy, education and tax reforms. According to the New York Times, however, “Mr. Obama has acknowledged that the economy will force him to recalibrate his program.”
For their part, Congressional leaders want to move quickly, to pass legislation to expand the State Children’s Health Insurance Program (SCHIP), “as a step toward the broader coverage Mr. Obama promised,” The Times reported Sunday. “Likewise, Democrats plan to incorporate his proposed middle-class tax cuts in the economic legislation or pass them in tandem.”
Interest groups such as SEIU Healthcare and Families USA have already made it clear that they will push for both substantive and speedy healthcare reform. According to CQ, SEIU Healthcare plans to hire 5,000 people who will travel throughout the US and “drum up support for an overhaul.” According to Families USA executive director Ron Pollak, the organization will push to get an overhaul “on the table” within the first 100 days of the Obama Administration.
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President-Elect Obama Faces Opportunities and Challenges in Reforming Healthcare
A changing political and economic landscape will present president-elect Barack Obama with both challenges and opportunities to pursue healthcare and other reforms, pundits were predicting just hours after the Democratic Senator from Illinois won Tuesday's presidential race.
Democrats solidified their majorities in both the Senate and House in the historic election, better positioning the new Administration to reform the U.S. healthcare system, commentators and Washington insiders noted. "A broad swath of businesses is prepared for a long-anticipated revamp of the nation's healthcare system," the Wall Street Journal reported yesterday.
But how the new balance of power in Washington and current economic turmoil -- a floundering global economy, a record federal deficit, the recently approved $700 billion Wall Street bailout, and the likely need for further bailouts and stimulus efforts - - will affect the particulars of healthcare reform is still a matter of conjecture.
"Democrats will have to limit or postpone any big new spending programs, such as ones to expand healthcare, upgrade education and advance renewable energy technology," given fiscal uncertainties, Reuters predicted. In a similar vein, the Journal suggested that the Obama Administration may have to aim, in the shorter term, for "an expansion of children's healthcare and changes in Medicare and Medicaid purchasing." With regard to Medicare expenditures, it noted, Democrats have already targeted payments to private Medicare Advantage plans, which cost taxpayers about 12% more than traditional Medicare. During his campaign, the president-elect promised to eliminate subsidies to the private plans.
Speaking with The Washington Post, however, Rep. Rahm Emanuel (D-Il), who will be White House chief of staff in the Obama Administration, countered that "no crisis should go to waste," suggesting that the economic crisis could "create an opportunity for the next president to offer big solutions on issues like energy and healthcare."
A strategy tying healthcare reform to economic recovery could make more ambitious changes feasible. "The return on investment (in healthcare reform) - slowing the long-run rate of healthcare cost growth through system improvements and seamless coverage - would arguably be the most significant economic achievement in decades," Jeanne Lanbrew, a member of the Clinton Administration's healthcare team and a contender for a similar post in the Obama Administration, told CQ Healthbeat. Potential strategies for linking healthcare to economic health include "scorable savings from capping and trading pollution permits to making a health overhaul plan part of budget reconciliation, a tactic that allows legislation with protection from filibuster," CQ Healthbeat reports today. In the Senate, where the outcomes of three races have yet to be determined, Democrats secured six additional Senate seats on Tuesday, boosting their number to 57 - three short of a filibuster-proof majority.
Decisions concerning the scope of healthcare reform will affect choices the president-elect makes while assembling his healthcare team, as will the "chemistry" among team members, CQ Healthbeat notes. Some pundits foresee former Senate Majority Leader Tom Daschle in a key healthcare position in the administration. Like Lanbrew, other former Clinton Administration healthcare staff are also considered likely additions to the team, as are Democrats associated with the Center for American Progress, a liberal think tank, and Obama campaign advisors.
While president-elect Obama will set much of the healthcare reform agenda, Congressional Democrats are simultaneously mulling reform priorities, including legislation expanding health coverage for children, USA Today reports this morning. President Bush twice vetoed legislative efforts to boost funding for SCHIP.
