Entries in Riddle, Clive (304)


Undermining the Health Reform Agenda From Within

Bureaucrats with CMS are determined to pull the plug on a family practice program for bureaucratic reasons, devastating a local government, a local economy in the midst of a recession, an underserved health care population and the Obama Administration’s own health care reform objectives. And if that can happen in one community, it will happen in another and another, with different scenarios but the same results. The administration’s health reform agenda can be undermined from within.

The emerging Medical Home movement is an important component of the Administration’s stated health care agenda. Medical Homes are primary care driven, in an era when the shortage of primary care physicians is accelerating. Thus CMS administrative actions taken to further reduce the supply of primary care physicians is not in the interest of Medical Homes.

Family Practice residency programs not only help develop the supply of community based primary care physicians, they deliver health care services to vulnerable populations, which is again an important component of the Administration’s agenda that CMS is thus undermining.

Where is all of this taking place? As reported in the local paper, the Modesto Bee, in the March 14, 2009 article Stanislaus County doctors program loses its funding: “The Stanislaus Family Medicine Residency Program...has lost its federal funding and that has put its future in doubt. The federal Centers for Medicare and Medicaid Services not only stopped payments to Doctors Medical Center, where the residents are trained, but required the hospital to pay back $19.1 million it received for the program from 2001 to 2008. Because DMC and the county split the costs of the program, the county is on the hook for half that amount.”

A March 30, 2009 California Healthline article, California Medical Residency Program Fights CMS for Funding, elaborates:“Founded in 1935, the program was originally a general practice residency at the public county hospital. It earned family medicine accreditation in 1975. When the county hospital closed in 1997, the residency program was taken over by Doctor's Medical Center, owned by Tenet Healthcare Corporation. The residency program is a key part of the safety net where 22% of county residents rely on Medi-Cal and 16% of the population is unemployed. The 27 residents and 30 primary care doctors who serve as faculty for the program care for about 70,000 patients, handling about 230,000 patient visits annually, according to the California Academy of Family Physicians.”

So why is the plug getting pulled? California Healthline reports that “until 2006, it was business as usual with the residency program training 27 family practice physicians and billing the federal government for support through Medicare reimbursements for education....About 18 months ago, CMS attorneys began questioning the way the program was transferred from the county hospital to the new parent hospital a decade before. Marc Hartstein, deputy director of CMS' hospital and ambulatory policy group, said CMS is following rules laid out in the Balanced Budget Act of 1997. ‘That law puts caps on the numbers of residents in programs," Hartstein said, adding, "This situation arises because of those caps.’ Because Tenet's Doctors Medical Center chose not to take on the assets and liabilities of the county hospital in 1997, ‘that ended the cap that was associated with the previous hospital,’ Hartstein said. In essence, the residency program ceased to qualify for educational funding in 1997 under CMS' interpretation of the regulations. Hartstein attributed the program's funding for several years to errors by unnamed third-party administrative contractors.”

The Modesto Bee adds “when the county hospital closed almost 12 years ago, DMC's parent company, Tenet Healthcare Corp., paid the county $12 million and guaranteed care for patients in the county's indigent health program. The physician training program was transferred to DMC based on a claim that, in effect, it had merged with the county hospital. The federal government provided DMC with $115,000 in annual reimbursements for each of the 27 physician slots, but CMS officials later said they disagreed with the merger theory. The reimbursement was lowered to $75,000 per resident on the premise a new program had been created at DMC. About 18 months ago, CMS attorneys came out with a determination that the program no longer qualified for reimbursements under the Balanced Budget Act of 1997. Some of the act's rules had not been written when the previous determinations were made. CMS also demanded that Doctors Medical Center repay the funding received since 2001. ...The government has said the hospital and the county can apply for reimbursements if they close the program for a year and then reopen with a new program with new faculty, a new director and a new set of residents.”

