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Health Policy, Healthcare Reform

Legislative Update: January 17, 2017

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Marilyn Singleton, MD, JD is back with her first legislative update for the 115th Congress. 

The 115th United States Congress has convened with the introduction of numerous health care bills. Most bills we looked at last year have “died in a previous Congress.” Bills are not carried forward from Congress to Congress. They have two years to make it into law.

Senate Sets Stage for Reconciliation Bill: First Step in Repealing ACA

On January 12, 2017, the Senate voted 51-48 along party lines (with a lone Republican “NAY” by Rand Paul) for the resolution – S.Con.Res. 3 –  that will start the reconciliation process. The House followed with its approval in a 227-198 vote on January 13. Reconciliation allows for expedited consideration of certain tax, spending, and debt limit legislation. A reconciliation measure cannot be filibustered and the Senate can pass such a bill with a simple majority. This is the same procedure used to pass the ACA. Under the resolution, the House and Senate committees must come up with repeal legislation by January 27th.  Under this process, however, only certain taxing/spending-related provisions of the ACA would be repealed, but would not repeal the entire law. For example, pre-existing condition mandates for insurers would remain.

Additionally, House Speaker Paul Ryan said he would like a “concurrent” replace and repeal.

 

Another Step Toward Interstate Licensure

Jan 9, 2017, H.R. 302, the Sports Medicine Licensure Clarity Act of 2017, was introduced by Brett Guthrie (R-KY). This was a re-introduction of the same 2016 bill. On January 9, 2017, the bill passed the House and was referred to Senate Committee on January 10th. The bill protects sports medicine professionals to who have malpractice insurance and provide services to an athlete in a Secondary State pursuant to a contract, the insurance shall cover the professional. If the professional is licensed in the Primary State, they are presumed to have satisfied licensure requirements for licensure in the Secondary State (where services were rendered). This bill’s language is another step in opening the door for interstate licensure.

Full text: https://www.govtrack.us/congress/bills/115/hr302/text.

 

Just What We Don’t Need: Another Commission

On January 5, H.R. 309, the National Clinical Care Commission Act, was introduced by Rep. Pete Olsen (R-TX).  On January 9, 2017, the House passed the bill.  This bill amends the Public Health Service Act to establish within the Department of Health and Human Services (HHS) a National Clinical Care Commission to evaluate and recommend solutions regarding better coordination and leveraging of federal programs that relate to supporting clinical care for individuals with complex metabolic or autoimmune disease, diabetes, or complications caused by such diseases.

The duties of the commission include: evaluating HHS programs regarding the utilization of preventive health benefits, identifying current activities and gaps in federal efforts to support clinicians in providing integrated care, making recommendations regarding the development and coordination of federally funded clinical practice support tools, recommending clinical pathways for new technologies and treatments, evaluating and expanding education and awareness activities provided to health care professionals, and reviewing and recommending methods for outreach and dissemination of educational resources. The commission must submit an operating plan to HHS and Congress within 90 days of its first meeting. The commission is terminated after it submits a final report, but not later than the end of FY2021.

Full text: https://www.govtrack.us/congress/bills/115/hr309/text.

 

On Jan 9, 2017, H.R. 315, the Improving Access to Maternity Care Act, was introduced by Rep. Michael Burgess (R-TX). On January 9, 2017, the bill passed the House and was referred to Senate Committee on January 10th. This bill amends the Public Health Service Act to require the Health Resources and Services Administration (HRSA) to identify areas within health professional shortage areas that have a shortage of maternity care health professionals, for purposes of assigning maternity care health professionals to those areas.

Full text: https://www.govtrack.us/congress/bills/115/hr315/text.

 

A Batch of Health Care Related Bills: Awaiting the Text

Ted Cruz introduced a bill to repeal the ACA in its entirety. This may end up being the only relevant bill. Multiple bills were introduced that chipped away at the Affordable Care Act. These may be posturing for the congressperson’s constituency or they honestly believe the ACA will not be repealed.  Rand Paul has tweeted out the first page of “THE Obamacare Replacement Plan,” which he says will be released in full soon.  He shared some details in an interview with CNN.

Senate:

On January 4, 2017, S. 28, the Health Savings Account Expansion Act of 2017 was reintroduced by Sen. Jeff Flake. It is a bill “to amend the Internal Revenue Code of 1986 to expand the permissible use of health savings accounts to include health insurance payments and to increase the dollar limitation for contributions to health savings accounts, and for other purposes.”  The House companion bill is H.R. 247, introduced by Rep. Dave Brat.

On January 5, 2017, S. 41, A bill to amend part D of title XVIII of the Social Security Act to require the Secretary of Health and Human Services to negotiate covered part D drug prices on behalf of Medicare beneficiaries was introduced by Sen. Amy Klobuchar (D-MN) and referred to the Senate Finance Committee.