President-elect Obama has proposed sweeping changes in the nation's healthcare system. The reform plan he outlined on the campaign trail calls for universal health coverage through a combination of private and expanded public health insurance. It would both mandate that all children have health insurance and require employers to either offer coverage to employees, or pay the government a set amount to do so via a new public plan. It calls for creating an affordable public health insurance plan open to those who can't get coverage through their employers' or existing programs such as Medicaid, Medicare, or the State Children's Health Insurance Program (SCHIP), as well as for expanding eligibility for Medicaid and SCHIP, and offering low-income Americans who don't qualify for these, but still need assistance, federal subsidies to buy into the new public plan or another qualified plan. During the campaign, president-elect Obama also called for a repeal of a ban preventing the government from negotiating with drug companies for lower prices for the Medicare prescription drug program, and for the elimination of the Medicare drug plan's "doughnut hole" coverage gap. He has called for greater emphasis not only on technology but also on research, prevention, and care coordination, and has voiced support for the patient-centered "medical home" model, long-term care reforms, and stepped up efforts to train more healthcare workers.
It's often difficult for Administrations to pursue multiple reforms at once, and it remains to be seen whether energy or healthcare, two top priorities, will be the initial focus of reform efforts. Both the president-elect and Congressional Democrats have sought to moderate expectations over the last three days, noting that it will take time to effect needed changes, particularly in the current economic climate. Pundits have also warned that pushing controversial reforms too hard and too fast will backfire.
"If the Democrats push hard on healthcare reform, social-cultural issues, they're going to miss a unique opportunity to come out during the honeymoon period and really make a very big difference," George Mason University public policy professor Mark Resell told USA Today.
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As Election Day Approaches, American Geriatrics Society Issues Updated Congressional Report Card Rating Federal Lawmakers' Records on Elder Healthcare Measures
Just in time for next Tuesday's elections, the AGS has issued an updated Congressional Report Card rating federal lawmakers' records on legislation affecting healthcare for older adults.
Nine U.S. Senators and Representatives have earned "A+" ratings for supporting legislation aimed at ensuring the nation's rapidly growing population of older adults access to quality healthcare. Another 15 Senators and 16 Representatives earned "A's" on AGS' Congressional Report Card.
The Society issued its first report card for the 110th Congress in November 2007. The newly released report card, updated to include several key votes on Medicare and other critical healthcare legislation this year, is accessible here. The report card evaluates the records of all Federal lawmakers, including presidential candidates Sens. John McCain (R-AZ) and Barack Obama (D-IL)
For their leadership on behalf of and support for legislation aimed at ensuring older Americans access to appropriate healthcare, four Senators and five Representatives earned "A+" ratings. They include Sens. Blanche Lincoln (D-AR), Barbara Boxer (D-CA), Susan Collins (R-ME) and Herb Kohl (D-WI) and Reps. Gene Green (D-TX), Rosa DeLauro (D-CT), Janice Schakowsky (D-IL), Carolyn Kilpatrick (D-MI) and William Jefferson (D-LA). All nine lawmakers have consistently supported legislation aimed at addressing growing nationwide shortages of geriatricians and other geriatrics healthcare professionals. The nine legislators have also advocated for increased funding for the National Institute on Aging. And they have advocated for critical legislation promoting coordinated care for seniors with chronic illnesses.
An additional 15 Senators and 16 Representatives earned an "A" on AGS' latest Congressional Report Card. They include Sens. Dianne Feinstein (D-CA), Thomas R. Carper (D-DE), Tom Harkin (D- IA), Barbara A. Mikulski (D-MD), John F. Kerry (D-MA), Amy Klobuchar (D-MN), Robert Menendez (D-NJ), Charles Schumer (D-NY), Sherrod Brown (D-OH), Ron Wyden (D-OR), Robert P. Casey (D-PA) Sheldon Whitehouse (D-RI), Tim Johnson (D-SD), Bernie Sanders (I-VT), and Patty Murray (D-WA). Note: Sen. Obama, Sen. McCain, Sen. Hillary Clinton (D-NY), Sen. Joseph Biden (D-DE), and Sen. Christopher Dodd (D-CT) received "Incompletes" because they missed votes to campaign. For each vote for which they were present, however, Sens. Obama, Clinton, Biden and Dodd voted in support of AGS' priorities. Sen. Clinton is also an original cosponsor and strong supporter of the Geriatric Assessment and Chronic Care Coordination Act.
Representatives earning an "A" include: Speaker Nancy Pelosi (D-CA), Reps. Ed Pastor (D-AZ), Mike Honda (D-CA), Maxine Waters (D-CA), Joe Baca (D-CA), Ron J. Klein (D-FL), Thomas H. Allen (D-ME), Barney Frank (D-MA), Ike Skelton (D-MO), Shelley Berkley (D-NV), Nita M. Lowey (D-NY), Christopher Carney (D-PA), Steve Ira Cohen (D-TN), Earl Blumenauer (D-OR), Joe Sestak (D-PA) and Tammy Baldwin (D-WI).
