New Physician Fee Schedule Just Days Away

CMS is expected to release its final rule on the 2010 Medicare Physician Fee Schedule by November 1, 2009. Cardiologists are still facing some of the biggest cuts.

Here's how one cardiologist in Arkansas describes his efforts to travel to rural areas to treat patients and how the cuts could hurt those efforts: http://www.youtube.com/guardinghearts#p/a/u/0/szk0wj0S-gY

Are There Really 46 Million Uninsured Americans?

It seems like the number of uninsured Americans always stays around 46 million. It doesn't go up by a huge percentage each year. And it seems like people always like to attack Texas and its "high uninsured population." But you rarely see a breakdown of what the uninsured population really looks like.

National Review Online did an interesting job of breaking down the 46 million uninsured Americans:

“The American health-care debate is a blizzard of numbers, but few get tossed around as frequently as “46 million.” According to the Census Bureau’s Current Population Survey (CPS), that’s roughly how many people (the more precise figure was 45.7 million) lacked health insurance at a given moment in 2007 — nearly one-sixth of the entire U.S. population. ... Economist Keith Hennessey, director of the National Economic Council under Pres. George W. Bush, has examined the 2007 data and sliced the 45.7 million uninsured into several distinct clusters, basing his estimates on an earlier government analysis, conducted in 2005. Hennessey reckons that

· “6.4 million were enrolled in Medicaid or the State Children’s Health Insurance Program — now known just as the Children’s Health Insurance Program (CHIP) — but misreported their status (a phenomenon known as the “Medicaid undercount”);

· “4.3 million were eligible for Medicaid or CHIP but not enrolled;

· “9.3 million were noncitizens;

· “10.1 million belonged to families earning more than 300 percent of the federal poverty level (FPL); and

· “5 million were childless adults aged 18 to 34.

“If we eliminate those individuals from the original 45.7 million, we are left with about 10.6 million.”

Cleveland Clinic's Top 10 Medical Innovations for 2010

The Cleveland Clinic's 2009 Medical Innovation Summit just wrapped up. They released their "Top 10 Medical Innovations for 2010" list. They include:

10. Whole-Slide Imaging for Management of Digital Data In Pathology: A technology for creating digital pathology slides with excellent image quality that can be viewed, stored, streamed over the Internet, and analyzed on a computer.

9. Devices for Occluding Left Atrial Appendage to Reduce Stroke Risk: Device alternatives to long-term warfarin use that can prevent clots from developing in patients with atrial fibrillation.

8. Oral Thrombopoeitin (TPO) Receptor Agonist That Stimulates Platelet Production: A recently approved drug that stimulates production of cells in bone marrow that form platelet cells in the blood.

7. Outpatient Diagnosis of Sleep-Related Breathing Disorders: Self-contained, reliable, at-home sleep-monitoring devices for screening, diagnosing, and treatment assessment of sleep-related breathing disorders.

6. Forced Exercise To Improve Motor Function in Patients With Parkinson's: Pedaling at 90 RPMs on a tandem bike to dramatically improve motor functioning of patients with Parkinson's disease.

5. Fertility Preservation Through Oocyte Cryopreservation: A rapidly-improving technology that allows eggs of a healthy woman to be safely frozen and stored, ready to be thawed and fertilized at a later date.

4. Non-Vitamin K Antagonist Oral Anticoagulants: Predictable and well-tolerated alternatives to the oral anticoagulant warfarin that provide a more convenient -- and safe -- way for patients to dose themselves and prevent blood-clot formation.

3. Continuous-Flow Ventricular Assist Devices: Tiny 3-ounce devices surgically attached alongside the heart that quietly and effectively take over the pumping ability of the heart.

2. Low-Volume, Low-Pressure Tracheal Tube Cuff To Reduce Ventilator-Associated Pneumonia: A device that dramatically reduces the risk of ventilator-associated pneumonia and death in the hospital ICU by providing continuous effective airway seals.

1. Bone Conduction of Sound For Single-Sided Deafness: A new non-surgical, removable hearing and communication device designed to imperceptibly transmit sound via the teeth to help people with single-sided deafness.

Cancer Prevention and Research Institute of Texas Grants Available

The state's new cancer organization announced new grants available to organizations for cancer outreach programs. The deadline to submit the grants is November 13, 2009.

Two Requests for Applications (RFAs) for cancer prevention grants are available on the CPRIT website (www.cprit.state.tx.us).

Evidence-Based Prevention Programs and Services
This RFA seeks grant applications from qualified organizations located in the State of Texas that would provide services aimed toward prevention and reduction of the risk of cancer, early detection, and improving the lives of those living with the disease. These projects would provide services that are based on scientific evidence of their effectiveness in prevention of cancer or improvement in quality of life. CPRIT expects measurable outcomes of supported activities that demonstrate impact on incidence, mortality, or morbidity or interim measures related to the outcomes. Successful applicants are eligible for a grant award of up to $1 million for up to 24 months.

