jeanne

Replacing the "hated" Sustainable Growth Rate Formula (SGR) in April of this year ended some deep flaws in the Medicare payment system for physicians, but other concerns remain, according to two papers published in the September 24 issue of the New England Journal of Medicine.

The replacement, called the Medicare Access and CHIP Reauthorization Act, works this way: Between 2016 and 2019, Medicare's payment will increase by 0.5% a year, with no rate changes between 2020 and 2025. Starting in 2019, Medicare payments will vary according to whether a physician chooses the Merit-Based Incentive Payment System (MIPS) or chooses to join an Alternative Payment Model, which includes accountable care organizations and medical homes.

Physicians who choose an Alternative Payment Model will receive 5% annual increases in Medicare payments through 2024. Physicians who choose the MIPS will be adjusted upward or downward (by 4% in 2019, increasing to 9% by 2022).

In their perspective article, Jonathan Oberlander, PhD, from the University of North Carolina, Chapel Hill, and Miriam Laugesen, PhD, from Columbia University in New York City, point out that this system relies on new payment and delivery models for cost control and quality improvement. However, the evidence of the models' effectiveness is "thin, mixed and preliminary," they write.

"Medicare, in other words, is set to pay physicians more to embrace innovations whose effectiveness is highly uncertain -- a remarkable leap of faith."

They also note that Medicare's MIPS will rely on development of a composite performance score, a third of which will depend on physicians' quality. But they are skeptical physician quality can be measured accurately and meaningfully and calculated into a score.

And although physicians will see bonuses and extra payments through 2024, after they expire, updates may not keep pace with increases in medical expenses, the authors write.

In another paper published in the same issue of the journal, Meredith B. Rosenthal, PhD, from the Harvard T.H. Chan School of Public Health, Boston, Massachusetts, says if the measures used to determine the physician quality portion of the MIPS score include factors outside physicians' control that affect their performance in unpredictable ways, then "the program will amount to allocating a share of physician pay by lottery." That would make incentives impotent and cause great physician dissatisfaction, she contends.

Those factors could also encourage physicians to be more selective with patients.

"[I]f the measures are systematically influenced by patient factors and these factors are not accounted for (e.g., through risk adjustment) in benchmarking physicians' performance, then the MIPS will be unfair and will create incentives for physicians to avoid patients who would negatively affect their performance scores," she writes.

Dr Rosenthal adds that giving physicians the option of choosing an APM may result in a tipping point for voluntary uptake of those models and "could potentially have a larger effect on value-based purchasing than the MIPS itself."

Mr. President, I am deeply grateful for your welcome in the name of all Americans. As the son of an immigrant family, I am happy to be a guest in this country, which was largely built by such families. I look forward to these days of encounter and dialogue, in which I hope to listen to, and share, many of the hopes and dreams of the American people.

During my visit I will have the honor of addressing Congress, where I hope, as a brother of this country, to offer words of encouragement to those called to guide the nation's political future in fidelity to its founding principles. I will also travel to Philadelphia for the Eighth World Meeting of Families, to celebrate and support the institutions of marriage and the family at this, a critical moment in the history of our civilization.

Mr. President, together with their fellow citizens, American Catholics are committed to building a society which is truly tolerant and inclusive, to safeguarding the rights of individuals and communities, and to rejecting every form of unjust discrimination. With countless other people of good will, they are likewise concerned that efforts to build a just and wisely ordered society respect their deepest concerns and their right to religious liberty. That freedom remains one of America's most precious possessions. And, as my brothers, the United States Bishops, have reminded us, all are called to be vigilant, precisely as good citizens, to preserve and defend that freedom from everything that would threaten or compromise it.

Mr. President, I find it encouraging that you are proposing an initiative for reducing air pollution. Accepting the urgency, it seems clear to me also that climate change is a problem which can no longer be left to a future generation. When it comes to the care of our "common home," we are living at a critical moment of history. We still have time to make the changes needed to bring about "a sustainable and integral development, for we know that things can change" (Laudato Si', 13). Such change demands on our part a serious and responsible recognition not only of the kind of world we may be leaving to our children, but also to the millions of people living under a system which has overlooked them. Our co Image result for pope francis in usa

mmon home has been part of this group of the excluded which cries out to heaven and which today powerfully strikes our homes, our cities and our societies. To use a telling phrase of the Reverend Martin Luther King, we can say that we have defaulted on a promissory note and now is the time to honor it.

We know by faith that "the Creator does not abandon us; he never forsakes his loving plan or repents of having created us. Humanity still has the ability to work together in building our common home" (Laudato Si', 13). As Christians inspired by this certainty, we wish to commit ourselves to the conscious and responsible care of our common home.

The efforts which were recently made to mend broken relationships and to open new doors to cooperation within our human family represent positive steps along the path of reconciliation, justice and freedom. I would like all men and women of good will in this great nation to support the efforts of the international community to protect the vulnerable in our world and to stimulate integral and inclusive models of development, so that our brothers and sisters everywhere may know the blessings of peace and prosperity which God wills for all his children.

Mr. President, once again I thank you for your welcome, and I look forward to these days in your country. God bless America!