So CMS initially signed off on the arrangement, reimbursed the program for a number of years, later ruled that the arrangement was not a merger but a new program- so they lowered their reimbursement, and subsequently decided that as a new program, it didn’t qualify for reimbursement at all, and demanded all their money back retroactively. Is it within CMS’ authority to have interpreted this differently? Is CMS’s pulling the plug helping advance their Administration’s health care agenda?Is CMS’s demand of retroactive repayment from a cash starved County government helping their Administration advance their object of economic stimulus?

Yes, No and No.

And watch out in your home town, because CMS oversees such a wide range of health care programs and services. Shuffle the deck a little, and your local community probably has some situation that could be a ticking time bomb for CMS to uncover, and blow up the Administration’s health care and economic stimulus agenda for you too.


Serious Games: Health Plans and Health Games

By Clive Riddle, March 25, 2009

Should you be playing games with your health? (Alright, maybe the correct word is “for” and not “with”, but I wanted your attention.) Nevertheless, a growing body of policy, research, health care, and health insurance organizations think you should.

The Serious Games Initiative founded at the Washington DC based Woodrow Wilson Center for International Scholars, applies cutting edge games and game technologies to a range of public and private policy, leadership, and management issues.” The Initiative earlier this decade launched Games for Health to coalesce a community of researchers, health care professionals and game developers involved with games designed for health care applications. The organization’s Games for Health Fifth Annual Conference will be held June 11-12, 2009 in Boston.

Humana became a believer in the movement. In September 2007 , Grant Harrison, vice-president of Humana’s Integrated Consumer Experience said “giving healthcare consumers the ability to become more closely connected with the management of their health through video games is a unique way in which to accomplish Humana’s goal of helping members become both mentally and physically health.” The company stated that Humana’s Innovation Center would research and develop “the best ways to connect with consumers using game technology. In collaboration with Serious Games pioneer Digitalmill Inc., Humana is evaluating all aspects of the games for health space.”

In May 2008 they launched HG4H: Humana Games for Health, a web site for their initiative, and began forging partnerships with schools and other organizations to offer various exercise and games for health programs. HG4H has since partnered with various game developers to offer “interactive video games that provide fun physical and mental workouts and motivate healthy lifestyle choices.” HG4H has categorized their offerings into six categories: exergames, persuasive games, casual games, educational games, virtual world games and pervasive games.

Just last month, when announcing new online games added to the HG4H program, Paul Puopolo, Humana’s director of consumer innovation stated “we know that a healthier lifestyle doesn’t have to be boring and these games are a perfect way for consumers to connect health with a technology they already enjoy. With childhood obesity on the rise, games like Lunch Crunch and Bubble Trouble give kids the lessons in health they need but present the message in an entertaining way – through a little friendly competition online. We also know that baby boomers are looking for ways to keep their minds young, so games like Split Words and Entangled Objects help with cognitive functions and attention skills – exercises that so many adults need.”

Lunch Crunch? Bubble Trouble? Split Words? Entangled Objects? These don’t sound like the offerings typically announced in press releases by health plan. Trying to get to the bottom of just what’s going on here, I spoke to Laura Fay, CEO of HAPPYneuron, Inc., a developer partner with Humana. HAPPYneuron is a majority owned subsidiary of Scientific Brain Training (NYSE Euronext: MLSBT) and offers a broad range of personalized brain training workouts in multi-media formats. Scientific Brain Training was founded in 2000, and the company has had a North American presence since 2006.

For Humana, the HAPPYneuron games offered online were “designed to stimulate your attention, language, memory, planning and abstract-thinking skills” with the core targeted audience including seniors for the purpose of deferring the onset of age related brain decline. Laura told me that their Humana applications have now been up two months with public access at www.humanagames.com with five HAPPYneuron click and play games offered.

Laura shared that HAPPYneuron offers direct to consumer individual products from their web site, in addition to partnerships with organizations such as Humana. Their current and prospective partners include health plans, publications, employers, pharmaceutical companies, research organizations, educational institutions, and senior centers.

