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.

With the aging baby boomer population, the need for a greater number of trained people in the health professions goes well beyond nurses and home care workers.  Shortages across the professions will be exacerbated by the retirement of physicians, nurses, pharmacists, dentists and other professionals.  In 2004, 23 percent of licensed pharmacists, for example, indicated they were leaving the profession within the year and 80 percent of pharmacy directors said they would leave within the decade. Substantial retirements of faculty in all schools of the health professions add to the problem.

With the overwhelming need for a health workforce for the nation, President Obama should be focusing his Jobs Initiative on education and innovative training programs for the health workforce.  President Obama should be looking for ways to provide incentives to academic health centers and their health professions schools for new ideas and innovative ways to develop a quality health workforce in a short time frame. 

One way is to receive funding and other incentives to create new career ladders for those people who are already employed within the health system and want to raise their skill levels and receive education in one of the more-skilled professions (and this can include the myriad allied health, imaging, medical records and IT jobs that are critical to the system).

There should also be funding to health professions schools to create innovative, perhaps fast tracked, retraining programs for the thousands of people who are losing their jobs in America’s dying manufacturing industries. 

The Obama Administration needs to look beyond small business and the green industries with regard to JOBS.  The health workforce should be the priority when it comes to jobs.

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.

  An essential step to improving health care is for the Department of Health and Human Services, specifically the Centers for Medicare & Medicaid Services (CMS) to more effectively support the innovative and life-saving therapies available during clinical research studies. The AAHC has urged the CMS to reassess the CTP to resolve the problems that emerged after its hasty establishment in 2000 but have not been addressed in an appropriate or satisfactory manner to date.

The AAHC requests CMS to revise the CTP to ensure that its intended goal of opening new realms of treatment for Medicare beneficiaries can be achieved.  

 The CTP’s current wording, and CMS’ deference to Medicare contractors in its interpretation, has produced inequitable disparities in coverage among different regions of the country. The Medicare program’s CTP, as currently constituted, not only inhibits access to clinical trials for Medicare beneficiaries, but also endangers the clinical research enterprise in the United States, by imposing a disproportionate compliance burden on the inclusion of Medicare beneficiaries in clinical trials.

 This is particularly troublesome given that the clinical enterprise is critical to having the U.S. remain a world leader in health. The aging of America’s population and the need for new treatments and cures for cancer and other diseases that disproportionately strike the elderly are the transformational forces motivating our call for change. The uneven application of the CTP has been a particular concern for our members in coverage of services during clinical trials relating to cancer, HIV and other medically and financially devastating diseases. By discouraging Medicare beneficiaries from participating in clinical trials, the CTP:

HHS needs to  ensure that  CMS acts now to:

• Reconsider the Medicare Clinical Trial Policy;

• Make immediate changes to the current CTP related to Medicare coverage to explicitly cover Phase I drug trials;

• Establish a position at CMS to oversee and coordinate Medicare coverage policy during clinical trials and to interact with other HHS agencies on clinical research; and

• Establish an interagency taskforce within HHS to harmonize regulations of CMS, the National Institutes of Health (NIH), the Agency for Health Research and Quality (AHRQ), the Food and Drug Administration (FDA) and other agencies that affect clinical research.

 The approximate amount of unrecovered costs of research for the past fiscal year ranged from 8 to 40 percent, with almost half of the institutions in the 20-40 percent range.  The same or higher amounts of unrecovered costs are projected for 2010.  Only two institutions are projecting  slight decreases of 1-2 percent.

 Academic health centers are being required to take on increasing amounts of cost sharing on grants received from the federal government. The cost sharing issue was particularly evident in funding of the clinical and translational science awards (CTSAs), an NIH program launched in 2006 to transform the conduct of clinical research through multisite, multi-disciplinary research.  CTSAs, while heralding major transformations in the nature, scope, and outcomes of biomedical research, are nevertheless an expensive undertaking. Current grantees noted cost sharing in the range of 15 to 50 percent annually, with the majority of institutions citing 25-50 percent  in cost sharing.

 Opportunities for new investigators and a strong pipeline of  talent are always significant issues and signs of stability within a system.  Such signs have not been positive for several years as reflected in the percent of first time RO1 grants awarded by the National Institutes of Health; the percentage of new RO1s have been on the decline for some time. Less interest by American students in seeking careers in academic research has also been an ongoing concern and does not speak well of the nation’s commitment to science and math education or, indeed, to higher education.

