July 15, 2011 Legislation






HHS is mandated by Obamacare to lower transactional costs by making new rules for patient eligibility for coverage and healthcare claim status.  This is hoped to save $12 Billion over 10 years and to clean up the current morass of rules.  Implementation for this Obamacare rule is estimated at $2.5-$5 Billion for health plans and $400-$800 million for providers over 10 years.   

Indiana has fined Wellpoint $100,000 for its data breach.  The company waited months to notify its consumers of the breach allowing them to be targets of consumer fraud.  Wellpoint will also magnanimously provide two years of credit monitoring and pay up to a whole $50 for any loss due to the negligence of the company.  That is a company that all should emulate.  There is a total of 645,000 people affected by their breach of ethics and law.   

The feds fined UCLA $865,000 for their breach of HIPAA and information used by their employees for their own gain.  This stems from the use of the hospital by Hollywood types.          Top


CMS has decided to pay the cost of Provenge, the $93,000 FDA approved treatment for end stage prostate cancer.  They will also pay for the Avastin treatment for breast cancer even though the FDA will probably remove their approval.

The Senate has dropped the cuts to Medicare for medical imaging.  The Senate has also delayed for a year the penalties paid by physicians who do not have EHR going to the Medicare fund.  This money then can be used anywhere.  This is a $400 million trade.  Chicken feed. 

Bipartisan legislation has been introduced to change the Obamacare rules on HSAs so people can control their own health care.  The original rules did not permit the HSA money to be used for OTC prescriptions.  Physicians now write prescriptions for the OTC prescriptions. This costs money for a physician visit and makes no sense.

They still don't get it.  The feds are again cutting the premiums for those with pre-existing conditions since no one wants to come to the party.  It's a good thing they did not drop the premiums in Colorado where a smattering of people are bankrupting the system.

CMS is planning to link payments to hospital and outpatient surgical centers to "quality", whatever that is.  They will start with eight "quality" measures to be reported starting in 2014.  The proposal also allows certain physician hospitals to request a waiver from the expansion ban.  CMS also plans to institute about $200 million in cuts for professional imaging fees.  this is to help offset the SGR.  

Both the GOP and the Dems want the IPAB removed but for different reasons.  Providers also want to be rid of the group but are afraid that the GOP rhetoric may cost them the prize they seek by alienating the Dems in the Senate.

Obama has said he is willing to have Medicare kick in two years later, age 67 in order to get the Republicans to pass a increase in the debt ceiling.  The Democrats said this would never get through the Senate.

The GAO has stated that Medicare's system to catch fraud is inadequate.  I hope they didn't spend too much money on the study that only states the obvious.

CMS has rolled out the standards for the health exchanges. The theory is to allow all individuals and small businesses to band together to get the same clout as big business when they negotiate for health insurance.  The rules leave much to the states as to how the program is carried out.  The CBO estimates that by 2019, about 24 million Americans will have their medical insurance by the exchanges with 80% getting federal assistance averaging $6400 per year.  This comes to alot of money.  Each state will name companies that meet "standardized comparative information" on costs and benefits.  The business may pick the level of benefits it is willing to pop for and how many companies the employees may pick from.  Sebelius touted the new exchanges were just as Congress and fed employees get.  She later stated her earlier statements were not true.

In Florida a new rule requires urgent care clinics to post the prices of their 50 most frequently provided services or face a $1000 a day fine until they do. The posted prices will apply to those who are paying cash not using insurance.  The law does not apply to EDs or private physician offices. 

Multiple states on July 1 have reduced payments to physicians and/or hospitals for Medicaid care.  This will lead to significant increases in hospital ED use and more money spent by both the states and the feds.  Primary care providers will be paid for two years Medicare rates to care for the patients but the specialists will be docked money.  There will be no specialists to see patients.  In Spartanburg, South Carolina, it is now one month for a Medicaid patient to see a primary care physician and no specialists see them.  

The Federal law providing $4.3 Billion in long term financing for both treatment and financial compensation for those suffering form the 9/11 attack has started for the New York residents. 

California has fined LA Care Health Plan $25,000 for screwing up claims and not paying on time and not paying interest.  The plan is a Medicaid HMO and so makes alot more money by not paying than the fine.  

The People's Republic of Massachusetts may again have significant financial problems with their teaching hospitals.  It appears that the teaching hospitals will lose $322 million in federal funding under the bipartisan proposal to decrease the budget.  

Wisconsin stole $200 million from the state liability fund that was paid into by physicians.  They attempted to use it for general purpose funds.  The state was sued and lost.  they are now putting back the stolen funds.  They had to pass a law to give the funds back.  They still have to pay penalties and interest.  The same thing happened in New Hampshire when the state attempted to steal $110 million from the physicians. The courts blocked the raid.  Pennsylvania is still contesting its theft of money from the physicians.  It is now before the state high court.

The IRS has let loose its expected requirements for hospitals to be eligible for community benefit status.  The effective date is March 23, 2012. The hospital organization will need to have each one of its campuses have a separate community benefit analysis and implementation strategy. All hospital organizations that do not comply will be fined $50,000 per hospital.   

NICE, the British board that controls costs for the NIH, has rejected Lucentis for macular edema.  They say it is not cost effective and that laser surgery that may stabilize the condition but will not improve it.  Lucentis may improve vision.  This is what we have to look forward to here in the US of A under Obamacare.   Top


The Governor of North Carolina has vetoed a bill that was physician friendly.  The original bill was to protect ED physicians from law suits but the legislature changed it at the last minute to protect any medical emergency anywhere in the hospital, except those involving pregnancy.  The cap on economic damages also was changed at the end from not applying to severely injured patients to all patients.  At least juries are now told how much insurance is paying for care.

Florida and Pennsylvania both passed laws that help physicians in med mal suits.  The Florida law now allows physicians and not insurance companies to decide whether or not to settle a case.  In Pennsylvania, defendants found less that 60% liable would not have to pay more than their percentage of liability.   This is driving the trial lawyer backed and paid for Democrats into a dizzy.        Top 


Maryland has bowed to pressure and revoked Cardiologist Mrk Midei's license.  Dr. Midei was accused of performing unneeded cardiac caths.  His license was revoked for falsifying data to show the patients needed the caths.  The state even said he increased the cost of medical care in their reasons.  An independent dean fro the University of Miami found no un needed caths.    

Missouri has passed a new medical licensing law.  This gives the medical board more teeth to immediately suspend licenses if they believe patients are at risk.  Physician information will also now be public including in my opinion wrongly pending but not proven disciplinary cases.    Top



DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.