Saturday, June 17, 2017

Of PAMA, MACRA, and the Affordable Care Act: The State of Healthcare Policy 2017

So, I'm back. 

As y'all know, I usually opine about Maryland state political matters on this blog. But during several past career intervals, I worked on Capitol Hill in different capacities, and had some recent experience working on federal healthcare policy for a small nonprofit in Columbia, Maryland. So, topics wise, I figured I’d switch things up with this one.

So, wonk Richard is giving politico Richard a week off, in other words. But I digress. Anyway, let's get to it. 

Before the Comey/Mueller/Russia stuff broke, the emerging Obamacare versus Trumpcare knife fight seemed poised to be the driving issue facing Washington in 2017. As the U. S. Senate mulls its own replacement to the Affordable Care Act (ACA), indications are that the healthcare debate is set to resume soon.

The outcome of that debate will change healthcare policy for the next generation and beyond. Everybody knows that.

Less known outside of the clannish network of providers, payers, administrators, practice managers, manufacturers, legislators, Hill staffers, lobbyists, accreditors, and activists is that change has already arrived.

And none of it has anything to do with the ultimate fate of the ACA or its GOP alternatives.

Two sweeping federal regulations finalized during the waning days of the Obama Administration have already transformed longstanding rules governing how healthcare practitioners in Maryland and elsewhere are reimbursed by Medicare.

One replaces the elaborate formula used to compute payments for clinical laboratory services.

The Protecting Access to Medicare Act of 2014 (PAMA) requires certain laboratories to periodically report to the Centers for Medicare and Medicaid Services (CMS) what they charge for certain laboratory tests. This data will be crunched to establish new, market-based rates starting January 2018.

The other moves healthcare past traditional fee for service medicine towards a model where Medicare payments are calculated using enumerated, quality-based performance targets.

By way of background, the “sustainable growth rate” (SGR) enacted during the 1997 bipartisan budget deal set caps on Medicare compensation for physicians. Unpopular and unsuccessful, it triggered a series of temporary annual congressional fixes.

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaces SGR in favor of a new, complex “Quality Payment Program" requiring doctors to choose between two different compliance tracks. 

Success is measured by meeting specific quality metrics outlined in the 2,400 page final MACRA rule. Doctors who have done so successfully qualify for rewards. Those that fail are penalized.

Providers across Maryland are now coping with a new set of regulatory complexities and deadlines. 

As for PAMA, confusion exists as to how exactly data should be collected and reported to CMS.

Further, according to CMS, only five percent of clinical laboratories are subject to PAMA requirements. Most hospital laboratory work is excluded, as are laboratories earning less than $12,500 in Medicare reimbursements annually.

Because larger laboratory conglomerates dominate the data reporting pool, many fear they will benefit to the detriment, and perhaps the ultimate extinction, of smaller, physician-operated laboratories (POLs).

In December, the Congressional Freedom Caucus made PAMA #80 on its hit list of 200 Obama-era regulations. A day later, a bipartisan group of 44 members of Congress sent a letter to the Obama Administration seeking revisions to the final rule.  

HHS Secretary Tom Price – who signed the aforementioned letter before he left Congress – extended the initial reporting deadline by 60 days, but based on current evidence, chances that Congress will engage in a meaningful attempt to rewrite the law are negligible.

As for MACRA, CMS initially estimated that smaller practices would be disproportionately most likely to receive penalties rather than bonuses. This sparked concern the law was biased in favor of large practices.

CMS adjusted the final role to ensure maximum compliance flexibility for physicians in 2017. But many healthcare advocates believe the MACRA final rule should be revised as well. 

Thanks to Hopkins Medicine, the University of Maryland Medical System, the National Institutes of Health, and many outstanding community-based hospitals and providers, Maryland is nationally regarded as a healthcare Mecca. The fundamental impacts these changes will have on these signature institutions is already being felt.

As the patients and families they serve, few know they even exist. But the specter of reduced patient choice seems likely if these two experiments fail.

Many patients prefer the convenience of testing performed during their regular visit with their family practitioner, as opposed to trekking to a remote reference laboratory, dealing with strangers, and longer wait times for results. This concern is especially evident in underserved rural communities.

The obvious benefits close-to-patient testing yield will become less and less available as the number of POLs shrinks.

