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Not perfect, but what legislation ever is? - Health Care Rx Panelists

Not perfect, but what legislation ever is?

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Unlike so many, I find myself being more impressed each time I delve into the new law. This is, ultimately, a piece of legislation that WILL achieve many stated and even unstated objectives:

1. It will extend the Medicare Part A trust fund for just long enough to allow BOTH sides to discuss meaningful reforms to make it truly sustainable.
2. It provides a real commitment to our nation's poor; and strengthens Medicaid at the same time. Here, too, there are opportunities for additional reforms, but this makes clear what our priorities are; and, importantly, demonstrates our national humanity and compassion for those less fortunate.
3. It dramatically reforms our understanding of and right to health insurance. We have never had a federal definition of health insurance and this begins that discussion in a meaningful way.
4. It is financially sustainable, as long as our elected officials do not undo the tax and revenue-generating items.

What do we need to wait for and hope for?
1. Tort reform and/or Malpractice reform. This should have been firmly part of this law, but will have to wait.
2. Sustainable Growth Rate legislative reform: This is universally recognized as necessary and putting it off, even for a few months, is a big disappointment.
3. Implementation of insurance regulation and insurance exchange regulation will be the first real tests of the success of the law.
4. Taking the Medicare savings and law changes as a first step; and not ignoring the very real legacy costs that we still have to address. AND working with the private (for-profit and not-for-profit) sector to develop a structure and process for improving the delivery of high-quality health care with consideration of cost.
5. Revisiting the notion of better patient education and not being scared off by hateful rhetoric. Discussions around end-of-life and compassionate care should not be politicized or used for pure political gain.

I remain very optimistic about this country and about seeing our elected officials, of both parties, come together around common goals and purposes. In the mean-time, I am proud of the many elected individuals (and their staffs) for having stood behind their promises and made this a reality.

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Can't be everything to everyone - Health Care Rx Panelists

Can't be everything to everyone

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Former Secretary of Health and Human Services Donna Shalala, now president of the University of Miami, has often told me that for major legislation to pass there must be consensus on the problem and the solution. In health care, most people agree on the problems: the U.S. health care system is too expensive, leaves too many Americans uncovered and fails to achieve its potential in quality.

As for the solution, a consensus remains elusive. For liberals, reform entails a public option, a Medicare and Medicaid expansion and government subsidies for low-income Americans. For conservatives, the solution calls for the development of an individual insurance market with purchasing across state lines, medical malpractice reform and the expansion of health savings accounts. Some liberals may have believed that a Democratic caucus with 60 members would thwart the need for consensus. However, centrist Senators, who represented votes 55 to 60, quickly ended those notions.

In any negotiation, the power lies with the coveted undecided. Without the counter-balance of major conservative ideas to court Republican votes, it is no surprise that many liberal ideals have been stricken from the bill. While this compromise has produced a bill that leaves both liberals and conservatives wanting, no single bill would ever have done everything for everyone. Health-care reform will be a continuous process of learning and adaptation with many opportunities in the future. Given the lack of consensus, for a bill to exist, compromise was necessary.

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Inevitable and sensible - Health Care Rx Panelists

Inevitable and sensible

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Compromises are inevitable in any complex piece of legislation. Those that address the unique needs of particular communities and increase the degree to which the legislation meets its fundamental goals are good compromises. Those unrelated to the purpose of the legislation turn the legislative process into a power game in which the strong prey upon the weak.

The decisions to drop the public option and the Medicare eligibility of 55-64 year olds were sensible. Once the Senate required insurers to cover everyone who applied, prohibited coverage limitations based on pre-existing conditions, provided subsidies for those who could not afford insurance, and created national exchanges to insure competition, the primary reasons for having a public option or for expanding Medicare melt away.

I liked the tanning salon tax, because salons probably increase the risk of skin cancer. I was disappointed that the Senate deleted the cosmetic surgery tax. Many plastic surgeons game the insurance system and Medicare by coding cosmetic surgery as reimbursable reconstructive surgery. While some cosmetic surgeries have medical and psychological benefits, the health benefit of others is marginal at best, and risky at worst. Anything that forces a more thoughtful decision on such surgeries would have been beneficial.

