Advocates want HHS to publicly release specific information on the current large-enrollment plans that could be used by states to define the health reform law's essential health benefits, saying in a December letter that the information would provide more certainty about the practical impact of HHS' intended regulatory approach with respect to EHB that was outlined last month in a bulletin.

The Congressional Research Service warned lawmakers that raising physician pay in a "doc fix" by allowing for greater Medicare expenditures likely would also mean raising premiums for many seniors, according to a late-December CRS report obtained by Inside Health Policy that outlines options for replacing the Sustainable Growth Rate formula that sets Medicare pay rates for physicians. Were Congress to "hold harmless" premiums and still raise the ceiling on physician-pay expenditures, the price tag for a permanent fix would cost more than the Congressional Budget Office's current estimate of $290 billion over 10 years, CRS concludes.

GOP governors in 26 states are telling the Supreme Court that the health reform law's Medicaid expansion is unconstitutionally coercive and argue the program's expansion was constructed to help fulfill what they also view as the law's unconstitutional individual mandate, according to the brief filed to the Supreme Court Tuesday (Jan. 10) by those governors who are also challenging the entire health reform law.

MedPAC on Thursday (Jan. 12) approved controversial draft recommendations to reduce pay for evaluation and management (E/M) services that are provided in hospital outpatient departments so they are equal to pay rates for those same services provided in doctor offices, a controversial proposal that the House used to help offset its two-year physician pay fix in December and will likely come up again as congressional conferees revisit 'doc fix' legislation. Hospital officials promptly blasted the recommendation, which they had earlier urged MedPAC to scrap.

Hospitals continue to lobby against several policies in play that would offset the cost of extending the physician pay patch until the end of the calendar year or beyond as a key Democratic House lawmaker signals hope that a final conference agreement will be agreed upon by the end of the month. The Association of American Medical Colleges wrote a letter to conferees saying that MedPAC's recent draft recommendation to reduce payments for hospital evaluation and management services (E/M) in outpatient departments is premature and should not be used as an offset and the American Hospital Association is also urging its members to oppose reductions in bad debt payment and several other payments that would adversely impact industry.

Several Republican lawmakers are chiding HHS for having issued a "bulletin" instead of a proposed rule on the health reform law's essential health benefits, saying the move is "the antithesis of an 'open and transparent' process," according to a Jan. 13 letter the lawmakers sent to HHS Secretary Kathleen Sebelius.

Nursing homes are protesting draft recommendations, approved by Congress' Medicare payment advisors Friday (Jan. 13), that would eliminate the market basket update for nursing homes, which the industry says would cut pay at least by 4 percent, would revise the nursing home pay system for 2013 and would begin rebasing pay in 2014, with an initial reduction of 4 percent and subsequent reductions. But the industry is somewhat supportive of the advisors' call to reduce pay for skilled nursing facilities with relatively high risk-adjusted rehospitalization rates for Medicare-covered stays.

Alaska Sen. Mark Begich (D) praises his state's new movement towards establishing a state-based exchange but tells Inside Health Policy he is "concerned with the slow pace of implementation and believe(s) it is unfortunate that Alaska missed out on no-strings-attached federal funding that would have covered the expense of planning an exchange." Begich had earlier urged the governor to apply for such funding.

The U.S. Chamber of Commerce says lawmakers must be willing to make adjustments to entitlement programs and has placed Medicare and Medicaid reform atop its agenda, which, in a noticeable shift from last year, does not mention a position on any provisions in the health law. Chamber President and CEO Tom Donohue suggested that the health law is already going through turmoil, so the group's focus will be on Medicare and Medicaid, which he says can be fixed by making targeted changes -- such as raising the Medicare eligibility age - rather than large-scale changes.

