The Game’s Not Over, and It May Not Even Be The Real Game

Brian Klepper

Posted 6/29/12 on Medscape Connect’s Care and Cost Blog

ImageLike most health law watchers, I was surprised by yesterday’s decision. I’m sure that on this issue, as with everything else, zealous responses will rationalize the result and split the country down the middle.

I expected the Court to be purely partisan, but apparently Chief Justice John Roberts acknowledged the gravity of his role and saw his way clear to support the law with some constraints. Here’s the comment from SCOTUS (Supreme Court of the United States) Blog: 

Salvaging the idea that Congress did have the power to try to expand health care to virtually all Americans, the Supreme Court on Monday upheld the constitutionality of the crucial – and most controversial – feature of the Affordable Care Act. By a vote of 5-4, however, the Court did not sustain it as a command for Americans to buy insurance, but as a tax if they don’t. That is the way Chief Justice John G. Roberts, Jr., was willing to vote for it, and his view prevailed. The other Justices split 4-4, with four wanting to uphold it as a mandate, and four opposed to it in any form.

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The Budget Fight: It Will Be A Long Hot Summer, And Fall, And Winter

Bob Laszewski

First published 3/14/11 on Health Policy and Marketplace Review

The good news is that Democrats and Republicans are finally seriously engaged over the country’s fiscal crisis.

And, each side is presenting a starkly different course for the voters to choose from.

When it comes to the health care entitlements, Republicans want to cut the health care entitlement benefits and therefore ease the pressure on federal spending.

Obama wants to largely leave the programs in place and raise taxes–about $1 in tax increases for every dollar in cuts.

Neither touches Social Security. Obama wants to make cuts to the Pentagon’s budget—the Republicans don’t.

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Changing the Game on Health Care Costs

Robert Laszewski

First published 4/10/11 on Health Policy and Marketplace Review

Last week, I posted that I was disappointed in Paul Ryan’s health care budget proposal because it lacked cost containment ideas other than the usual conservative reliance upon the market and defined contribution health care.

In my last post, Why ACOs Won’t Work, I argued that the latest health care silver bullet solution, Accountable Care Organizations (ACOs), are just a tool in a big tool box of care and cost management tools. But, like all of the other tools over the years like HMOs and IPAs, they won’t be used as they were intended because everybody—providers and insurers—can make more money in the existing so far limitless fee-for-service system.

How do you make the American health care system efficient?

You change the game.

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Why ACO’s Won’t Work

Robert Laszewski

First published 4/7/11 on Health Policy and Marketplace Review

First, I think Accountable Care Organizations (ACOs) are a great idea. Just like I thought HMOs were a good idea in 1988 and I thought IPAs were a good idea in 1994.

The whole notion of making providers accountable for balancing cost, medical necessity, appropriateness of care, and quality just has to be the answer.

But here’s the problem with ACOs: They are a tool in a big tool box of care and cost management tools but, like all of the other tools over the years like HMOs and IPAs, they won’t be used as they were intended because everybody—providers and insurers—can make more money in the existing so far limitless fee-for-service system.

Continue reading “Why ACO’s Won’t Work”

Accountable Care Organization (ACO) Regulations: First Look

David Harlow

First published on 4/3/11 and 4/5/11 on Health Blawg

ACO regulations and related federal issuances hit the street last Thursday, after several months of waiting — from CMS, OIG, FTC, DOJ and IRS.  They cover the waterfront, ranging from the central regulation defining the structure and workings of the ACO, to  limited Stark self-referral ban and anti-kickback statute waivers in the fraud and abuse arena, to new frameworks for antitrust analysis, to rules governing joint ventures involving taxable and tax-exempt organizations.

I had the opportunity to discuss the regs the day after they were issued on a special edition of the Blog Talk Radio show, ACO Watch, hosted by Gregg Masters(@2healthguru).  Gregg’s guests included Mark Browne (@consultdoc), Vince Kuraitis(@VinceKuraitis), Jaan Sidorov (@DisMgtCareBlog) and yours truly (@healthblawg).  We are geographically diverse, and bring a variety of perspectives to the table.  I invite you have a listen — we enjoyed the opportunity to discuss the rules, we all learned from each other, and we hope you enjoy the conversation as well.  (It runs about 90 minutes.)

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Tire Kickers Need Not Apply – 8 First Impressions of the Medicare ACO Rule

Vince Kuraitis

First published 4/1/11 on e-Care Management

On March 31, CMS released the long-awaited “Medicare Shared Savings Program: Accountable Care Organizations” document (ACO Rule). Read the details here (strong suggestion: unless you’re working on your PhD in ACOs, start with the fact sheets).