I am disappointed that the legislation did not more aggressively address health-care access, quality, and cost issues. As a piece of legislation designed to make health insurance universal, it is relatively good. However, the ultimate problem with mandatory universal health insurance remains how to pay for it without creating other problems. The penalty for young, healthy people who choose not to get insurance is too low, and the subsidy for the older, less healthy people is too generous. If either the House or Senate legislation gets enacted, we will have serious financial problems we will eventually have to address.

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Michael,
As with sausage, this legislation will be most appealing when fully cooked...and it isn't even in the skillet yet. As usual, you are right...that the "gaming" by practioners will continue if unenforced, and if kept unduly complicated. The key to reimbursment coding "games" is in assigning the appropriate (and defensible) diagnosis codes. Docs can too often blame their $10/hour staff for using the wrong billing code...but they have no defense in using the wrong diagnosis code that comes only from the docs lips. Even Doctor Nip&Tuck knows what is cosmetic and what is reconstructive. That's where our Medicare police need to concentrate. With pending new cuts in Medicare reimbursement now slated for 1Q2010, the pressure will even highten for unscrupulous practices to cheat...and even more the need to tighten the controls that are needed to curtail costs at the point of delivery.

Follow the money trail. It's blazed not with crumbs...but with cash!

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Finally, a smart move - Health Care Rx Panelists

Finally, a smart move

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Expanding Medicare for individuals younger than 65 would have accelerated the rate at which the system would become insolvent and ultimately leave many without adequate coverage or access. The administration seems all too focused on the word "coverage" without any attention to the importance of quality. It is not enough to be able to simply state that people are covered and the job is done. I would challenge any Senator to give their child or spouse a $5,000 check and tell them that is all they have to spend for health care and tell them they are "covered."

The effects of any reform will not kick in until 2013 when a new administration (or the current one) steps in. We dodged a major bullet by dropping the Medicare buy-in, but lets not throw the public off the plane without a parachute

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It was a bad idea - Health Care Rx Panelists

It was a bad idea

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I was pleased to see that the provision for a buy-in for people under age 65 has been removed from the health-care legislation. I had some serious concerns about the proposal. This is obviously the most expensive segment of the population (not already covered by Medicare) to insure, so insurance for this distinct group would have very high costs. This would shift a significant burden to the federal government. And, because of the high costs, it is unlikely the government could charge individuals enough to cover the real costs.

I was also concerned about the low reimbursement rates from Medicare, and the cost-shifting that it leads to. Currently, Medicare payments to physicians do not cover the costs of providing the care. Expanding the Medicare pool could result in lower operating revenue as people over the age of 55 drop their current insurance and switch to Medicare. Depending on how many individuals were to sign up for the Medicare buy-in, it could lead to shifting more costs to the commercial market. This could encourage employers to institute practices that would encourage their older employees to leave or to at least leave the employers' insurance and go with the Medicare buy-in.

Additionally, many physicians will see only a set number of Medicare patients, if they see them at all, because of lower reimbursements. As a result, fewer patients over 65 would have had access to physicians due to the addition of younger members.

There is nothing in Medicare now that adequately provides incentives for evidence-based care and appropriate end-of-life care. I hope that if something is implemented legislatively, it encourages a greater focus on quality improvement and high-value care rather than high-volume.

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Briefer than a fruitfly - Health Care Rx Panelists

Briefer than a fruitfly

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Under normal laboratory conditions, adult fruit flies have an average lifespan of seven days. The average fruit fly would have therefore outlived the tentative Medicare buy-in compromise presented by the gang of 10 Senators this last week.

Senator Lieberman was the immediate and proud killer. Yet as Amy Goldstein makes plain, other assassins waited in the wings, including physician groups, community hospitals, otherwise-progressive senators from rural states. There is a useful lesson here. Democrats have cast insurers as the all-purpose villain in health care reform. There are sound political reasons to do so. Particularly in the non-group market, the industry certainly lives down to its villainous stage role.