On January 10, 2017, S. 85, a bill to amend the Internal Revenue Code of 1986 to repeal the amendments made by the Patient Protection and Affordable Care Act which disqualify expenses for over-the-counter drubs under health savings accounts and health flexible spending arrangements was introduced by Sen. Pat Roberts (R-KS) and referred to the Senate Finance Committee. The sister bill in the House, H.R. 394, was introduced on January 10th by Rep. Lynn Jenkins (R-KS) and referred to the House Ways and Means Committee.

On January 10, 2017, S. 93, a bill to allow women greater access to safe and effective contraception was introduced by Sen. Joni Ernst (R-IA) and referred to the Senate Finance Committee. The sister bill, H. R. 421 was introduced by Rep. Mia Love (R-UT) and referred to the House Energy and Commerce and Ways and Means Committees.

On January 12, 2017, S. 106, a bill to repeal the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010 in its entirety was introduced by Sen. Ted Cruz (R-TX) and referred to the Senate Finance Committee.

On January 12, 2017, S. 109, a bill to amend title XVIII of the Social Security Act to provide for coverage under the Medicare program for pharmacist services was introduced by Sen. Charles Grassley (R-IA) and referred to the Senate Finance Committee.

House:

On January 6, 2017, H.R. 352, a bill to amend the Social Security Act to replace the Medicaid program and the Children’s Health Insurance program with a block grant to the States was introduced by Rep Todd Rokita (R-IN) and referred to the House Appropriations, House Committee on Education and the Workforce Committee, and 6 other committees.

On January 9, 2017, H.R. 370, a bill to repeal the patient Protection and Affordable Care Act and health care-related provisions in the Health Care and Education Reconciliation act of 2010, was introduced by Rep. Bill Flores (R-TX) and referred to the House Appropriations, House Committee on Education and the Workforce Committee, and 7 other committees.

On January 10, 2017, H.R. 407, a bill to amend the Internal Revenue Code of 1986 to allow a deduction for premiums for insurance which constitutes medical care, was introduced by Rep. Steve King (R-IA) and referred to the House Ways and Means Committee.

On January 10, 2017, H.R. 408, a bill to amend the Internal Revenue Code of 1986 to expand health savings accounts was introduced by Rep. Steve King (R-IA) and referred to the House Ways and Means Committee.

On January 10, 2017, H.R. 409, a bill to amend title XVIII of the Social Security Act to sunset certain penalties relating to meaningful electronic health records use by Medicare eligible professionals and hospitals was introduced by Rep. Steve King (R-IA) and referred to the House Energy and Commerce and Ways and Means Committees.

On January 10, 2017, H.R. 410, a bill to amend title XVIII of the Social Security Act to exclude coverage of advance care planning services under the Medicare program was introduced by Rep. Steve King (R-IA) and referred to the House Energy and Commerce and House Committee on Ways and Means Committees.

On January 12, 2017, H.R. 499, a bill to require members of Congress and congressional staff to abide by the Patient Protection and Affordable Care Act with respect to health insurance coverage was introduced by Rep. Ron DeSantis (R-FL) and referred to the House Energy and Commerce and House Administration Committees, and 2 other committees.

On January 12, 2017, H.R. 508, a bill to expand Medicare coverage to include eyeglasses, hearing aids, and dental care was introduced by Rep. Lucille Roybal-Allard (D-CA) and referred to the House Energy and Commerce and Ways and Means Committees.

On January 13, 2017, H.R. 521, a bill to amend the Internal Revenue Code of 1986 to provide an exemption to the individual mandate to maintain health coverage for individuals residing in counties with fewer than two health insurance issuers offering plans on an Exchange was introduced by Rep. Mark Amodei (R-NV) and referred to the House Ways and Means Committee.

On January 13, 2017, H.R. 537, a bill to amend the Internal Revenue Code of 1986 to provide an exemption to the individual mandate to maintain health coverage for individuals residing in counties with fewer than two health insurance issuers offering plans on an Exchange; to require members of Congress and congressional staff to abide by the Patient Protection and Affordable Care Act with respect to health insurance coverage was introduced by Rep. Andy Biggs (R-AZ) and referred to the House Energy and Commerce and House Administration Committees, and 2 other committees.

On January 13, 2017, H.R. 562, a bill to amend the Internal Revenue Code of 1986 to flatline the individual mandate penalty was introduced by Rep. Luke Messer (R-IN) and referred to the House Ways and Means Committee.

On January 13, 2017, H.R. 563, a bill to amend the Internal Revenue Code of 1986 to exempt certain individuals from the individual health insurance mandate was introduced by Rep. Luke Messer (R-IN) and referred to the House Ways and Means Committee.