HAPPYneuron product offering include individual online memberships with “access to more than 3,000 hours of unique game play with its 34 innovative online games... designed and developed by a team of neurologists and cognitive psychologists to work the brain’s five major cognitive functions: memory, attention, language, visual/spatial and executive” and “HAPPYneuron Junior, a series of 24 online games has been developed by a group of neurologists and specifically designed for children 8 through 12 years old.” The company also offers CD/DVDs and books.

Their core offerings involve memory games providing “cognitive training fun with very diverse exercises, each one with numerous options, difficulty levels and data sets.” Laura stated an end result is to deliver a level of peer comparison, with exercise data results that provide feedback on a given exercise compared to the applicable peer group

I asked Laura what ROI can their cognitive training games offer Humana or other health care partners? She answered that “a one-point increase in cognitive activity corresponded with a 33% reduction in the risk of Alzheimer’s” and share the following cost implications (citing the Alzheimer’s Association as her source):

  • 10 million Boomers will get Alzheimer’s Disease
  • The average lifetime cost of care for someone with Alzheimer’s disease is $174,000
  • The annual of caring for someone with Alzheimer's is $18,400 for someone with mild symptoms, $30,100 for moderate symptoms and $36,132 for severe symptoms.
  • Medicare costs for beneficiaries with Alzheimer’s disease were $91 billion in 2005. Medicare costs are expected to increase by 75% to $160 billion in 2010 and to $180B by 2015

For developers such as HAPPYneuron, there’s more than fun and games at stake here in the emerging games for health sector. According to the Health eGames Market Report 2008 “iConecto estimates the Health eGaming market at approximately $7 billion during the next 12 months including the markets for brain fitness ($267M), exergaming ($6.4B+) and other Health eGames on the consumer and professional side ($250M+).”


Employers Committed to Active Employee Health Benefits for 2010

by Clive Riddle, March 9, 2009

Are employers going to shed health benefits from their employee compensation packages as the recession deepens? Last week, Hewitt Associates released results from a January 2009 employer survey, in their report: Survey Findings: Challenges for Health Care in Uncertain Times 2009.

Commenting on the survey results, Jim Winkler, Hewitt’s head of Health Management Consulting, said "in today's environment, employers are under pressure to cut health care expenses, but they realize that short term cost management tactics do not address the underlying drivers of health care cost. This leaves them with two options: making a long-term commitment to improving the health of employees and their families, or exiting health care altogether. Most companies believe that investing in the long-term health of their population is the most effective way to mitigate costs and create a more productive and engaged workforce."

However, in keeping with survey results and company headlines, Hewitt found retiree health benefits are not as sacred. While less than 1% of the 340 large employers surveyed plan to eliminate health benefits for their active populations, 13% indicated plans to eliminate benefits for their retirees next year.

Furthermore, while employers thus remain committed to offering benefits to actives, they intend to make a number of reductions and adjustments in order to cope with the economic downturn. Hewitt found that:

  • 49% intend to reduce the number ofplans and options offered
  • 65% plan on increasing the level of employee cost sharing with insurance premiums
  • 30% intend to reduce, and 6% eliminate incentive programs; while 24% will reduce and 2% eliminate wellness programs, often just recently put in place
  • Another 26% plan on reducing retiree health benefits, in addition to the 13% who will eliminate them
  • 13% will reduce, and 6% eliminate health benefits for part time employees

On the other hand, despite the downturn, many employers are looking to enhance certain programs and initiatives for 2010:

  • 40% will increase consumer driven plan offerings
  • 33% will increase wellness programs
  • 20% will increase incentive programs
  • 13% will increase their overall health benefits package

Because the impact of the recession didn’t hit until the 2009 benefit year was already put into place, whatever employers are going to change as a result of the recession, their changes are coming in 2010 versus having already implemented them in 2009.


Health Care Stakeholders Weigh In On the Obama Budget

By Clive Riddle, February 27, 2009

So how do some key stakeholders view the health care implications of President Obama’s FY 2010 budget?

