By Melissa Attias, CQ Staff

April 23, 2010 -- Although telehealth technologies have strong potential for improving patient health and decreasing U.S. health care costs, economic disincentives, inadequate broadband connectivity, regulatory uncertainty and a lack of digital literacy among seniors all create barriers to their adoption, witnesses said Thursday at a hearing of the Senate Special Committee on Aging.

The hearing examined how the Federal Communications Commission's National Broadband Plan, which was created in the 2009 economic stimulus law (PL 111-5) to ensure that all Americans have access to broadband, might aid implementation of telehealth technologies. Also known as "eCare," telehealth technologies are tools that deliver health-related services and information using telecommunications technologies to facilitate remote monitoring of people in their homes, increase access to specialty services in rural areas and allow individuals access to clinicians remotely.

"There are multiple barriers that must be resolved in order to develop the ecosystem of broadband-enabled health IT," FCC Digital Healthcare Director Mohit Kaushal said in prepared testimony. "Technology alone will not solve our health care challenges. It must be coupled with payment reform, innovation in service delivery and improved regulatory transparency before we will recognize the health benefits and cost savings promised by these technologies."

According to Kaushal, estimates show that the benefits and savings associated with telehealth technologies could be significant. One study he cited said that the remote monitoring of patients with just four chronic conditions would generate net savings of roughly $200 billion over 25 years.

In addition, the Care Coordination/Home Telehealth Program implemented by the veterans hospital system has already resulted in a 19 percent reduction in hospital admissions and a 25 percent reduction in bed days for those veterans that are admitted, Kaushal said. At $1,600 per patient per year, Kaushal said the program costs far less than the Veterans Health Administration's home-based primary care services ($13,121 per patient per year) and nursing home care rates ($77,745 per patient per year).

A study conducted by Robin A. Felder, professor of pathology and associate director of clinical chemistry at the University of Virginia School of Medicine, similarly found that monitored seniors residing in a senior living facility demonstrated a 36 percent reduction in billable medical procedures, a 78 percent reduction in hospital days and a 68 percent reduction in cost of care, Felder testified.

Yet all witnesses agreed that several major obstacles would delay the successful implementation of telehealth technologies. For one thing, the National Broadband Plan estimates that 93 million Americans are not connected to broadband, Kaushal said, and approximately 3,600 small physicians' offices are not served by the existing mass-market broadband infrastructure.

"It is imperative that hospitals and physicians offices have adequate connectivity, as any care that will be delivered to an individual's home will originate in a health care facility of some description," Kaushal said in his testimony.

Kaushal, Richard Kuebler of the University of Tennessee and Eric Dishman of Continua Health Alliance agree that another significant obstacle to successful implementation of telehealth technologies is inadequate reimbursement policies. The traditional fee-for-service reimbursement system pays for volume, not outcomes, and prevents many of these telehealth technologies from being paid for, they testified. Kuebler heads the Telehealth Department at the University of Tennessee's Health Science Center, and Dishman serves as senior policy adviser at Continua Health Alliance.

"All the promising research done on aging-in-place and telehealth solutions will never come to fruition unless we find ways to ensure that the broadband infrastructure is there to support these activities and Medicare and other health programs acknowledge the value of the services these eCare technologies provide," Dishman said in written testimony. "The acknowledgement must be in the form of reimbursement for the service or an incentive to the provider to provide eCare."

Yet another concern is whether the new technologies will fall under the jurisdiction of the Federal Communications Commission, which regulates general-purpose communications devices, or the Food and Drug Administration, which regulates medical devices, Kaushal said. Other obstacles include patient concerns with privacy and a lack of digital literacy among senior populations.

"The demand side is the key issue," Farzad Mostashari, senior adviser to the national coordinator for health information technology at the Department of Health and Human Services, said during the hearing. "People have to have a reason for getting online."

Democratic Sen. Ron Wyden of Oregon, who chaired the hearing, asserted in prepared remarks that examining telehealth technologies should be a top priority for whoever is confirmed as head of the federal Medicare program.

"Only when the United States has a reliable broadband infrastructure and policies in place to encourage the development and deployment of innovations in health care will we transform our health system into one that emphasizes health care rather than sick care," Wyden said in his opening remarks. "If we can achieve this, we can enable America's seniors the ability to comfortably age in place."

By Jane Norman, CQ HealthBeat Associate Editor

April 19, 2010 -- The White House on Monday announced that Donald Berwick has been nominated as administrator of the Centers for Medicare and Medicaid Services, filling the administration's last major health care position 15 months after President Obama took office.

