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Wednesday, December 16, 2009

Health Reform: Senator Joe Lieberman Skewered by Ann Telnaes

Thus far, the best indication of Senator Joe, Let-the-Poor-Die, Lieberman's take on what he would like the health care bill to look like comes from a searing Washington Post Cartoon done by Ann Telnaes. She disembowels the Senator using his own words and a few well placed pen lines dancing to modern technology's tune. I've posted the link to the cartoon below along with Ann's Bio on the Washington Post.

Senator Joe Lieberman skewered by Ann Telnaes

Ann Telnaes, who was awarded the Pulitzer Prize for editorial cartooning in 2001, has published her work in newspapers and magazines around the world. Her cartoons have been exhibited at the Library of Congress, in Paris and in Jerusalem and have been collected in two books, "Humor's Edge" and "Dick.

On the Huffington Post--the best quote I've seen in print yet although I heard something very similar expressed by our own Ed Craig.

If I wanted Joe Lieberman to write health care reform, I would have voted for John McCain.

Later in the post, this tidbit of information

The Trojan Horse at the center of the Senate's health care package is the mandate that people without health insurance be forced to purchase it from private health insurance companies or pay a fine. And the dirty secret of the package is that the price they will be paying is quite high - like up to 10% of income. So the way that we move along the path towards greater coverage is that the taxpayers and poor and working class people pay more to the insurance companies. What part of this is the "good"?

I haven't seen the 10% data in a first source document anywhere but if that is true just imagine Santa Claus coming down the chimney for the insurance industry with 10% of all working class American paychecks in his sack for all the good little greedy toads and toadies in Insurance Land. I'd quit and take my blanket and lie on the steps of the Senate before I'll be shackled to an insurance company, private or nonprofit.

Good grief, both France and Britain have dared to work together to fine and limit their banking industry and America can't even find the spine to tell the Insurance Companies they have to compete to survive? I think the American Senate has been paying Lucy van Pelt for advice.

In the meantime Howard Dean is calling in an Op-Ed piece on the Washington Post for a No-Vote on the now worthless reform bill and for the Senate to start over again. On a Dr. Dean site there is a form for submitting a supportive statement to the tune of

Give America a choice. We support healthcare reform that allows individual Americans to choose either a universally available public healthcare option like Medicare or for-profit private insurance. A public option is the only way to guarantee healthcare for all Americans and its inclusion is non- negotiable.

From Susie Madrak on the CrooksandLiar's website

WASHINGTON -- Howard Dean said a public health insurance option is more important than bipartisanship, and that Democrats should pass health-care legislation that includes the option with 51 votes if necessary.

Dean added that Democrats should have "no intention" of working with Republicans if it's not the strongest possible legislation that could be passed with a simple majority.

"If Republicans want to shill for insurance companies, then we should do it with 51 votes," Dean said during a news conference at the first day of the liberal America's Future Now! conference here.

Dean, though, also praised what he called President Obama's "realist" approach to trying to pass health care reform.

If you want or need a quick lesson on how the "media" can get their own private agenda across without a word just take a look at this site and the picture of Dean the site has chosen to put up discussing his views on health reform.

Speaking of the media, here is a nice clip from the White House (Obama) on the House bill passed this summer. Note the words "...all Americans..." not "SOME" Americans. What happened to your Senate President Obama?

"I thank Chairmen Rangel, Waxman, and Miller for their hard work on this bill that fundamentally reforms the health care system. As this process moves forward, I look forward to continuing to work with all House members in ensuring this legislation helps all Americans and plays an essential role in reducing deficits and bringing fiscal sustainability to our nation."

Searching on Thomas, Library of Congress, I came across the text for December 15, 2009 that I have posted at the end of the blog. But before I post this blog-o-information clips, I thought I'd share my own poignant morning discovery. I went into Fort Collins to visit the Harmony Campus Lab to get a routine blood test ($150) done for my doctor's appointment tomorrow. I was told at the receptionist's desk I'd have to show a photo ID to the nurse. The people in front of me were told the same thing.