We should recognize, however, that strategic imperatives and message discipline can cloud analytic clarity. Virtually the entire supply side of the medical economy has a strong economic interest in constraining the growth and bargaining power of Medicare. This includes traditional targets of liberal wrath such as big Pharma and device manufacturers. It also includes warmer and fuzzier constituencies, too: community hospitals, the Mayo Clinic, academic medical centers and many others. Effective cost control requires us to stringently bargain with these institutions. They will resist efforts to strengthen government's bargaining leverage to accomplish this task. As we saw in the demise of this modest but worthy Medicare compromise, our failure to confront this political fact brings real human and financial costs.

A few words about the substance. Near-seniors age 55-64 face serious risks that make them a natural constituency for health reform. Too young for Medicare, but old enough to face marked health risks, this group includes the most immediate victims of preexisting condition exclusions, large medical expenses and accompanying bankruptcies, chronic illness and disabilities. Not surprisingly, then, polls indicate that this group ranks among the most enthusiastic supporters of health reform. Equally unsurprising, support for health reform plummets at age 65, once seniors secure Medicare coverage.

Based on what we know, the proposed Medicare buy-in would have been helpful, but it would have had a very small immediate effect. Over the next several years, the main beneficiaries would apparently have been a small population of men and women with chronic illnesses eligible for high-risk pools, who suffer costly conditions and who have been uninsured. High-risk pools can be a useful stop-gap. They are not an effective or humane long-term policy. We don;'t know enough details to evaluate Medicare buy-in as a specific policy. Over the long-term, liberal hopes matched provider and conservative fears about where this might head. These possibilities were enough to prove fatal in a world in which reform requires 60 Senate votes.

Now that the buy-in is dead, those who favor reform should move on to address the serious problems millions of near-seniors face, and would have faced even if the buy-in had become law. Near-seniors need strong regulation to prevent insurer discrimination on the basis of illness or disability. They need generous affordability credits and better protections against high out-of-pocket costs, particularly for those with incomes around 300 percent of the poverty line. They need rapid implementation of health insurance exchanges, which are several years off.

The buy-in deserves an honest obituary. We should mourn its quick death and what might have been. It's now time to pass the bill, and to focus on essential details that remain to be done. In doing so, we should remember who killed the buy-in, and others who were happy to see it dead. As we move to secure the rudiments of universal coverage, we can't wage every fight. When the current health reform is done and we look more seriously to control costs, we'll be fighting other battles soon enough.

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The push for American Exceptionalism - Health Care Rx Panelists

The push for American Exceptionalism

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"[T]he ideals of human rights and rule by the people require not suspicion of government but use of it...confident that human ingenuity [can] devise mechanisms that... at once protect liberty, allow effective government, and rest on the consent of the people." Quoted from Ralph Ketcham, a noted historian and political scientist speaking on behalf of the Federalists who defended the Constitution, I am reminded of its relevance in today's health-care reform debate.

It speaks to American Exceptionalism-- the belief in American uniqueness, shaped by a singular history, and cultivated by sacred convictions that rest in individual rights, freedom, liberty and the pursuit of happiness. It applauds our ability to form a veritable democracy capable of energetic government -- not arbitrary, excessive or dangerous to its citizenry.

If we are an exceptional nation, and I believe we are, then we must admit that we have an exceptional problem. Our health-care system is at once unparalleled in excellence and plagued by troublesome ironies. It is a disservice to all Americans and the iconic American brand if we fail to forge a solution or at least make considerable progress in that direction, similar to the spirit that enacted Social Security, Medicare and Medicaid. We need meaningful, transparent health reforms, which place us on the path to a unique American hybrid of private and publicly provided health benefits.

Sadly, the push to optimize our current health system is proving tortuous. With each arduous tick of the game clock, another permutation is churned out but falls short of the coveted 60 votes. And just recently, late-breaking maneuvers to include a Medicare buy-in appear to have been scrapped. Indeed this move would have satiated much of the appetite for a public insurance program but without the new bureaucracy. It remains unclear, however, whether new enrollees would have been entitled to the same Medicare benefits as current beneficiaries and if this would have complicated solvency issues.