The nomination was delayed while Congress and the White House were preoccupied with the year-long battle to enact the health care law, but Berwick's selection came as no surprise since White House officials said in late March that Berwick would be the nominee. It puts Obama's selection at the helm of an agency that will be central to the work of implementation of the new law (PL 111-148) as Medicare cuts are put in place and Medicaid undergoes a massive expansion. CMS is a major purchaser of health care in the United States and influential in its cost.

Yet it's also a tough and sensitive post in its need for a chief who can keep at bay the many members of Congress with strong opinions about federal health programs that exercise a direct impact on many constituents' lives.

Obama in this pick has selected a pediatrician by training who's focused on quality improvement in health care in his career and is already well-known throughout the health care policy world.

Berwick currently is president and CEO of the Institute for Healthcare Improvement, and is a professor at Harvard Medical School and the Harvard School of Public Health. He's also a pediatrician, adjunct staff in the Department of Medicine at Boston's Children's Hospital and a consultant in pediatrics at Massachusetts General Hospital.

"Dr. Berwick has dedicated his career to improving outcomes for patients and providing better care at lower cost," Obama said in a statement. "That's one of the core missions facing our next CMS administrator, and I'm confident that Don will be an outstanding leader for the agency and the millions of Americans it serves."

Congressional aides said Berwick's hearing will be the jurisdiction of the Senate Finance Committee, which oversees Medicare and Medicaid. The Senate Health, Education, Labor and Pensions Committee will not be involved. A Finance hearing date has not been announced. The nomination was sent to the Senate by the White House shortly after it was announced.

Finance Committee Chairman Max Baucus, D-Mont., said the hearing process will be "expeditious" and praised the CMS choice. "Dr. Berwick is an experienced health policy expert and researcher whose career has focused on innovative and effective ways to improve health care quality," Baucus said in a statement.

"Implementing innovative ideas that work and boosting health care quality will be critical goals for the next administrator of CMS, particularly in our fight to deliver better health care outcomes and lower costs for patients across the country. Improving health care quality was a major part of the landmark health reform bill passed this year and the CMS administrator will play a crucial role implementing that law."

Republicans have promised scrutiny. Sen. Charles E. Grassley of Iowa, the top Republican on Finance, said at the time Berwick's probable nomination was reported in March that the committee "will need to explore the nominee's preparedness for the enormous challenges that face the agency."

House Ways and Means Committee Chairman Sander M. Levin, D-Mich., said Berwick has been a "visionary leader" in the field of health care, working to make the system more efficient and patient-centered. "I appreciated his insight in developing legislation to accelerate the translation of cutting-edge medical research and health care delivery best practices into bedside care, a form of which was included in the new health care reform law," said Levin.

Rep. Pete Stark, D-Calif., chairman of the health subcommittee, said he wants to see the Senate act quickly on the Berwick nomination. "His leadership and expertise are needed now as the agency implements critical Medicare reforms and other health reform initiatives at CMS," said Stark.

In a 2005 interview with the magazine Health Affairs, Berwick discussed the role of government in influencing the health agenda, and specifically about CMS.

"Government remains a major purchaser," he said. "It's much bigger than GE. So as CMS goes and as Medicaid goes, so goes the system. CMS needs to continue to develop to be the best and possible purchaser of care, on behalf of its beneficiaries. To do that through giving more choice to individuals. . . is a very weak lead. To do it as an aggregate purchaser, demanding performance, is a very strong lead."

In another interview, this one with the publication Biotechnology Healthcare in 2009, Berwick was asked about the value of comparative effectiveness research and whether it will rein in costs, and specifically about critics who say it will lead to rationing.

"We can make a sensible social decision and say, 'Well, at this point, to have access to a particular additional benefit [new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.' We make those decisions all the time," he said. "The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open. And right now, we are doing it blindly."

Berwick's nomination was met with praise from sectors of the health care industry, who said he's a proven leader.

"Dr. Berwick is a true leader of the national movement to improve the quality of care in the United States," said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents for-profit institutions, in a statement. "His efforts have made a material difference in the quality and safety of hospital care in this country."

The American Hospital Association, which represents non-profit hospitals, applauded as well. "Don is a true leader in health care quality improvement and brings a wealth of knowledge and experience to CMS," said Rich Umbdenstock, president and CEO. "Through his work at the Institute for Healthcare Improvement, Don has led a movement to engage hospitals, doctors, nurses and other health care providers in the continuous quest to provide better, safer care,"

The American Medical Association also cited his work on patient care. "He is widely known and well-respected for his visionary leadership efforts that focus on optimizing the quality and safety of patient care in hospitals and across health-care settings," said Nancy H. Nielsen, AMA immediate past president.