Proposed mega-mergers between health insurance giants prompted by the Affordable Care Act won't harm the level of competition in the market, two chief executives pledged this week to skeptical lawmakers from both parties. The recent plans by Aetna Inc. to acquire Humana Inc., and by Anthem Inc. to buy Cigna Corp., have raised concerns over the economic impact that such mergers, which would eliminate two of the five largest insurers to create three companies, would have on consumers. The Justice Department is investigating the deals.

In their attempt to convince senators of the mergers' virtues, the CEOs of Aetna and Anthem each said healthcare should be viewed within a local context and that the mergers would lead to robust competition without raising prices for consumers.

"Simply put, the combination of Anthem and Cigna will allow us to provide better health insurance to more people," said Joseph Swedish, CEO of Anthem.

"There would be no material change in the competitiveness of the commercial insurance market," said Mark Bertolini, CEO of Aetna.

However, some senators, including Richard Blumenthal (D-Conn.), expressed skepticism about the concentration of power in fewer hands. The mergers, Blumenthal said, appear to be more the "triumph of hope over experience."

He recalled Aetna's billion-dollar acquisition of Prudential Health Care in 1999. Leemore Dafny, a professor at Northwestern's business school, testified that the deal cut both jobs and wages in the locations where the two companies overlapped, as well as reduced payments to health care providers.

"There is no evidence that mergers have led to improved quality or more innovation," said Dafny, who noted that public data on such mergers is limited.

Senators from both parties raised concerns about how the deals would affect healthcare costs. According to a new survey, American workers saw their out-of-pocket medical costs jump again this year, as the average deductible for an employer-provided health plan grew nearly 9% to more than $1,000.

The American Hospital Assn., a powerful hospital lobby, has also challenged the consolidation plans. Richard Pollack, the group's president and CEO, testified that he was concerned about the possibility of rising prices and limited choices under an Aetna/Humana merger, especially for the millions of seniors who buy Medicare Advantage plans.

Furthermore, with Anthem's affiliation with the extensive Blue Cross and Blue Shield system, a merger with Cigna, he said, could all but eliminate competition and entrench the system's domination in nearly every state.

If the deals are approved, Pollack said, the top three insurers would cover 131 million people, or 40% of Americans with health insurance.

"We are very concerned that both deals could result in fewer choices for consumers, narrower networks and providers in what few choices remain and higher premiums and out-of-pocket costs," said Pollack.

United Health Group Inc., which would round out the top three largest insurers if the mergers proceed, did not participate in the hearing.

Sen. Mike Lee (R-Utah), chairman of the Judiciary antitrust subcommittee, said Tuesday's hearing was not about President Obama's landmark 2010 healthcare law.

Since then, there has been a trend in hospital mergers. More than 70 deals have been announced this year alone, and 2015 is on track to surpass the 100 hospital transactions announced in 2014, according to research company Irving Levin Associates. Proponents of hospital consolidation say consolidation leads to cost savings and others believe the mergers are a response to healthcare reforms.

Some upsides to insurance mergers include reduced administrative costs, alternative payment models and investments in data and analytics to support providers, said Paul Ginsburg, a public policy professor at USC.

Jeanne's Comment: Yeah, like we should trust these CEOs ... like we "trusted" the tobacco industry CEOs who said cigarette smoking wasn't addictive or harmful ... or the auto execs who told us their cars were safe and didn't have acceleration or breaking problems and that their cars didn't pollute ... or the banking CEOs who told us that their sub-prime mortgage manipulations were all fine and dandy ... or coal industry CEOs ... or the industrial farming execs ...and the list goes on ...

Democrats facing tough elections have been running away from Obamacare in their campaigns almost since the law was passed (and paid dearly for this mistake by losing big in off year presidential elections), but Hillary Rodham Clinton is taking a different approach for 2016. She is embracing it. On the campaign trail, Clinton is leaning into the Affordable Care Act, touting the health insurance mandate as a signature achievement of Democrats as the law -- about which the public remains deeply divided -- has become firmly embedded in the nation's healthcare system and is delivering sweeping new benefits to millions of voters.

This week Clinton unveiled a plan to expand the law's reach with a proposal to force down the prices of prescription drugs. She will call for new federal rules to cap what consumers are forced to pay out of pocket for medicines, and she would allow the federal government to negotiate directly with drug makers to secure lower drug costs for seniors on Medicare.

"I want to do more to bring down the costs for families," Clinton said at a rally here, where she previewed the plan. "It is disgraceful ... Medications for a lot of diseases are going up to thousands of dollars a month."

The plan would allow Americans to buy prescription drugs abroad, where prices are often lower; prohibit drug companies from writing off the cost of advertising; and limit profits the companies can make from drugs developed with the help of federal research subsidies. It would also boost spending at the Food and Drug Administration so prescription drugs could be approved for sale more quickly. Prescription drugs account for just 10% of the nation's healthcare spending, but rising prices and the proliferation of headline-grabbing specialty medications that cost tens of thousands of dollars, such as the hepatitis C drug Sovaldi, are driving public anxiety.