 Academic health centers are experiencing increasing difficulties to fill the gap in research funding.  Clinical practice revenues have been the traditional source of funds as academic health centers recycle monies from clinical practice into research endeavors.  Several AAHC institutions said that 95-100 percent  of funding comes from clinical revenues, which this year may be in grave danger depending on the outcome of health reform.  Indications are that physician fees will be reduced, which in turn will result in cuts in reimbursement to academic health major reductions in monies available for the research enterprise. 

 For public institutions, monies are not available from the state.  State budget cuts were noted in the range of 2-27 percent (in many instances this was the second, third, or even fourth year of decreases from the state). Decreased funding for endowments, which are particularly critical to funding at private universities,  ranged from 9.9% to 30%, last year with the majority of institutions in the 18-25% range.  For 2010, the projections for decreased funding ranged from 4-30 % for endowments and up to almost 25% for state funding.

These are only some of the critical warning signs of erosion of the research enterprise that call for review and reassessment of the nation’s commitment to and strategies for R&D and biomedical research, in particular, for the future.  With many other nations and companies throughout the world now making investment choices that will have an impact on the next decade of technology development , the U.S. choices and  policy on biomedical research are of profound importance.   The nation needs to recommit to biomedical research and consider a new business model for the research enterprise for the future–one that is viable and sustainable and competitive in a global marketplace.  This is what the Association of Academic Health Centers is now examining.  Stay tuned for updates on this important endeavor.

Secretary Sebelius, as secretary of Health and Human Services (HHS), presides over this agency and knows something about payments to insurers, having been an insurance commissioner back in Kansas.  With that background, she should know how critical CMS is to the functioning of the health care system. It is troubling that Secretary Sebelius has not taken action to fill what is the perhaps the most significant and essential slot in HHS.  At this critical juncture, there is no leadership in place to assess the structure and resources of CMS that will have the massive task of implementing any health reform legislation. 

Of great importance to academic health centers,  the Administration has not taken action on some of the most pressing issues for Medicare beneficiaries, which fall under the purview of CMS, specifically  participation of Medicare beneficiaries in clinical trials.  The current clinical trials policy hampers such participation.  In fact, the clinical trial policy threatens the nation’s ability to conduct clinical research and compete globally?  Secretary Sebelius and Mr. Sunstein, our new regulatory czar in the White House, have been made aware of the future dangers but have taken no action.   Why is CMS not an issue?  

Waiting for health reform is no answer.  The problems with CMS organization, resources, and policies will only be heightened.  Action must be taken now.  Nominating and appointing someone to head this agency is critical.

 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.

Also significant, the legislation also now includes language identical to the recommendation made by the Association of Academic Health Centers (AAHC) that a permanent health workforce advisory committee develop and implement “an integrated, coordinated, strategic national health workforce policy.”  The AAHC has advocated for a national workforce planning entity because it believes that the nation’s workforce policy must be changed; the nation’s customary piecemeal approach to the workforce is no longer viable or appropriate for the 21st century.

A  comparable Senate bill is still being negotiated. The Senate should not only include such language in any final bill but also move to ensure the creation of a permanent planning entity that operates continuously, makes ongoing findings and recommendations, and is available at any time to provide consultative support to federal, state, and private health workforce stakeholders. The planning entity must serve as an active policymaking partner, not a passive advisor.

The AAHC has been urging the congressional committees and congressional leadership to broaden the scope of activity of the proposed advisory committee/national commission to fully support a strategic national policy approach.

Specifically, the AAHC recommends the following modifications be incorporated into any health reform legislation considered by the full House and Senate:

1. Make development and implementation of an integrated, coordinated, strategic national health workforce policy the primary objective of any advisory committee or national commission.
2.  Constitute the advisory committee or national commission as a continuously available policy research and consultative resource, not simply as a body of external experts that convenes from time to time to make periodic recommendations.
3. Amend the enumerated issues to be addressed by the advisory committee or national commission to include the harmonization of conflicting national and state-based regulatory and private self-regulatory standards (e.g., licensure, scope of practice, accreditation).

4.    As an interim step, create a national health workforce coordinator to assess current federal capabilities and prepare agencies for their interactions with the advisory committee or national commission once it is fully functional.

 This is the way to ensure that the nation  has the health workforce it needs for the short and long-term.