 

Only My Opinion

There a bill from the last Congress that I am glad is dead. Sen. Ron Wyden (D-OR) introduced Senate Resolution 590, a resolution commemorating 100 years of health care services provided by Planned Parenthood, “affirm[ing] that Planned Parenthood remains an essential thread in the fabric of society.” My objection is that Planned Parenthood’s founder, Margaret Sanger is quite controversial. She supported eugenics, noting, “Eugenics suggests the reestablishment of the balance between the fertility of the “fit” and the “unfit.” In The Pivot of Civilization (1922) she referred to immigrants and poor people as “reckless breeders,” “spawning…human beings who never should have been born.”  No matter what one’s views on today’s Planned Parenthood or abortion are, Planned Parenthood’s advocates should include a denunciation of its founder’s extreme views alongside its praise for the present-day organization.

Culture & Society, Health Policy, Healthcare Reform, Medicare, Medicine, Op-eds

Obama the Emperor Has No Clue

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The Emperor Has No Clue

By Marilyn M. Singleton, M.D., J.D.,

When President Obama hawks the wonders of the misnamed Patient Protection and Affordable Care Act, I’m reminded of those “As Seen on TV” products.

True believers ridiculed critics of the Independent Payment Advisory Board and its unchecked power to ration health care. They were impressed by the $575 billion cut to Medicare, although lower payments lead physicians to accept fewer Medicare patients. They cheered because 11 million Americans will be added to the Medicaid rolls over the next ten years.

While Medicaid looks like is a good deal with its low co-pays, provider payments are so low that only one-third of physicians accept new Medicaid patients.

True believers scoffed at claims of loss of privacy. After the NSA snooping revelations, a Pew survey revealed that 70 percent of Americans believe the government is using data for purposes other than fighting terrorism.

Not only could unethical employees misuse health and financial information, the health “Data Hub” can be shared among seven federal agencies for ill-defined “routine uses.” According to a former HHS general counsel, the federal government’s computer program for insurance exchanges lacks privacy safeguards and could expose applicants to identity theft.

President Obama has repeatedly promised that “if you like your health care plan, you can keep it.” Even his Praetorian Guard has now defected. The National Treasury Employees Union—which represents the IRS folks who are ultimately in charge of ObamaCare—does not want its members to be “pushed out” of the Federal Employees Health Benefits Program and into the insurance exchanges.

Candidate Obama promised: “If you already have health insurance, the only thing that will change for you under this plan is that you will spend less on premiums.” Au contraire. Insurance premiums have risen an average of 30 percent since ObamaCare’s enactment. In Orange County, California, premiums for a 25-year-old in good health will rise by 95 percent.

Insurance will cost less for the lucky 26 million Americans who are eligible for health insurance exchange subsidies that can pay more than half the cost of policies. Subsidies—paid directly to insurance companies—are available for those with incomes from 138% ($15,415 for individuals; $29,326 for a family of four) to 400% ($45,960 for individuals; $94,200 for a family of four) of the poverty level.

The ACA was to have employers report whether they were offering employees “affordable” care. Now with the employer mandate delayed, exchanges may accept applicants’ statements that they qualify for subsidies without further verification.

Another wrinkle in the program could limit access to care. If enrollees pay one month’s premium, exchanges must provide a grace period of three consecutive months during which coverage cannot be terminated. However, insurers are only required to pay claims during the first 30 days of the grace period.

Thus, patients with valid insurance cards in hand can seek treatment at a doctor’s office on day 31 through 90 of the grace period. When the physician in good faith submits a claim to the insurer, the claim can be denied. Although the physician can bill the patient, realistically, many patients simply will not pay.

Chalk up another win for the insurance industry, which has off-loaded two-thirds of the risk of nonpayment onto physicians.

ObamaCare ignores human nature. Despite the claimed efforts to have patients adopt behaviors that help control costs, two recent studies in the journal Health Affairs demonstrate that people do not change merely because you tell them to.

Uninsured and Medicaid patients reported that they preferred care in an emergency room to a doctor’s office. For Medicaid patients the financial cost of an ER visit and the physician’s office were similar, but the ER was more convenient. The uninsured reported the cost of office care was higher because of additional testing or specialist visits.

Another study revealed that a majority of patients didn’t want costs to enter into their medical decisions. Some participants even chose expensive care “out of spite” because of antagonism toward their insurance company.

Hucksterism cannot overcome reality. Government efforts at mass control are doomed.

Successful reform requires innovation, maximization of personal engagement with medical treatment, and minimization of third party involvement. ObamaCare does the opposite.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

Health Policy, Healthcare Reform, Law, Medical Ethics, Medicare, Medicine

The Medicare Bundlers and Bunglers Are Coming!