Similarly, should MACRA breed a culture where smaller practices fail under the new regulatory rubric, patients will ultimately suffer due to the constriction of provider options.

Members of the House and Senate blinded by the politics of the moment must not shirk their responsibility to educate patients and practitioners about these changes to the healthcare system. In the wake of sweeping healthcare change, the rewards of success, and the responsibility of failure, rests with those who enacted them.

But patients always bear the ultimate consequences.

Friday, January 13, 2017

I'm Back

Well, the bad boy blogger is back.

Sorry for the long absence. I retired the blog for a while because, quite frankly, I didn’t know what to do with it. 

When I started it years ago, I was seeking a creative outlet as well as a platform to opine about politics. And, to be honest, I wanted to needle some of my adversaries in Maryland political circles.

Well, the needling got old.

I found I enjoyed writing about policy and politics in an agnostic fashion more than personalities. So, I focused on opeds for newspapers such as The Sun and The Hill.

This approach got me into as much trouble as my blogging did. But I’ll get to that in a moment.

Anyway, 2016 was a year of highs and lows for everyone, and my experience was no exception. But in my case, the highs outweighed the lows for three reasons.

1) I wrote a tribute to my ailing, formidable first boss – Congresswoman Helen Bentley – which appeared in The Sun on the day she died. But what made the experience special is that I got to personally show it to her when I visited her with former Baltimore Councilman Todd Huff about 10 days before she died. Crusty former journalist that she was, she read it carefully as I stood there – the acolyte waiting for the mentor’s verdict. She nodded, quietly handed it back to me, grabbed my arm and said, “You can visit me anytime.” I nearly cried.

2) I participated in the GOP convention in Cleveland, where I had the opportunity to write the so-called “Benghazi mom’s” incendiary speech. Then, when I got back home, I wrote an oped that summarized the experience which got me both national attention (“Anderson Cooper would like you to appear on his show. Can we send a car to pick you up?”) and a boatload of trouble (“The convention people are really mad at you”).  In both cases, I felt like a hunted animal.

3) In December, I closed out the year appropriately by returning to my alma mater, St. Paul’s School in Brooklandville, where I had the chance to speak to students about these experiences (Thanks to Alumni Director Charley Mitchell for making it happen).

On the less positive side of 2016, I turned 50 and it wasn’t a fun experience. I dealt with career and personal angst, and wrestled with some health issues. Part of the aftermath of 2016 is that a lot of people are mad at me at the moment - even more than usual.

So why am I resurrecting this blog, which I last updated in November 2015?

Well, my friend - life coach, fellow blogger - and I were talking about the value of New Year’s resolutions. She found them trite, and while I agree, given the volatility of 2016, I probably need to set some goals if not outright “resolutions” for myself.

So here they are…

 I    I will spend more time focusing on the future than dwelling on the past.

      I will be a better friend. Other than my sister, I have no surviving family – at least not that I care to ever talk to again. The positive side: it gives you the chance to build your own “family,” so to speak, from the ranks of the people you meet and connect with organically. I truly love my friends, but let some of them down last year. Specifically, I have committed what I have long regarded as the cardinal sin of friendship: I cancelled plans at the last minute, on multiple occasions. This has cost me dearly in some cases. I am ashamed.

      I will do a better job of listening. I don’t think I am a selfish person, but I have a tendency to get wrapped up in my own stuff, especially when I am in a period of transition or tumult. It's an introvert thing, I guess. Consequently, some people I care about a lot now think I take them for granted and, in some cases, take me for granite.

      I will learn to integrate my emotions with my intellectual side. I have always been a better Spock than a Kirk, and this led to some awkward moments in 2016.

      I will work to Make America Great Again.

OK, that last one was a joke.

Anyway, I promise to blog in a less confessional, Richard-centered manner, and with greater regularity, in the future. I may also make it less political - the Kardashians need love too.

Coming out of a fractious year, I need to hit the “reset” button. If I have disappointed you, I hope you will give me the chance to reset.

My hero, Richard Nixon, was once asked why he still got out of bed in the morning. “I do it to confound my enemies,” he replied.

I’m not looking to confound enemies in 2017. But I do want to shatter expectations.

Happy New Year.

Wednesday, November 4, 2015

The GOP CNBC Debate: Everything Old Is New Again?