AHIP (America’s Health Insurance Plans) applauds the health care agenda, sort of. As the voice of the health plan industry, AHIP is compelled register very deep concerns over cutting Medicare Advantage payments to plans. Will we return to the Medicare health plan market withdrawals of a decade ago? Karen Ignagni, AHIP President, states:

“We have strongly supported recent efforts by the Administration and Congress to strengthen the health care safety net, expand coverage for kids, conduct comparative effectiveness research, and invest in health information technology. Our Board of Directors has offered a comprehensive proposal that starts with us playing a leadership role in advocating for market reforms and addresses the core issues of cost, access, and quality. Health plans will continue to be constructive participants in the health care reform discussion. We recognize that to achieve reform of this magnitude, every stakeholder group will be expected to contribute and will be challenged to innovate, perform better, and be held accountable for results.“As policymakers evaluate the entire Medicare program, including Medicare Advantage, as part of health care reform, it is vital that seniors continue to have access to the benefits and services they rely on. Medicare Advantage plans provide care coordination, disease management, and prevention programs for seniors and reward clinicians for delivering quality care to patients. Unfortunately, this proposal would force seniors enrolled in Medicare Advantage to fund a disproportionate share of the costs to reform the health care system. A cut of this scale would jeopardize the health security of more than ten million seniors enrolled in Medicare Advantage and would turn back the clock on innovative payment incentives to improve the quality of care that patients receive.”

The AHA (American Hospital Association) commends the President, sort of. They are quite concerned that “half of the reserve fund would come from savings in health care programs, including proposals to bundle Medicare payments for hospital and post-acute care ($17.84 billion in savings), reduce payments to hospitals with certain readmission rates ($8.43 billion), and link a portion of inpatient hospital payment to performance on specific quality measures ($12.09 billion). The budget outline also cites the need to address physician self-referral to facilities in which they have a financial interest."

AHA President and CEO Rich Umbdenstock states, "We commend President Obama for making health reform a top priority in his budget blueprint. However, we are concerned about any cuts that would affect the work hospitals do for their communities during this economic downturn. We remain ready to work with the president and Congress to strengthen health care in America."

The AMA (American Medical Association) offers applause without the reservations in bold print. They like the rollback of planned physician Medicare payment cuts. Nancy H. Nielsen, MD, President, American Medical Association states “President Obama’s budget proposal takes a huge step forward to ensure that physicians can care for seniors by rejecting planned Medicare physician payment cuts of 40 percent over the next decade. Looming widespread physician shortages coupled with aging baby boomers highlight the urgent need for permanent Medicare physician payment system reform to preserve seniors’ access to health care. “The AMA is committed to working with the administration and Congress to develop reforms that will reward and preserve access to high-quality care for seniors and all Americans.”

AARP (the Amer) not only applauded the budget, but now tells Congress to step up and act on it. AARP CEO Bill Novelli states “We are making it clear to our leaders that they need to work with the president in a bipartisan fashion to complete the plan for reform and finance reform in a fiscally—and morally—responsible way. They must make sure that any savings from Medicare and Medicaid are dedicated to reforms that strengthen the quality, efficiency and performance of our health care system, including these critical lifeline programs.”

AARP also announced key priorities to be included in health reform legislation in 2009, including: Making affordable health care coverage options available to everyone, especially people ages 50-64 who are among the fastest growing group of uninsured; Keeping Medicare affordable by rewarding doctors and hospitals for quality rather than the quantity of care; Promoting prevention and healthy behaviors; Eliminating fraud, waste and abuse; and Improving care coordination for people with chronic conditions and helping them stay in their homes and out of institutions.

The National Business Group on Health is pleased and concerned: they are “very pleased to see such emphasis on making health care affordable for all American” but don’t like new taxes and Medicare Advantage cuts.

Helen Darling, President of the National Business Group on Health states "with respect to proposed financing schemes for health reform, we have concerns that the funding mechanism could be subject to constant political pressures. The proposed 10-year $634 billion health-care fund - paid for through new taxes and particularly cuts to Medicare Advantage beneficiaries - approximates the annual portion of health spending that is estimated to be wasteful, redundant, or even harmful. We believe there are other ample opportunities to reduce costs through eliminating overuse of services, preventing serious adverse avoidable medical errors, and combating waste. As legislation is crafted in the coming months, we strongly encourage policymakers to look at the root causes of higher health care costs and use health reform as an opportunity to make lasting structural reforms - many of which have been discussed previously by both the President and congressional leadership - that will yield long-term savings and improve patient care and safety."

