Investment Platform
The Healthymagination Fund draws on capabilities from across GE Healthcare, GE Capital and GE Global Research and has a global footprint. The investment committee is comprised of senior leaders of these groups.
Exciting new $250mm HIT investment fund launched by GE Capital offers unprecedentedly aggressive and bullish HIT private equity joint venture. Ideas abound...
The legislative landscape for health care after House passage
Posted By kbh On November 9, 2009 @ 12:45 pm In budget, featured, health | 8 Comments
The House passed their version of health care reform Saturday night on a 220-215 vote. Today I’m going to update my projections and analysis, and focus on upcoming “pivot points” in the health care debate.
- Pass a partisan comprehensive bill through the House and through the regular Senate process with 60, leading to a law this year; (was 50% –> 40%)
- Pass a partisan comprehensive bill through the House and through the reconciliation process with 51 Senate Democrats, leading to a law this year; (was 10% –> 20%)
- Fall back to a much more limited bill that becomes law this year; (was 10% –> 20%)
- No bill becomes law this year Congress. Process continues into next year. (was 29.99% –> 20%)
I have adjusted the scenarios based on two assumptions, making the new numbers not precisely comparable with the old:
- I assume the Finance Committee bipartisan solution path is dead (I only had it at 0.01% chance last time); and
- I assume virtually no chance of a signed law this year, so I have adapted the timeframes accordingly. I say this despite recent statements from the President and Leader Reid that they want/intend to get a law by 31 December.
Pivot points and the importance of recess
Pivot points (my term) are opportunities for legislative momentum to shift. These opportunities are to some extent predictable. This past week had four pivot points, which is extraordinary:
- Election Day – loss of momentum for D’s;
- the Senate Democratic Policy Lunch on Tuesday – loss of momentum for D’s;
- Friday’s politically challenging employment report – loss of momentum for D’s; and
- Saturday night’s House passage vote – momentum gain for D’s.
Sometimes a pivot point will pass without any noticeable change in the legislative outlook. But to the extent these dates/events are predictable, it at least tells you when to look for important shifts.
Here are obvious pivot points over the next few months:
- every Tuesday after the Senate Democratic Policy Lunch;
- whenever CBO releases its score of the Reid substitute amendment;
- the Monday/Tuesday after Thanksgiving recess;
- Friday, December 4th, when the next jobs report is released;
- Th/F December 17-18, the end of the week before the Christmas recess;
- the first week Members are back in DC after the holiday recess;
- late January, for the President’s State of the Union Address.
The most potentially significant consequence of the slower schedule is that Members will be home for two long recesses before a bill might be completed. Will Members feel the same intensity of pressure they did in August? If so, that could greatly shift momentum.
Will Leader Reid will begin Senate floor consideration before Thanksgiving recess? If he does, then he will probably have to show his amendment to the world before that recess, and expose his Members to pressure on specific text over that short break. If he waits until after recess, his Members may have a slightly less painful Thanksgiving break, but at the expense of lost time on the backend and a lower probability of Senate passage before Christmas. I would expect him to try to “back up” final passage before the Christmas recess, by in effect telling the Senate around December 18th “you can go home for Christmas only after we’ve finished the bill.” The smell of jet fumes is usually enough to cause Members to vote aye on cloture to shut off a filibuster, but in this case I’m not so sure.
The three-part strategic question
In December Democratic leaders may face a two-part strategic question:
- If we cannot hold 60 D’s, do we use reconciliation to pass a bill with 51, or instead go for 60 on a much more limited bill?
- When do we make this decision?
- Conference or ping pong?
My survey of (Republican) insiders is split on what Democrats may decide on (1), but nearly unanimous on question (2): almost all say this strategic shift would come in January at the earliest. The earliest projection was December 18th.