So far, the GOP presidential debates have been a lot of fun to watch, mostly due to the antics of Donald Trump.  Indeed, one CNN pundit brilliantly described the circus-like debates as “Fonzie on stage with a whole bunch of Richie Cunninghams.”  

The CNBC debate was different than the others. This time Trump was less the publicity-consuming forest fire, giving some of the other candidates a rare chance to poke their head into the spotlight.

This made the debate – for me, at least – the most interesting session yet.

It wasn’t because of the alleged bias of the CNBC “moderators.” Blaming the media or pollsters when your candidate loses smacks of blaming the refs in the NFL. However, the CNBC crew was, bias-wise, more egregious and self-embarrassing than most. 

What made the CNBC debate truly interesting was the showdown that occurred between former Florida Governor Jeb Bush and current Florida Senator Marco Rubio.

As has already been widely reported, Bush confronted Rubio for missing votes in the Senate, and Rubio – clearly anticipating the attack – responded aggressively and effectively. It was a "you sank my battleship" moment for Bush, and may have been a defining moment for both campaigns, as Rubio’s surging and Bush’s sinking poll numbers could indicate.

Still, what made it most interesting for me is the strange déjà vu feeling I had.

First, here is the relevant clip of the Bush-Rubio exchange during the CNBC debate.



Watching it, I felt I had seen a similar debate moment before.  A brief search of YouTube reminded me I have.

The date was October 11, 1992, when President George H. W. Bush – desperately fighting for reelection – called out Governor Bill Clinton for alleged patriotic lapses.



In the Bush – Clinton exchange, a genteel political aristocrat known for his aversion to engaging personally in sharp-edged attacks tentatively launched a volley against his Democratic foe clearly orchestrated by his campaign team. And, it backfired.

In the Bush – Rubio exchange, a soft-spoken, wonkish ex-governor who prefers talking policy rather than competing in the kind of garish scrum into which the GOP debates have devolved awkwardly attacked a political protégé on a perceived vulnerability. 

That backfired, too.

For the record, I would be very comfortable with Governor Bush as the next president.

The question isn’t whether Jeb would be a good president.  The question is, given the strange dynamics of 2016, can he be a good candidate? 

Concerns about the economy overshadowed Bush 41's historic foreign policy successes, leaving the man who won so convincingly in 1988 a spent political force by 1992. 

The times shape the candidate. Can this candidate Bush shape the times? 

Tuesday, August 11, 2015

Steve Kreseski

In the most recent, and much maligned, Indiana Jones film, Indy muses that he had reached the point at which life stops giving you things and starts taking them away.

Last week, I experienced a similar epiphany.

Steve Kreseski, former chief of staff to Congressman and later Governor Bob Ehrlich, passed away after a long illness. He played a big role in my career, and in the careers of many others.

Now, I am no stranger to loss. Long ago, I buried my parents, and lost a fiancee.

But the passing of a personal mentor barely a decade older than I am raises its own set of complicated emotions about human mortality.

Steve was personally responsible for bringing me onto Team Ehrlich when the congressman was first elected to the House of Representatives as part of the first Republican congress in 40 years. I barely knew Ehrlich at the time, and some people in Baltimore County political circles tended to regard me as a bit of a live wire.

This live wire thing must be shocking to some of you, I know…but I digress.

But Steve fought for me, and I remember him reaching out to me on December 31st, 1994 – I was in Dallas for a high school buddy’s wedding – to tell me I had gotten the job. That launched the defining experience of my professional career.

It was a band of brothers experience, as we devoted ourselves to our new boss and his ambitions during what seemed like a heady and historic time.



Sometimes, brothers clash.

Steve’s devotion to the congressman was absolute, and he was mindful of the challenges of managing a very young, neophyte staff. As for me, I was eager and anxious to prove my value.  Understandable tensions between a risk averse chief of staff and a brash young press secretary occasionally resulted – a common dynamic across Capitol Hill.

He pushed me to deliver, to be more than the introvert that sat quietly writing press releases and talking points. And in the process he helped me evolve.

Some might even say he created a monster. Again…I digress. :-)

Still, at the end of the day, I never doubted his friendship.

Anyway, it was the best work experience of my life, and Steve Kreseski made it possible.

I worked with him again in the State House. In what is often a self-centered business, Steve was the rare exception – a manager and a mentor who actually cared that the people under his charge learned, grew, and thrived.