So, what does your spokesperson have to say about the ten year $634 billion health care fund, and the budget?




The Path to Reform as laid out by the Commonwealth Fund


By Clive Riddle , February 19, 2009


The Commonwealth Fund Commission on a High Performance Health System today published their report, the Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, which the Commonwealth Fund in a press release distributed today bills as a proposal for “a comprehensive set of insurance, payment, and system reforms could guarantee affordable health insurance coverage, improve health outcomes, and slow the growth of health spending by $3 trillion by the end of the next decade” and “details the Commission’s recommendations for an integrated set of policies and assesses the impacts of specific policy actions from 2010 to 2020, compared to the status quo.”


The Commonwealth Fund is a major policy stakeholder organization in Washington, and has the ear of various key Democratic party health care leaders. Not that the eventual Administration or Congress reform proposal would mirror the Commonwealth Fund’s report by any means, but it has significant potential to influence the discussion, and thus bears reading.


 Here’s some projected results the report touts would be ultimately achieved via their proposed package:


  • Insurance reforms would extend coverage to everyone within two years, with only 1 percent uninsured throughout the next decade. The number of uninsured, currently 48 million and estimated to increase to 61 million by 2020, would instead under the proposal decrease to 19.7 million in 2010, 6.3 million in 2011 and stabilize at 4 million for the rest of the decade
  • Combined with payment and system reforms initiated in 2010, the integrated approach to reform could slow the growth of national health spending by a cumulative $3 trillion by 2020.
  • Spending would still go up but at a slower rate. The U.S. is expected to spend $42 trillion on health care over the next 11 years, with spending rising 6.7 percent per year, the proposal package would lower this rate to 5.5 percent per year.

So how would such lofty results be achieved? Here’s a verbatim summary as provided in the 122 page report:

  • National Health Insurance Exchange. Offers businesses and individuals a choice of private plans and a new public plan, phased in by size of firm with all eligible by 2014. Premium of the public plan would be community rated within broad age bands. Benefits are similar to the standard option in the Federal Employees Health Benefits Program. The plan would use Medicare’s claims administrative structure and reformed payment methods and rates.
  • Individual Mandate. All individuals are required to obtain coverage.
  • Affordability. Premiums are capped at 5 percent of income for low-income individuals and 10 percent of income for those in higher-income tax brackets.
  • Shared Financial Responsibility. Employers are required to provide coverage or contribute to a trust fund. The example used in the model included 7 percent of payroll, up to $1.25 an hour.
  • Medicaid/SCHIP Expansion. All individuals with incomes up to 150 percent of the federal poverty income level are eligible for Medicaid acute care benefits. Medicaid provider payment rates are raised to Medicare levels. The federal matching rate is increased to offset state costs.
  • Medicare. The two-year waiting period for coverage of the disabled is eliminated. Medicare beneficiaries are offered a supplement with the same acute care benefits as in new public plan and premium affordability provisions.
  • Insurance Market Reforms. Require community-rate premiums (age bands permitted) and guaranteed issue and renewal of policies. Premium and insurance information would be publicly available on the Web.
  • Enhance Payment for Primary Care. Increase Medicare payments for primary care by 5 percent and apply differential updates for primary care and other care.
  • Encourage Development and Spread of Patient-Centered Medical Homes. Provide payment per patient in addition to fee-for-service to practices qualified to provide patient-centered care. Reduced premiums and cost-sharing available to patients who designate a primary care practice as their medical home. Shared savings would be distributed on the basis of performance.
  • Bundled Payments for Acute Care Episodes. Expand acute care payment to include services during the hospital stay and 30 days post-discharge in a global fee. The policy would be phased in, starting with inpatient services in 2010, then post-acute care in 2013, and hospital inpatient and outpatient physician care in 2016.
  • Correcting Price Signals. Modify payments by: 1) slowing the rate of Medicare payment updates in geographic areas with high costs; 2) reducing prescription drug costs by having Medicare pay Medicaid prices for drugs used by dually eligible beneficiaries and determining Medicare payments for unique drugs with effective monopolies based on prices paid in other countries; and 3) resetting benchmarks for Medicare Advantage plans in each county to projected per-capita spending under traditional Medicare.
  • Accelerate the Adoption and Use of Health Information Technology. Require all providers to report key health outcomes electronically by 2015 to qualify for payment updates. Provide funding to support health information networks and assistance for safety-net providers and small practices through a 1 percent assessment on insurance premiums and Medicare outlays.
  • Center for Medical Effectiveness and Health Care Decision-Making. Create a mechanism to develop information on the clinical and cost-effectiveness of alternative treatment options. Fund the Center with a .05 percent assessment on insurance premiums and Medicare and Medicaid spending. Use the information in benefit designs with higher out-of-pocket costs or differential pricing depending on comparative effectiveness and include physician–patient shared decision
  • Reduce Tobacco Use. Increase federal taxes on tobacco products by $2 per pack of cigarettes. Use revenues to fund public health programs and insurance expansion.
  • Reduce Obesity and Alcohol Use. Establish a new tax on sugar-sweetened soft drinks of 1 cent per 12-ounces to finance state obesity prevention programs, and increase the federal excise tax on alcohol by 5 cents per 12-ounce can of beer, with proportionate increases on other alcohol products. Use funds for prevention and insurance expansion.