Clinton's embrace of Obamacare as a potential boon to Democrats at the polls next year is a notable contrast from Democratic strategy in previous elections. Congressional candidates in the 2010 and 2014 midterms sidestepped the issue whenever possible. Even Obama largely kept his campaign spotlight off healthcare during his race for reelection, with the exception of the campaign's Latino strategy, which heavily promoted the law's promise in Spanish-language advertising. But now more than 9 million Americans have gained health insurance through Medicaid or private insurance marketplaces created by the Affordable Care Act. The nation's uninsured rate has fallen more rapidly than at any time in at least half a century, a point Clinton seized on in Little Rock and at a campaign event earlier Monday in Baton Rouge, La., as she noted that every GOP candidate wants to repeal the law.

"I'm not going to let them tear up that law, kick 16 million people off their health coverage and force this country to start the healthcare debate all over again," Clinton said in Baton Rouge. "Not on my watch."

"Why would you repeal something that is working to help people?" she said.

Clinton was particularly critical of Republican governors who spurned federal dollars to expand their Medicaid programs, a key provision of Obamacare. In Baton Rouge, she called out by name Gov. Bobby Jindal, himself a presidential candidate, for refusing the subsidies, charging that it left 190,000 people in the state without insurance. Jindal responded by challenging Clinton to a debate on the issue.

The Medicaid issue will probably play prominently next year in the crucial election battleground state of Florida, which has also rejected federal subsidies intended to bring coverage to large numbers of low-income residents without insurance. Jeb Bush, a GOP heavyweight in the presidential race and a former Florida governor, urged lawmakers to reject the subsidies.

Clinton chose Arkansas and Louisiana on Monday to begin focusing on healthcare because of the vastly different experiences the two states have had with the law. In Arkansas, which has embraced Obamacare, the uninsured rate has plummeted from 22.5% in 2013 to 9.1% in the first half of 2015, the largest decline of any state, according to Gallup surveys. By contrast, Louisiana has seen its uninsured rate decline less than half as much, falling from 21.7% to 16.3%. The state's health indicators -- including life expectancy-- are among the worst in the nation.

While Republicans continue to call for repealing the law, only a handful of GOP candidates have offered a blueprint for what their replacement would look like. And even those who have, including Wisconsin Gov. Scott Walker -- who dropped out of the race Monday -- have not detailed how they would pay for a replacement.

Jeanne's Groan #9643 ... It seems that Republicans against raising the minimum wage are actually arguing that if you are stuck in a low paying job, it just a case of your gross income pittance.

ABSTRACT: In addition to expanding and reforming most of the nation's system of health insurance coverage, the Affordable Care Act (ACA), otherwise known as "Obamacare," contains numerous provisions intended to resolve underlying problems in how health care is delivered and paid for in the United States. These provisions focus on three broad areas: testing new delivery models and spreading successful ones, encouraging the shift toward payment based on the value of care provided, and developing resources for system-wide improvement. This brief describes these reforms and, where possible, documents their initial impact at the ACA's five-year mark. While it is still far too early to offer any kind of definitive assessment of the law's transformation-seeking reforms, it is clear that the ACA has spurred activity in both the public and private sectors, and is contributing to momentum in states and localities across the U.S. to improve the value obtained for our health care dollars.

OVERVIEW: In addition to its more familiar health insurance coverage reforms, the ACA contains numerous provisions that directly target how health care is organized, delivered, and paid for in the United States. These provisions take aim at the well-known shortcomings of the U.S. health system, from the inefficiency and high cost of our predominantly fee-for-service system to the extreme variability in the quality of care patients receive from region to region. Building on existing reform models in the private and public sectors, the law takes multiple, complementary approaches to addressing the health system's longstanding problems. These center on:

-- testing new models of health care delivery
-- shifting from a reimbursement system based on the volume of services provided to one based on the value of care
-- investing in resources for system-wide improvement

With Obamacare now five years old, this brief reviews these approaches and reports on the early impact of specific reforms and initiatives for which reliable data are available. Because many of these provisions are still in the early stages of implementation and testing, it is difficult, if not impossible, to make any definitive assessment of their impact. Nevertheless, it is useful at the five-year mark to review some of the law's delivery and payment reforms in some detail and reflect on the experience of patients, providers, and payers as these profound changes unfold.

Accountable Care Organizations

An accountable care organization (ACO) is an entity formed by health care providers -- from primary care physicians and specialists to hospitals and post-acute care facilities -- that agree to collectively take responsibility for the quality and total costs of care for a population of patients. Beginning in 2012, the ACA established the Medicare Shared Savings Program to encourage the development of ACOs. If participating ACOs meet quality benchmarks and keep spending for their attributed patients below budget, they receive half the savings that result, with the rest going to the Centers for Medicare and Medicaid Services (CM²), which administers the program. To keep a larger share of the savings (up to 60 percent), ACOs can choose to participate in a "two-sided risk" model, whereby they must repay a share of losses if health care spending for attributed patients exceeds the budget target.

In 2015, there are more than 400 Shared Savings ACOs serving nearly 7.2 million beneficiaries, or 14 percent of the Medicare population. While these participation numbers have exceeded expectations, results from the program's first year of operation, 2013, were mixed. Of the 220 Shared Savings ACOs that year, only 52 were able to meet quality-of-care benchmarks and keep spending below budget targets; these ACOs generated $700 million in total savings and roughly $315 million in shared-savings bonuses (Exhibit 1). Another 60 ACOs kept spending under their targets but either did not fulfill their requirements to measure the quality of care delivered to patients or did not reduce spending enough to meet the minimum criteria to share in savings.