On the day I buried my mother – a snowy December morning in 2003, not to mention the worst day of my life – he unexpectedly showed up at my home. He was the only senior member of Team Ehrlich who did.

I never forgot that.

When I heard he was ill, I reached out to him. Typically, he turned the conversation back to me and my own particular career issues and aspirations.  “Once I have beaten this,” he told me, “I will do what I can to help you.”

Greatness starts with goodness, and Steve Kreseski was a truly good person. He lived his life with compassion and kindness. Putting other people first was an ingrained part of his DNA. He was everyone’s generous uncle, and everyone whose life he touched was made better as a result of having known him.

RIP, Steve. We will miss you.  

Tuesday, September 16, 2014

Derek Hunter Said What?!?!?!

So I pride myself on being a pretty laissez faire kind of guy. And I understand that talk radio is a vehicle for controversial, sometimes incendiary opinions.

And, while I agree with much of what he says from a philosophical basis, I found myself getting a bit annoyed by WBAL’s Derek Hunter and his playful critique of the Baltimore Orioles’s longtime theme song, Orioles Magic.

Hunter began his segment by asking if listeners had “heard of” the song, a staple of the Orioles 1979 and 1983 periods of glory. 

Yes, Derek, we know it well. 

He portrayed the song as a gaudy mix of 1970s polyester kitsch and a Ken Burns PBS documentary soundtrack, and then argued that it needed to be updated significantly.

Now, I get that Hunter was being deliberately provocative, and I respect that. I also know that he’s from Detroit and that – not having grown up in Baltimore – he wasn’t exposed to the song and its attendant fond memories the way home grown Orioles fans like me were.

And yes, I agree that the song is a little hokey. But Hunter is missing a valuable point: Most sports team theme songs are. 

Have you heard “Hail to the Redskins” lately? The old Colts fight song is a strictly retro production, too.  How about all those the times when Harry Carey used to sing “Take Me Out to the Ballgame?” 

Their kitsch is their charm.

The anachronistic nature of Orioles Magic helps some of us connect with past team traditions, glories, and memories. It serves the same cultural purpose as the statues which now dot the sports complex.

Perhaps a more modern song will emerge as the anthem of the moment, like “Who Let the Dogs Out” did for the Ravens in 2000. I hope that happens. 

But there will always been room for Orioles Magic and, for that matter, Thank God I’m a Country Boy in the Orioles’ musical universe. 

Could the song lyrics be updated to reflect the team’s 2014 roster and players? Sure. But let’s not change it too much.  Let’s celebrate the present, but we can do that and leave our past alone.

Go Os!!!

Monday, September 15, 2014

Ehrlich and New Hampshire: Part II

The Washington Post’s Robert Costa wrote this blog piece about the Ehrlich campaign trip to New Hampshire.

You know, a bunch of us have for years been joking about a phase of the never ending Ehrlich comeback saga which featured a quixotic bid for the presidency. We even joked about poor ol’ Greg Massoni loping alongside Ehrlich across the Granite State’s landscape, playing the dutiful Sancho Panza to Ehrlich’s Don Quixote.

So, I was especially amused by this portion of Costa’s piece:

"Greg Massoni, a longtime Ehrlich confidant and political adviser who once served as Ehrlich’s gubernatorial spokesman, accompanied him from stop to stop."

So what’s happening here?

I think Ehrlich misses the political game.

I think it’s been difficult for him to watching the party nominate another gubernatorial standard bearer – one who, depending on which poll you believe, seems to be waging a competitive campaign. Since 2010, Ehrlich has asserted that, if he could not win back the governor’s mansion, no one can.

And, I think that Ehrlich and some of the people close to him dreamed up this New Hampshire jaunt as something of a consolation prize for him - kind of like giving a restless retiree something to do.

I respect Ehrlich wanting to have a national voice – every ambitious, competitive politician does. I just don’t think you need to go to New Hampshire to do it. The mere act of going there overshadows whatever message you hope to convey.

In 2010, I stated that candidate Ehrlich reminded me of Joe Louis during the final phase of his career, when he was past his prime and knocked out by Rocky Marciano. This New Hampshire trip evokes memories of Joe Louis when he was a greeter at Caesar's Palace in Las Vegas, now a curiosity rather than a contender.

Anyway, I’ll take a little credit for my prescience, even if it was borne out of an attempt to be funny. 

