By John Reichard, CQ HealthBeat Editor

March 1, 2010 - -The rate of hospitalization for heart disease varies sharply among Medicare patients depending on where they live, the Centers for Disease Control and Prevention reported Monday.

In what it called the first-ever such analysis based on county-level data, the public health agency said that the rates were highest in counties located primarily in Appalachia, the Mississippi Delta, Texas and Oklahoma.

CDC officials said the findings could be used to target policies and programs to prevent heart disease to communities with the highest hospitalization rates.

"With targeted public health efforts, such as prevention and early identification of risk factors, and increased access to appropriate medical care, the burden of heart disease can be reduced," said Darwin Labarthe, director of CDC's Division for Heart Disease and Stroke Prevention.

The study found that in the states with the highest rates of hospitalization for Medicare heart disease patients, the rate was generally double that of the states with the lowest rates. For example, in Louisiana there were 95.2 hospitalizations for every 1,000 Medicare beneficiaries, compared with 44.8 in Hawaii.

The heart disease hospitalization rate was much higher among blacks than whites or Hispanics. Specifically, the rate was 85.3 hospitalizations per 1,000 beneficiaries for blacks, 74.4 per 1,000 for whites and 73.6 per 1,000 for Hispanics.

CDC said it's a national priority to reduce heart disease, the nation's leading cause of death. It estimated a cost this year of $316.4 billion in health care services, medications, and lost productivity.

Separately, a report released Monday by the Robert Wood Johnson Foundation and Trust for America's Health examined geographic variations in spending on public health programs.

The report found that CDC funding to states to prevent disease and improve health ranged from a per capita low of $13.33 in Virginia in fiscal 2009 to a high of $58.65 in Alaska. The report also found that states in the Midwest received the least federal funding for disease prevention while Northeastern states received the most.

By Edward Epstein and Kathleen Hunter, CQ Staff

March 4, 2010 -- Majority Leader Steny H. Hoyer laid out on Thursday a schedule to bring the long battle over health care to the House floor by late March.

It was the firmest indication yet that Democratic leaders are preparing for a final House vote on health care overhaul legislation that has bitterly divided Congress and the country before Congress leaves town for two weeks beginning March 26.

Hoyer's comment came after White House Press Secretary Robert Gibbs said early Thursday, "We're on track to get something done" before March 18, when Obama is scheduled to leave on an international trip.

But many lawmakers find the time line unreasonable — if only because so much has to happen: The House would have to pass the Senate version of the health care bill (HR 3590) and then pass a separate so-called corrections bill incorporating changes negotiated among White House officials and House and Senate leaders.

Then, under expedited budget reconciliation procedures, the Senate would have to get at least 50 senators to vote for the corrections bill. Reconciliation bars filibusters and allows a simple majority vote for passage.

And, Speaker Nancy Pelosi, D-Calif., conceded Thursday that she does not know whether she has sufficient Democratic votes to win final passage and will not have a firm head count until the corrections bill is written and vetted by analysts to determine its cost and she can start selling it to members.

"They want to see the actual legislative language" before members of the Democratic Caucus commit to supporting it, Pelosi said, a day after Obama called for an up-or-down vote on health care legislation based on a legislative outline the White House released Feb. 22.

"My expectation is, we will moving another bill in the near future, by that I mean by the Easter break," Hoyer said in remarks on the House floor.

House leaders said they are in the home stretch of drafting the corrections bill, which will then be sent along with the Senate-passed health care bill to the Congressional Budget Office for a cost estimate, perhaps by the end of this week.

Moderates in both chambers have warned that they would not be able to support the bills absent assurances that the changes do not swell the total cost.

Echoing a statement by Senate Majority Whip Richard J. Durbin on Wednesday, Pelosi said she will share the legislative language with members to gauge its viability.

Pelosi has an additional burden. She has to overcome House members' skepticism that the Senate will keep its end of the bargain and pass the corrections bill, which is geared toward winning over House members who object to provisions in the Senate bill.

"When I talk to my members I have to have two important pieces of information. One, what is the final status of the bill? And what is the Senate prepared to take?" Pelosi said.

Durbin's Take
Separately, Durbin said Thursday that Senate Democratic leaders already had locked down some preliminary commitments in favor of a final vote on the corrections bill.