ACOs in the Shared Savings Program showed some improvement on most of the 33 quality measures -- from diabetes care to depression screening -- compared with other Medicare providers (Exhibit 2). However, these organizations were eligible to share in savings for simply reporting data on all measures, regardless of actual performance. Beginning in 2014, Shared Savings ACOs were required to meet minimum quality standards to qualify for a share in any savings, though performance data are not yet available.

The majority of the participating ACOs have opted for one-sided risk, which means they can share in savings produced but are not subject to paying a share of the losses incurred if spending exceeds targets. A key question for CM² officials is how they can sustain participation in the future while encouraging and supporting providers to assume greater financial risk. A global budget covering all patients is one potentially important strategy for encouraging clinicians to deliver care in innovative ways, invest in value-producing services that are generally not currently reimbursable (such as taking time to email or educate patients), and devote resources to infrastructure enhancements (such as information technology systems) that improve coordination with other providers.

However, most providers across the country have limited experience in managing care to a budget and limited capacity to coordinate care with other providers. Hence, many are not ready to take on the extra financial risk. For providers equipped to test more advanced payment models and stringent quality thresholds, CM² has launched the much smaller Pioneer ACO program, which is administered by the newly created Center for Medicare and Medicaid Innovation. Known as the CM² Innovation Center, this agency has the authority to test and nationally expand new models that are proven to reduce health care costs while maintaining or improving quality of care. The idea is that lessons learned from the Pioneer ACOs can be incorporated into the Shared Savings Program.

In the second year, 11 of 23 Pioneer ACO participants earned financial bonuses totaling $68 million, while three ACOs faced penalties of roughly $7 million. The Pioneer ACO that generated the most savings was Montefiore Medical Center, a safety-net system located in The Bronx, New York (read more about Montefiore's experience here). Although Pioneer participants are considered among the most advanced ACOs, some have had difficulty meeting financial targets, and 13 have dropped out of the program as of March 2015, with most switching to the Shared Savings model.

In recognition of the challenges providers face to be successful Medicare ACOs, CM² is allowing providers to take it slow by adopting the one-sided risk model for at least three years and by getting credit for simply reporting on quality measures in the first year. (See Exhibit 5 on page 8.) In addition, low-cost loans are being made available to help spread the model to smaller provider organizations and those in rural areas with limited start-up capital; in fact, one rural organization, Rio Grande Valley ACO, had achieved one of the highest levels of savings as of 2014. ACOs that have proved successful from the start tend to make investments in information technology systems, data analytic tools, and the necessary staff to identify high-risk patients and closely monitor their care.

Medicare's ACO programs are likely to evolve with the accumulation of experience. An important marker of impact to watch will be whether ACOs' investments improve outcomes for patient populations beyond Medicare.

Primary Care Transformation Through Implementation of Medical Homes

Although primary care is fundamental to a well-functioning health system, the U.S. has undervalued and underinvested in it for decades. The neglect of primary care is largely a byproduct of the prevailing fee-for-service reimbursement approach: providers have inherent financial incentives to favor higher-priced procedures over care management and other cost-saving services. As a result, the care U.S. patients receive is often poorly coordinated and expensive.

On the flip side, there is considerable evidence that comprehensive, coordinated, and well-targeted primary care can improve outcomes and reduce per-patient costs. These characteristics are embodied in the patient-centered medical home, a model of care that emphasizes more comprehensive care coordination, care teams, patient engagement, and population health management.

A number of the ACA's reforms seek to transform primary care by way of the medical home model, through programs and initiatives involving private physician practices, community health centers, and even home-based care providers. The ACA also is helping health systems and states to experiment with ways to improve the quality of primary care, spread promising models, and integrate primary care more seamlessly with other health care services, such as behavioral health and long-term care services (see appendix for a summary of several primary care-related provisions in the law). Below we present recent findings from two of the CM² Innovation Center's large-scale, multi-payer primary care initiatives that seek to change the face of primary care in the U.S. (Exhibit 3).

Comprehensive Primary Care Initiative. This national initiative involving 29 payers (excluding CM² ), nearly 500 providers, and some 2.5 million patients is testing a new way to deliver and pay for care that is designed to improve access, coordination, and chronic disease management while engaging patients and their caregivers. The program offers participating physician practices enhanced payment, technical assistance, and ongoing feedback on performance. Evaluation results show that in the initiative's first year, spanning October 2012 to September 2013, the practices generated enough savings to cover most of the $20 per-member, per-month care management fee paid on average by CM² (although not enough to produce net savings overall). While there was considerable variation in performance among the seven participating U.S. regions, across all markets emergency department visits decreased by 3 percent and hospital admissions by 2 percent after year¹. Significant effects on quality were few.²