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Healthcare a Top Issue for Voters in the Upcoming Election, Survey Finds
Healthcare is a top issue for voters in the November election - second only to concerns about the economy, according to a recent survey, finding that healthcare is a "major issue" or "one of the major issues" for 58%.
The nationwide survey was sponsored by the non-partisan Partnership to Fight Chronic Disease - a national coalition that includes the AGS. The coalition is dedicated to raising awareness of chronic disease. The survey sampled 1,500 registered voters between October 5 and 9.
When asked whether they'd prefer that candidates focus on improving the cost, quality, or accessibility of healthcare, close to 38% of survey respondents said something should be done to improve cost; about 32% favored improving access; and 18 percent favored improving quality.
In addition, nearly 70% of respondents agreed that "catching and treating chronic diseases early" is the best way to improve healthcare. More than half (58%) said they were "very concerned" that chronic diseases are "a major driver of health care costs -- accounting for more than 75 cents of every dollar we spend on health care in this country." However, 60% noted that candidates are either not discussing these issues at all or are not discussing them enough.
Additional findings include:
- One quarter of respondents (26%) ranked healthcare (including Medicare) as one of their top two "most important" issues in the election.
- Healthcare is a top concern for swing voters: 64% of women and 56% of men who consider themselves independents said it was "the major issue" or "one of the major issues" influencing their vote.
- When asked what issue affecting their families they worry about most, 21% said healthcare, and 19% cited economic concerns such as "the rising cost of gas and food," which ran a close second.
"Americans are looking to their next president to bring forward new ideas to improve healthcare," said Ken Thorpe, executive director of the Partnership to Fight Chronic Disease. "As this survey tells us, Americans believe that fighting chronic disease is the best way to do this. It is my hope that the candidates will use the time before the election wisely by telling Americans more about how they plan to address this important issue."
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New HHS-VA Collaborative Effort Will Help Older Americans and Veterans Remain Independent
A new initiative will make $36 million available to help veterans and older Americans, including those with Alzheimer's disease, remain as independent as possible.
More than $19 million of this funding involves collaboration between the Departments of Health and Human Services (HHS) and Veterans Affairs (VA) to provide consumer-directed home and community-based services to older Americans and veterans, as part of a Nursing Home Diversion (NHD) grants program.
This new program will be overseen by HHS' Administration on Aging (AoA) in collaboration with the Veterans Health Administration. Under the program, HHS will provide $10.5 million through AoA, with an additional $5.7 million provided by states. The VA anticipates purchasing a minimum of $3 million in veteran-directed home and community-based services for older veterans and for younger veterans who need long-term care. The number of veterans over age 85 has tripled during the past decade -- increasing the need for expanded long-term care services.
In addition, $17 million in grants will be provided to 22 states under AoA's Alzheimer's disease demonstration programs in an effort to improve the delivery of home and community-based services to people with the disease and their family caregivers.
Funding levels for the Nursing Home Diversion grants program for 2008 and the Alzheimer 's disease Demonstration Grants to States Awards for 2008 are available on the HHS Web site.
"This historic HHS-VA initiative combines the expertise of the HHS' national network of aging services providers with the resources of the Veterans Health Administration to provide more people, including our nation's veterans, with improved long-term care options," said HHS Secretary Mike Leavitt. "This unique effort supports the President's New Freedom Initiative which calls upon all federal agencies to help people who need long-term care and prefer to live in their own homes and communities to do so. Through this joint program, many people who would have previously been placed in nursing homes will be able to remain at home."
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"Independence at Home Act" Would Establish Medicare Demonstration Program To Expand At-Home Care for Beneficiaries With Chronic Conditions
Legislation that aims to improve health outcomes and care options for chronically ill Medicare patients was recently introduced by Sen. Ron Wyden (D-OR) and Rep. Ed Markey (D-MA). The 'Independence at Home Act' establishes a three-year Medicare demonstration project in 26 states that will expand at-home services for Medicare beneficiaries with multiple chronic conditions, CQ Healthbeat reports. The aim of the project is to enable such adults to remain independent and in their homes as long as possible.
Under the bill, beneficiaries would receive a comprehensive care plan directed by a physician or nurse practitioner and developed in collaboration with the patient. To be eligible to participate, older adults must have functional impairments, two or more chronic illnesses and must have made recent use of other health services.