Health Promotion, Public Education, and Outreach Programs
This RFA seeks grant applications from qualified organizations located in the State of Texas that propose education and outreach efforts that have the potential to demonstrate change in the behaviors that can prevent or reduce the risk of cancer. CPRIT seeks projects and partnerships that will apply evidence based strategies in novel ways, leverage resources and can demonstrate measureable outcomes in personal behaviors leading to prevention, risk reduction, early detection of cancer and improve the quality of life for survivors. Successful applicants are eligible for a grant award of up to $300,000 for up to 24 months.

The online application system for prevention grant submission will be available October 15, 2009 at 7:00a.m. CST. The deadline for grant submissions is November 13, 2009 at 3:00 p.m. CST. CPRIT expects to award the first round of prevention grants in March or April of 2010.

CPRIT has created two new list serves to provide up-to-date information by email to anyone interested in agency news and grant information. To sign up for the list serves, please visit the CPRIT website (http://www.cprit.state.tx.us) and click the “Listserve” button on the top information bar.

Health Care Overhaul Package Before Thanksgiving?

There is talk that the Congress could attach a health care overhaul package to one of the tax bills before Thanksgiving. Of course, nobody knows if that would include a public health insurance option or not.

In addition, eight moderate Democrat senators sent a letter to congressional leadership asking them to present the health care bill at least 72 hours before a vote. They include: Bayh, Lincoln, Pryor, McCaskill, Landrieu, Ben Nelson, Lieberman and Webb.

Powerchair Registration Forms in a Dallas Hospital Waiting Room

I am sitting in a Dallas hospital and there is a box where you can place registrations for a powerchair from Nationalwide Medical Equipment, Inc. "Register for a free evaluation." I wonder if the hospital realizes that this registration box is here.

WSJ Article Examines Pennsylvania Health Care Outcomes System

Today's Wall Street Journal examined Pennsylvania's extensive health care outcomes reporting system for Pennsylvania health care facilities. "Hospitals Find Way to Make Care Cheaper - Make It Better" looked at the death and complications rates that are reported to the state.

Texas will soon enforce its own health-care associated infections (HAI) in health care facilities. Regulators will hold a meeting in Austin later this month to examine reporting requirements.

The article can be viewed by clicking here: http://online.wsj.com/article/SB125478721514066137.html

Corrections to Senate Finance Committee CBO Score

The Senate Finance Committee made a few corrections to the Chairman's Mark. The Congressional Budget Office (CBO) requested this so that they could score the bill. They are mostly technical in nature.

 CORRECTIONS
Page 56, Children’s Health Insurance Program
The maintenance of effort requirement for children in Medicaid and for CHIP expires on September 30, 2019, not on December 31, 2019 as the document indicates.
Page 116, CMS Innovation Center
Strike the sentence beginning with “To be approved for expansion” and ending with “individualized care plans.
Page 126, Redistribution of Unused Graduate Medical Education Slots
The GME redistribution pool was reduced to 65% in the Modification to the Mark.
The implementation date for the redistribution of residency slots should be July 1, 2011 rather than July 1, 2010.
Page 252, Review and Report by the U.S. Department of Veterans Affairs
The review and report by the Secretary of the U.S. Department of Veterans Affairs shall review and report to Congress on the effect of the fees outlined in Title VI of the Chairman’s Mark not just the fees on branded drugs and medical devices.
CLARIFICATIONS
Page 12, Grandfathered Plans
Any individual or group with existing coverage would be able to keep this plan through the grandfather policy – not just those with a policy equal in value or greater than the “young invincible” plan.
Page 23, Deductible for Small Employer Plans
The deductible amounts for small employer plans ($2,000/$4,000) are indexed to premium growth.
Page 35, Penalty Amount in 2017 and Beyond
The penalty amount of $750 is indexed to CPI-U after 2017.
Page 35, Threshold for Affordability Exemption
The 8% threshold for the affordability exemption is indexed in the same manner as the income caps in the exchanges.
Page 38, Cap on Employer Penalty
The $400 cap on the employer penalty is indexed to premium growth. Page 2
Page 116, CMS Innovation Center
The list of potential opportunities for improving quality and reducing costs are intended to be illustrative not binding; the Secretary would have authority to focus on identifying, designing, testing, and evaluating models that would be expected to reduce program costs while preserving or enhancing the quality of care received by individuals receiving benefits.
Page 128, Promoting Greater Flexibility for Residency Training Programs
Hospitals and eligible training sites participating in a jointly operated residency training program will receive GME payments proportional to the resident costs incurred at each facility.
Page 164, MA Coding Intensity
The policy to transition current MA benchmarks to competitively bid benchmarks from 2011 through 2013 also includes the current law coding intensity adjustment over that time frame.
Page 168, Grandfather Policy for MA Plans
The grandfather policy applies only to beneficiaries enrolled in MA on the date of enactment and excludes rebate payments or performance bonus payments under competitive bidding.
The Secretary shall review the utilization factor for grandfathered plans and only allow factors that reasonably capture added use of care from the extra benefits allowed by the grandfather provision based on historical bids.
Page 174, MA Private Fee-for-Service Plans
The waiver for employer-based PFFS plans only applies to employer-sponsored plans (as defined in 1857(i)(2)) that have enrollment as of the date of enactment.
Page 176, Provider-Specific Cap on Home Health Outlier Payments
The Secretary would continue to withhold 5% from episode payments for the outlier pool, with payouts capped at 2.5%.
Page 183, Extension of Section 508 Reclassifications
In implementing this provision, the Secretary shall use the hospital wage index promulgated in the Federal Register on August 27, 2009 (74 Fed. Reg. 43754) and any subsequent corrections.
Page 187, Medicare Market Basket Cuts
The first paragraph should read: “For hospitals, the provision would require a market basket minus 0.25% reduction in 2010 (effective January 1, 2010) and 2011 for inpatient and outpatient hospitals, inpatient psychiatric facilities, inpatient rehabilitation and long term care hospitals.”
Page 187, Productivity
The first sentence should read: “The provision would provide for updates based on the MB or CPI minus full productivity for all Parts A and B providers, except for Graduate Medical Education, who are subject to a MB or CPI update.”
Page 188, Clinical Labs
Add to the fifth year of the 1.75% reduction x percentage point additional reduction to equal $100 million in additional savings.