Multi-Payer Advanced Primary Care Practice Demonstration. Medicare has joined eight state-sponsored pilot programs involving Medicaid and private insurers to test the impact of per-member, per-month fees paid to primary care sites for providing medical home services.³ In the demonstration's first full year of operation, 2012, more than 3,800 providers in 700 practices serving 2.2 million patients participated. Recent evaluation results estimate $4.5 million in savings generated in year one, translating to a return on investment of $1.35 for every $1 Medicare paid out. In Vermont and Michigan, growth in Medicare fee-for-service health care spending significantly slowed as hospital inpatient care expenditures fell. There is less evidence, however, that the state initiatives were able to reduce hospitalizations, readmissions, and emergency department visits.⁴

A major theme emerging from these efforts to transform primary care is the critical role of technical and financial support in building the capacity of physician practices to function as medical homes. Each of the ACA-supported transformation initiatives includes some level of support for practices to address common challenges. These include: collecting, reporting, and using data in a timely fashion for care management and quality improvement; changing the practice culture to enable effective teamwork; and obtaining information about patients from settings outside the practice.

In general, federal investments have stimulated unprecedented collaboration and dialogue among payers, both private and public, and providers on how to reorganize primary care at the local level to achieve the aims of reform. Still, Medicare, despite collaborating more actively with primary care providers and other payers since Obamacare's passage, needs to identify ways to share data more quickly with local partners and communicate programmatic changes clearly.

REFORMING PROVIDER PAYMENT

Obamacare included many payment reform provisions aimed at promoting the development and spread of innovative payment methods to facilitate the adoption of effective care delivery models. The earliest of the ACA's provisions related to provider reimbursement have slowed growth in fee-for-service payment levels. The intention was to provide some budget relief, particularly for the Medicare Trust Fund, and to send a clear signal to providers that they will need to adapt quickly to incentives that reward appropriate, high-quality care and good patient outcomes.

For example, reflecting the anticipated reduction in uncompensated care from increased insurance coverage, the ACA lowered annual increases in Medicare payment rates for hospitals and other facilities and explicitly set an expectation for providers to become more efficient over time. The law also reduced overpayments to private plans administering Medicare benefits through the Medicare Advantage program, bringing these payments more in line with traditional Medicare costs, and linked, as of 2012, plan payments to performance ratings and made the results public.⁵ Today, even with these lower payments, increasing numbers of beneficiaries are enrolling in private plans, with many choosing higher-performing plans.⁶

Other ACA provisions target quality problems that lead to inefficiencies and jeopardize patient health. For example, the law imposes financial penalties on hospitals with high rates of hospital-acquired conditions and readmissions, an effort that has likely contributed to the recent reduction in associated adverse medical events (Exhibit 4). The new value-based purchasing program for hospitals, meanwhile, fosters greater accountability for performance by dispensing bonuses and penalties tied to publicly reported quality measures; similar programs for physicians are being implemented in phases, starting in 2015, with a full rollout to all fee-for-service providers in 2017.

The ACA provisions also seek longer-term, systemic change in how health care is organized and delivered. In addition to the accountable care programs and medical home initiatives discussed above, the ACO is also testing a payment approach known as bundled payment, a single reimbursement for all the services required for a given medical condition or procedure. This means that physician, hospital, or post-acute services can all be covered under a single payment, which should incentivize the various providers involved in a given patient’s care to work better together. Nearly 7,000 postacute care providers, hospitals, and physician organizations have signed up to participate in bundled-payment demonstrations, which represent a further step away from payment for individual services and toward shared accountability for quality and costs.

Most of the new payment models are still in their early phases, and evidence of their impact is far from definitive. Many initiatives have adopted an incremental approach to financial accountability, often starting with pay-for-reporting or bonus-only options (Exhibit 5). The gradual approach recognizes that the type of structural change required to be successful under risk-based payment systems takes time, a concern repeatedly voiced by providers.

The pace of change is about to pick up, however. Earlier this year, the U.S. Secretary of Health and Human Services (HHS) announced a goal to have at least 90 percent of traditional Medicare payments linked to some form of ACO, medical home, bundled payment, or other value-related approach by 2018.⁷ A private-sector consortium has set a similar goal for its member businesses.⁸ In fact, an important effect of the ACA is how it has opened up new channels of communication between providers and CMS about the design and implementation of new payment and delivery models. The CMMI Innovation Awards program, for example, encourages health care organizations to propose new care delivery and payment initiatives for piloting. And provider involvement in the design of the law's ACO and bundled-payment provisions enabled CM² to create programs that have attracted large numbers of participants. CM² and providers are now sharing much more data to monitor and gauge program performance. While implementation of these new programs has not been without delays and hiccups, the culture change occurring across the health care sector may soon make greater strides possible.

Jeanne's Groan #9441: No one is born a politician, they're made. Which may explain why so many of them have a screw loose.