In addition, the legislation sets minimum performance standards for health outcomes and measures the satisfaction of patients, caregivers and providers. Participating providers would be required to show savings of at least 5% a year compared to the cost of care for Medicare beneficiaries who have chronic conditions but are not in the program. As an incentive for participating, providers would be able to keep 80% of the savings.
The bill has garnered considerable support in both the House and Senate, from legislators including Senators Barbara Mikulski (D-Md), Sheldon Whitehouse (D-RI), Ben Cardin (D-MD), and Representatives Chris Smith (R-NJ) and Rahm Emanuel (D-IL).
"For too long, people struggling with multiple chronic conditions have had to handle their health challenges while wading their way through a complex system of multiple specialists, with too little guidance and coordination," said Sen. Wyden. "The Independence at Home Act will not only improve patients' health and offer them more freedom - it should also lead to finding better ways to deliver care and cut costs."
"Our bill puts patients first by promoting coordinated care designed to quickly identify and treat emerging health problems and, where possible, avoid hospitalizations, improving patients' quality of life while also cutting costs," said Rep. Markey. "Patients and their families will spend less time juggling conflicting diagnoses and multiple doctors, and more time focused on living their lives as independently as possible, in their own homes."
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Assessing Care of Vulnerable Elders (ACOVE) Investigators, RAND and UCLA Medical School Receive 2008 John M. Eisenberg Patient Safety and Quality Award
For developing the groundbreaking and comprehensive Assessing Care of Vulnerable Elders (ACOVE) set of quality measures, the RAND Corporation, the UCLA School of Medicine and ACOVE's investigators have received the 2008 John M. Eisenberg Patient Safety and Quality Award for Research from the Joint Commission and National Quality Forum. AGS congratulates RAND, UCLA and the ACOVE principal investigators -- Drs. Neil Wenger, Paul Shekelle, David Solomon, Carol Roth, Debra Saliba, David Reuben, and Roy Young -- whose accomplishments have significantly improved the care of frail older adults.
Recognizing the need for quality measures specifically designed for high-risk older adults, the investigators developed the ACOVE quality indicators (QIs) based on a comprehensive examination of the data available that is applicable to vulnerable elders and the clinical expertise of experienced clinicians.
In addition to developing, testing and updating the indicators, the ACOVE investigators have also created a now widely used screening tool to identify vulnerable, high-risk older adults, and have designed and assessed interventions based on the ACOVE measures. These interventions have been shown to improve the care primary care physicians provide to community-dwelling vulnerable seniors for geriatric conditions.
The widely disseminated ACOVE indicators are a key resource for groups working to develop quality measures for use by both the Center for Medicare and Medicaid Services (CMS) and private insurers. The AGS used several ACOVE quality measures as the basis for the Geriatrics Quality Measures developed by the American Medical Association Physician Consortium for Quality Improvement (PCQI), approved by the National Quality Forum and AQA Alliance, and currently part of the CMS Physician Quality Reporting Initiative (PQRI 2007). ACOVE quality indicators have also been used as a basis for measures considered by the National Committee for Quality Assurance (NCQA) Geriatric Measurement Advisory Panel (GMAP).
In collaboration with the American College of Physicians (ACP), the ACOVE QIs are now being used in a national study of quality improvement for older patients focused on falls and incontinence. The ACOVE set is also being used in a collaborative project with the Alzheimer's Association to improve care for patients with cognitive impairment.
Established in 2002 by the National Quality Forum (NQF) and The Joint Commission, The Eisenberg award honors John M. Eisenberg, MD, Director of the Agency for Healthcare Research and Quality, a member of the founding Board of Directors of the NQF and an impassioned advocate for healthcare quality improvement. The award recognizes the achievements of individuals and organizations who, through a specific initiative or project, have made an important contribution to patient safety and healthcare quality in the areas of research or system innovation. ACOVE was developed as a joint project of RAND and Pfizer Inc.
Nominated for the award by AGS President Todd Semla, MS, PharmD, the ACOVE nomination was supported by letters of endorsement from Drs. Wayne C. McCormick, William J. Hall, Joseph G. Ouslander, and John Tooker, American College of Physicians Executive Vice President and CEO.
"The ACOVE project has had and will continue to have a national impact on the quality of care provided to vulnerable older adults, and on the healthcare workforce responsible for improving the health, independence, and quality of life for our nation's elderly population," said Dr. Semla.
The December 2008 issue of the Joint Commission Journal on Quality and Patient Safety will feature an interview with ACOVE project leader, Neil Wenger, MD.