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Medicare: The Bundlers Are Coming! The Bunglers Are Coming!

Author/contributor:  Marilyn M. Singleton, M.D., J.D.

My long-time self-paying patient opined that the end of fee-for-service payments (payment for what you get) was imminent. I lightheartedly asked her how physicians would be paid. Would they be housed in military barracks and given vouchers for necessaries?

Perhaps she read section 3023 of the “Patient Protection and Affordable Care Act” (PPACA or “ObamaCare”), the National Pilot Program on Payment Bundling, which applies to certain Medicare beneficiaries.

The program’s stated goals are to improve access to care, quality, coordination, and efficiency (i.e., reduce costs) of services. Pilot programs, which started this year, will be conducted for 5 years, or longer if extension results in improved quality and reduced spending.

An earlier “pilot program” on payment by diagnosis (DRG or diagnosis related group), regardless of what the patient did or did not receive, simply became national practice in 1983 without looking at the results. Then there’s the HMO method of payment by the head (capitation), regardless of care or lack thereof. How will payment by the bundle be different?

A bundle or an episode of care includes the three days prior to admission to the hospital, the hospital stay, and 30 days (not 31 days) after discharge from the hospital. It comprises “applicable services”: acute inpatient services, all physicians’ services in and outside the hospital, outpatient and emergency room services, all post-acute care services (e.g., skilled nursing facility, rehab, home health), and other services the Secretary deems appropriate.

The amount of payment will depend partly on “quality” measures developed by the Secretary in consultation with the Agency for Healthcare Research and Quality. The measures include: functional status improvement, reducing rates of avoidable hospital readmissions, rates of discharge to the community, rates of admission to an emergency room after hospitalization, incidence of health care acquired infections, efficiency measures, measures of patient-centeredness of care, and measures of patient perception of care.

What do these things mean? Does “functional status” mean ability to perform ADLs (activities of daily living)? What if patient is so disabled that his ability to do ADLs can’t improve? What if he still needs a lift to get to the toilet, but can now beat his grandson at gin rummy? Does that count as an improvement?

What about the ultimate measure of functional status—being alive rather than dead? Might a hospital’s “efficiency” rating be better if the patient dies, instead of being readmitted or acquiring an infection?

The bundle will be characterized by a code from the soon-to-be-required U.S. ICD-10CM system. This International Classification of Diseases—Clinical Modification system is based on the 1992 World Health Organization ICD-10 codes. It increases the number of diagnostic codes in the current ICD-9 system from 17,000 to 68,000, including different codes for right or left side. Providers will have to be much more specific in their coding.

Even though providers will have to do much more work to code and do other documentation tasks, the bundled payments cannot be more than what would otherwise be paid for the beneficiary’s care. It is not clear who all will have to share the payment—perhaps the hospitalist, perhaps the patient’s own physician, along with all the team members needed to provide whatever the Secretary deems appropriate.

The changes in “payment methodology” may be seen as a power struggle. Rick Mayes wrote in 2007:

For the first time, the federal government gained the upper hand in its financial relationship with the hospital industry.

Medicare’s new prospective payment system with DRGs triggered a shift in the balance of political and economic power between the providers of medical care (hospitals and physicians) and those who paid for it—a power that providers had successfully accumulated for more than half a century.

Some claim that bundling is a way to save Medicare, previous measures including the Sustainable Growth Rate (SGR) fee cuts having failed. In reality, it simply adds to the opportunity for bureaucratic bungling, while moving payment still further away from the value of care to real live patients.

Instead of more complex formulas, we need more transparency so that beneficiaries can make their own informed decisions about their individualized medical care, without interference from bureaucrats and the special interest groups that feed on the current muddled system.

Dr. Marilyn SingletonDr. Marilyn M. Singleton, MD, JD is a board-certified anesthesiologist and member of the Association of American Physicians and Surgeons (AAPS).

Dr. Marilyn Singleton ran for Congress in California’s 13th District in 2012, fighting to give its 700,000 citizens the right to control their own lives.

While still working in the operating room, Dr. Marilyn Singleton attended UC Berkeley Law School, focusing on constitutional law and administrative law. She also interned at the National Health Law Program and has practiced both insurance and health law.

Dr. Marilyn Singleton has taught specialized classes dealing with issues such as the recognition of elder abuse and constitutional law for non-lawyers. She also speaks out about her concerns with Obamacare, the apology law and death panels.

Congressional candidate Dr. Marilyn Singleton presented her views on challenging the political elite to physicians at the Association of American Physicians and Surgeons annual meeting in 2012.

Follow Dr. Marilyn Singleton on Twitter @MSingletonMDJD

More info about Dr. Marilyn Singleton

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