I assume liberals would prefer a reconciliation path that would probably produce a bill closer to the House-passed bill, at the price of painfully splitting off moderate Senate Democrats. This is a slash-and-burn partisan path, but may be the highest probability path to a signed law. I also assume moderate Democrats would prefer a scaled-back bill. We know Democratic moderates would support the Finance Committee reported bill, so if Senate liberals could swallow hard and wait for the next step, this would be the easiest path to Senate passage. Leader Reid tacked away from this when he announced his amendment would contain a strong public option.
If the Senate can pass a bill, Democratic leaders will need to wrestle with question (3).
Conference or ping pong?
Everyone knew the House would eventually pass something, given the enormous Democratic margin in the House. House Republicans were more effective in their resistance than I anticipated. This contributes to an apparent loss of momentum in the Senate. There are now two games ahead: Senate passage, and reconciling differences between the House and Senate.
In theory, if the Senate passes a bill, the chance of a law skyrockets. But the House passed its bill with a left-edge coalition – most of the Democratic no votes were from moderates. If the Senate passes a bill through regular order (with 60 votes), it will be relatively more moderate, and more compatible with an alliance on the other side of Pelosi’s caucus. This could be quiet difficult. How do Speaker Pelosi and Leader Reid work out differences between a bill that Lieberman, Nelson, and Lincoln support and one opposed by moderate House D’s? Splitting the difference may alienate both sides of the Democratic caucuses. We’re already starting to see lines drawn in the sand on abortion.
This is why some observers think Senate passage may lead to ping pong rather than a conference. Normally after the House and Senate pass versions of a bill, the body that votes second requests a conference with the other body and appoints a handful of members to be conferees. The second body then agrees to a conference and appoints its own conferees. The conferees negotiate and produce pretty much whatever new text they want, although they generally stay within the scope of the contents of the two bills. The conference report language must then be passed by both bodies to go to the President.
Ping pong is a colloquial term for skipping conference. The House-passed bill will soon arrive in the Senate. The Senate will presumably take up the House bill and amend it. If and when the Senate passes its version, it would not request a conference, and would not appoint conferees, but would instead send the amended bill back to the House. the House could then try to further amend the Senate bill, or just take it up and pass it. This ping pong can go back and forth a few times.
Conventional wisdom seems to be that House and Senate Democratic leaders are intensely focused on the downsides of a conference. It puts tremendous pressure on the leaders and conferees to resolve differences. It also gives House and Senate Republicans certain procedural opportunities to cause mischief before and during conference.
But ping pong has its own downsides. The minority, especially in the Senate, gets another crack at amending the bill. Smart money would bet today on ping pong rather than a conference, but I expect this to be revisited often over the next couple of months.
My projections
It is highly likely the legislative process will continue at least into January.
I am still projecting a 60% chance that a comprehensive bill becomes law this year, but I have shifted some of that 60% from the regular order path to the reconciliation path. By itself I’d never expect the Senate to shift to a reconciliation path after failing to get 60 – Senate-only logic says heck no, and the strain on Reid’s caucus would be too great. But if Democratic leaders are forced to shift away from regular order on a comprehensive bill, I would guess that Speaker Pelosi would push hard for the Senate to use reconciliation to produce a bill more compatible with the House-passed bill rather than dialing back expectations. This puts me at 40% regular order success, 20% reconciliation success, 20% fall back to a narrower bill, and a 20% chance the whole thing implodes. It’s the slow pace and the two intervening recesses that give me hope.
Insiders: Please send me your thoughts privately, especially if you disagree.
(photo credit: Speaker Pelosi’s site [1])
Article printed from KeithHennessey.com: http://keithhennessey.com
URL to article: http://keithhennessey.com/2009/11/09/after-house-passage/
URLs in this post:
[1] Speaker Pelosi’s site: http://www.speaker.gov/newsroom/photogallery?id=0009
Click here to print.
Analyzing the impact of the House vote to pass health reform this past weekend.
The legislative landscape for health care after House passage
Posted By kbh On November 9, 2009 @ 12:45 pm In budget, featured, health | 8 Comments
The House passed their version of health care reform Saturday night on a 220-215 vote. Today I’m going to update my projections and analysis, and focus on upcoming “pivot points” in the health care debate.