"We have tentative commitments in support of a final package," Durbin said.

House and Senate leaders are inching closer each day to a deal on revised language, Durbin said.

"We're just working out some important details," he said. "At some point the Congressional Budget Office has to step in and tell us what it costs and if it works. Some of these things are interactive. You never know if one provision here is going to have a cost impact on another provision."

Still, Durbin acknowledged some that Democratic senators might oppose voting on the corrections bill if leaders, as expected, push it through under the reconciliation process.

"There's some who've expressed concern," Durbin said. "But they haven't seen the bill. And I've told them all, 'Wait. Take a look at what it looks like.' It will be the Senate bill plus some pretty positive changes. It's hard to argue against any changes we're considering."

Senate leaders may try to get Democratic senators to commit in writing to voting for the corrections bill in an effort to assuage wary House members.

"We need to assure our friends in the House that this effort on their part is going to be supported on our side," Durbin said. "And they have every right to be skeptical. The Senate rules and our record over the last year are not encouraging to anyone on the House side."

GOP Complicates Pelosi's Climb
For her part, Pelosi has been talking to Democrats who have voiced concerns that the corrections bill may not adequately address parts of the Senate bill they oppose. She has sought to reassure them, contending the White House's plan for the corrections measure largely adheres to House-passed language.

The Speaker, for example, said the corrections bill will include a more aggressive closing of a gap, known as the doughnut hole, in prescription drug coverage under Medicare.

The measure also might require equal treatment for all states under expanded Medicaid, a change meant to do away with controversial provisions in the Senate-passed bill that gave Nebraska additional subsidies to cover the state's portion of costs to expand the program.

Complicating Pelosi's effort to round up the necessary votes is an effort by Sen. John Thune,, R-S.D., the Republican Policy Committee Chairman, and his allies to put pressure on moderate House Democrats to keep the health care overhaul from being enacted.
Republican senators have been reaching out to moderate House Democrats who voted for
the House version of the bill and urging them not to vote for a revised package, Thune acknowledged. The lobbying is meant to counter White House and Democratic efforts to get House Democrats to vote the same way they voted in the first instance.

In informal talks, Thune and other Republicans have tired to rebut White House arguments that Democrats who switch their votes will pay a steep political price for abandoning their previous support for health care.

"That's what the White House is telling them, and I think some of them are starting to believe that," Thune said. "The worst thing they can do is walk off the edge of this cliff and hope that the people of the country are going to support them for that. I just don't think it's going to wash."

Abortion Provision
Pelosi seemed eager to sidestep the issue of federal funding for abortion services, an issue that has proved difficult for Democratic leaders to reconcile. Anti-abortion Democrats led by Rep. Bart Stupak, D-Mich., are threatening to vote against a final bill if it includes Senate-passed abortion language.

"This is not about abortion. This is a bill about providing quality affordable health care for all Americans," Pelosi said.

Before the House passed its version of the health care legislation (HR 3962) in November, it added an amendment by Stupak that would prohibit health insurance plans receiving federal subsidies from covering abortion procedures. Stupak had threatened to rally enough votes to sink the underlying bill unless his amendment prevailed.

Now, he is rallying anti-abortion allies to oppose the Senate-passed language, saying it is less restrictive. The Senate's language would attempt to prevent federal funding for abortion coverage by requiring people buying subsidized policies to make two monthly payments to their insurers — one to cover abortion services, and one for all other medical coverage.

Stupak said there are about 10 Democrats who will oppose the health care bill without changes to the Senate's abortion language.

"If you believe there should be no federal funding for abortion, and if you believe there should be no change in the policy, and if you believe we need health care for all Americans, we will pass the bill," Pelosi said.

Pelosi said the president and Democratic House and Senate leaders are determined to pass a bill soon and that it's time to get serious. "When people think there isn't going to be a bill, they can take whatever position they want. Now they know there is going to be a bill. . . . Let's talk," she said.
First posted March 4, 2010 2:21 p.m.

By Jane Norman, CQ HealthBeat Associate Editor

March 1, 2010 -- The Medicare Payment Advisory Commission in its annual report to Congress issued Monday rapped the continuing payment disparity that benefits private Medicare health plans over traditional Medicare.