Excuse me? This is not a plane. I haven't read any terrorist threats lately to blow up Poudre Valley anything. It is a place of healthcare where people go to be cared for and to gain comfort. It is a place where people who take the Hippocratic oath work. It is not your friendly, give me your data, your ID, your social security number, your health care history, your fingerprints--so I can give it to the authorities to make sure you are going to put in your 10% to the Christmas Fund for the Insurance Elites type of place. Doctors do not swear to treat people only if they pass the photo identification test. If don't have an ID do you not pass go? Do you not get medical treatment? Maybe they can just do a skin test to see if you are brown and legal. If the medical center is really nice they can lay down a doormat in the foyer and allow the really sick and undocumented to die on a nice comfortable mat. Or the homeless, take your pick.

Really, while my rhetoric may be a bit extreme, the privacy invasion is getting out of hand. Do we surrender our individual identities in the name of efficiency? We didn't surrender it in the face of Redcoats, the Confederacy, or the Nazis. Are we going to do it under the guise of healthcare reform? I sure hope not. Electronic records may be a step towards efficiency but there are some things that are just not for sale in America. And never should be.

Here is the text page of amendments. I am not sure why I am posting this here. Maybe I am imagining that there is some one out there who can decipher and make sense of this process. From my read through it looks like the Senate is making a mountain of regulations designed to control the initial development of what the press have referred to as the "nonprofit option". This option was batted about to negate the need for a true public option. I wrote on this topic a couple of months ago suggesting it was a really bad way to produce quality care but a great way to ensure that private insurance"and medical care organizations would face little competition or reform. Here it looks like they are trying to develop the structure for a model to then be used nationwide. I could be wrong.

I repeat... I could be wrong. So if there is anyone reading with a clearer understanding of the process of amending Senate bills and you want to take a shot at it--please feel free to correct my interpretation.

TEXT OF AMENDMENTS -- (Senate - December 15, 2009)

``(2) EXCEPTIONS.--The following rules shall apply to a proposal transmitted pursuant to paragraph (1):

[Page: S13274]  GPO's PDF

``(A) RECOMMENDATIONS FOR ACHIEVING TARGET.--The requirement under subsection (c)(2)(A)(i) shall not apply.

``(B) REQUIRED INFORMATION.--The proposal shall not include--

``(i) recommendations described in subsection (c)(2)(A)(i), pursuant to subsection (c)(3)(B)(i); or

``(ii) an actuarial opinion by the Chief Actuary of the Centers for Medicare & Medicaid Services certifying that the proposal meets the requirements of subsection (c)(2)(A)(i), pursuant to subsection (c)(3)(B)(iii);

``(C) CONTINGENT SECRETARIAL PROPOSAL.--The Secretary shall not submit a proposal if the Board fails to submit a proposal pursuant to subsection (c)(5).


``(i) Subparagraphs (A) and (B) of subsection (d)(3) shall be applied by substituting `subsection (c)(2)(C)' for `subparagraphs (A)(i) and (C) of subsection (c)(2)'.

``(ii) Subparagraphs (D) and (E) of subsection (d)(3) and subsection (d)(4)(B)(v) shall be applied by requiring a simple majority rather than three-fifths of the Members duly chosen and sworn.

``(iii) Subsection (d)(4)(B)(iv) shall not apply.

``(iv) Subsection (d)(4)(C)(v)(II) shall be applied by substituting `subsection (c)(2)(C)' for `subparagraphs (A)(i) and (C) of subsection (c)(2)'.

``(v) Subsection (d)(4)(E)(iv)(II) shall be applied by substituting `subsection (c)(2)(C)' for `subparagraphs (A)(i) and (C) of subsection (c)(2)'.

``(E) SECRETARIAL IMPLEMENTATION.--Subsection (e) shall not apply and the Secretary shall not implement the recommendations contained in the proposal unless the Secretary otherwise has the authority to implement such recommendations.