Susan DeVore, president and CEO of Premier healthcare alliance, which includes 2,300 hospitals, said the nomination by the White House sent a strong signal. "While with the Institute for Healthcare Improvement, Dr. Berwick earned respect and admiration from all sectors of health care for his ability to understand what drives errors and inefficiencies, challenge the status quo and overcome barriers to achieve continuous quality improvements," she said in a statement.

The American College of Cardiologists said: "As CEO of the Institute for Healthcare Improvement, Don worked alongside the ACC on our Hospital to Home campaign, an initiative that is reducing unnecessary and costly hospital readmissions and improving care transitions for cardiovascular patients. With Don's help, we're on our way to meeting our goal of reducing all-cause readmission rates among patients discharged with heart failure or acute myocardial infarction by 20 percent by December 2012."

By Emily Ethridge, CQ Staff

April 20, 2010 -- Responding to public anger over double-digit rate hikes for health insurance, a Senate panel heard testimony Tuesday about legislation that would give the federal government authority to block rate increases in states that lack such power.

Bill sponsor Dianne Feinstein, D-Calif., warned that more insurance companies may follow the lead of Anthem Blue Cross, which recently hiked rates 39 percent for some California customers, before the new health care overhaul (PL 111-148, PL 111-152) begins to take full effect in 2014.

"There is a gaping hole in our regulatory system, and it is unacceptable," said Tom Harkin, D-Iowa, chairman of the Senate Health, Education, Labor and Pensions Committee.

Feinstein's bill (S 3078) would allow the secretary of Health and Human Services to review premium increases in states where the insurance commissioner does not have sufficient authority to do so, and to block or modify them before they go into effect. The secretary also could take corrective actions such as providing rebates to consumers affected by large increases.

Under the new health care law, insurance companies must use the vast majority of money from premiums to pay for medical claims — 85 percent for large groups and 80 percent for small groups and individuals. The federal government can review rate increases, including an annual review of potentially "unreasonable" hikes.

But the government cannot halt spikes in premium rates like the one proposed by Anthem.

"Less responsible companies are going to attempt to price out people who are sick or injured, or might become sick or injured by 2014," Michael T. McRaith, director of the Illinois Department of Insurance, told the Health, Education, Labor and Pensions Committee on Tuesday.

Panel Republicans oppose the measure, saying insurance commissioners in many states already are allowed to block rate increases they deem excessive. Additional federal intervention would be unnecessary and unhelpful, the GOP members said.

"This is another Washington takeover of state responsibility," said Lamar Alexander, R-Tenn.

Prospects Uncertain
Insurance companies said the true drivers of health care costs are more expensive medical services, and neither the health care law nor Feinstein's proposal would adequately address that issue.

Karen Ignagni, president and chief executive of the insurance industry group America's Health Insurance Plans, requested that Congress wait to see the effects of the current health care law before trying to address its suspected shortcomings.

The group is "very concerned about the prospect of new legislation," Ignagni said.

Harkin acknowledged that rate review is not a panacea for rising costs, but he quoted the National Association of Insurance Commissioners, which said that "rate review authority is an important tool for regulators, and can help keep insurance companies honest."

He also noted that about 22 states in the individual market and 27 states in the small-group market do not currently require a review of premiums before they go into effect.

President Obama had included Feinstein's proposal in his blueprint for the health care overhaul. Lawmakers left it out, however, when the Senate parliamentarian ruled that the language would not survive a challenge under procedural rules.

Harkin told reporters he would try to "get this bill moving" this year, adding that there is "more support than opposition" to the measure in the Senate.

Feinstein, however, seemed less certain about the bill's prospects. She said she may offer the legislation as an amendment to another bill, but she did not specify which one.

John Reichard contributed to this story.

By Jane Norman, CQ HealthBeat Associate Editor

April 21, 2010 -- A major new study by University of Pennsylvania researchers found that a California law mandating minimum nurse-to-patient ratios reduced patient deaths and allowed nurses to give more attention to their patients.

The study published in the journal Health Services Research looked at data from more than 22,000 nurses in California, New Jersey and Pennsylvania. California was the first state to require minimum nurse-to-patient ratios in acute care hospitals.

The study headed up by Linda Aiken, a registered nurse and director of the Center for Health Outcomes and Policy Research at the university, said that nurse workloads in California in 2006, two years after the law's enactment, were "significantly lower" compared to workloads in New Jersey and Pennsylvania.

"Nurses in California care for an average of one fewer patient each, and these lower ratios have sizable effects on surgical patient mortality," said the study. "In medical and surgical units, where nurse recruitment and retention has long been difficult nationally, nurses in California on average care for over two fewer patients than nurses in New Jersey and 1.7 fewer patients than nurses in Pennsylvania."