The report was released as President Obama and congressional Democrats mount a fierce onslaught on payments for the private health plans as they seek funding for their proposed health care overhaul.

The plans, known as Medicare Advantage plans, continue to enroll members, are widely available, and offer enhanced benefits, MedPAC said. "However, taxpayers and beneficiaries in traditional fee-for-service Medicare subsidize these benefits, often at a high cost," said the report. Meanwhile, Medicare Advantage continues to swell, with 24 percent of all Medicare beneficiaries enrolled in the program as of November, for a total of 10.9 million people.

Yet commissioners also reminded Congress that fundamental problems remain within the traditional system, and recommendations included in the report for changing the base rates paid by Medicare to providers won't solve those problems, they said. Providers are paid more for delivering additional services whether or not they add to quality or value, said MedPAC Chairman Glenn Hackbarth in his letter submitting the report to Congress.

"While the commission maintains that Medicare's payment systems must be reformed, in the interim it is imperative that the current fee-for-service payment systems be managed carefully," he said. And such reform is unlikely to happen "without steady pressure on the level of prices paid by Medicare as well as attention to the relative values assigned to different services," Hackbarth said.

The commission has made many recommendations to increase the quality of care and improve coordination among scattered providers, including the beginning of bundling of payments for multiple services, "medical homes" and accountable care organizations.

The idea of the medical home is to have chronically ill patients under the supervision of physician practices that deliver effective preventive care and improve coordination of services. Accountable care organizations would creates teams of providers to better coordinate treatment.

MedPAC, as it's known, is a non-partisan and independent congressional agency set up to advise Congress on issues surrounding Medicare. While its recommendations are not binding, they are widely quoted in health care policy debates and the agency's data is relied upon by members of Congress.

The report said that the Medicare Advantage program continues to be more costly than fee-for-service Medicare. While commissioners support private plans they also believe that the Medicare program should not pay Medicare Advantage plans more than fee-for service plans. The higher spending results in additional government spending and higher Part B premiums for all beneficiaries "at a time when both the Medicare program and its beneficiaries are under increasing financial stress," said the report.

Specifically, if currently scheduled 21 percent cuts to physician reimbursement payments take effect in 2010, Medicare Advantage payments per enrollee would be an estimated 113 percent of comparable fee-for-service spending in 2010, the commission said. If the physician fees are not cut, the payments would be a projected 109 percent of comparable fee-for-service spending.

While the recommendations on Medicare Advantage are not a new stance, the slap at private plans comes while Democrats in health care overhaul measures approved in both the House and Senate are attempting to cut funding for the plans. They do so in the face of opposition from the industry and from some in Congress. "Millions of seniors. . .who have chosen Medicare Advantage will lose the coverage that they now enjoy," said Rep. Paul Ryan, R-Wisc., at a bipartisan health care summit at the White House on Feb. 25.

But President Obama said that money saved by cutting Medicare Advantage could be used to fill the prescription drug "doughnut hole" encountered by seniors who exhaust their regular benefits. He said, "I just want to focus on Medicare Advantage because I haven't seen an independent analyst look at this and say seniors are healthier for it or taxpayers are better off for it."

At a briefing for reporters, Mark Miller, the executive director for MedPAC, also highlighted what he said are press accounts that in the past have overstated the problems that Medicare beneficiaries have finding primary care physicians. Miller said that MedPAC surveys have found 6 percent of beneficiaries report they are seeking new physicians. Of that group, about a quarter say they are having trouble finding a doctor — which he said translates to roughly 1 to 2 percent of all beneficiaries. Commissioners, however, remain concerned about the access issue and the direction in which it might be heading, Miller said.

The report also includes recommendations on provider payment rates that commissioners voted on at their January meeting, including those for hospitals, physician services, dialysis, hospices and more.

By John Reichard, CQ HealthBeat Editor

March 1, 2010 -- The Government Accountability Office released a report Monday saying that 55 percent of Medicare enrollees taking at least one of a category of high-cost pharmaceuticals known as "specialty tier" drugs reached what Medicare considers to be "catastrophic" levels of out-of-pocket drug spending.