Tuesday, September 9, 2014

Bob Ehrlich's High Hopes

Yesterday, the Ray Rice story, and the seismic impact the so-called elevator video has had on the NFL, the Baltimore Ravens, and the national conversation regarding domestic violence, dominated the news.
Among the overshadowed stories: This tidbit from the Washington Post about former Governor Bob Ehrlich.
According to the Post piece:
“Ehrlich is booked as the keynote speaker at a Steak Out in Nashua (New Hampshire) on Sept. 12 being hosted by the Nashua Area Republican City Committee. He is also expected to attend the New Hampshire Young Republicans Lobster Bake and Straw Poll in Laconia the following day.
“Ehrlich’s travel plans were first reported last month by WMUR-TV, the ABC affiliate in Manchester. Ehrlich could not be reached for comment Friday.”
New Hampshire, eh?
As in the state which traditionally hosts the first presidential primary election, and where Governor Martin O’Malley has been spending a lot of time in the service of his own presidential ambitions?
I heard rumblings of “big news” coming from the ex-governor’s camp – or what’s left of it -
from a former Ehrlich world colleague of mine. So far, however, no one on Team Ehrlich has publicly commented as to the purpose of the trip to the Granite State.
So before we jump to conclusions, let’s tick down all the possible reasons Ehrlich may be headed north.
1) He’s going to campaign for GOP senate nominee Scott Brown:  Former Massachusetts Senator Scott Brown is now challenging incumbent Democratic New Hampshire Senator Jeanne Shaheen. Polls now have the race statistically tied. Could Ehrlich be lending support to his fellow GOP moderate? This is plausible, but one wonders why such an announcement didn’t come directly from the Brown campaign.
2) He’s performing “truth squad” activities against O’Malley:  Governor O’Malley has been aggressively stumping in New Hampshire, Iowa, and other key primary states. Did the RNC or some other partisan entity dispatch Ehrlich to the "Live Free or Die" state so he can poke holes in O’Malley’s campaign trail bombast? Again, this is plausible, but Ehrlich is perhaps not the best choice for this assignment. Democrats would likely attribute Ehrlich’s motives to sour grapes coming from a sore loser. There are at least half a dozen other GOP officials and legislators in Maryland – including Nicolee Ambrose, Kelly Schulz, Jeannie Haddaway-Riccio, and Joe Cluster, just to name a few – who could ably perform this same assignment minus Ehrlich’s baggage.
3) Ehrlich is there to sell books: The former governor has been peddling his latest book – America: Hope for Change – at political fundraisers for GOP candidates across Maryland. Could he now be taking his book tour to other states? The book in question was released in November 2013, and, according to Amazon.com, it’s currently ranked #1,236,783. What kind of readership can he possibly expect to find outside of Maryland?

4) Ehrlich is sticking it to O’Malley:  The disdain that Bob and Kendel Ehrlich have for the man who ended Bob's political career is well documented. With O’Malley spending so much time up in New Hampshire in furtherance of his own longshot presidential hopes, could this be a stunt by the Ehrlichs to gain payback by infringing upon O'Malley's limelight? Given the level of enmity that has historically existed between these two pols, anything is possible. Nonetheless, I think O’Malley is more focused on Hillary Clinton’s plans rather than the vengeful exploits of a long-vanquished foe.  But if the Ehrlichs are doing it to have a little fun, more power to them.
6) Ehrlich is testing the waters for a possible presidential bid: This is the most fun, if also the silliest, of the options listed. As a former Republican governor of a deep blue state, Ehrlich would get some measure of attention from the media and GOP activists in New Hampshire, due largely to the as-yet undefined nature of the 2016 GOP presidential primary field. But it defies reason to assume that a pro-choice Republican who was the only governor in the country defeated for reelection in 2006, whose comeback bid in 2010 yielded an even bigger margin of defeat as well as a black voter suppression scandal, would gain any traction whatsoever.
That said, the notion of those signature blue and white Ehrlich signs dotting places like Nashua, Derry, and Dixville Notch makes me chuckle.
This New Hampshire push is part of Ehrlich’s continuing quest to stay relevant. It’s another phase of the comeback story that never ends but never seems to go anywhere, either. It’s the latest attempt to resurrect a once promising political career that some feel ended too early.
Anyway, if an Ehrlich for president bid does launch, here is one possible campaign song: