Back To Our Healthcare Bill Review

Wanted to backtrack just a moment before I move on from my review last night.

On page 19 of the healthcare bill it states:

A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors

Definition of Insurance from Wikipedia:

Insurance, in law and economics, is a form of risk management primarily used to hedge against the risk of a contingent loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for a premium, and can be thought of as a guaranteed and known small loss to prevent a large, possibly devastating loss. An insurer is a company selling the insurance; an insured or policyholder is the person or entity buying the insurance. The insurance rate is a factor used to determine the amount to be charged for a certain amount of insurance coverage, called the premium. Risk management, the practice of appraising and controlling risk, has evolved as a discrete field of study and practice.

So, when we allow everyone in with their pre-existing conditions and agree to automatically pay for things that are "known", technically it is no longer insurance.

Okay, now onward from page 200. You can join in for your reading pleasure if you like - Here's the link: Health Care Bill.

Page 241: The act provides for the designation of "service categories" There are 3 -

(i) services in the category designated Evaluation and Management in the Health Care Common Procedure Coding System
(ii) preventive services
(B) All other services not described in subparagraph (A)

Then catch this one:

Service categories established under this paragraph shall apply without regard to the specialty of the physician furnishing the service.

Does this mean they can determine what the provider will receive for reimbursement regardless of their area of specialty???

Page 253 - The Secretary appears to be able to put a value on the provider's time based on the following:

‘‘(i) IN GENERAL.—The Secretary shall establish a process to validate relative value units under the fee schedule under subsection (b).
‘‘(ii) COMPONENTS AND ELEMENTS OF WORK.—The process described in clause (i) may include validation of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, and stress due to risk) involved with furnishing a service and may include validation of the pre, post, and
intra-service components of work.

Page 258: It appears that our professional service providers are going to be required to do additional paperwork regarding "quality measures" with perhaps some sort of incentive payment? It really isn't clear:

‘‘(H) FEEDBACK.—The Secretary shall provide timely feedback to eligible professionals on the performance of the eligible professional with respect to satisfactorily submitting data on quality measures under this subsection.’’.

‘‘(A) The development of measures, the reporting of which would both demonstrate—
‘‘(i) meaningful use of an electronic health record for purposes of subsection
(o); and
‘‘(ii) clinical quality of care furnished to an individual.

Page 260 - of course, California gets it's own special treatment:

‘‘(6) TRANSITION TO USE OF MSAS AS FEE
21 SCHEDULE AREAS IN CALIFORNIA.—
‘‘(ii) TRANSITION.—For services furnished on or after January 1, 2011, and before January 1, 2016, in the State of California, after calculating the work, practice expense, and malpractice geographic indices described in clauses (i), (ii), and (iii) of paragraph (1)(A) that would otherwise apply through application of this paragraph, the Secretary shall increase any such index to the county-based fee schedule area value on December 31, 2009, if such index would otherwise be less than
15 the value on January 1, 2010.

Page 267 - It appears to me that the government can decide the costs allowed and whether or not some of these options are allowed for items such as power-driven wheelchairs, brachytherapy, home infusion therapy - they are requiring a report to Congress on home infusion therapy:

Not later than 12 months after the date of enactment of this Act, the Medicare Payment Advisory Commission shall submit to Congress a report on the following:
(1) The scope of coverage for home infusion therapy in the fee-for-service Medicare program under title XVIII of the Social Security Act, Medicare Advantage under part C of such title, the veteran’s health care program under chapter 17 of title 38, United States Code, and among private payers, including an analysis of the scope of services provided by home infusion therapy providers to their patients in such programs.
(2) The benefits and costs of providing such coverage under the Medicare program, including a calculation of the potential savings achieved through avoided or shortened hospital and nursing home stays as a result of Medicare coverage of home infusion therapy.
(3) An assessment of sources of data on the costs of home infusion therapy that might be used to construct payment mechanisms in the Medicare program.

Page 270

SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO SUBMIT COST DATA AND OTHER DATA.

Page 272 appears to allow the Secretary to determine if Cancer Treatment Hospitals are allowed or funded and at what rate:

‘‘(A) STUDY.—The Secretary shall conduct a study to determine if, under the system under this subsection, costs incurred by hospitals described in section 1886(d)(1)(B)(v) with respect to ambulatory payment classification groups exceed those costs incurred by other hospitals furnishing services under this subsection (as determined appropriate by the Secretary).
‘‘(B) AUTHORIZATION OF ADJUSTMENT.— Insofar as the Secretary determines under subparagraph (A) that costs incurred by hospitals described in section 1886(d)(1)(B)(v) exceed those costs incurred by other hospitals furnishing services under this subsection, the Secretary shall provide for an appropriate adjustment under paragraph (2)(E) to reflect those higher costs effective for services furnished on
or after January 1, 2011.’’.

Page 288 and a few pages before - best I can tell, they are going to withhold some portion of payments to hospitals who have "readmissions" for the same or similar illness, based on definitions set by the Secretary:

‘‘(E) READMISSION.—The term ‘readmission’ means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. Insofar as the discharge relates to an applicable condition for which there is an endorsed measure described in subparagraph
(A)(ii)(I), such time period (such as 30 days) shall be consistent with the time period specified for such measure.

Another part of 288-289:

‘‘(7) MONITORING INAPPROPRIATE CHANGES IN ADMISSIONS PRACTICES.—The Secretary shall monitor the activities of applicable hospitals to determine if such hospitals have taken steps to avoid patients at risk in order to reduce the likelihood of increasing re-admissions for applicable conditions. If the Secretary determines that such a hospital has taken such a step, after notice to the hospital and opportunity for the hospital to undertake action to alleviate such steps, the Secretary may impose an appropriate sanction.

Can someone please explain to me how all these "studies" and all this "monitor" of activities by the government is going to be paid for? Who is going to do all this work? How much are they going to be paid? How many more levels of bureaucracy is this all going to create??? Are hospitals and providers going to be able to concentrate on treating patients, or are they going to be too busy worried about big-brother breathing down their neck?

Page 297 - they are going to conduct yet another study to see how they can apply the same "readmissions" definitions to physicians directly:

(d) PHYSICIANS.—(1) STUDY.—The Secretary of Health and Human Services shall conduct a study to determine how the readmissions policy described in the previous subsections could be applied to physicians.

Here's how:

(A) creating a new code (or codes) and payment amount (or amounts) under the fee schedule in section 1848 of the Social Security Act (in a budget neutral manner) for services furnished by an appropriate physician who sees an individual within the first week after discharge from a hospital or critical access hospital;
(B) developing measures of rates of readmission for individuals treated by physicians;
(C) applying a payment reduction for physicians who treat the patient during the initial admission that results in a readmission; and
(D) methods for attributing payments or payment reductions to the appropriate physician or physicians.

Now think about this - have you ever been treated in a teaching hospital? Yes, you have a primary physician who is "responsible" for your care, but how many different physicians come in and out and check on you, change things about your care, make notes on your chart, etc? How willing would you be to take on the role of the "primary" physician in this case, knowing that you could be financially penalized by something you didn't even do? At least, that's how it appears to me reading this. I cannot imagine how they'll be able to track this.

Page 298 - Am I reading this right??? They are going to allot $25 million dollars to conduct this oversight and these studies from this section about re-admissions we looked at above????

(e) FUNDING.—For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services for the Center for Medicare & Medicaid Services Program Management Account
$25,000,000 for each fiscal year beginning with 2010.

This is all I can do tonight folks. Stick with me and we'll see what else is there. If you are reading this yourself, feel free to comment on anything that's made an impression on you.