- Pass a partisan comprehensive bill through the House and through the regular Senate process with 60, leading to a law this year; (was 50% –> 40%)
- Pass a partisan comprehensive bill through the House and through the reconciliation process with 51 Senate Democrats, leading to a law this year; (was 10% –> 20%)
- Fall back to a much more limited bill that becomes law this year; (was 10% –> 20%)
- No bill becomes law this year Congress. Process continues into next year. (was 29.99% –> 20%)
I have adjusted the scenarios based on two assumptions, making the new numbers not precisely comparable with the old:
- I assume the Finance Committee bipartisan solution path is dead (I only had it at 0.01% chance last time); and
- I assume virtually no chance of a signed law this year, so I have adapted the timeframes accordingly. I say this despite recent statements from the President and Leader Reid that they want/intend to get a law by 31 December.
Pivot points and the importance of recess
Pivot points (my term) are opportunities for legislative momentum to shift. These opportunities are to some extent predictable. This past week had four pivot points, which is extraordinary:
- Election Day – loss of momentum for D’s;
- the Senate Democratic Policy Lunch on Tuesday – loss of momentum for D’s;
- Friday’s politically challenging employment report – loss of momentum for D’s; and
- Saturday night’s House passage vote – momentum gain for D’s.
Sometimes a pivot point will pass without any noticeable change in the legislative outlook. But to the extent these dates/events are predictable, it at least tells you when to look for important shifts.
Here are obvious pivot points over the next few months:
- every Tuesday after the Senate Democratic Policy Lunch;
- whenever CBO releases its score of the Reid substitute amendment;
- the Monday/Tuesday after Thanksgiving recess;
- Friday, December 4th, when the next jobs report is released;
- Th/F December 17-18, the end of the week before the Christmas recess;
- the first week Members are back in DC after the holiday recess;
- late January, for the President’s State of the Union Address.
The most potentially significant consequence of the slower schedule is that Members will be home for two long recesses before a bill might be completed. Will Members feel the same intensity of pressure they did in August? If so, that could greatly shift momentum.
Will Leader Reid will begin Senate floor consideration before Thanksgiving recess? If he does, then he will probably have to show his amendment to the world before that recess, and expose his Members to pressure on specific text over that short break. If he waits until after recess, his Members may have a slightly less painful Thanksgiving break, but at the expense of lost time on the backend and a lower probability of Senate passage before Christmas. I would expect him to try to “back up” final passage before the Christmas recess, by in effect telling the Senate around December 18th “you can go home for Christmas only after we’ve finished the bill.” The smell of jet fumes is usually enough to cause Members to vote aye on cloture to shut off a filibuster, but in this case I’m not so sure.
The three-part strategic question
In December Democratic leaders may face a two-part strategic question:
- If we cannot hold 60 D’s, do we use reconciliation to pass a bill with 51, or instead go for 60 on a much more limited bill?
- When do we make this decision?
- Conference or ping pong?
My survey of (Republican) insiders is split on what Democrats may decide on (1), but nearly unanimous on question (2): almost all say this strategic shift would come in January at the earliest. The earliest projection was December 18th.
I assume liberals would prefer a reconciliation path that would probably produce a bill closer to the House-passed bill, at the price of painfully splitting off moderate Senate Democrats. This is a slash-and-burn partisan path, but may be the highest probability path to a signed law. I also assume moderate Democrats would prefer a scaled-back bill. We know Democratic moderates would support the Finance Committee reported bill, so if Senate liberals could swallow hard and wait for the next step, this would be the easiest path to Senate passage. Leader Reid tacked away from this when he announced his amendment would contain a strong public option.
If the Senate can pass a bill, Democratic leaders will need to wrestle with question (3).
Conference or ping pong?
Everyone knew the House would eventually pass something, given the enormous Democratic margin in the House. House Republicans were more effective in their resistance than I anticipated. This contributes to an apparent loss of momentum in the Senate. There are now two games ahead: Senate passage, and reconciling differences between the House and Senate.