House Energy and Commerce members signaled interest last week in a bipartisan plan that would amend the Affordable Care Act (Obamacare) to keep employers with 51 to 100 workers from having to comply with more stringent insurance coverage requirements.
The bill (HR 1624), with 40 Democrats among its 215 cosponsors, drew a warmer response from Energy and Commerce Health Subcommittee Democrats than past efforts targeting the 2010 overhaul. Frank Pallone Jr. of New Jersey, the ranking member of the full committee, called the hearing a "turning point" in the debate, though he added the legislation could be premature.
"As opposed to using the ACA as a political football through repeated, futile attempts to repeal or defund the law, Republicans and Democrats have come together in a bipartisan fashion to improve and strengthen the ACA," Pallone said, "I'm hopeful this spirit can continue."
Under the law, businesses with 51 to 100 workers are categorized as small employers. State regulators, however, have the option of designating them as large employers until 2016, meaning they can offer health coverage through the large group market that does not have to cover specified benefits and meet other requirements that apply to smaller groups.
To prevent midsized employers from being forced to change coverage and possibly absorb premium increases, the bill would automatically place businesses with 51 to 100 workers into the large employer category, while still allowing states to treat them as small employers if they choose. Monica Lindeen, president of the National Association of Insurance Commissioners, said her group endorsed the bill because it would allow states to continue to have control over the small-group market and ensure stability.
Although the effects would vary by state, Lindeen warned of premium increases and reduced flexibility to tailor benefits for the firms in question if the legislation is not passed. Employers with younger and healthier workers could self-insure to avoid fallout from the change.
Kurt Giesa, a partner at the management consultant Oliver Wyman, said his analysis found that 64 percent of midsized employers would see their premiums rise in 2016, with an average boost of 18 percent. After firms with younger, healthier workers leave the market, he estimated that premiums for small businesses in the new combined market could go up 3 to 5 percent.
But Washington State Insurance Commissioner Mike Kreidler testified against the legislation, saying insurers are counting on an expanded risk pool to keep requested premium decreases. Making the change "so late in the game will be very disruptive to the market in the state of Washington," he said.
Kreidler also noted that employees would not have access to the guaranteed benefits under the health care law and suggested that lawmakers could postpone the change rather than remove the requirement. "The jump is a good one for health care reform and for the small group market," he said.
North Carolina Republican Renee Ellmers questioned why Kreidler opposed the measure when a state could opt out of the definition change. But Kreidler said Washington state law sets its coverage limit at 50 employees, meaning he would have to gain legislative approval -- the odds of which he put at "zero to none" given the link to the health law.
Lindeen noted that the Obama administration has offered a transition policy that could allow relief for mid-sized employers in participating states until October 2017, but she said her group thinks the legislation is necessary to preserve coverage options and for future stability. She also dismissed the notion that consumers would have fewer protections under the bill and said that the requirement for plans to offer certain benefits wasn't needed for the large-group market.
"It's important not to deny the small businesses that are currently utilizing a product that works for them to be able to continue to do that," Lindeen said.
Jennifer Sherman, spokeswoman for bill sponsor Brett Guthrie, R-Ky., said a preliminary estimate from the Congressional Budget Office found that the legislation would save $400 million over a decade. That should insulate the measure from the offset concerns that dogged other efforts to change that health law that garnered bipartisan support.

With the GOP-controlled House of Representatives poised to vote on yet another bill to cripple President Obama's health care law and the multitudinous GOP candidates finding success in catering to their conservative constituencies with new hues and cries for "REPEAL AND REPLACE" (with what is always only whispered and masked in vagueness), the question arises: Why do Republicans persist in their so-far futile efforts?
Republicans say they persist because the law is an example of government overreach and is proving unworkable. For many elected in the 2010 and 2014 Republican waves, their opposition to the law is the reason they are in Congress. And, they say, voting to repeal the law is good politics, as it remains extremely unpopular among Republican voters. Republicans and some business owners also say they resent the way in which the law was written and passed by Democrats in 2009-10. Jeffrey S. Kelly, the chief executive of Hamill Manufacturing, a small Pennsylvania company that produces metal parts for Navy ships, made that point at a recent hearing to examine the effects of the law on businesses.
"Haven't you really reaped what you've sown?" Mr. Kelly asked House Democrats. "Look at the history of this law. It was passed without any support on the Republican side."
O.K., fair enough as far as that argument goes: but left out is the history surrounding the passage of the "Medicare Modernization Act of 2003" ... the law that gave us Medicare Part D, a drug benefit that assured the pharmaceutical industry of massive profits (drug prices have more than doubled and for some commonly ordered Medicare drugs, have quintupled since then) but prohibited the Medicare program from negotiating the price ... but even more importantly, the MMA created a new Medicare Part C ... ... ... a for-profit alternative plan that was supposed to lead to "competition" among insurers but instead has led to companies like Humana reaping 85% of their profits from Medicare and costing the program on average 14% more per year than coverage under traditional Medicare.

GOP PLANS FOR PRIVATIZING MEDICARE
This law was the "model" for Rep. Paul's Ryan's "Vouchercare" proposal, which has passed the House, to dismantle traditional Medicare and replace it with a "profit-driven" privatization plan, that would raise out-of-pocket expenses for middle-income Medicare beneficiaries by $8,000 or more per year by 2022, while lining the pockets of the for-profit health insurance industry ... no wonder these companies contribute so much via their political action committees to Republican candidates. "Vouchercare" (privatized Medicare) is now the basic model for the several 2016 GOP-candidate proposals to "repeal and replace" Obamacare. The 2003 GOP-written MMA was passed without a single Democratic vote in the middle of the night after holding the bill open on the House floor for over 9 hours (the usual time is 15 minutes) while GOP whips gathered enough votes to pass the bill without Democratic support ... and passing the bill in the Senate over a possible Democratic filibuster using a little known legislative process known as "reconciliation." Sound familiar? Obamacare was passed in the same way by the Democrats in 2010 ... but now the GOP cries "FOUL!"