The Commonwealth Fund Commission on a High Performance Health System was established by the organization in 2005, to “seek opportunities to change the delivery and financing of health care to improve system performance, and to identify public and private policies and practices that would lead to those improvements. It also explores mechanisms for financing improved health insurance coverage and investment in the nation's capacity for quality improvement.”


So who has a seat at the table for the Commission. Not all major stakeholders. Integrated hospital/medical group systems, large non profit health plans, some progressive employers, and like-minded associations, policy institutions and academic institutions are well represented. For profit health plans and health care providers, non-integrated private providers, public agencies and dissimilar institutions are not. Here’s the list of the Commission members:

  • James J. Mongan, M.D. (Chair), President and CEO, Partners HealthCare System, Inc.
  • Maureen Bisognano, Executive Vice President and COO, Institute for Healthcare Improvement
  • Christine K. Cassel, M.D., President and CEO, American Board of Internal Medicine and ABIM Foundation
  • Michael Chernew, Ph.D., Professor, Department of Health Care Policy, Harvard Medical School
  • Patricia Gabow, M.D., CEO, Denver Health
  • Robert Galvin, M.D., Director of Global Health Care, General Electric Company
  • Fernando A. Guerra, M.D., Director of Health, San Antonio Metropolitan Health District
  • Glenn M. Hackbarth, J.D., Consultant
  • George C. Halvorson, Chairman and CEO, Kaiser Foundation Health Plan, Inc.
  • Robrrt M. Hayes, J.D., President, Medicare Rights Center
  • Cleve L. Killingsworth, Chairman and CEO, Blue Cross Blue Shield of Massachusetts
  • Sheila T. Leatherman, Research Professor, School of Public Health, University of North Carolina
  • Gregory P. Poulsen, Senior Vice President, Intermountain Health Care
  • Dallas L. Salisbury, President and CEO, Employee Benefit Research Institute
  • Sandra Shewry, President and CEO, California Center for Connected Health
  • Glenn D. Steele, Jr., M.D., Ph.D., President and CEO, Geisinger Health System
  • Mary K. Wakefield, Ph.D., R.N., Associate Dean for Rural Health and Director, Center for Rural Health, University of North Dakota
  • Alan R. Weil, J.D., Executive Director, National Academy for State Health Policy
  • Steve Wetzell, Vice President, HR Policy Association