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Polls, NEJM Articles Underscore Importance of Healthcare in 2008 Presidential Election
Though the economy is the "top issue" for the majority of voters, healthcare, education and the environment rank second, according to a recent Wall Street Journal/NBC News poll. The poll, conducted between Sept. 19 and 22, included 1,157 voters -- 1,085 of whom were registered voters.
Fifty-four percent of registered voters trust Democratic presidential nominee Sen. Barack Obama (IL) more than Republican presidential nominee Sen. John McCain (AZ) to take on healthcare issues, a second poll, by The Los Angeles Times/Bloomberg finds. Just 25% of those included in the poll said they trusted Sen. McCain more than Sen. Obama when it came to healthcare. The poll, conducted between Sept. 19 and Sept. 22, included 1,428 adults -- 1,287 of them registered voters.
In addition, the New England Journal of Medicine recently published a number of columns concerning healthcare as it relates to the presidential election. These include "Election 2008: Access to Quality and Affordable Health Care for Every American" by Sen. McCain; "Election 2008: Modern Health Care for All Americans" by Sen. Obama; and "Election 2008: Campaign Contributions, Lobbying, and the U.S. Health Sector -- An Update";"Election 2008: Primum Non Nocere -- The McCain Plan for Health Insecurity"; and "Election 2008: Symptomatic Relief, but No Cure -- The Obama Health Care Reform".
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Senate Finance Committee Approves Two Bills Aimed at Preventing Elder Abuse
The Senate Finance Committee last week approved two bills that seek to prevent neglect and abuse of elderly patients, CQ Today reports.
The Elder Justice Act (S 1070), introduced by Sen. Orrin Hatch (R-UT), would authorize $777 million to establish state and local training and assistance programs for long-term care employees. In addition, the legislation would establish a database to identify and track elder abuse cases.
"Every year, millions of American seniors are victims of abuse and neglect. This bill will bring focus to the problem of elder abuse and elevate it to the same level as other family violence issues," said Rep. Rahm Emanuel (D-IL), who introduced a companion measure (HR 1783) in the House.
A second Senate bill, the Patient Safety and Abuse Prevention Act of 2007 (S 1577), would require screening of long-term care workers for a history of abuse or a violent criminal record. Introduced by Sen. Herb Kohl (D-WI), the legislation would also expand a seven-state pilot program, providing up to $160 million in grants over three years, for national and state background checks of long-term care workers.
"The earlier demonstration project kept thousands of prospective employees with disqualifying criminal records from gaining access to nursing home residents and other frail patients. Patients are safer because of that law," said Senate Finance Committee Chair Max Baucus (D-MT).
The Senate "has a limited number of days to try" to reach agreement with the House on the two bills, according to CQ Today. In a letter to Senate Finance Committee Chairman Baucus and Ranking Member Chuck Grassley (R-IA), the Leadership Council of Aging Organizations (LCAO), of which the American Geriatrics Society is a member, wrote: "With few legislative days remaining in the 110th Congress, it would be tragic to allow any more older Americans to suffer the pain of abuse, neglect and exploitation because Congress failed to act."
The AGS has reviewed and supported the Elder Justice Act (S 1070). The Patient Safety and Abuse Prevention Act of 2007 is currently under review by AGS leadership.
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Just 2% of U.S. Medical Students Plan to Practice Primary Care, Study Finds
Only 2% of U.S. medical students participating in a recent survey intend to pursue careers in internal medicine, according to a study published in the Journal of the American Medical Association (JAMA). By one estimate, there will be a shortfall of 200,000 doctors in the U.S. by 2020, USA Today reports.
General internists provide a large percentage of care for older patients and people with chronic conditions. With the number of aging Americans expected to double by 2030, the need for both general internists and geriatricians, who specialize in the care of older adults, is growing rapidly.
The vast majority of the 1,177 students surveyed at 11 U.S. medical schools cited quality-of-life factors, such as income and work hours, as reasons not to pursue general internal medicine, said study author Karen Hauer, MD, a general internist and University of California - San Francisco faculty member.
Their debt load didn't seem to influence their choice of specialty, according to Dr. Hauer. According to the Association of American Medical Colleges (AAMC), the average 2007 medical school graduate was carrying $140,000 in student debt, an 8% increase from 2006.
In a letter to the editor in the same issue of JAMA, Mark Ebell, MD, of the University of Georgia, notes that internal medicine is one of the lowest paying medical specialties. According to Dr. Ebell, U.S. medical students are pursuing higher paying fields. In 2007, family medicine offered the lowest average salary, $186,000, and only 42% of family medicine residency spots were filled by U.S. students. In contrast, orthopedic surgery offered an average salary of $436,000, with 94% of residency spots filled by U.S. students.