``(h) Annual Report With Recommendations With Respect to the Private Sector.--

``(1) IN GENERAL.--Not later than July 1, 2014, and January 15, 2015, and annually thereafter, the Board shall submit to Congress, the Secretary, and the Medicaid and CHIP Payment and Access Commission a report that includes recommendations on--

``(A) requirements under the program under this title (or requirements included in the proposal submitted under this section in the year); and

``(B) in the case of any report submitted in a year after a determination year (beginning with determination year 2017) in which the Chief Actuary of the Centers for Medicare & Medicaid Services has made a determination described in subclause (I) or (II) of subsection (c)(3)(A)(ii), other requirements determined appropriate by the Board;

that should be included in the requirements established under section 1311(c) of the Patient Protection and Affordable Care Act for a health plan to be certified as a qualified health plan, such as requirements that improve the health care delivery system and health outcomes (including by promoting integrated care, care coordination, prevention and wellness, and quality and efficiency), decrease health care spending, and other appropriate improvements


``(A) IN GENERAL.--The Secretary shall review the recommendations contained in the report submitted to the Secretary by the Board under paragraph (1). The Secretary may, if determined appropriate, incorporate such recommendations into the requirements for certification under such section 1311(c).

``(B) REPORT TO CONGRESS.--Not later than December 31, 2014, and June 15, 2015, and annually thereafter, the Secretary shall submit to Congress a report on the application of subparagraph (A). Such report shall include, with respect to each recommendation contained in a report submitted by the Board in that year, a description of whether or not the Secretary incorporated the recommendation into the requirements for certification under such section 1311(c), and if not, the reasons why.

``(3) MACPAC.--The Medicaid and CHIP Payment and Access Commission shall--

``(A) review whether or not recommendations contained in a report submitted to the Commission by the Board under paragraph (1) would improve the Medicaid program under title XIX and the Children's Health Insurance Program under title XXI if implemented under such programs; and

``(B) include in the Commission's annual report to Congress the results of such review.''.

SA 3241. Mr. CARPER (for himself, Mr. Conrad, and Mrs. Shaheen) submitted an amendment intended to be proposed to amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr. Dodd, and Mr. Harkin) to the bill H.R. 3590, to amend the Internal Revenue Code of 1986 to modify the first-time homebuyers credit in the case of members of the Armed Forces and certain other Federal employees, and for other purposes; which was ordered to lie on the table; as follows:

On page 722, after line 20, insert the following:


(a) In General.--In order to improve health care quality and reduce costs, the Secretary of Health and Human Services (in this section referred to as the ``Secretary'') shall develop, in consultation with major integrated health systems that have consistently demonstrated high quality and low cost (as determined by the Secretary and verified by a third party) a collaboration initiative (referred to in this section as ``the Collaborative''). The Collaborative shall develop an exportable model of optimal health care delivery to apply value-based measurement, integrated information technology infrastructure, standard care pathways, and population-based payment models, to measurably improve health care quality, outcomes, and patient satisfaction and achieve cost savings.

(b) Participation.--Prior to January 1, 2010, the Secretary shall determine 5 initial participants who will form the Collaborative and at least 6 additional participants who will join the Collaborative beginning in the fourth year that the Collaborative is in effect.

(1) INITIAL PARTICIPANTS.--Initial participants selected by the Secretary shall meet the following criteria:

(A) Be integrated health systems organized for the purpose of providing health care services.

(B) Have demonstrated a record of providing high value health care for at least the 5 previous years, as determined by the Secretary in consultation with the Medicare Payment Advisory Commission.

(C) Agree to participate in the Medicare shared savings program under section 1899 of the Social Security Act, as added by section 3022, the National pilot program on payment bundling under section 1866D of such Act, as added by section 3023, or a program under the Center for Medicare and Medicaid Innovation under section 1115A of such Act, as added by section 3021.

(D) Any additional criteria specified by the Secretary.

(2) ADDITIONAL PARTICIPANTS.--Beginning January 1, 2013, the Secretary shall select 6 or more additional participants who represent diverse geographic areas and are situated in areas of differing population densities who agree to comply with the guidelines, processes, and requirements set forth for the Collaborative. Such additional participants shall meet the following additional criteria:

(A) Be organized for the provision of patient medical care.