Pete Stark, D-Calif., Chairman of the House Ways and Means Committee's Health Subcommittee, released a statement saying that the best way to help these seniors is for Congress to fill the "doughnut hole" in Medicare prescription drug coverage, in which patients must pay 100 percent of their pharmaceutical costs.

The House-passed drug overhaul bill (HR 3962) and the package of overhaul revisions recommended by President Obama would fill the doughnut hole.

Prescription drug plans in the Medicare program can assign drugs to different tiers of coverage, with out-of-pocket costs varying by tier. Thus, to encourage the use of lower-cost generic drugs, a plan sponsor might have a tier with generic drugs that charges a lower out-of-pocket charge than it does for a tier with more costly, brand-name drugs.

The Centers for Medicare and Medicaid Services also allows plans to establish a specialty tier when the total monthly cost of a drug exceeds a specified amount, set by CMS as $600 per month in 2010. Drugs eligible for the specialty tier are not necessarily the same as "specialty drugs," although the two groups do overlap. Specialty drugs treat complex conditions and require special handling, while a specialty-tier drug is simply one that exceeds the cost threshold.

Medicare enrollees who use specialty-tier drugs typically face much higher out-of-pocket charges.

"Among all beneficiaries who used at least one specialty-tier-eligible drug in 2007, 55 percent reached the catastrophic coverage threshold, after which Medicare pays at least 80 percent of all drug costs," the GAO reported. "In contrast, only 8 percent of all Part D beneficiaries who did not use a specialty-tier-eligible drug reached this threshold in 2007."

Prices negotiated by plans for specialty-tier drugs are rising quickly — by an average of 36 percent over the past three years, Stark said, citing the GAO report. For example, the report found that the average negotiated price for the breast cancer drug Gleevec increased 46 percent between 2006 and 2009, from about $31,200 per year to about $45,500 yearly.

Stark said that the health care overhaul should ensure that the federal government, as the biggest purchaser, gets the best price for specialty-tier drugs. Critics say that expanding the government's negotiating power would lessen industry research and development, among other ills.

By Alex Wayne, CQ Staff

March 3, 2010 -- Flanked by doctors and nurses, President Obama demanded Wednesday that Congress send him health overhaul legislation on an up-or-down vote — a tacit endorsement of Democratic leaders' plan to use budget reconciliation procedures to finish the legislation.

Noting that both chambers had already passed health care bills (HR 3590 in the Senate, HR 3962 in the House), Obama said that a final bill, modeled on a proposal he released last week, "deserves the same kind of up-or-down vote that was cast on welfare reform, the Children's Health Insurance Program, COBRA health coverage for the unemployed and both Bush tax cuts — all of which had to pass Congress with nothing more than a simple majority."

While the president never used the word "reconciliation," all of the initiatives he mentioned were passed by a GOP-controlled Senate using the expedited parliamentary procedure that blocks the minority party's ability to stage a filibuster.

Obama said he had asked congressional Democratic leaders to schedule votes on a final bill "in the next few weeks." And he appealed to wavering Democrats worried that another vote on health care could end their political careers, as well as to Senate Republicans determined to stop the legislation at all costs.

"From now until then, I will do everything in my power to make the case for reform," Obama said. "And I urge every American who wants this reform to make their voice heard as well — every family, every business owner, every patient, every doctor, every nurse."

Moments after he spoke, the White House announced that the president would travel to Pennsylvania and Missouri next week to talk about the health legislation.

After weathering months of criticism that he had not done enough to shape health care legislation, the president has now offered a timeline, specific proposals and talking points. And he left no doubt that he planned to bring pressure on wavering members of his own party.

"At stake right now is not just our ability to solve this problem, but our ability to solve any problem," he said. "The American people want to know if it's still possible for Washington to look out for their interests and their future."

While completing a health care overhaul is expected to be a heavy lift in both houses, there were some signs lawmakers might be closing ranks. On the Senate floor immediately after his remarks, Sen. Max Baucus, D-Mont., echoed the theme that passing a final bill through a simple majority vote was "the right thing to do."

Earlier in the day, Majority Whip Richard J. Durbin, D-Ill., said that Democrats were "coming to closure" on revised language being written jointly by House and Senate lawmakers and White House officials.