Between 2002 and 2007, the number of foreign graduates pursuing careers in primary care grew by 3,300, while 2,600 fewer U.S. doctors chose to train in primary care, according to another study published in JAMA. "Primary care is holding steady but only because of international medical school graduates," said study co-author Edward Salsberg of the AAMC.
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Senate Legislation Would Create "Health Care Comparative Effectiveness Institute"
Recently proposed legislation -- The Comparative Effectiveness Research Act of 2008 - would create a public-private Health Care Comparative Effectiveness Research Institute charged with identifying the most efficient medical treatments and practices, CQ HealthBeat reports.
Senate Finance Committee Chair Max Baucus (D-MT) and Senate Budget Committee Chair Kent Conrad (D-ND) have introduced the bill, The Health Care Comparative Effectiveness Research Act of 2008. According to Congressional Budget Office Director Peter Orszag, the U.S. could save up to $700 billion annually on healthcare by identifying and avoiding treatments that don't yield the best health outcomes. The proposed institute would set national priorities and work with agencies and organizations such as the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).
The federal government now spends $15 million a year on comparative effectiveness research. The proposed legislation, if passed, would provide $5 million for the institute in FY 2009 and $300 million by FY 2013. In keeping with the measure, the institute would become an "all payer" system in 2011, with the feds providing $75 million a year through 2018, and private insurers contributing $1 per insured person per year, and Medicare trust funds providing $1 per beneficiary annually.
The non-profit private institute would be governed by a 21-member Board of Governors representing the public and private sectors. Members of the Board would include the Secretary of Health and Human Services and the directors of the AHRQ and NIH. The other 18 members would include representatives from pharmaceutical, device, and technology companies; insurers; patients; physicians; and agencies administering public health programs.
Sen. Baucus is committed to passing the bill this year despite time constraints, according to his spokesperson, who stated, "It is important to start serious discussion on an issue important to consider in the context of health reform."
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During Congressional Hearing, Small Healthcare Practices, Others, Air Concerns Regarding Barriers to Adopting Health Information Technology
Small and private healthcare practices looking to adopt health information technology will likely face barriers, such as high costs and patient privacy concerns, lawmakers and witnesses noted during a recent House Committee on Small Business hearing, CQ HealthBeat reports.
Installing an electronic health records (EHR) system could cost a physician more than $44,000, and upkeep would add to the price tag, said Committee Chair Nydia Velazquez (D-NY). "For small health care providers with limited resources, these upfront costs are enough to break the bank," Velazquez continued, adding that "only a handful of solo practitioners" currently use EHR systems, compared with about 57% of larger practices.
Physicians at the hearing called on Congress to develop health IT standards that would prevent interoperability issues -- such as communication problems among physicians, laboratories and pharmacies that are using different and incompatible systems.
They also urged federal officials to establish incentive programs for healthcare providers who adopt health IT and criticized a recommendation by Congressional Budget Office Director Peter Orszag to use a "stick" approach to prod healthcare providers to do so. In keeping with such an approach prescribers failing to adopt these systems would face negative financial consequences. See related story
"Health information technology is a complex issue," said Committee ranking member Steve Chabot (R-OH). "The decision to implement health information technology in a small medical practice is considered an act of courage by many physicians."
Legislation (HR 6357) that would promote the adoption of health information technology to improve quality of care and reduce healthcare costs is currently being considered by the House.
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Medicare to Offer Incentive Payments to Healthcare Providers Who Take Up E-Prescribing
Starting next year, Medicare will offer incentive payments to physicians and other eligible professionals who successfully adopt electronic prescribing systems. The new program is part of the Administration's widespread efforts to accelerate the adoption of health IT and improve quality and cost-effectiveness.
Healthcare providers who adopt e-prescribing will receive a 2% bonus payment in 2009 and 2010; a 1% bonus in 2011 and 2012; and a 0.5% bonus in 2013.
Beginning in 2012, eligible professionals who have not adopted e-prescribing will see their payments reduced. Professionals may be exempt from the payment reduction, however, if compliance with this requirement would result in significant financial difficulties.
Medicare is expected to save up to $156 million over the five years of the program, due to anticipated reductions in adverse drug events. According to some estimates, as many of 530,000 Medicare beneficiaries experience adverse drug events each year due to interactions with other drugs or a prescriber's lack of information about their patients' medication histories.