HHS' second move under the health reform law to deem an insurer's rate increases "unreasonable" were protested by the insurer involved, and sparked renewed calls from the insurance industry trade group for the government to look beyond premiums and consider all factors behind rate hikes. HHS insurance oversight official Gary Cohen, in a conference call Thursday (Jan. 12), called on Trustmark Life Insurance to rescind its rate hikes, issue refunds or publicly explain its refusal to do so.

Consumer advocates and community pharmacists say the Federal Trade Commission's recent settlement with CVS Caremark over mispriced drugs on CVS' Medicare Part D list demonstrates the need for legislation requiring pharmacy benefit managers to disclose more information about deals between PBMs and drug companies. In some cases, the mispriced CVS drugs were 10 times more expensive than their listings, and the advocates and community pharmacists argue that antitrust law is likely insufficient to police the problem.

States would have the statutory authority to establish a "Very Integrated Program (VIP)" that would use managed care plans to provide all Medicare and Medicaid services to beneficiaries eligible for both programs, under a proposal by the Association for Community Affiliated Plans (ACAP) that has caught the attention of state Medicaid officials. ACAP officials say the proposal borrows the structure from the Program for All-Inclusive Care for the Elderly (PACE). Under ACAP's plan, states would be responsible for contracting with managed care plans and would be able to "passively" enroll beneficiaries, while CMS' Medicare-Medicaid Coordination office would set the patient protection standards.

The National Association of Insurance Commissioners subgroup tasked by the health reform law to recommend revisions to the two most popular Medigap plans generally agrees that advanced imaging and durable medical equipment are two services that should be considered as candidates for cost-sharing, according to discussions the subgroup had during a conference call this week.

Staff for House Ways and Means Chair Dave Camp (R-MI) and Senate Finance Chair Max Baucus (D-MT) on Wednesday (Jan. 11) convened a bipartisan, bicameral meeting of staffers for conferees working on legislation to override Medicare physician pay cuts and extend payroll-tax cuts and unemployment insurance, according to a House aide. A Senate Republican aide said the most likely outcome will be an additional 10-month override of the Sustainable Growth Rate formula that determines physician pay, but some lawmakers are still pushing for a two-year deal.

Advocacy group Families USA on Tuesday (Jan. 10) unveiled two new reports that aim to provide state-based consumer advocates a roadmap for monitoring state efforts to institute accountable care organizations and other delivery system reforms, and the group lays out specific questions it says advocates should ask to ensure ACOs in their area are committed to providing coordinated services that not only lower cost but also improve care. One report offers detailed information on various financing mechanisms and options for designing quality benchmarks, while the other explores shared savings models.

CLASS proponents are working behind the scenes to come up with alternative ways to carry out the reform law's voluntary long-term care insurance program's mission, with one source saying some policy discussions are honing in on Medicaid. The discussions come as the House Ways & Means Committee repealed CLASS on Wednesday (Jan. 18) and Reps. Charles Boustany (R-LA) and Richard Neal (D-MA) are readying a separate long-term care insurance proposal that contains some pieces advocates could probably support, advocates tell Inside Health Policy.

A bipartisan group of 14 senators is pressing CMS to hold off distributing draft lists of maximums that the federal government will offer state Medicaid programs for generic drugs until the CMS drafts a regulation explaining how it calculates those Federal Upper Limits. The senators are responding to concerns from pharmacists, who believe that CMS' approach will discourage the use of generic drugs by setting reimbursement too low.

Republican Sens. Tom Coburn (OK) and Scott Brown (MA) have asked CMS Acting Administrator Marilyn Tavenner if CMS is utilizing free online applications, such as Google Earth, to determine if a billing address actually exists, and also want to know which unimplemented HHS OIG and GAO fraud-fighting recommendations the agency is considering. The request comes after a Thompson Reuters' investigation -- the results of which have been forwarded to the HHS OIG -- found that shell companies remain a prime tool in perpetrating Medicare and Medicaid fraud, which Thompson and other analysts have said could cost taxpayers $125 billion a year.