Obama on Feb. 22 had outlined what he wants to see in a health care compromise, posting a summary on the White House's Web site. On Tuesday, he indicated a willingness to incorporate four Republican proposals that were outlined at a White House health care summit on Feb. 25.

Obama's plan would cost about $950 billion over 10 years — more than the Senate bill, less than the House bill and more than Obama's own target of $900 billion.

White House officials say the president's proposal would extend coverage to more than 31 million uninsured Americans and reduce the federal budget deficit by about $100 billion in its first 10 years and by about $1 trillion in its second decade.

By Alex Wayne, CQ Staff

March 2, 2010 -- President Obama told congressional leaders Tuesday that he was willing to include at least four Republican proposals in a final health care bill, in a gesture to a minority party that has steadfastly opposed his top domestic priority.

In a letter to the top leaders of both parties in each chamber, Obama said that he was "exploring" provisions to address the four issues: combating waste and abuse in health programs by using undercover investigators posing as patients; finding new ways to stem medical malpractice lawsuits; increasing Medicaid reimbursement rates to providers; and expanding the use of health savings accounts in conjunction with high-deductible insurance plans. He did not say outright that he would include them in legislation, however.

"I said throughout this process that I'd continue to draw on the best ideas from both parties, and I'm open to these proposals in that spirit," Obama wrote.

The gesture comes a day before Obama lays out an endgame on health care and as congressional Democratic leaders discuss how they might finish the legislation without any Republican support. Both chambers have passed a bill (HR 3590 in the Senate, HR 3962 in the House), but Democrats are unable to clear a conference report for Obama to sign because they lost their 60th Senate vote in January, when Republican Scott P. Brown was elected to the seat formerly held by Massachusetts Democrat Edward M. Kennedy (1961-2009).

In remarks Tuesday afternoon, House Speaker Nancy Pelosi, D-Calif., applauded Obama for reaching out to Republicans, in what she described as an effort to seek bipartisan accord on the health bill.

"For one solid year he has been striving for that bipartisanship," she said. "What we will do is to hope that he can still find 60 votes [in the Senate], but if not we're going to have to go with the simple majority."

For both procedural and political reasons, Democrats would prefer to simply win the votes of one or two Senate Republicans for a final bill. But that seems unlikely in a polarized political environment in which public opinion has turned against the majority party and November midterm elections are fast approaching.

The concessions Obama offered to Republicans, however, are a far cry from the demands by GOP leaders that he start from scratch on the health bill.

Early Republican reaction was negative. Both of Maine's Republican senators, Olympia J. Snowe and Susan Collins, say they wouldn't support "an amalgamation of the House and Senate bills," as Collins called it, with a few GOP ideas thrown in.

In the absence of any GOP votes, the anticipated Democratic strategy is to use expedited budget reconciliation procedures to pass a bill through the Senate that would amend the earlier Senate-passed bill with changes desired by House Democrats. The House would then clear both measures.

That strategy faces considerable obstacles. House Democrats would like the Senate to pass the reconciliation bill first, but Senate Budget Chairman Kent Conrad, D-N.D., says that is impossible. Republicans, meanwhile, threaten to fight the reconciliation bill, and would be expected to offer hundreds of amendments that could delay its passage indefinitely.

In his letter, Obama said that he would consider supporting a suggestion from Sen. Tom Coburn, R-Okla., that medical professionals be engaged to conduct "random, undercover investigations of health care providers" receiving payments from federal programs, to combat fraud.

He said he would also consider adding an additional $50 million to the health care bill to fund state experiments to reduce medical malpractice lawsuits, such as special "health courts." Medical malpractice lawsuits are a top concern of Republicans, but Obama and his party do not support the GOP's primary policy prescription for the issue — capping damages in the lawsuits.

Sen. Charles E. Grassley, R-Iowa, suggested at the health care summit Obama hosted on Feb. 25 that if Medicaid is expanded, as the Democratic health bills propose, its payments to health providers should be increased. Obama endorsed the idea in his letter, but without detail and with the condition that it be "addressed in a fiscally responsible manner."

And Obama said he was willing to include language in the bill to clarify that insurance plans employing health savings accounts could be sold in new government-run exchanges that the legislation would create. The Senate bill already would allow the exchanges to offer HSA plans.