The Institute of Medicine (IOM) estimates that more than 1.5 million Americans are injured each year as a result of drug errors. E-prescribing has the potential to improve health outcomes by providing updated information concerning appropriate drug usage; offering providers and dispensers current information about formulary-based drug coverage; and speeding up prescription renewals.
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Eric Coleman, MD, Expert on Care Transitions, Testifies Before Senate Special Committee on Aging
“Person-centered” models of care -- such as the “medical home” and “Green House” models – are “excellent” models for older adults, but the quality of care older patients receive can “unravel” rapidly during transitions among these and other care settings unless these transitions are handled appropriately, the AGS’ Eric Coleman, MD, told the Senate Special Committee on Aging last week.
Dr. Coleman, professor of medicine and director of the Care Transitions Program at the University of Colorado at Denver and Health Sciences Center, testified during a July 23 committee hearing devoted to person-centered models of care. These include the medical home model, (see related story) in which primary care physicians lead teams of healthcare professionals that work closely with patients, offering increased monitoring, more frequent communication, care coordination and other services designed to improve care. Another person-centered alternative, Green House homes are smaller alternatives to nursing homes, typically providing the same services but including fewer than a dozen older residents, offering both community and private space, and encouraging greater self-reliance. Interest and investment in both models is growing.
“These models are particularly suited for persons whose medical conditions are primarily in a stable or steady state,” Dr. Coleman told those at the hearing, convened by Sen. Bob Casey (D-PA). “Inevitably, many of these persons will experience a worsening or exacerbation of their medical conditions or a sudden traumatic event that requires a transfer to settings such as an emergency department or a hospital.”
Unless properly handled, such transitions “can confound our best attempts to provide person-centered care, he explained. During care transitions, which can “occur with astounding frequency and variability,” older patients are at high risk of medication and other care errors.
With support from the John A. Hartford Foundation, the University of Colorado Care Transition Program has developed a Care Transitions Intervention model that can help prevent these errors, added Dr. Coleman, who offered an overview of the four-week program, which is aimed at patients with complex care needs and their family caregivers. Through the program, patients and caregivers work with a “Transition Coach” to learn self-managements skills designed to ensure that their needs are met during transitions among care settings. Research has shown that patients enrolled in the program are significantly less likely to be readmitted to the hospital. Moreover, each Transitions Coach -- who can manage at least 350 chronically ill hospitalized adults -- can “produce a conservative net cost savings of $300,000,” Dr. Coleman reported.
“Although demand for the Care Transitions Intervention continues to grow, the primary barrier to making this model available to all Americans with chronic and complex care needs concerns the lack of financial mechanisms within the Medicare program to support” this and other self-management models,” said Dr. Coleman who outlined other successful approaches to promoting person-centered care through greater support for family caregivers.
During the hearing, Dr. Coleman also referred members of the committee to the Institute of Medicine’s recent watershed report on preparing the nations healthcare workforce to meet the needs of an aging America. Afterward, he thanked Sen. Blanche Lincoln ( D-AR) for championing the Geriatric Assessment and Chronic Care Coordination Act, which would fill a gap in traditional Medicare by covering assessment and care coordination services for beneficiaries with multiple chronic conditions.
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Obama Promises Health Plan That Would Generate Savings, But Will It?
Likely Democratic presidential nominee Sen. Barack Obama (IL) has vowed to implement a healthcare plan that will cut annual health coverage costs for the average family of four by $2,500 -- and do so by the end of his first term as President -- but whether that level of savings is feasible is in question, The New York Times reports.
"While there is consensus that the American health care system is bloated with waste, eliminating enough to save $2,500 per family would require simultaneous and synergistic solutions to a host of problems that have proved intractable for decades," Times reporter Kevin Sack writes. Analysts are unsure "whether significant savings would materialize in as little as four years, or even in 10."
Among other things, Sen. Obama's plan would provide coverage for the 47 million Americans who lack health insurance by requiring insurers to accept all applicants, regardless of health status, and provide tax credits to low-income individuals and families. The credits, which would cost more than $100 billion, could be used to buy coverage provided by a new federal health plan or private plans "marketed through a government exchange," The Times reports. The Obama plan also calls for $6 billion a year in tax credits for small businesses offering their employees health insurance and an unspecified sum to "help buffer businesses from high-cost insurance claims." In addition, it would invest $50 billion to speed the implementation of electronic medial record keeping.