Suffice to say, the art of compromise is rife with concessions, but the challenge is striking the right balance for the greatest good--that is what government was intended to do.

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Medicare's fundamental flaws - Health Care Rx Panelists

Medicare's fundamental flaws

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I am strongly opposed to adding any more participants to the Medicare system until we correct its fundamental flaws and make it financially solvent for the long term. There is no question that adults who are between 55 and 64 years old, and who are either retired from businesses that have no retiree medical coverage, or who are employed by companies that do not have medical coverage have a high likelihood or being either uninsured or underinsured.

This is especially true in states like Connecticut, which allow insurance companies to adjust individual and group rates based on age, with the older insurance participant paying more. Lawmakers need to do something for this population.

But rather than opening up Medicare to these participants, we should simply require insurance companies to cover them, eliminate pre-existing condition provisions, and create more competition through national exchanges that do not allow for as steep a premium increase as a result of age. Provide subsidies as needed.

Medicare is flawed because its costs are out of control since it pays for activity, not results, and makes no attempt to monitor excessive use of drugs, doctor's visits, hospital readmissions, or diagnostic tests. In those instances in which more care produces worse outcomes, Medicare has done nothing to control costs, and has no infrastructure to do so.

Moreover, Medicare coverage and payment decisions are highly politicized and controls on questionable medical processes and activities are unlikely to withstand the power of special interest groups. Good changes, like the addition of diagnostic tests that will help determine the value of a new cancer drug, are under-reimbursed because of the long lead time on changes.

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Old idea, new context - Health Care Rx Panelists

Old idea, new context

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A Medicare early buy-in for people ages 55 to 64 is not a new idea. It was previously proposed as a useful incremental step in extending coverage to people who would otherwise struggle to obtain health insurance in the current system. In the context of broader health-care reform, however, the role of an early buy-in would be different than the one conceived by its proponents in years past.

In the past, an early buy-in was seen as a way to get coverage to 55 to 64-year-olds for whom the existing health insurance system does not work. If these older adults have retired, they may have no access to group or individual coverage, especially if they have pre-existing conditions that insurers will not cover. In the absence of other health reforms, a Medicare early buy-in has been seen as a relatively simple, incremental way of getting help to people who have few other viable options.

Today, however, we are on the brink of major reforms to our health-care system. A Medicare early buy-in would exist within a new framework built around a well-regulated marketplace or exchange. Health insurance plans will be subject to much stronger consumer protections, including prohibitions on exclusions for pre-existing conditions and strict limits on age-rating and other underwriting. Lower-income people will be eligible for subsidies to assist them with premiums and out-of-pocket costs. As a result, it is not yet clear how an early Medicare buy-in would provide greater help to this age cohort. Key questions that would need to be clarified include:

· Subsidies: Both the House and Senate bills recognize that subsidies are necessary to make health coverage and care affordable for people with low to moderate incomes (up to 400 percent of the poverty level). It is currently unclear which subsidies would apply to a Medicare early buy-in. Congress will have to ensure that an early buy-in option is affordable and determine what combination of policies to use to accomplish this goal.

· Benefits: Medicare has an incomplete benefits package. Notably, it has no annual or lifetime out-of-pocket limits. Plans in the exchange will be required to have such limits. Congress will need to determine how the out-of-pocket limits would apply to a Medicare early buy-in.

· Risk pooling: It is unclear who would be most interested in joining an early buy-in. On average, 55 to 64-year-olds are healthier than people with Medicare, and so including the buy-in population with the existing Medicare risk pool could strengthen Medicare's fiscal status. On the other hand, if the early buy-in attracts a disproportionate share of those in poorer health, it may make more sense to create a separate risk pool to avoid an adverse impact on existing Medicare beneficiaries.

None of these questions create insurmountable obstacles to a Medicare early buy-in. They do, however, show that the benefits of an early buy-in will have a considerably lesser impact than the original stand-alone versions of such a provision.

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A big 'if' - Health Care Rx Panelists

A big 'if'

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The Medicare buy-in would make sense only if we solve current money problems, such as how much Medicare pays doctors. Otherwise, that's just millions more patients plugged into a system that physicians are only too willing to abandon.

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