Many Americans are mired in a now 30+ years-old conservative suckhole and have a total misunderstanding of the word "socialist" (to most Americans "socialism" equals "communism"). With 35 years of "inside-the-beltway" political experience under my belt, to me this is more than enough proof of the fact that Bernie Sanders can never be elected president of the United States ...

Should he, by some chance, win the Democratic Party's nomination next summer, he would be blown out of the water and swamped by a large portion of that Koch brothers-pledged $900 million spent "informing" Americans that Sanders is an "avowed socialist" ... Americans do not know what socialism is, they have been brainwashed by 65 years of cold war rhetoric telling them that socialism is "bad", worse than bad, it is "evil," and most of them will believe this to be true and will be overwhelmed by the lies that will be spread. Today, most Americans have never even heard of Bernie Sanders and when they do hear about him it will be under a massive Koch-financed umbrage of lies ... today they do not know that Sanders admits to being a socialist and when they do learn this, they will turn away in droves not because his message is wrong but because they will perceive it as un-American ...

I am faced with a serious conundrum (not the first in my life BTW <smile>) ... my children, grandchildren, and many of my friends are jumping on the Sanders bandwagon (all too frequently bad-mouthing the other Democratic candidates in the process) ... so let me say, I admire Bernie Sanders, I agree with 95% of the things he is supporting. America's "St. Ronald of Reagan conservative suckhole" is destroying our vaulted "middle class" and we have to act to change the nation's direction. But I am also a well-worn down political pragmatist and I want to win in 2016 ... we have to win in 2016 ... at least 3 members of the Supreme Court will be stepping down over the coming years, if a "President Scott Walker" or "President Jeb Bush" or worse, a "President Ted Cruz" is in office, it will be a national disaster.

Americans don't change their political thinking that quickly and he would lose not only the presidency if by some chance he wins the Democratic nomination, but would drag down the Congress with him to super majorities for right-wing loonies to continue their destruction of America's middle class ... Should Bernie Sanders get the nomination, he has my vote and apparently that of at least 312 of my friends and family, now all we need is 69,999,687 more to vote for him and make sure that they are in the right states, like Florida and Ohio (ask Al Gore about that) ... and oh by, the way, wait until the average Joe American hears that Bernie is an avowed socialist ... his policies may be great and wonderful, but they'll never get past the $900 million in Koch money that will scream "SOCIALISM" incessantly should he actually get the nomination ... massive crowds showed up at Eugene V. Debs rallies in the 30's ...and he won less than 2% of the vote ... naive views of the US political system will guarantee a right-wing Supreme Court that will last until your children have grandchildren ...

Democratic progressives like Elizabeth Warren and Bernie Sanders play a critical role, but we are a deeply divided nation ...Senator Warren knows her job (and she has openly stated this and it should also be that of Bernie Sanders,) is to hold Hillary's feet to the fire and keep her focused on progressive issues ... neither Warren or Sanders can win with just lefty votes and would be killed in the money contest by the right-wing nutcases ...Democrats just have to keep their enthusiasm in check and avoid bad-mouthing Hillary in such a way as to be destructive to Democratic chances in the 2016 elections … Republican neo-cons financed by the likes of the Koch brothers are feeding this anti-Hillary frenzy on the left and too many Democrats are selling themselves to the right .

... today's Republicans argue, "Give a man a fish and he'll eat for a day; teach a man to fish and he'll eat for a lifetime" ... but then while it is true that our society relies heavily on individual responsibility, and people need to take charge of their own lives as much as possible, Republicans will proceed to grant tax breaks to corporate fisheries to base their operations offshore; deregulate air and water usages polluting the oceans, seas and lakes nearly destroying the fishing beds; defund the public schools where people are being taught to fish and in the process vilifying their teachers ... all the while complaining that if the government does anything that would be socialism. ...

One of the main ways the Affordable Care Act (Obamacare) seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently. The law takes a carrot-and-stick approach by encouraging the formation of accountable care organizations (ACOs) in the Medicare program. Providers make more if they keep their patients healthy. About 6 million Medicare beneficiaries are now in an ACO, and, combined with the private sector, at least 744 organizations have become ACOs since 2011. An estimated 23.5 million Americans are now being served by an ACO. You may even be in one and not know it. While ACOs are touted as a way to help fix an inefficient payment system that rewards more, not better, care, some economists warn they could lead to greater consolidation in the health care industry, which could allow some providers to charge more if they're the only game in town.

