You’ll find ACOs under section 3022 of the new Patient Protection and Affordable Care Act (that’s the PPACA), which calls for the establishment of the ACO program no later than January 1, 2012. The Secretary of the Department of Health and Human Services  will determine the policies and procedures that will apply to ACOs. 
 Who’s eligible?   An ACO may be formed by a wide range of professionals, including physicians in group practice arrangements, networks of individual physician practices, hospitals, and partnerships or joint ventures between hospitals and physician groups, that are willing to be held to the accountability standards. 

Among the qualifications: Providers must agree to participate in the program for at least three years  and they have to have the HHS Secretary assign it at least 5,000 Medicare beneficiaries and include a sufficient number of primary care physicians for serving those patients.  The Secretary can give preferences to  ACOs that participate in similar arrangements with private third party payers.

The ACO is not a new idea, but rather builds on ideas and models (from Mayo to Kaiser health) that have been discussed for years. Cost savings and quality improvement are key.  How that will be achieved, measured, and evaluated is still open to question, with critics noting this could be managed care in disguise.  And if the patients sense a “warmed over” product focused on cost-savings, the hopes for real success could be dimmed. The division of savings could make some family physicians uncomfortable with ACOs, according to the American Academy of Family Physicians. As the degree of risk borne by ACOs increases, the need for regulation of the financial security of these organizations will also increase, which could influence patient care decision making. Financing and regulatory policies will still continue to create pressures in ways that may take the focus off the patient.

But that gets to the cost issues again.  If the focus is on how to best coordinate the care of Medicare beneficiaries—and they may mean more connections rather than less connections to a host of other providers and community and social service agencies than envisioned in this plan. Whether this will be a successful evolution—or revolution—remains to be seen.

At a recent International Forum in Washington,  health leaders from around the world were congratulating me and other Americans because our nation finally made the grade, so to speak, with regard to health care.  The U.S. finally recognized that health care is national issue–that translates into security economic growth and prosperity for the nation.  Most of all, it means that our nation has finally learned that the role of  government is to protect and take care of  all the people who believe in justice and democracy.

 Is this too little too late?  Where was the President’s voice early on? The process the President set in motion months ago has clearly emboldened the insurers and pharmaceutical companies.  One could argue that they know now that nothing substantive will change and they have carte blanche to do whatever they want.

HHS Secretary Sebelius is also confusing the insurance issue.  Today she told insurers,  “It’s not too late to work on this issue together, for insurance companies to come to the table and work with us.’’ Last week, the Secretary was attacking rate hikes by insurers in California. 

It’s hard for the American public to get the Administration’s message straight. The President and the Secretary have not focused on the day-to-day actions of the insurers that people can relate to and understand.  The insurers have gone hog wild on restrictions on drugs and services and pre-certifications for drugs and services.  People experience that every day.  People are frustrated and fighting that every day—and time and energy with the insurers (I should say with a recorded message machine that the insurers hide behind).  That’s the insurance industry the American people know.  Who will monitor that? Where is that in health reform? Will supporting health reform get the insurers out of medical decision making?  That is what the people want and that is what the President is not addressing.

Sen. Bernie Sanders,  the Independent from Vermont, is telling the world that the proposed legislation is not good.  Yesterday, he said that he could not accept the health reform bill in its current form because it does not control costs or rein in health insurance companies.  More important,  Senator Sanders showed the courage of his convictions and brought a real answer to the Senate and the American people.  He proposed a single-payer amendment to the current bill.  In calling up his amendment, Sanders said, “For the first time in American history, the Senate will debate a proposal to create a single-payer, Medicare-for-all health care system.” Unfortunately, Senator Tom Coburn (R-Okla.) objected to Mr. Sanders’s request to dispense with the reading of the 767-page amendment (as called for earlier by  Coburn).  After nearly three hours of listening to a team of Senate clerks read the proposal,  Mr. Sanders gave up and withdrew his amendment (Why,  Bernie? There’s nothing to fear but fear itself.)

(Of course, Coburn knew that would be the outcome because the dealy would prevent a vote on a funding bill for the Department of Defense. The current funding provision expires at midnight tomorrow).

George Will reflects today in The Washington Post on the latest CNN poll showing that 61 percent of the public oppose what the Democratic Senate is trying to do to health care.  “It is clear what the public wants Congress to do: Talke a mulligan and start over.”

Bernie and George are both saying that what we have is not good enough.  President Obama should say the same and ask for the creation of a “super special” congressional committee to start anew in January.  Health reform before the holidays may not make the season jolly.

 Lack of meaningful oversight of the hugely expansive and expensive private insurance industry bureaucracy, resulting in rate increases that do not go to patient care. The most recent memorandum from the board of the group health insurance plan associated with my workplace shows double digit increases in the rate history of the medical plans provided by this group.  These are increases above inflation and cost of living and above the rate of any raises received by the average American. 

 Interestingly, some of the largest increases came in 2009, as health insurance reform started to move forward (from 12.4 to 28%, depending on the plan). Insurers are not stupid. They know how to make a fast killing as reform creeps forward and there is nothing to mandate that such actions do not continue into any reform era.      

 Tiered prescription and prescription precertification. Insurers are making medical decisions.  Insurance companies are mandating increasing numbers of medications must be pre-certified.  Insurance companies, not physicians, will tell you whether you are allowed to take the drug prescribed by your physician.  This is happening now and nothing in the legislation will prevent more of this in the future.

 Who will investigate the subversive practices that are emerging, such as demanding precertification for an ever-expanding list  of procedures and then denying payment (a practice that is growing at a startling speed)?  