Kidney Dialysis Payment Changes

Several weeks ago, CMS proposed a new payment system for renal dialysis facilities - bundled payments. It is expected to hurt some drug makers. However, the verdict is out as to how it could impact facilities.

Meanwhile, the Office of Inspector General, in its FY 2010 Work Plan, included a few renal issues in its items to be analyzed. Among them:

Medicare Payments for End-Stage Renal Disease Drugs
We will review dialysis facilities’ fourth-quarter 2008 average acquisition costs for selected ESRD drugs and compare these to fourth-quarter 2008 Medicare payment amounts. Medicare bases payment on 106 percent of the drugs’ ASPs. However, effective January 1, 2011, MIPPA will change payments for ESRD items and services by bundling ESRD drugs, which are currently billed separately, with all of the other costs of ESRD care. Previous OIG reviews have found that Medicare payments for the majority of separately billable ESRD drugs are consistently higher than average acquisition costs reported by dialysis facilities and prices paid by the Department of Veterans Affairs (VA). We will also compare facilities’ 2008 fourth-quarter average acquisition costs to the costs that facilities reported for these drugs in previous quarters.
(OEI; 03-09-00280; expected issue date: FY 2010; work in progress)


Renal Dialysis Facilities’ Dosing Guidelines for Erythropoiesis-Stimulating
Agents
We will review whether protocols used by renal dialysis facilities for erythropoiesis-stimulating agents (ESA) adhere to FDA labeling recommendations. In response to research published in 2007, FDA approved revised labeling for ESAs, including a “black box” warning recommending that ESAs be dosed to maintain a hemoglobin value of less than 12 g/dL. According to the revised labeling for ESAs, maintaining hemoglobin levels above 12 g/dL can adversely affect a patient’s health, possibly resulting in death. There are concerns that dialysis facilities may be using dosing guidelines, standards, and protocols that are not consistent with the revised labeling
recommendations. We will determine the extent to which renal dialysis facilities’ protocols for administering ESAs are consistent with CMS’s monitoring policy for ESA claims.
(OEI; 03-09-00010; expected issue date: FY 2010; work in progress)

Ambulance Services Used To Transport End-Stage Renal Disease Beneficiaries
We will review the extent to which ambulance services are used to transport ESRD beneficiaries to and from dialysis facilities. CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 10, § 10.3, describes coverage of ambulance services to and from renal dialysis facilities for ESRD patients who require dialysis. Furthermore, section 623(f) of the MMA requires the Secretary to develop a report on a bundled PPS for ESRD services. The bundled PPS for ESRD services generally does not provide for ambulance services. In CY 2005, payments for ambulance services between beneficiaries’ residences and hospital-based or freestanding ESRD facilities were approximately $262 million. We will examine factors such as the percentage of
the population using ambulance services, the feasibility of contracting by freestanding facilities with ambulance suppliers, and the coverage policies of other health insurance programs.
(OAS; W-00-10-35417; various reviews; expected issue date: FY 2010; new start)