(B) Be capable of implementing infrastructure and health care delivery modifications necessary to enhance health care quality and efficiency, as determined by the Secretary in consultation with the Medicare Payment Advisory Commission.

(C) The participant's cost and intensity of care do not meet the definition of high value health care.

(D) Agree to participate in the Medicare shared savings program under section 1899 of the Social Security Act, as added by section 3022, the National pilot program on payment bundling under section 1866D of such Act, as added by section 3023, or a program under the Center for Medicare and Medicaid Innovation under section 1115A of such Act, as added by section 3021.

(E) The participant would benefit from such participation (as determined by the Secretary, based on the likelihood that the participant would improve its performance under section 1886(p) of the Social Security Act, as added by section 3008, section 1886(q) of such Act, as added by section 3025, or any similar program under title XVIII of the Social Security Act).

(3) ADDITIONAL CRITERIA.--In addition to the criteria described in paragraphs (1) and (2), the participants in the Collaborative shall meet the following criteria:

(A) Agree to report on quality, cost, and efficiency in such form, manner, and frequency as specified by the Secretary.

(B) Provide care to patients enrolled in the Medicare program.

(C) Agree to contribute to a best practices network and website, that is maintained by the Collaborative for sharing strategies on quality improvement, care coordination, efficiency, and effectiveness.

(D) Use patient-centered processes of care, including those that emphasize patient and caregiver involvement in shared decision-making for treatment decisions.

(E) Meet other criteria determined to be appropriate by the Secretary.

(c) Collaborative Initiative.--

(1) IN GENERAL.--Beginning January 1, 2010, the Collaborative shall begin a 2 year development phase in which initial participants share the quantitative and qualitative methods through which they have developed high value health care followed by a dissemination of that learning model to additional participants of the Collaborative.

(2) COORDINATING MEMBER.--In consultation with the Secretary, the Collaborative shall select a coordinating member organization (hereafter identified as the Coordinating Organization) of the Collaborative.

(3) QUALIFICATIONS.--The Coordinating Organization will have in place a comprehensive Medicare database and possess experience using and analyzing Medicare data to measure health care utilization, cost, and variation. The Coordinating Organization shall be responsible for reporting to the Secretary as required and for any other requirements deemed necessary by the Secretary.

(4) RESPONSIBILITIES.--The Coordinating Member shall--

(A) lead efforts to develop each aspect of the learning model;

[Page: S13275]  GPO's PDF

(B) organize efforts to disseminate the learning model for high value health care, including educating participant institutions; and

(C) provide administrative, technical, accounting, reporting, organizational and infrastructure support needed to carry out the goals of the Collaborative.


(A) IN GENERAL.--Initial participants in the Collaborative shall work together to develop a learning model based on their experience that includes a reliance on evidence based care that emphasizes quality and practice techniques that emphasize efficiency, joint development and implementation of health information technology, introduction of clinical microsystems of care, shared decision-making, outcomes and measurement, and the establishment of an e-learning distributive network, which have been put into practice at their respective institutions.

(B) RESPONSIBILITIES.--The Coordinating Member shall do the following:

(i) Partner with initial participants to comprehensively understand each institution's contribution to providing value-based health care.

(ii) Provide and measure value-based health care in a manner that ensures that measures are aligned with current measures approved by a consensus-based organization, such as the National Quality Forum, or other measures as determined appropriate by the Secretary, while also incorporating patient self-reported status and outcomes.

(iii) Create a replicable and scalable infrastructure for common measurement of value-based care that can be broadly disseminated across the Collaborative and other institutions.

(iv) Implement care pathways for common conditions using standard measures for assessment across institutions, targeting high variation and high cost conditions, including but not limited to--

(I) acute myocardial infarction (AMI) and angioplasty;

(II) coronary artery bypass graft surgery and percutaneous coronary intervention;

(III) hip or knee replacement;

(IV) spinal surgery; and

(V) care for chronic diseases including, but not limited to, diabetes, heart disease, and high blood pressure.

(v) Deploy and disseminate the comprehensive learning model across initial participant institutions, achieving improvements in care delivery and lowering costs, and demonstrating the portability and viability of the processes.