In theory, if the Senate passes a bill, the chance of a law skyrockets. But the House passed its bill with a left-edge coalition – most of the Democratic no votes were from moderates. If the Senate passes a bill through regular order (with 60 votes), it will be relatively more moderate, and more compatible with an alliance on the other side of Pelosi’s caucus. This could be quiet difficult. How do Speaker Pelosi and Leader Reid work out differences between a bill that Lieberman, Nelson, and Lincoln support and one opposed by moderate House D’s? Splitting the difference may alienate both sides of the Democratic caucuses. We’re already starting to see lines drawn in the sand on abortion.
This is why some observers think Senate passage may lead to ping pong rather than a conference. Normally after the House and Senate pass versions of a bill, the body that votes second requests a conference with the other body and appoints a handful of members to be conferees. The second body then agrees to a conference and appoints its own conferees. The conferees negotiate and produce pretty much whatever new text they want, although they generally stay within the scope of the contents of the two bills. The conference report language must then be passed by both bodies to go to the President.
Ping pong is a colloquial term for skipping conference. The House-passed bill will soon arrive in the Senate. The Senate will presumably take up the House bill and amend it. If and when the Senate passes its version, it would not request a conference, and would not appoint conferees, but would instead send the amended bill back to the House. the House could then try to further amend the Senate bill, or just take it up and pass it. This ping pong can go back and forth a few times.
Conventional wisdom seems to be that House and Senate Democratic leaders are intensely focused on the downsides of a conference. It puts tremendous pressure on the leaders and conferees to resolve differences. It also gives House and Senate Republicans certain procedural opportunities to cause mischief before and during conference.
But ping pong has its own downsides. The minority, especially in the Senate, gets another crack at amending the bill. Smart money would bet today on ping pong rather than a conference, but I expect this to be revisited often over the next couple of months.
My projections
It is highly likely the legislative process will continue at least into January.
I am still projecting a 60% chance that a comprehensive bill becomes law this year, but I have shifted some of that 60% from the regular order path to the reconciliation path. By itself I’d never expect the Senate to shift to a reconciliation path after failing to get 60 – Senate-only logic says heck no, and the strain on Reid’s caucus would be too great. But if Democratic leaders are forced to shift away from regular order on a comprehensive bill, I would guess that Speaker Pelosi would push hard for the Senate to use reconciliation to produce a bill more compatible with the House-passed bill rather than dialing back expectations. This puts me at 40% regular order success, 20% reconciliation success, 20% fall back to a narrower bill, and a 20% chance the whole thing implodes. It’s the slow pace and the two intervening recesses that give me hope.
Insiders: Please send me your thoughts privately, especially if you disagree.
(photo credit: Speaker Pelosi’s site [1])
Article printed from KeithHennessey.com: http://keithhennessey.com
URL to article: http://keithhennessey.com/2009/11/09/after-house-passage/
URLs in this post:
[1] Speaker Pelosi’s site: http://www.speaker.gov/newsroom/photogallery?id=0009
Click here to print.
Analyzing the impact of the House vote to pass health reform this past weekend.
Investment Platform
The Healthymagination Fund draws on capabilities from across GE Healthcare, GE Capital and GE Global Research and has a global footprint. The investment committee is comprised of senior leaders of these groups.
Exciting new $250mm HIT investment fund launched by GE Capital offers unprecedentedly aggressive and bullish HIT private equity joint venture. Ideas abound...
Investment Platform
The Healthymagination Fund draws on capabilities from across GE Healthcare, GE Capital and GE Global Research and has a global footprint. The investment committee is comprised of senior leaders of these groups.
Exciting new $250mm HIT investment fund launched by GE Capital offers unprecedentedly aggressive and bullish HIT private equity joint venture. Ideas abound...
