Washington Watch

Carter L. Alleman, J.D.

The ACS Revises Principles

The American College of Surgeons (ACS) has updated its guidelines to clarify when this may be appropriate and what patients should know before consent.

The guidelines are part of a larger document called Statements on Principles. The ACS advises against concurrent or simultaneous surgeries and defines them as, "the critical or key components of the procedures for which the primary attending surgeon is responsible are occurring all or in part at the same time."

The guidelines state: "A primary attending surgeon's involvement in concurrent or simultaneous surgeries on two different patients in two different rooms is not appropriate." But "overlapping" surgeries are different and may be appropriate; for instance, if "key or critical elements" of the first operation are finished, freeing up the primary attending to start an operation in another room while others finish the first operation.

Opioid Response Bills in Committees

House committees compiled a broad array of measures seeking to address specific aspects of efforts to combat the abuse of prescription opioid drugs. The range of measures looks to renew and broaden grant programs, adjust policies and seek reports and guidance on the addiction epidemic. House leaders plan to consider some of the measures in voting on the House floor during the week of May 9. Democrats throughout the process will likely point out that none of the bills add additional funding to programs combating opioid drug abuse.

The House Judiciary Committee will advance a bill closely resembling a Senate-passed measure addressing the issue (S 524). The committee’s main proposal (HR 5046) addresses addiction treatment, prevention and management of controlled substances. The committee also has prepared bills seeking to evaluate grant programs and a review of Good Samaritan laws pertaining to responding to opioid overdoses.

The House Energy and Commerce committee today begins to complete action on a separate batch of opioid abuse program bills. The measures address treatment infrastructure needs (HR 4982), adjust rules regarding access to medication-assisted treatment (HR 4981) and target FDA procedures on opioid product approvals (HR 4976). Other bills offer grant programs for opioid reversal drugs (HR 3680 and HR 4586), allow partial prescriptions (HR 4599) and restrict the sale (HR 3250) of select controlled substances and seek guidance on best practices for pain management (HR 4641) and the dangers of opioid abuse by athletes (HR 4969). The committee’s opioid agenda is completed by bills renewing substance abuse treatment programs for pregnant women and young children (HR 3691) and reporting on opioid dependence in infants (HR 4978).

Check your 2015 Open Payments Data

The Centers for Medicare & Medicaid Services’ continues to publish data from applicable manufacturers and group purchasing organizations about payments they make to physicians and teaching hospitals on its website, https://openpaymentsdata.cms.gov/.

Republicans Still Drafting Health Care Law Replacement

Key House Republicans are still having just preliminary conversations as they prepare to draft an alternative to the health care law before the Republican National Convention in July, but they remain optimistic about meeting their informal deadline.

House Speaker Paul D. Ryan, R-Wis., tasked three committee chairmen - Kevin Brady, R-Texas, of the Ways and Means Committee; Fred Upton, R-Mich., of the Energy and Commerce Committee; and John Kline, R-Minn., of the Education and the Workforce Committee - with writing a replacement plan to the health law. The goal is to unite the conference behind a blueprint for early action in 2017, should a Republican win the White House. However, lawmakers are far from ready to start deciding exactly what will be in their white paper, following a closed-door meeting of the task-force set up to draft the replacement.

Many of the policies under discussion are familiar. Quite a few have been included in other Republican policy documents. GOP lawmakers and several lobbyists mentioned policies like expanding the use of health care savings accounts or ensuring coverage can be purchased across state lines. Several also mentioned the inclusion of tax credits to help consumers pay for their coverage.

One policy under consideration that's generating attention: a cap on the health care tax exclusion, which would limit the amount an employee could contribute to his or her health care premiums tax-free. Republicans want to continue allowing employers to deduct their health coverage costs from their tax expenditures, several sources off the hill said. Including that policy could raise a great deal of revenue to pay for other changes in the bill. The health care tax exclusion is one of the country's biggest tax breaks.

But the policy would have an effect much like the so-called Cadillac tax, an excise tax on the most expensive health plans. Advocates say both policies would help lower health care costs by reducing plan generosity and giving patients more skin in the game. But the tax is hugely unpopular among both business groups and labor unions, and sizeable bipartisan opposition led to Congress passing a two-year delay of the tax last year.

Medicare Expenses Outpaced Savings in Early Results of Key Test

Medicare reported disappointing early results from its Comprehensive Primary Care Initiative, which is designed to shape an eventual overhaul of federal payments for basic medical services for the elderly and disabled. The savings in the program's first two years failed to offset its expenses, while the quality of medical care did not improve as expected, Medicare officials reported.

Monthly expenses fell by an average of about $11 per patient in the program, with reductions ranging from $1 to $21, according to a Mathematica Policy Research report for the Centers for Medicare and Medicaid Services. That adds up to about $91.6 million in total savings, possibly because closer contact between doctors and patients reduced the need for hospitalizations and use of skilled nursing centers. The reduced costs, though, were not enough to offset a fee averaging $18 a month per person enrolled in Medicare, the report said. The New England Journal of Medicine published the initial results.

The Obama administration is moving away from the traditional fee-for-service program, which some say results in uncoordinated patient care and needless expenses, such as duplicated tests and hospitalizations. The authors of the New England Journal of Medicine paper included Patrick Conway, the chief medical officer for the Centers for Medicare and Medicaid Services. Conway announced plans for another primary-care test program.

MedPAC Approves Payment Changes

Members of the Medicare Payment Advisory Commission (MedPac) voted unanimously by a show of hands to approve a report on the initial steps needed to move toward creating a unified payment for so-called post-acute care. They discussed the broad themes of this work, but left many of its details to be revealed when the report is published in June.

Medicare payments for post-hospital care more than doubled, to $59 billion, between 2001 and 2013 despite concerns about fiscal waste. The absence of clear guidelines on appropriate post-hospital care is seen as one of the reasons for this growth. People can be assigned fairly randomly now to care in one of four tracks: skilled nursing centers, specialty inpatient rehabilitation centers, long-term care hospitals and services provided at home. Medicare often pays more in certain settings for care of similar patients, without establishing if there is an advantage to the more expensive care.

The law mandates MedPAC to publish ideas for a payment overhaul-- through the report the panel approved Thursday -- by June 2016. The Department of Health and Human Services then must issue another report by 2022. MedPAC must respond by around 2023 with a design for a new post-hospital payment. Lawmakers in search of an offset for a future budget deal next year or beyond may be tempted to mandate changes in post-acute care that could save Medicare funding and allow more spending elsewhere in the federal government.

Centers for Medicare and Medicaid Services Comprehensive Care for Joint Replacement Model addresses one of the biggest areas in post-acute care, which is how people on Medicare recover after hip and knee replacements, the most common inpatient surgery among people on Medicare. The program paid more than $7 billion for more than 400,000 procedures in 2014.

Medicare on April 1 kicked off this program that compels about 800 hospitals in 67 regions of the country to eventually face financial risks and rewards based on how well people fare after hip and knee replacements. The hospitals' future pay will reflect how well their elderly and disabled patients are judged to fare in the 90 days after their discharges after surgery.