There are many surprises. Here are eight first impressions on this 429 page tome:

  1. The bar has been set high…very high.  Tire kickers need not apply.
  2. Don’t expect to see many or any small ACOs.
  3. Patients will be confused by ACOs.
  4. Concerns over maintaining competition and avoiding antitrust are being taken seriously.
  5. CMS scores points for coordinating the ACO Rule across Federal agencies.
  6. CMS loses points for micromanagement and a controlling mindset.
  7. Possible losers — hospitals, ACO vendors.
  8. Possible winners — physicians, health plans.

The details follow.

Continue reading “Tire Kickers Need Not Apply – 8 First Impressions of the Medicare ACO Rule”

FAQs on Accountable Care Organizations

Jenny Gold

First published 3/31/11 on Kaiser Health News

Accountable care organizations take up only seven pages of the massive new health law yet have become one of the most talked about provisions. This latest model for delivering services offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs. A cottage industry of consultants has sprung up to help even ordinary hospitals become the first ACOs on the block.

The President’s Health Care Predicament

James C. Capretta

First published 3/31/11 on Kaiser Health News

Last week marked the one-year anniversary of President Barack Obama’s health reform law. It’s an appropriate time to take a look back at the events of last year, and what they might mean in 2012 when the president will almost certainly be seeking reelection.

In early 2010, after Republican Scott Brown was elected to the Senate from Massachusetts, Obama had no choice — if he really wanted the health bill enacted — but to turn its passage into a make-or-break moment for his presidency. Nothing else would have worked. He wasn’t winning the public argument over its merits, and wasn’t going to. The balance of public opinion had been solidly against it ever since the first trillion-dollar cost estimates were released in mid-2009. The only way he was ever going to get it across the finish line was by tying the measure’s success to that of his presidency, thus forcing the hand of wavering Democrats, who didn’t want to vote yes on the legislation but were even more squeamish about derailing their own party’s fresh and promising administration. And so he made that his closing argument. As numerous press accounts documented, in private conversations with lawmakers, the president pleaded with his allies to save his presidency by voting yes on the health measure.

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High Deductible Plans: When Spending Less on Health Care Isn’t Always Good News

Jonathan Cohn

First published 3/30/11 on Kaiser Health News

Conservatives think traditional health insurance provides too much financial protection from medical expenses. They also think that the Affordable Care Act will make this situation worse. That’s one reason they want to repeal it.

The problem, according to the conservatives, is that insurance dulls the average person’s consumer instincts. When medical care is cheap or free, people don’t bother to shop around for the best prices — and they don’t think twice before seeing the doctor. In other words, they end up with too much care at too high a price. Insurance and government programs spread that cost around, so that eventually all of us end up paying more in the form of higher premiums or taxes over which we have little individual control.

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GAO Report Outlines Alternatives To Individual Mandate

Merrill Goozner

First published 3/29/11 on Gooz News

Democratic Senator Ben Nelson of Nebraska, who faces a tough re-election battle in 2012, raised hackles among health care reform supporters in early February when he told Chris Matthews on MSNBC’s “Hardball” that “we need to find an alternative” to the individual mandate, which requires that the uninsured buy coverage once the state-based health insurance exchanges are up and running after 2014. With that mandate under legal assault by governors, state attorneys general and conservative activists at least 20 states, including Nebraska, it appeared the Blue Dog Democrat, who voted for reform, was moving to his right in an effort to shore up his electoral base.

See here.

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Logical Bare Necessities


Originally published 2/7/11 on Organon

Andrew Koppelman at Balkinization calls Judge Vinson’s opinion a “bizarre collection of non sequiturs.” I’ve also noticed instances of the opposite: super-sequiturs—conclusions which logically follow from any premise whatsoever because they are necessarily true. Here’s one:

[T]he record seems to strongly indicate that Congress would not have passed the Act in its present form if it had not included the individual mandate.

(p. 66-67 of the opinion [pdf])(oomphasis added). I don’t know about the record, but the law of material equivalence strongly indicates that Vinson is right: if Congress had passed the ACAwithout the individual mandate, Congress would not have passed the ACA in its present form—with the individual mandate.

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It Will Be Democratic Senators Leading The Charge To Fix Or Improve The New Health Law


Originally published 1/31/11 on Kaiser Health News

When the House of Representatives roll was called Jan. 19, only three Democrats joined with House Republicans in voting to repeal the new health law. This development was notable in that it meant most of Democrats who voted against the overhaul the first time around, and were reelected to Congress in November, voted not to repeal it this time — evidence that they may be sensing that support for the health overhaul hardening. A quick examination of public opinions offers evidence as to why this idea might be taking hold.

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