The estimate of a $2,500 premium savings per family comes from calculations by three Harvard professors advising the Obama campaign, The Times reports. The three offered their "best guesses" that a range of changes would result in more than $200 billion in savings annually, or 8% of the 2.5 trillion in healthcare spending projected for 2009. Their calculations, based on recent studies, estimated that improving prevention and chronic disease management would save $81 billion a year; investing in computerized medical records, $77 billion a year; and "reducing administrative costs in the insurance industry," up to $46 billion.
The study on which the $77 billion figure was based, however, has since come under criticism. And whether the major reforms the candidate has proposed will, in fact, bring about an 8% reduction in healthcare spending-- and a resulting $2,500 cut in healthcare care costs for the average family of four -- remain matters of debate.
Healthcare cost expert Kenneth Thorpe of Emory University, for example, recently estimated that Sen. Obama's proposals could reduce health spending by between $203 billion and $273 billion by 2012. He also estimated that half of these savings would accrue to the federal government. On the other hand, the health research group The Commonwealth Fund has projected that an ambitious overhaul of the healthcare system involving 15 broad initiatives would result in a savings of only 6%, and that, after 10 years.
"Doing it by the end of a first term is ambitious and would require tough policies," Commonwealth Fund president Karen Davis told the Times.
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New Pilot Programs Examine Whether Medical Homes Improve Quality of Care and Reduce Costs
Medicare, states and private health insurers are launching pilot programs to determine whether the "medical home" model -- in which physicians and staff more carefully monitor and work in collaboration with patients, together creating a medical "home base" of sorts -- can improve quality of care and reduce costs, USA Today reports.
At the heart of the medical home concept is coordinated preventive and routine care provided by "teams" of medical professionals, which may include nurse practitioners, nutritionists and other healthcare providers. In keeping with the model, these teams offer closer patient monitoring, more frequent communication with patients (including contact via phone or email), longer office hours, and same-day appointments, and employ electronic medical record-keeping.
Ostensibly, the medical home approach should reduce the frequency of hospitalizations and emergency department visits and the prevalence of chronic disease and complications - and save money. In fiscal year 2002-2003, North Carolina saved $231 million through the establishment of medical homes in the state Medicaid program. This year, Medicare will choose eight states to participate in a pilot program that will test whether medical homes can improve the quality of care its beneficiaries receive and reduce costs.
Under most of the medical home pilot projects that are now up and running, physicians who participate receive extra payments - ranging from a few dollars monthly per patient to more than $35,000 annually per physician.
It is still unclear "how well such plans will work," USA Today reports.
"If all we're doing is rearranging the deck chairs on the medical Titanic and spending more money, that's clearly not something we want to do," Joseph Antos, an economist at the American Enterprise Institute, said of medical homes.
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McCain Vows to Balance Budget by 2013 by Overhauling Entitlement Programs, But Provides Few Details
If elected, likely Republican presidential nominee Sen. John McCain (R-AZ) plans to balance the federal budget by 2013 in part by overhauling Medicare, Medicaid, and Social Security.
According to a white paper the Senator's campaign released July 7, the "only way to keep the budget balanced is successful reform of the large spending pressures in Social Security, Medicare and Medicaid." The paper does not provide details concerning these reforms, however.
Sen. McCain has also called for a one-year freeze in most domestic spending subject to annual appropriations, to allow for a "comprehensive review." According to the New York Times, he has proposed capping overall growth in spending at 2.4% annually. Federal spending has been growing an average of more than 6% a year for the last five years. Like his proposal for reforming entitlement programs, his plan for reining in spending is vague, say analysts, who have questioned whether the Senator can limit spending enough to compensate for the tax cuts he has proposed.
Sen. McCain has also come out in favor of ending the tax breaks that currently encourage employers to provide heath insurance for employees, and replacing these with tax credits of up to $5,000 that employees can use to buy their own insurance. Overall, his healthcare plan aims to shift the emphasis from insurance provided by employers to insurance purchased by individuals, an approach that he argues will foster competition and drive down prices, The New York Times reports.
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Legislation Extends Medicaid GME Moratorium
President Bush has signed legislation delaying implementation of a Centers for Medicare & Medicaid Services (CMS) regulation that would eliminate federal Medicaid spending for graduate medical education (GME), deferring this until April 1, 2009. The legislation, the Supplemental Appropriations Act of 2008 (HR 2642), also delays implementation of five other Medicaid regulations until that date.
The Senate voted 92-6 on July 26 to adopt a House version of the domestic portion of the appropriations bill. Among other things, the spending bill also includes $150 million for scientific research at the National Institutes of Health.
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