With all the new money flowing into health IT, particularly with the $35 billion or so in federal money (a net $19 billion after accounting for expected efficiency savings) for electronic health records, someone's going to have to build, install, deploy and train people to use the systems, right? Studies estimate that there was a need for 10,000 to 15,000 new health IT professionals nationwide, but those were conducted before the enactment of the federal stimulus back in February. So there's clearly a huge demand for a health IT workforce, Health Leaders Media reports.
More recently, the an American Hospital Association survey found that 25 percent of responding organizations are shorthanded when it comes to IT staff and expertise. However, the economic downturn that has left so many talented IT professionals unemployed could provide an unprecedented opportunity for healthcare. "We have to figure out a strategy to take IT professionals from other disciplines and orient them to healthcare, and then look at the educational system and the places where they are training people who are specializing in healthcare issues to beginning to look at healthcare IT as a piece of the curriculum," says AHA spokesman Rick Wade.
While these seasoned IT pros can be of immediate help in building secure infrastructure, they will have to be trained for the unique needs of healthcare. "It's all about understanding clinical business processes," says Alex Rodriguez, CIO of St. Elizabeth Healthcare in Edgewood, Ky. "That is the separation-being able to have the communication skills to dive into how the business processes work, the communication skills and the thinking skills to determine how the new technology applications are going to be used," he explains to Health Leaders.
While the increased demand could drive up salaries, Rodriguez says people are looking for professional growth and stability in these trying times, so hospitals may not have to break the bank when augmenting their health IT staff.
For more on the staffing implications of the stimulus:
- take a look at this Health Leaders Media storyRelated Articles:
Blumenthal: Conversion to EMR will create 50,000 new HIM jobs
Economic woes or not, it's full speed ahead for AHIMA '09
Many more HIT pros needed as EMRs roll out
Musings on HIT, health reform message management and the twenty-second amendment...
Health IT is not getting the attention in needs from the senior White House officials and it must be elevated to a central issue during the next phase in the legislative process to pass health reform - The Senate. Health IT has always been the most directly attractive core element of the president's plan, but it has been missing from the fundamental arguments made directly to the American people, a critical error in strategy as it may be the only idea with little resistance on either side of the aisle. Not only is health information technology politically popular, its also one of the very few threads of the larger and infinitely more complex health reform debate that nearly every consumer can understand at a high level.
'Connected Care' and 'Telemedicine' provide the most obvious opportunity to create an emotional investment among voters in the "meat and potatoes" of how Obama's reform initiative will accelerate the modernization medical business. Rahm would be wise to shift debate whenever possible on Sunday circuit away from the billion dollar price tags that currently dominates the discussion and onto the opportunities available for jobs, higher quality health care, and a "smarter" society - steal it from IBM's most recent commercials if you must.
If voters believe that a plan exists that would achieve hyper-saturation of new bioinformatics-driven hardware and software products for consumers - mobile hardware and software needed to facilitate telemedicine services at the level of individual practices and regional health systems - re-election is a slam dunk and the twenty-second amendment (Presidential Term-Limits) could be justifiably revisited. While a lifetime of Barack is a nausating thought, the twenty-second amendment was a mistake and a strong argument could be made that it has prevented the most qualified man in America from re-entering public service - Bill Clinton. Without any legitimate reasoning as to why ambition and uncharacteristic success at a young age should somehow deprive great leaders from leading. Nobody benefits from suppression of genius under any circumstances.
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Telemedicine
For purposes of Medicaid, telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient's health. Electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (e.g., face-to-face consultations or examinations between provider and patient) that states may choose to cover. This definition is modeled on Medicare's definition of telehealth services located at 42 CFR 410.78. Note that the Federal Medicaid statute (Title XIX of the Social Security Act) does not recognize telemedicine as a distinct service.
Distant or Hub Site means the site at which the physician or other licensed practitioner delivering the service is located at the time the service is provided via telecommunications system.
Originating or Spoke site means the location of the Medicaid patient at the time the service being furnished via a telecommunications system occurs. Telepresenters may be needed to facilitate the delivery of this service.
Asynchronous or "Store and Forward" means transferring data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation. Asynchronous or "store and forward" applications would not meet the above definition of telemedicine--see telehealth.