(6) ADDITIONAL BEST PRACTICES.--As additional methods of improving health care quality and efficiency are identified by members of the Collaborative or by other institutions, Initial Participants in the Collaborative shall incorporate those practices into the learning model.

(d) Implementation of Learning Model.--Beginning January 1, 2013, as additional participants are selected by the Secretary, Initial Participants in the Collaborative shall actively engage in the deployment of the learning model to educate each additional participant in the common conditions that have been identified.

(1) DISSEMINATION OF LEARNING MODEL.--Dissemination methods shall include but not be limited to the following methods:

(A) Specialized teams deployed by the Initial Participants to teach and facilitate implementation on site.

(B) Distance-learning, taking advantage of latest interactive technologies.

(C) On-line, fully accessible repositories of shared learning and information related to best practices.

(D) Advanced population health information technology models.


(A) IN GENERAL.--Evaluation of initial participants shall be based on documented success in meeting quality and efficiency measurements. Specific statistically valid measures of evaluation shall be determined by the Secretary.

(B) PERFORMANCE TARGETS.--The Secretary shall develop performance targets for participants. Performance targets developed under the preceding sentence shall be based on whether participants have improved their performance under section 1886(p) of the Social Security Act, as added by section 3008, section 1886(q) of such Act, as added by section 3025, or any similar program under title XVIII of the Social Security Act (as determined by the Secretary).

(e) Measurement of Learning Model.--Participants shall implement techniques under the comprehensive learning model. The Secretary shall determine whether such implementation improves quality and efficiency, including cost savings relative to baseline spending for the common conditions specified under subsection (c)(5)(B)(iv) and quality measures endorsed by a consensus-based organization or otherwise chosen by the Secretary. The Collaborative shall prepare a report annually on each participant's performance with respect to the efficiency and quality measurements established by the Secretary. Such report shall be submitted to the Secretary and Congress and shall be made publicly available.

(f) Administrative Payment.--For purposes of carrying out this section, there are authorized to be appropriated $228,000,000, to remain available until expended. Amounts appropriated under the preceding sentence shall be distributed in the following manner:

(1) The Coordinating Organization shall receive $10,000,000 per year for program development related to the Collaborative, including for health information technology and other infrastructure, project evaluations, analysis, and measurement, compliance, auditings and other reporting. Not less than $5,000,000 of such funds shall be provided for education and training, including for support for the establishment of training teams for the Collaborative, to assist in the integration of new health information technology, best practices of care delivery, microsystems of care delivery, and a distributive e-learning network for the Collaborative.

(2) Each Initial Participant shall receive $4,000,000 per year for internal program development for health information technology and other infrastructure, education and training, project evaluations, analysis, and measurement, and compliance, auditing, and other reporting.

(3) Beginning in 2013, the Secretary may provide funding to additional participants in the Collaborative in an amount not to exceed $4,000,000 per participant per year under the same use guidelines as apply to the Initial Participants.

(g) Continuation or Expansion.--

(1) TERMINATION.--Subject to paragraph (2), the Collaborative shall terminate on the date that is 6 years after the date on which the Collaborative is established.

(2) EXPANSION.--The Secretary may continue or expand the Collaborative if the Collaborative is consistently exceeding quality standards and is not increasing spending under the program.

(h) Termination.--The Secretary may terminate an agreement with a participating organization under the Collaborative if such organization consistently failed to meet quality standards in the fourth year or any subsequent year of the Collaborative

(i) Reports.--

(1) PERFORMANCE RESULTS REPORTS.--The Secretary shall provide such data as is necessary for the Collaborative to measure the efficacy of the Collaborative and facilitate regular reporting on spending and cost savings results relative to a value-based program initiative.

(2) REPORTS TO CONGRESS.--Not later than 2 years after the date the first agreement is entered into under this section, and annually thereafter, the Secretary shall submit to Congress and make publicly available a report on the authority granted to the Secretary to carry out the Collaborative under this section. Each report shall address the impact of the use of such authority on expenditures for, access to, and quality of,

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