The Department of Justice is sticking with its argument that the health reform law's individual mandate provision operates as a tax law, even though that argument has not taken hold in lower courts, as a part of its defense of the mandate in a brief filed with the Supreme Court Friday (Jan. 6). The tax argument is part of a multi-pronged defense of the mandate in which the administration largely hews to arguments it has made in lower courts.

House Minority Leader Nancy Pelosi (D-CA) said Friday (Jan. 6) that seniors deserve to have the confidence that they may see their doctors for "the rest of the year," possibly signaling that House Democrats will push for a one-year patch to the looming 27.4 percent Medicare physician pay cut. Rep. Allyson Schwartz (D-PA), an appointee to the House-Senate negotiations for a Medicare physician payment fix, told Inside Health Policy over the holiday break that she was pushing for a two-year patch.

The American Hospital Association is strongly urging HHS not to narrow its use of anti-kickback waivers for accountable care organizations, and is also calling on CMS and the Office of Inspector General to allow the waivers for other programs that seek to coordinate health care among health care providers. A hospital representative outside AHA says an even bigger problem is that the waivers apply to ACOs but not the individual entities that make up ACOs, which the source says could be a major hurdle for hospitals that want to fund the creation of ACOs.

The hospital industry is asking the Supreme Court to ax the reform law's Medicare and Medicaid cuts if the individual mandate if found unconstitutional. In a "friend of the court" brief filed Friday (Jan. 6), key hospital trade groups say they support the mandate, but argue that if the high court throws out the mandate it should scrap along with it three key health reform provisions: disproportionate share hospital (DSH) payment reductions, readmissions program, and productivity adjustments and market basket cuts. The hospital industry tells the court it agreed to the reform law's package of cuts with the express understanding that an individual mandate would be in place.

Home medical equipment suppliers are trying to get included in doc-fix legislation an alternative to the controversial Medicare competitive bid program, and industry's proposal has the support of a key, independent expert on auctions. The Congressional Budget Office is scoring the proposal by the American Association for Homecare, an industry source says, and industry expects it to be budget neutral but will adjust it if CBO determines that it costs money.

A key advocate of physician reporting backs CMS' recent decision to delay when drug and medical device makers must begin collecting information on the gifts that they give doctors and teaching hospitals, but he is pushing CMS to maintain the law's 2013 start date for reporting that information.

CMS' newly unveiled interim final rule to standardize the format and data content of health care electronic fund transfers generally hew to recommendations issued by the National Committee on Vital Health and Statistics last February. The rule, which implements a provision of the health law that is estimated to save physician practices and hospitals from $3 billion to $4.5 billion over 10 years, is effective as of Jan. 1, and all HIPAA covered entities -- including private and public health plans -- must be compliant by Jan. 1, 2014.

Medical device industry officials continue to press for repeal of the health reform law's $20 billion device tax, though some industry stakeholders express apprehensiveness about the chances of Congress passing the costly repeal given the recent showdown over offsets for the payroll tax. Nonetheless, medical device trade groups said they will continue to push for repeal of the tax this year and next, looking also to tax reform or changes to the healthcare law as possible vehicles.

On the same day that Premier announced its QUEST initiative saved more than 24,000 lives and nearly $4.5 billion over three years, the Congressional Budget Office said Medicare demonstrations that build on the kind of data sharing and medical-practices development engendered by QUEST showed no evidence of reducing Medicare spending. Premier has been urging Congress to credit hospitals that reduce costs through care coordination initiatives under next year's 2 percent Medicare sequestration, but a hospital lobbyist says CBO is unlikely to do so.

The White House is pointing to several states' movement toward creating their own exchanges as evidence that health reform is taking hold, yet administration officials on Wednesday (Jan. 18) gave few details related to the minimum states will have to do in order for HHS to fully certify their exchanges by the start of 2013, and sources say the department has been scant on details regarding conditional exchange approval, a proposal outlined in draft regulations.