Reimbursement/Billing—Reimbursement for Medicaid covered services, including those with telemedicine applications, must satisfy federal requirements of efficiency, economy and quality of care. With this in mind, States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telemedicine technology. For example, States may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site. States can also reimburse any additional costs such as technical support, transmission charges, and equipment. These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state. If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service. While telemedicine is not considered a distinct Medicaid service, any State wishing to cover/reimburse for telemedicine services should submit a State Plan Amendment to the Centers for Medicare and Medicaid Services for approval.
Medical Codes—States may select from a variety of HCPCS codes (T1014 and Q3014), CPT codes and modifiers (GT, U1-UD) in order to identify, track and reimburse for telemedicine services.
Telehealth (or Telemonitoring) is the use of telecommunications and information technology to provide access to health assessment, diagnosis, intervention, consultation, supervision and information across distance.
Telehealth includes such technologies as telephones, facsimile machines, electronic mail systems, and remote patient monitoring devices which are used to collect and transmit patient data for monitoring and interpretation. While they do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and reimbursed as part of a Medicaid coverable service under section 1905(a) of the Social Security Act such as laboratory service, x-ray service or physician services.
Other Considerations:
Medicaid guidelines require all providers to practice within the scope of their state practice act. Some States have enacted legislation which requires providers using telemedicine technology across state lines to have a valid state license in the state where the patient is located. Any such requirements or restrictions placed by the State are binding under current Medicaid rules. Medicare Conditions of Participation (COPs) applicable to settings such as long-term care facilities, and hospitals may also impact reimbursement for services provided via telemedicine technology. For instance, the Medicare COPs for long-term care facilities require physician visits at set intervals. Current regulations require that the physician must be physically present in the same room as the patient during the visit. This requirement must also be met for Medicaid to pay for services provided to Medicaid eligible patients while in a Medicare or Medicaid certified facility. Similarly, federal regulations require face-to-face visits for home health, and telemedicine cannot be used as a substitute for those visits. However, a telemedicine encounter may be used as a supplement to the required face-to-face visits.
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Link: Telemedicine allows for long-distance diagnoses - The Washington Times.
As mentioned in an earlier post, 4 years ago Telemedicine was in its infancy, perhaps used for monitoring status of patients with pacemakers... Now, according to this article in the Washington Times, Dr. Kenneth Bird, a Harvard professor affiliated with Massachusetts General Hospital, innovated an approach to patient care using monitors and remote access to hospitals to examine, diagnose and treat his patients.
Also, according to the article, patients are wearing monitors that can be remotely tracked and physicians can be notified and/or paged when necessary. Telemedicine (a.k.a. Telehealth) is not a substitute for direct patient care, but rather, it is an augmentation to the existing delivery of care. That said, installation/implementation can be a huge expense (ranging between $2.5 and $3.5 million), so larger hospitals are more likely to implement remote monitoring.
The article continues with explanation of "concierge" medicine approaches, which are light years ahead of the status quo. The benefits to patients is purportedly rapid care from providers, from home or within a specialized, technology enabled facility.
It's an interesting thought, and another example of how technologies can be used to improve patient care if used appropriately. That said, there are likely significant privacy and security issues related to the "transaction" between patient and providers. For more information about HIPAA Requirements, The HIPAA Privacy Rule, The Security Rule, or The HITECH Act visit The Online HIPAA Survival Guide.
And, if you are interested in keeping current on the issues, sign up for the FREE HITECH/HIPAA Compliance Newsletter.
Courtesy of Healthcare & Technology Blog (By: Deborah Leyva): http://www.myhealthtechblog.com/2009/10/telemedicine-allows-for-long-distance-diagnoses.html
Telemedicine (Telehealth) is starting to get the attention it deserves, but innovation will not occur in a vacuum of unsustainable business models. Until self-sustainability for for telemedicine initiatives is achieved and replicated on a widespread basis it will not be as significant in the provision of care as it should be.