ACOs have become one of the most talked about new ideas in Obamacare. Here are answers to some common questions about how they work:

An ACO is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. At the heart of each patient's care is a primary care physician. In Obamacare, each ACO has to manage the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years. Think of it as buying a television, says Harold Miller, president and CEO of the Center for Healthcare Quality & Payment Reform in Pittsburgh, Pa. A TV manufacturer like Sony may contract with many suppliers to build sets. Like Sony does for TVs, Miller says, an ACO brings together the different component parts of care for the patient -- primary care, specialists, hospitals, home health care, etc. -- and ensures that all of the "parts work well together." The problem with most health systems today, Miller says, is that patients are getting each part of their health care separately. "People want to buy individual circuit boards, not a whole TV," he says. "If we can show them that the TV works better, maybe they'll buy it," rather than assembling a patchwork of services themselves.

As lawmakers searched for ways to reduce the national deficit, Medicare became a prime target. With baby boomers entering retirement age, the costs of caring for elderly and disabled Americans are expected to soar. The health law created the Medicare Shared Savings Program. In it, ACOs make providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work, they have to seamlessly share information. Those that save money while also meeting quality targets keep a portion of the savings. Providers can choose to be at risk of losing money if they want to aim for a bigger reward, or they can enter the program with no risk at all. In addition, the Centers for Medicare & Medicaid Services (CM2) created a second strategy, called the Pioneer Program, for high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk.

In 2014, the 20 ACOs in the Medicare Pioneer Program and 333 in the Medicare Shared Savings generated $411 million in total savings but after paying bonuses, the program resulted in a net loss of $2.6 million to the Medicare trust fund. That's far less than 1 percent of Medicare spending during that period. Still the program is expected to be expanded and Health and Human Services Secretary Sylvia Burwell has set a goal of tying 50 percent of all traditional Medicare payments to quality or value by 2018 through new payment models, including ACOs.

In Medicare's traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. That drives up costs, experts say, by rewarding providers for doing more, even when it's not needed. ACOs don't do away with fee for service, but they create an incentive to be more efficient by offering bonuses when providers keep costs down. Doctors and hospitals have to meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers get paid more for keeping their patients healthy and out of the hospital. If an ACO is unable to save money, it could be stuck with the costs of investments made to improve care, such as adding new nurse care managers. An ACO also may have to pay a penalty if it doesn't meet performance and savings benchmarks, although few have opted into that program yet. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help them build the infrastructure necessary for coordinated care -- a concession the Obama administration made after complaints from rural hospitals.

In 2014, the third year of the Medicare ACO program, 97 ACOs qualified for shared savings payments of more than $422 million.

Doctors and hospitals will likely refer patients to hospitals and specialists within the ACO network. But patients are usually still free to see doctors of their choice outside the network without paying more. Providers who are part of an ACO are required to alert their patients, who can choose to go to another doctor if they are uncomfortable participating. The patient can decline to have his data shared within the ACO.

ACOs can include hospitals, specialists, post-acute providers and even private companies like the drug chain CVS. The only must-have element is primary care physicians, who serve as the linchpin of the program. In private ACOs, insurers can also play a role, though they aren't in charge of medical care. Some regions of the country, including parts of California, already had large multi-specialty physician groups that became ACOs on their own by networking with neighboring hospitals.

In other regions, large hospital systems are scrambling to buy up physician practices with the goal of becoming ACOs that directly employ the majority of their providers. Because hospitals usually have access to capital, they may have an easier time than doctors in financing the initial investment, for instance to create the electronic record system necessary to track patients. Some of the largest health insurers in the country, including Humana, UnitedHealth and Aetna, have formed their own ACOs for the private market. Insurers say they are essential to the success of an ACO because they track and collect the data on patients that allow systems to evaluate patient care and report on the results.

ACOs may sound a lot like health maintenance organizations. "Some people say ACOs are HMOs in drag," says Kelly Devers, a senior fellow at the Urban Institute. But there are some critical differences -- notably, an ACO patient is not required to stay in the network. Steve Lieberman, a consultant and senior adviser to the Health Policy Project at the Bipartisan Policy Center in Washington, D.C., explains that ACOs aim to replicate "the performance of an HMO" in holding down the cost of care while avoiding "the structural features that give the HMO control over [patient] referral patterns," which limited patient options and created a consumer backlash in the 1990s. In addition, unlike HMOs, the ACOs must meet a long list of quality measures to ensure they are not saving money by stinting on necessary care.

Many health care economists fear that the race to form ACOs could have a significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs and limit patient choice. But Lieberman says while ACOs could accelerate the merger trend, consolidations are already "such a powerful and pervasive trend that it's a little like worrying about the calories I get when I eat the maraschino cherry on top of my hot fudge sundae. It's a serious public policy issue with or without ACOs."

ACOs are already becoming pervasive, but they may be just an interim step on the way to a more efficient American health care system. "ACOs aren't the end game," says Chas Roades, chief research officer at The Advisory Board Company in Washington. One of the key challenges for hospitals and physicians is that the incentives in ACOs are to reduce hospital stays, emergency room visits and expensive specialist and testing services -- all the ways that hospitals and physicians make money in the fee-for-service system, explains Roades. He says the ultimate goal would be for providers to take on full financial responsibility for caring for a population of patients for a fixed payment, but that will require a transition beyond ACOs.

This article was produced by Kaiser Health News with support from The SCAN Foundation.

HOW AN ACO WORKS (Graphically-designed for the conceptually-impaired like me)