The researchers used predicted probabilities of dying from adjusted models to estimate how many fewer deaths would have occurred in New Jersey and Pennsylvania hospitals if the average patient-to-nurse ratios in those hospitals were the same as the average ratio across the California hospitals They said there would have been 13.9 percent fewer surgical deaths in New Jersey and 10.6 percent fewer surgical deaths in Pennsylvania.

"Most California nurses, bedside nurses as well as managers, believe the ratio legislation achieved its goals of reducing nurse workloads, improving recruitment and retention of nurses and having a favorable impact on quality of care," the study added.

It was praised by National Nurses United, an organization of registered nurses. "This research documents what California RNs have long known — safe staffing saves lives," said Malinda Markowitz, co-president of the California Nurses Association and National Nurses United.

By John Reichard, CQ HealthBeat Editor

 
April 19, 2010 -- Two of the nation's biggest health insurers, UnitedHealthcare and Wellpoint, announced Monday they will allow young men and women who otherwise would lose coverage in coming weeks to stay on their parents' health plans.

Under the new overhaul law (PL 111-148), insurers must allow young adults to stay on their parents' plan until age 26. However, that provision doesn't take effect until Sept. 23, 2010.

UnitedHealth Group, the corporate parent of UnitedHealthcare, said some college students ordinarily would have to come off their parents UnitedHealthcare plan in coming weeks when they graduate. But "we want students to graduate into a secure future, not the ranks of the uninsured, so we are working with employers to make sure these young adults have health coverage available to them ahead of the new requirements," said Gail Boudreaux, president of UnitedHealthcare.

The move is "another tangible step we are taking to help translate the new, complex health reform directives into workable reality," she added.

Wellpoint said in its announcement that "each year in June, many individuals are no longer eligible as dependents on their parents' insurance policies because of their age, student status or other factors." The insurer added that "as a proactive measure, its plans starting June 1 will automatically retain these young individuals on their parents' policies in both fully insured group and individual health plans. Our self-insured clients and members will have the option of not offering this extended coverage."

HHS Secretary Kathleen Sebelius said in a statement that "we are encouraged by the actions of Wellpoint, UnitedHealthcare and other companies to bridge the gap." Sebelius noted that HHS also is asking other insurers to follow suit.

A Sebelius letter sent Monday to other major insurers said there would be substantial benefits for avoiding a scenario in which college students and young adults not in college were disenrolled and then re-enrolled Sept. 23.

Keeping them in their plans without that happening "would enable young, overwhelmingly healthy people, who will not engender large health care costs, to stay in the insurance pool and retain important insurance coverage," Sebelius wrote. "Taking this step will also save money for your companies by avoiding the administrative costs of disenrolling and then re-enrolling young adults." It also is "good business and will offer relief to grateful families across country."

By Rebecca Adams, CQ Staff

April 22, 2010 -- The most common feeling among U.S. voters about the massive health care legislation signed into law is "confused," according to a new poll by the Kaiser Family Foundation, a nonpartisan health research organization.

When asked how they felt about the law, 55 percent of survey respondents said they were confused, while 45 percent were pleased and 30 percent were angry. The poll surveyed 1,208 adults two weeks after President Obama signed the legislation in late March.

"People are struggling to understand how the law will affect them and their families and to separate fact from political spin," said Kaiser President and CEO Drew Altman.

The political good news for Democrats who are bracing for losses in the November congressional elections is that a majority of those surveyed expressed support for all 11 provisions listed in the poll that will take effect this year. Republicans joined Democrats and independents in backing nine of the 11 issues.

But the downside for Democrats is that respondents who are registered to vote were equally divided in their opinions about the overall bill, with 44 percent favoring the legislation, 44 percent opposed and 12 percent undecided.

The poll found that political leanings of respondents were a major factor in how they viewed the law, as they have been throughout the debate. About 77 percent of Democrats supported the overall law, compared with 12 percent of Republicans and 37 percent of independents.

When it comes to provisions taking effect this year, the most popular one would provide tax credits to small businesses that cover their workers, with 84 percent of Republicans and 91 percent of Democrats supporting it, the poll found. The least popular provision, which would limit future increases in Medicare provider payments, was supported by 57 percent of all respondents. About 40 percent of Republicans and 70 percent of Democrats supported the lower payments.

Officials at AARP, the advocacy group for seniors, focused on the positive reactions of those surveyed to specific provisions of the law, such as providing additional financial support to help Medicare beneficiaries pay for their prescription drug costs and restricting insurance company practices such as rescinding coverage when people get sick. AARP officials said the confusion revealed by the survey demonstrates why the organization needs to get information to voters that spell out the positive aspects of the law.

"A year of misinformation has left many people unaware about what the law means for them," said Drew Nannis, senior vice president at AARP. "In the coming weeks, months and years, AARP will use every available channel to ensure our members and all older Americans understand exactly what the new law means for them."