 Will Congress now make a change and ensure strong oversight of this industry?  Who will monitor the rate increases?  What will be the penalities?  Who will enforce the law? Too many in the Congress have conflicts of interest when it comes to the industry–whether through contributions or spouses sitting on boards or lobbying for the industry. 

 The insurance companies have been emboldened by the ineffectiveness of Congress on health reform.  Until Congress can push back and ask the hard questions of the companies that over the last decade increased rates well beyond any cost of living or national standard, we will have no real reform.

What is “affordable access to care,” according to Olympia Snowe?  How will states decide that they have  more than five percent of the population who qualify?  Who decides how much a health plan will cost?  Who decides what the plan will cover–and for how long?  What about the middle class people–with coverage–who are now going bankrupt because of their medical bills?  Will they be in the five percent?  

Who decides at what point premiums get raised–or that certain conditions will no longer be covered?  What about the family with the 17 pound baby who was denied health insurance coverage and deemed to have a pre-existing condition–obesity– by the health insurers?  Will his family be counted? Maybe it takes 17 pounds to pull the trigger?

Here’s the bottom line: With a true public option, Americans would not have to ask those questions–or worry now about what a public option means.  Olympia Snowe’s “trigger” is just another way of shooting ourselves in the foot!  It’s time to stop playing games and have a real public option as an American right.

With the Baucus proposal, we can truly say that  the federal government does not control health care but the insurance industry does? When and how often you see a doctor–and whether or not you get the necessary lab tests you need–and even which provider you see—are all determined–and will continue to be determined– by the insurers. 

Yesterday, I heard about a patient who was on the verge of a heart attack.  He saw his cardiologist who determined he needed a nuclear stress test immediately.  Did I say immediately?  According to  a top cardiologist he did?  According to his insurer, he had to wait two weeks for the test. Was this the government intruding in health care?  No, way. 

The government is not in your doctor’s office–but the health insurers are.   And now they will be in every house in America–like roaches, they are taking over.  Break out the Combat.

 Insurers broke out the champagne last night, knowing they succeeded in getting Senator Baucus  to allow them to make a killing with provisions for  U.S.  families to pay 13% of their income for healthcare coverage or pay a fine. A family of four with annual income of $65,000 would be asked to spend $8,450 on health insurance premiums before receiving any federal subsidy.  

 Certainly, Senator Baucus has been receiving too much  money from health insurance lobbyists to be in touch with the reality of the average American who cannot pay out 13% of their income on health insurance premiums.  The insurers are already raising premiums to cushion any blow that would come from doing away with non-payment for preexisting conditions.  After all, who is there to stop–or regulate– them?  The government?  With leaders like Baucus, I doubt it.

Where’s the reform?  Where’s the coverage?  Where’s the safety net? Where are the promises of President Obama?  The rising stock prices tell us who is benefiting from reform.  Perhaps Wall Street is also telling us that we learned nothing from the scandals of last year.  If the profits are only benefiting some big companies, something is very wrong.  It is time for Senator Baucus to recuse himself from the debate given that the first reaction to his health reform bill was mild pandemonium on Wall Street.

Obama exhorted Americans to believe in their power—and the power of government—to do good.  He called on Americans to address health care as a moral issue, emphasizing that social justice and the character of the nation are at stake.

That said, what did we learn?  The President said that if we do nothing to slow the costs of Medicare and Medicaid, they will eat up the entire budget.  On the other hand, Obama made of point of saying that if you’re enrolled in Medicare, Medicaid, or the VA, or have employer based health insurance, nothing will change. Does that mean that the government will not cut Medicare and Medicaid payments? 

 The President’s plan will provide more security and stability to those who have insurance, provide insurance to those who do not, and slow the growth of health care costs.  His plan is to “make insurance work better for you.”  Will the insurers just pay for less (especially since they will have to cover pre-existing conditions)? How much will insurers change their pricing with academic health centers?

For those individuals without insurance, they will be required to get insurance (like auto insurance, said the President). The interesting thing is that some states do not make motorists show proof of insurance on routine traffic stops. Insurance is required, but only in the event of an accident. While fines can run to $5000, most are in the $500 range and only a few states impound your car—or send you to jail.  How will the government enforce the mandate?

As for the new insurance exchanges to be established, “customers will have leverage with the insurers,” said the President, who added that he will hold insurers accountable. The President did not say how that would happen.  I hope you’re right, Mr. President, but it sounded a bit like Shangri-la.  

Most importantly, the President will end fraud and abuse in Medicare.  While a worthy goal, it raises concern for academic health centers. The government does little now to evaluate providers (many fraudulent) who apply for a Medicare provider ID and run off with millions of dollars in payments for services never rendered.  So where is there money to be found?  The government is able to collect money by establishing Recovery Audit Contractors and other vehicles to search for supposed billing errors by academic health centers.  Is this the “fraud” the President is talking about?  Will we see some RAC clones established or a new wave of billing regulations? 

The President said the details of the plan are yet to be worked out.  The coming days will show the true impact of the speech and whether we see any change in attitude or action on Capitol Hill.

I can’t understand such a proposal.   Is Baucus worried about not throwing enough business to his backers–the insurance companies?  Reform should be so good that everyone wants “in.”   Something tells me that Baucus is not offering much if he has to fine the non-participants.   Sounds like our current system where people, mostly for financial reasons, do not buy insurance.   Today, many people say, “OK, I’ll pay the medical bills for my post-college age kid because health insurance premiums are either too high or don’t provide decent coverage.”

In Baucus’ plan, we see he penalizes the victim–adding insult to injury to those people who cannot afford insurance–even with a government subsidy, which will amount to peanuts.  So we make the non-insured pay a fine–and then what?   Do they still go the emergency room of an academic health center hospital to get care?  Will Senator Baucus pay for that?